Tässä kopioituna englantilaisen osteopatian opettajan Caroline Stonen tekemä koonti lastenosteopatiasta, sen tutkimisesta, mahdollisista hyödyistä sekä mahdollisuuksista toimia yhteistyössä muiden terveydenhuollon ammattilaisten kanssa.
Abstract
This Document sets a potential framework for discussing paediatric health services for children in Finland, by Osteopaths, a regulated health profession in Finland.
Caroline Stone D.O.(Hons), MSc(Oste), MEd, MClinEd
Researcher
9th December 2024
This document has been prepared as a collaborative effort between the College of Non Musculoskeletal Osteopathy, offering post graduate training in paediatrics, and the whombs organisation, a clinical special interest group focusing on women’s health and paediatrics services by regulated osteopaths.
Contents
Osteopathic Child Health Services In Finland
Introduction
Osteopathy is a regulated health profession in Finland. [1] There is a clear and well-articulated need for research into complementary and alternative (CAM) health service use by the finnish Population (Pyykkönen et al., 2023) (Zimmermann et al., 2017) and this is especially so when it is clear that finnish parents are already seeking a range of non-standard welfare and healthcare services for their children. (Sointu et al., 2021) Finnish children are also themselves seekers of types of CAM therapy use, for wellbeing and health purposes. (Siponen et al., 2012) Thus it is timely to consider inter-professional dialogue and understanding between mainstream and regulated health service providers in Finland such as Doctors, Paediatricians, Nurses, and Osteopaths, and this dialogue should form part of a research enterprise similar to those already operating in other countries, such as Quebec, (Morin et al., 2017) to better inform health policy and public information regarding paediatric osteopathy health services in Finland.
Many regulated osteopathy professions internationally reference the following standards documents – the European CEN standards – which outline general professional training and basic competencies for osteopathic practice, and follow on from the WHO (World Health Organisation) Benchmarks for Training in Osteopathy.[2] Both these cover the general scope of osteopathic practice. In Finland, there are schools that are accredited by the Austrian Standards Institute [3] as meeting CEN Standards. Research into continuously improving education and training for pre-registration osteopathic practitioners is a continuing process to which the global profession is committed. (MacMillan et al., 2023)
First Contact Practitioners – understanding the position of osteopathic health provision in wider health services
Osteopaths globally operate as first-contact practitioners[4] – people can attend an osteopath without being required to have a general practitioner or consultant referral. This places various demands on curricula, training and competence and capability dynamics, to ensure patient safety, and inter-connectedness with mainstream health service provision. The standards, competencies, and capabilities required for osteopathic practice state that screening, education and referral protocols, and limitations for either general or personal scope of practice should be well articulated.
As first contact practitioners, Osteopaths regularly report having a paediatric patient population according to various surveys,[5] (Burke et al., 2013; Plunkett et al., 2022; Schwerla et al., 2021) (Vaucher et al., 2018) but more data is required, as regards to age, gender, health status, area of concern and other relevant data, investigations performed, treatment given, and outcomes recorded, and a finnish-specific study on paediatric osteopathic practice is called for.
The process for regulatory recognition in Finland was for a profession whose training provided for competence in engaging with a population wide health dynamic. Osteopathy training includes childrens osteopathy, and regulated practice in Finland covers practice involving childrens osteopathy. Osteopaths provide a health role and a health service, which includes many things, not just hands on therapeutics, and practice encompasses a wide range of capabilities. (Stone et al., 2011)
As part of the health service to the finnish population, osteopaths are therefore trained in providing a variety of health and wellness advice and education, as well as referral understanding, for when any condition requires more investigation and / or medical diagnosis. This health service role is relevant for all parts of the finnish population, not just children and their families.
Health needs, and health services for the paediatric population in Finland
Child health services in Finland are well established, [6] and include discussion and health needs, about the family, siblings as well as the child in question, and the delivery vaccination services, for example. (Nieminen et al., 2022)
Extended case history taking, gather general health and developmental and functional and quality of life information, as well as exploring self-care understanding are standard components of an osteopathic consultation. (Ellwood & Carnes, 2021) These consultations also include advice for self-management and onward referral as required. Osteopaths are also increasingly oriented to the dynamics of monitoring for safeguarding issues and children, (Feld et al., 2015; Maddick et al., 2014) as week as issues of consent and communication. (Maddick & Laurent, 2012) In Finland, there are also specific rights of minors that locally practicing osteopaths would be aware of. [7]
Accordingly, this commentary can pose questions regarding the wider health services that osteopaths could / do deliver in Finland and globally – such as screening services, referral portals, and parent (and where appropriate, to the child) education regarding health concerns. And to consider the value to the general health service for children in Finland, of such an osteopathic service, especially where studies show that time and money involved in health discussion with trained health professionals take up nearly a quarter of costs in health consultations for children. (Nieminen et al., 2022)
Capabilities required for osteopathic paediatric practice
So, whilst it is recognised that the treatment of children is part of the global osteopathic population’s scope of practice, specific competencies and descriptors of skills for the practice of paediatric osteopathic care (in addition to those required for general practice) are clearly necessary, but are less well articulated. Globally, apart from the United States of America, where Osteopaths are regulated as medical health professionals, osteopaths are not usually required to undertake any speciality or post-registration training in paediatric care, although several jurisdictions recognise that osteopaths should practice according to their self-assessed competence and knowledge base, such as the General Osteopathic Council in the UK and the Osteopathy Board of Australia. (Evans, 2018) Uniquely, the New Zealand Register of Osteopaths: the Osteopathic Council of New Zealand undertook a project led by this author to identify the Capabilities required for Paediatric Osteopathic Practice, [8] as it was established that the pre-registration training available in New Zealand, and the educational biography / profile of the diversely overseas trained osteopaths registered in NZ may not be sufficient for practice, without further training.
Accordingly, it is timely to consider the nature of paediatric osteopathic practice, the clinical decision making, evidence base, and research priorities relevant to its practice and implications for policy and education in Finland. It is also important to note that osteopaths who work in the neonatal and paediatric world do not operate in a private silo, but prefer engaging as part of a health care team and prefer interprofessional and integrative activities aimed at supporting adaptive capacity and resilience for paediatric patients, (Lunghi et al., 2021) and can collaborate in various clinical situations, including for infant feeding difficulties and lactation evaluation. [9]
Clinical Decision-Making in Osteopathy
As stated above, patient safety and informed consent are central to regulated osteopathic practice, and as part of a thorough health screening and clinical case analysis process, osteopaths utilise a range of standard clinical processes, which are mirrored across all health professions (such as the technical-rational approach, professional artistry, the hypothetico-deductive method and others). (Thomson et al., 2014) Criticality, reflection, phenomenological approaches and intuition are also well established in osteopathic case analysis processes. (King et al., 2018) (Grace & Orrock, 2015; Spadaccini & Esteves, 2014)
Diagnostic and screening tools and case analysis approaches by osteopaths
Therapeutic modalities utilised by osteopaths
In the wider literature framework, evidence about the advisability of spinal manipulation for the paediatric population (Milne et al., 2022) and the possibilities of adverse clinical outcomes is also familiar to the osteopathic profession, who avoid spinal manipulation for the younger paediatric population and who utilise a range of gentle soft tissue mobilisations and gentle tissues releases for which there are seemingly no significant adverse events reported in the literature. The osteopathic profession is aware of physiotherapy profession statement relating to spinal manipulation,[10] which may be broadly reasonable, but it is important to state that many of the therapeutic approaches in osteopathic practice are NOT spinal manipulation, which do not carry the same risk profile. It should be noted though that spinal manipulation in older children by physiotherapists for conditions such as neck pain, is an accepted form of treatment for musculoskeletal pain relief, [11] and so will similarly, commonly be applied in osteopathic practice in such circumstances.
Of the gentler approaches used by osteopaths, such as soft tissue mobilisation, gentle articulation and stretching, inhibition and massage, many are already utilised in a neonatal and paediatric setting, for pain management, for example, (Sharma et al., 2023) (Liu et al., 2022) and seem to carry low risk of adverse events (Humphreys, 2010) which places osteopathic approaches to the management of paediatric pain amongst an established evidence framework. Massage therapy in paediatrics is also established with a growing evidence base (Shipwright & Dryden, 2012) and osteopaths are familiar with evidence regarding adverse events following non-orthopaedic massage (for example on the abdomen) on young babies, where the adverse events may depend on the experience of the practitioner (for example paediatric nurse) who is delivering the therapy.
and osteopathy in the cranial field (not to be confused with craniosacral therapy)
The nature of paediatric health concerns brought to osteopaths
The common conditions presenting in paediatric osteopathic practice have been summarised in a table format, (Schwerla et al., 2021) derived from two different practice audits / surveys.
Various systematic reviews and meta-analyses have been conducted, (Bagagiolo et al., 2022; Franke et al., 2022; Parnell Prevost et al., 2019; Posadzki et al., 2022) which show moderate to low quality data for some manual medicine approaches delivered by osteopaths. But whilst the data from osteopathic research have historically been heterogeneous, it is improving, but more meaningful conclusions for all health conditions are still required. The fiscal barriers and research capabilities challenges within the global osteopathic profession are well known, as it remains a relatively small profession, with most practitioners in private practice and outside the traditional university research centers / hubs, hindering research efforts.
There are significant efforts supported by various osteopathic associations and bodies, [12] that are encouraging the use of practice-based research networks and hubs to overcome some of these barriers, and to encourage multi-centre clinical trial design and implementation, to support the evidence base for practice. (Rushton et al., 2014) (Steel et al., 2020)
However, it should be noted that many manual approaches used by other manipulative professions (such as physiotherapy) are also used by osteopaths, and when the wider manual medicine literature for the paediatric population is considered, higher quality evidence for manual medicine approaches exists across a range of conditions.
In the context of general manual medicine for the paediatric population, the literature shows several areas of positive data for its use therapeutically, or as part of a screening tool / process.
Osteopathy is also regarded as being a strongly patient-centred form of care, and it is enactive, with a strong therapeutic alliance construct, (Esteves et al., 2022) with a strong interdisciplinary dynamic, and is a highly rewarding subdomain of osteopathic practice. [13] This means the typically long consultations (30-60 minutes each) allow for a patient-parent-osteopath rapport to build which is essential for engendering trust in health service provision and clinical outcomes. This is particularly so when considering the maternal-infant dyads, and support the new family unit (Accardi et al., 2023) – the therapeutic space has been found to be a key component for sharing and support of the mum and the new family (and this is important even when no MSK treatment has been asked for, or delivered – it is part of the wider support of the family unit that seems so important to parents).
It is in this context that the education, reassurance, monitoring for emotional issues (such as red flags for maternal mental health, or paediatric-failure-to-thrive or suspicion of non-accidental injury to a child) and other self-help or self-care education needs can emerge and be managed. Indeed, many osteopathic health services for the paediatric population consist entirely of education, rehabilitation, parental guidance for infant handling and repositioning, and advice for older children on posture and recovery from minor orthopaedic strains; thereby providing a positive benefit to the general population (and likely leads to a reduction on pressure, resources and costs to the wider health service provision).
Musculoskeletal conditions and associated pain in the paediatric population
As stated above, osteopaths have the competence and skill set to manage various musculoskeletal minor injury, joint pain / minor orthopaedic conditions and symptoms, and these forms the majority of clinical presentations to osteopaths in the paediatric population. Musculoskeletal health in the paediatric population is important, and is reflective of many systemic health and homeostasis and hormonal dynamics in the paediatric population, (Faienza et al., 2023) and this medical knowledge is included in general and paediatric osteopathy training.
It is worth noting that osteopaths routinely assess for MSK restrictions in these populations, but also prescribe self-movement exercises, muscle development exercises, and movements to restore ranges of motion, including advice for handling and parent carrying for example, [14] and encourage patient / child movement confidence, and not all therapy delivered by the osteopath consists of hands on work.
Complementary manual medicine inclusion to therapeutic management of non MSK conditions
Complementary manual medicine approaches within the context of a wider inter-disciplinary approach to various paediatric conditions which are not primarily musculoskeletal (MSK), but which depend on effective MSK functioning. Osteopaths also understand this and are trained to support and manage these situations, utilising evidence from physiotherapy, manual medicine and osteopathic literature sources. Examples include head turn preference in paediatric movement development (Rodríguez-Huguet et al., 2024) ; deformational / positional plagiocephaly disorders which are impeded by general body; limb and trunk movement asymmetries, complicating motor patterning use of the cervical muscles, contributing to the deformational plagiocephaly dynamics (Blanco-Diaz et al., 2023) ; temporomandibular movement and global oral motor use for infant feeding (bottle or breast) dynamics as these are known to interfere with latch success (Greenwood et al., 2023; Herzhaft-Le Roy et al., 2017, 2019) ; chest movement and muscular restrictions decreasing chest wall compliance and diaphragm function in children with a variety of respiratory conditions (Courtney, 2017) ; pelvic floor muscle dyssynergia in paediatric (non neurogenic) defecation and voiding conditions. (Nemett et al., 2008)
Even wider conditions, such as in autism spectrum and those with learning delays, who also have complications of functional visceral and gut based problems may benefit from manual therapy approaches, which are within the osteopathic scope of practice and experience. [15]
General and common presentations in infant and young children care
These include infant feeding, recovery from traumatic birth and tissue injury (where this occurred, as not all birth is traumatic, requiring care). It also includes frequent crying, unsettledness, poor sleep dynamics, and general stress for the new family unit, and osteopathy may play a role in these types of presentations. (Carnes et al., 2018)
Beyond specific conditions there is also the role of therapeutic touch, which is relevant across a whole range of presentations, [16] and osteopathic therapeutic touch (McGlone et al., 2017) may also have significant clinical value when used in support of standard care of a range of medical conditions in paediatrics. It is also worth noting that the effects of osteopathic light touch may extend beyond changes in the musculoskeletal system and may influence autonomic nervous system parameters giving relevance to its use in a wider clinical context for newborns and pre-terms. (Manzotti et al., 2022)
High-risk category paediatric populations
As a specialised or informal extended scope of practice, some paediatric osteopaths become experienced in neonatal and pre-term infant care, and work collaboratively within NICU and high dependency units. This collaboration has lead to some interesting research highlighting how the addition of osteopathic services in these medical units may provide benefits relating to length of stay, and other parameters. (Cerritelli et al., 2013; Cicchitti et al., 2020; Manzotti et al., 2020; Marinelli et al., 2019; Roland et al., 2022; Vismara et al., 2022)
The Osteopathic Paediatric Health Service
This paper gives brief insights into the application of osteopathy as a paediatric health service in Finland, and its potential for development, to benefit the Finnish Population and to support existing Finnish Child Health Services.
Osteopaths are highly trained, regulated health professionals in Finland, and are well placed to support children in Finland.
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[1] https://www.suomi.fi/services/registering-the-protected-occupational-title-of-osteopath-trained-in-eu-eea-national-supervisory-authority-for-welfare-and-health/8b80f8a5-66dd-4575-b6cb-30570311fc4a
[2] https://osteopathyeurope.org/osteopathic-standards/#:~:text=The%20CEN%20standard%20sets%20a,published%20in%2033%20European%20countries.
[4] In the USA, the Doctor of Osteopathy title confers full medical practice rights, whereas in the rest of the world the majority of osteopaths do not practice as medical doctors, and qualify as independent health professional sand as complementary and medical therapist, depending on their geographical / legislative jurisdictions.
[5] https://oialliance.org/osteopathy-and-osteopathic-medicine-a-global-view-of-practice-patients-education-and-the-contribution-to-healthcare-delivery-2013/
[8] https://www.osteopathiccouncil.org.nz/common/Uploaded%20files/Publications/Policies%20and%20Guidelines/Paed_Final_July2015.pdf
[9] Managing breastfeeding difficulties in a multidisciplinary way involving lactation consultants and osteopaths
[10] Spinal manipulation and mobilisation in paediatrics – an international evidence-based position statement for physiotherapists
[11] Spinal manipulation and mobilisation in paediatrics – an international evidence-based position statement for physiotherapists
[13] ‘Thrown at twins’ – A qualitative study exploring the lived experience of Australian osteopaths who regularly treat paediatric patients
[14] Guidance strategies for infantile asymmetry prevention: A Systematic Review (pre-print ahead of publication)
[15] Effectiveness of visceral osteopathic treatment on gastrointestinal indicators and behaviour patterns in autistic children: using questionnaire and biochemical markers …
[16] Touch medicine: bridging the gap between recent insights from touch research and clinical medicine and its special significance for the treatment of affective disorders
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