Reconceptualizing the therapeutic alliance in osteopathic practice: Integrating insights from phenomenology, psychology and enactive inference

Exploring the role of therapeutic alliance and biobehavioural synchrony in musculoskeletal care: Insights from a qualitative study

BACKGROUND

Person-centred care underscores the therapeutic alliance (TA) as fundamental, fostering positive treatment outcomes through collaborative patient-clinician interactions. Biobehavioural synchrony within the TA, essential for effective care, reflects an adaptive process where organisms align responses during interactions. Enactivism and active inference provide profound insights into human perception, reshaping musculoskeletal care understanding. Touch and verbal communication, integral to the TA, foster synchrony and alignment of personal beliefs.

AIM

This study aimed to identify the tools used by manual therapists in musculoskeletal care to establish a TA with patients. Furthermore, it endeavours to evaluate the alignment of these strategies with current literature and their correlation with biobehavioural synchrony, enactivism, and the role of touch in active inference.

METHODS

The methodology followed rigorous qualitative research principles, particularly Grounded Theory and interpretative-constructivist principles, conducting eleven semi-structured interviews with open-ended questions.

RESULTS

The core category identified in the study is elucidated as follows: "Interwoven Connection: The Fabric of Therapeutic Synchrony." The interviews unveiled three main categories, each comprising sub-categories: (1) Creating a meaningful dialogue; (2) Promoting active patient participation; (3) Synchronisation.

CONCLUSION

Fostering meaningful dialogue, patient involvement, and therapeutic synchrony is crucial for a robust therapeutic alliance in musculoskeletal care. This underscores the importance of establishing a deep connection between clinicians and patients, central to effective person-centred care. Clinicians must prioritise two-way communication, empathy, and patient collaboration in defining personalised goals. Emphasizing touch and seeking patient feedback are also pivotal. Further research is needed to explore these elements and their impact.

Epistemological Flexibility in Person-Centered Care: The Cynefin Framework for (Re)Integrating Indigenous Body Representations in Manual Therapy

BACKGROUND

Chiropractic, osteopathy, and physiotherapy (COP) professionals regulated outside the United States traditionally incorporate hands-on procedures aligned with their historical principles to guide patient care. However, some authors in COP research advocate a pan-professional, evidence-informed, patient-centered approach to musculoskeletal care, emphasizing hands-off management of patients through education and exercise therapy. The extent to which non-Western sociocultural beliefs about body representations in health and disease, including Indigenous beliefs, could influence the patient-practitioner dyad and affect the interpretation of pillars of evidence-informed practice, such as patient-centered care and patient expectations, remains unknown.

METHODS

our perspective paper combines the best available evidence with expert insights and unique viewpoints to address gaps in the scientific literature and inform an interdisciplinary readership.

RESULTS

A COP pan-professional approach tends to marginalize approaches, such as prevention-oriented clinical scenarios traditionally advocated by osteopathic practitioners for patients with non-Western sociocultural health assumptions. The Cynefin framework was introduced as a decision-making tool to aid clinicians in managing complex clinical scenarios and promoting evidence-informed, patient-centered, and culturally sensitive care.

CONCLUSION

Epistemological flexibility is historically rooted in osteopathic care, due to his Indigenous roots. It is imperative to reintroduce conceptual and operative clinical frameworks that better address contemporary health needs, promote inclusion and equality in healthcare, and enhance the quality of manual therapy services beyond COP's Western-centered perspective.

Does Osteopathic Heart-Focused Palpation Modify Heart Rate Variability in Stressed Participants with Musculoskeletal Pain? A Randomised Controlled Pilot Study

Heart rate variability (HRV) describes fluctuations in time intervals between heartbeats and reflects autonomic activity. HRV is reduced in stressed patients with musculoskeletal pain and improved after osteopathic manipulative treatment and mind-body interventions. Heart-focused palpation (HFP) combines manual and mind-body approaches to facilitate relaxation. This randomised controlled pilot study investigated the feasibility and sample size for a future randomised controlled trial and the effect of a single treatment with HFP or sham HFP (SHAM) on short-term HRV. A total of Thirty-three adults (47.7 ± 13.5 years old) with stress and musculoskeletal pain completed the trial with acceptable rates of recruitment (8.25 subjects per site/month), retention (100%), adherence (100%), and adverse events (0%). HFP (n = 18), but not SHAM (n = 15), significantly increased the root mean square of successive RR interval differences (p = 0.036), standard deviation of the NN intervals (p = 0.009), and ratio of the low-frequency to high-frequency power band (p = 0.026). HFP and SHAM significantly decreased the heart rate (p < 0.001, p = 0.009) but not the stress index and ratio of the Poincaré plot standard deviation along and perpendicular to the line of identity (p > 0.05). A power analysis calculated 72 participants. Taken together, the study was feasible and HFP improved HRV in stressed subjects with musculoskeletal pain, suggesting a parasympathetic effect.

Functional Neuromyofascial Activity: Interprofessional Assessment to Inform Person-Centered Participative Care-An Osteopathic Perspective

Introduction: Health professionals and bodyworkers may be pivotal in promoting prevention programs, providing tailored advice and guidance to patients' adherence to self-care strategies, such as physical activity. Contemporary evidence encourages manual therapists to involve patients in decision-making and treatment procedures integrating passive and active approaches in treatment planning. This manuscript provides a definition and applications of neuromyofascial movement patterns, discusses the significance of functional assessment, and gives an example of clinical applications in the osteopathic field to highlight how this assessment can promote interdisciplinarity. Methods: The reporting framework used in the current manuscript followed guidelines for writing a commentary. Results: The manuscript highlights the crucial role that the neuromyofascial system plays in human movement and overall well-being and the importance of a functional neuromyofascial activity assessment in the context of person-centered participative care. Conclusions: Understanding individual neuromyofascial patterns could help healthcare practitioners, movement specialists, and bodyworkers in tailoring treatment plans, meeting patients' unique needs, and promoting a more effective personalized approach to care. The current perspective could spark debates within the professional community and provide a research roadmap for developing an evidence-informed interprofessional framework.

[Touching and being touched, the bodily experience of osteopathic touch]

The theme of touch is present in many contemporary issues. During the Covid-19 pandemic, the introduction of barrier gestures had an impact on touch, to the point of prohibiting it. Touch is essential to health care, and retains a fundamental place in the healing professions, particularly osteopathy.

Historical Osteopathic Principles and Practices in Contemporary Care: An Anthropological Perspective to Foster Evidence-Informed and Culturally Sensitive Patient-Centered Care: A Commentary

Historical osteopathic principles and practices (OPP)-considering the patient as a dynamic interaction of the body, mind, and spirit and incorporating the body's self-healing ability into care-are inherited from traditional/complementary and alternative (CAM) principles. Both concepts are familiar to contemporary osteopathic practitioners, but their incorporation into healthcare for evidence-informed, patient-centered care (PCC) remains unclear. Further, a polarity exists in the osteopathic profession between a 'traditional-minded' group following historical OPP despite evidence against those models and an 'evidence-minded' group following the current available evidence for common patient complaints. By shifting professional practices towards evidence-based practices for manual therapy in line with the Western dominant biomedical paradigm, the latter group is challenging the osteopathic professional identity. To alleviate this polarity, we would like to refocus on patient values and expectations, highlighting cultural diversity from an anthropological perspective. Increasing an awareness of diverse sociocultural health assumptions may foster culturally sensitive PCC, especially when including non-Western sociocultural belief systems of health into that person-centered care. Therefore, the current medical anthropological perspective on the legacy of traditional/CAM principles in historical OPP is offered to advance the osteopathic profession by promoting ethical, culturally sensitive, and evidence-informed PCC in a Western secular environment. Such inclusive approaches are likely to meet patients' values and expectations, whether informed by Western or non-Western sociocultural beliefs, and improve their satisfaction and clinical outcomes.