1.1

General organization of osteopathy in France

Article 75 of law 2002-203 of 4 March 2002, pertaining to patient rights and health system quality, reorganized the practice and teaching of osteopathy for non-physicians and non-physiotherapists in France. The decree concerning the procedures and conditions of practice of osteopathy by non-physicians was first published in March 2007; this decree was reinforced in January 2008 by the French Council of State .

Article 1 of this decree stipulates that osteopaths are allowed to prevent and treat the “functional disturbances of the human body” using external manual musculoskeletal and/or myofascial manipulations. These manipulations must be done in the context of the good practice recommendations of the French National Health Authority (HAS). “Non-physicians” must therefore be able to make a “negative” diagnosis of an organic lesion.

Article 3 indicates that non-osteopathic physician is not allowed to perform gyneco-obstetric manipulations and pelvic examination, for example. He/she is allowed to perform acts of manipulation of the skull, face and spine in infants and manipulations of the cervical spine in adult patients only after diagnosis by a doctor who has written a certificate of non-contra-indication. This of course presupposes that the doctor knows about manual medicine-osteopathy and assumes all or part of the responsibility.

Article 5 underlines that using the title of “osteopath” professionally is subject to the practitioner having a university degree, inter-university diploma or a diploma from a private licensed, non-medical institution. This degree or diploma must be registered at the prefecture of the department on which the osteopath is practicing. Provided by accredited schools that sprang up quickly after the promulgation of the decree, the full training program lasts 4 years (3520 h) after the baccalaureate (Bac +4). After completing their certification as a physiotherapist ( diplôme d’État de masseur-kinésithérapeute ), physiotherapists have to take more classes (1225 h) in order to be qualified as an osteopath/chiropractor; these classes are offered either by an accredited private school or a public university.

As for manual medicine-osteopathy as practised by physicians, it has been taught in a highly structured framework for a long time.

1.2

Manual medicine-osteopathy: initial training and continuing education

The 3rd cycle of medical studies (starting at Bac +6) allows physicians, be they generalists or specialists, to gain the skills needed in MMO. MMO education in France is organised homogeneously, and it takes place in the context of an inter-university diploma of manual medicine-osteopathy. This diploma, given for the initial training in orthopaedic and osteopathic medicine, has little by little replaced the university degrees in manual medicine.

These university degrees appeared after the foundation the French Society of Osteopathy by Dr Lavezarri in 1952 and the French Society of Orthopaedic Medicine and Manual Therapeutics in 1959/60 by Dr Robert Maigne. In 1969, the Hotel Dieu (Paris VI) established the first University Certificate of Orthopaedic Medicine and manual therapies. Subsequently, most French universities introduced these university degrees, with the initial title of “Manual therapeutics and physiotherapy applied to the spine”, which later became “Manual and orthopaedic medicine” in 1988 : Aix-Marseille in 1982 (Pr Bardot), Rennes in 1982 (Dr Lesage), Bobigny in 1982, Reims in 1994 (Pr Etienne – Dr Garcia), Strasbourg in 1985 (Pr Isch). These university degrees had highly variable titles and a very heterogeneous form and content. These degrees were designed for specialists in Rheumatology and Physical Medicine, and they were recognized by the College of Physicians only for specialists.

It was in this educational context that a 1993 preliminary inquiry conducted by the French police on the illegal practice of medicine concluded that “the osteopathy taught in France is not sanctioned by a national diploma. It is recognized neither medically nor legally. Osteopathy is practiced by physiotherapists in a storefront location. The Council of the Order does not consider osteopathy as being a recognized medical practice…”.

In reaction to these conclusions, a national inter-universitary diploma (IUD) in manual medicine-osteopathy was created in 1995, driven by the National Council of the Order of Medicine, headed by Professor Glorion, and various stakeholders in the discipline of osteopathy. This diploma was recognized by the Council of the Order of Medicine in its 203rd and 205th session for all GPs and specialists.

The title of the IUD was much discussed in 1996, as it was in 2009. The title was too restrictive for proponents of orthopaedic medicine; for others, it was too esoteric. Most people consider the title to be pragmatic. The IUD has a minimal common model that is destined to evolve (Appendix 1). It is open to final-year medical students who are specializing (DES) under certain conditions. The program of study lasts 2 years (250–300 h) and is preceded by a probationary review and validated at the end of the 1st and 2nd year.

Fourteen Departments of Medicine (UFR) offer this diploma in France: Aix-Marseille 2, Paris XIII, Bobigny, Bordeaux 2, Caen, Dijon, Grenoble 1, Lille, Lyon 1, Paris VI, Reims, Rennes 1, Strasbourg, Toulouse 4, Tours, and La Pitié-Salpêtrière-Paris. All Departments of Medicine (UFR) offering the IUD are grouped in a college, College of postgraduate Education in Manual Medicine-Osteopathy (Cemmo), whose registered office has been at the University Hospital Centre in Strasbourg since 21 July 2006.

This initial training program is completed by specific continuing education programs offered by scholarly societies: the French Society of Orthopaedic and Osteopathic Manual Medicine (SOFMMOO), the French Osteopathy Society (SFO) and the European Manual Medicine and Osteopathy Federation (FEMMO), which gather the various associations of private MMO educational programs. Both the initial training programs and the continuing education programs are rooted in the articles published in the Revue de Médecine Manuelle Ostéopathie ( Journal of Manual Medicine-Osteopathy ), a scientific journal dedicated to manual medicine.

To practice osteopathy, the MMO IUD is necessary and sufficient. This diploma is recognized by the State Council on 23 January 2008 . Physicians must register their diplomas at the Departmental Office of Social and Health Affairs (DDASS) of the department in which they practice. As a matter of fact, the decision-making bodies and courts consider the competence acquired during their medical studies, including the required curriculum of all medical students and then the internship at a hospital (10 years), a sufficient pre-requisite.

The program of study is designed to professionalize the domain. As such, it has allowed to about 3000 doctors to learn and practice manipulation techniques. Reserved for doctors, the MMO IUD must evolve to become a 3-year homogenized program. In the future, the IUD should exist at the university in parallel to an osteopathy degree (DU) destined for physiotherapists, nurses and midwives, as authorized by the March 2007 decrees. Ideally directed by Departments of Medicine (UFR) in association with physiotherapy schools, this MMO IUD will enhance and complement the training of non-physicians in the field of manual therapeutics.

1.3

MMO: ethical competence

Before practicing MMO, the practitioner is first and foremost a doctor. As a medical doctor, he/she must apply the Ethical Code, just like every other doctor. Some sections of this code apply specifically to manual therapeutics.

Article 70 of the Ethical Code states: “Every physician is, in principle, entitled to perform all diagnostic, prevention and treatment procedures, but he/she does not, except in exceptional circumstances, undertake or continue care nor make provisions in areas beyond his/her knowledge, experience and own resources”.

Article 33 of the same code stresses the importance of medical diagnosis: “The physician must always make his/her diagnosis with the utmost care and devote the time necessary, whenever possible using the most appropriate scientific methods and appropriate assistance, if needed”. In MMO, the overall diagnostic approach should minimize the risk of loss of opportunity due to the absence of or an error in the medical diagnosis.

Article 32 highlights the limits not to exceed: “Once he/she has agreed to provide treatment, the doctor personally undertakes dedicated conscientious care based on scientific data, using third-party correspondents where appropriate”.

Article 11 requires the physician to maintain and upgrade his/her knowledge through continuous training and assessment practices.

Article 39 is especially appropriate to MMO care: “The doctor cannot offer an illusory or inadequately tested procedure to his/her patients or their relatives as a beneficial or safe remedy. Any practice of quackery is prohibited”. Thus, the code of medical ethics marks out very seriously the domains of competence of MMO doctors.

1.4

MMO: therapeutic and diagnostic skills

The “traditional” MMO indication is related to musculo-skeletal pathology, more accurately called minor intervertebral dysfunction (MID), which is responsible for pain and/or restricted mobility without reference to the cause. This general indication is found in most instances of neck pain, back pain and cervicogenic headaches .

In practice, the situation is more complex since the scientific literature, although abundant, does not provide definitive proof . In general, spinal manipulations, in the broadest sense, have a short-term analgesic effect for acute low back pain compared to placebo; they are also beneficial for treating chronic low back pain and coccygodynia . However, for acute radicular disc pain, spinal manipulations are contra-indicated . Finally, for the cervical spine level, the recommendations are very weighty because of the risk of serious injury. Only by combining manipulations, mobilizations and exercises can MMO doctors achieve good clinical and statistical results . Spinal manipulations performed in isolation are not indicated.

The MMO doctor must also have skills in early diagnosis of complications and vertebral manipulation accidents, particularly cervical manipulations. There are many high-quality articles in the literature about these accidents related to ischemic stroke, most often in the vertebrobasilar territory , can be found. These accidents must, however, be compared to the accidents caused by other therapies used to treat neck pain. Very favourable for the lumbar spine, the risk/benefit ratio for the cervical spine appears to be more uncertain for many authors, especially neurologists and neurosurgeons . For this reason, the scholarly societies have issued a number of recommendations to be observed before any spinal manipulation . Table 1 presents the recommendations of the French Society of Orthopaedic and Osteopathic Medicine.

MMO doctors, who have completed 10 years of medical studies through learning a specific osteo-articular semiology , are capable of making a precise etiologic diagnosis of most mechanical problems of the locomotor system. Their skills allow them to retain an indication of manual therapeutics that both respects and applies the contra-indications ( Table 2 ).

The manipulative techniques themselves are very numerous. A number of basic techniques can be mastered by students after 2–3 years of study and can be specified in a traditional therapeutic treatment: the cervical rotation manipulation, known as the “ volant ”; the manipulation of the cervical spine in a sitting position, called “ main antérieure ”; the cervicothoracic manipulation, called “mandoline”; the “ RM ” technique; or the “ menton-pivot ” technique. Dorsal techniques include “ main épigastrique ” manipulation, the dorsal roll, the “ charnière dorso-lombaire en rotation à cheval ” and the high thoracic spine manipulation, known as the “ Nelson ”. Lumbar and lumbosacral techniques, in supine and lateral rotation, rely primarily on the “ cavalier ” and “ tireur à l’arc ” manipulations. These techniques and their infinite variations are widely described in literature . In the context of the IUD, only practical instruction, under the guidance of qualified instructors, can bring the necessary technical expertise. The monitor demonstrates each technique on a student and then explains why it works. Then students practice each technique, as many times as necessary. Groups of six to eight students gather round variable-height examination and treatment tables, and the students play the role of the patient and the MMO doctor, respectively.

Before playing this game “for real”, young MMO doctors must necessarily know the steps for the diagnostic procedures to use on patients: a thorough clinical examination, the interpretation of all available medical imaging (e.g. MRI), electrical (e.g. EEG) and biological (e.g., blood work) examinations. To do this, they must know how to use all scientific, biomedical, morphological, physiological, pharmacological and biomechanical data rehabilitation, rheumatology, and know how to communicate effectively with physicians and other stakeholders in the context of managed care, which is essential.

For these reasons, MMO is now causing real excitement, especially among young doctors. The pre-eminence of the clinical examination, the body language and technical mastery necessary to the treatment, reinforces this MMO approach.