Osteopathy and osteopathic manipulative treatment (Still)

1. Introduction

Version followed: osteopathy as described in the WHO Benchmarks for training in osteopathy (2010), the UK General Osteopathic Council's Osteopathic Practice Standards, and US osteopathic medicine (DOs) as described by US osteopathic bodies. This guide is written for a psychotherapist who refers to, and works alongside, a registered or licensed practitioner. A psychotherapist does not deliver osteopathic manipulative treatment (OMT).

What it is. Osteopathy is a manual-therapy system developed by Andrew Taylor Still, a US physician and surgeon, in the mid-1800s. He founded the first independent school of osteopathy in 1892 [source: WHO Benchmarks 2010]. That school was the American School of Osteopathy in Kirksville, Missouri [source: NBOME 2019]. Some secondary sources date the origin of osteopathy to 1874 [source: Wikipedia, citing a Missouri registration record and Gevitz 2014; uncertain: primary record not verified]. John Martin Littlejohn was a Scottish academic who was treated by Still in 1897 and became dean of the Kirksville school in 1899. He founded the British School of Osteopathy in London in 1917. Because its trainees were denied access to hospitals, British osteopathy began as a manipulation-only discipline that was not licensed [source: The DO, "An ocean away"].

Two professions share one name. Clients often confuse them:

• US osteopathic physicians (DOs). They are fully licensed physicians with full medical practice rights. They prescribe, operate and practise in any specialty, and some use OMT [source: The DO, "An ocean away"]. Secondary sources report that DOs in general practice use OMT "less and less" (Gevitz 2006, as cited) [source: Wikipedia].
• Non-physician osteopaths outside the US. These are primary-contact manual therapists without prescribing rights:
  • UK: statutory regulation since the Osteopaths Act 1993. The General Osteopathic Council (GOsC) keeps the register [source: The DO; ASA]. A voluntary register without title protection existed from 1939 [source: The DO].
  • Australia: registration with the Osteopathy Board of Australia under the National Law since 1 July 2010, supported by Ahpra. In NSW and Queensland, complaints go to the Osteopathy Council of NSW and the Office of the Health Ombudsman [source: Osteopathy Board of Australia].
  • New Zealand: the Osteopathic Council of New Zealand (OCNZ) issues practice guidelines [source: OCNZ draft 2022].
  • Canada: mostly "osteopathic manual practitioners" (an estimated 1,300 or more, mainly in Quebec and Ontario) and very few US-trained DOs [source: Wikipedia; uncertain: provincial regulation not verified].
  • Rest of Europe: regulation varies by country, from statutory regulation to none, and in some countries manipulation is reserved to doctors or physiotherapists [uncertain: not verified country by country; check the national regulator].
  • Training: WHO describes two training routes. Type I is about 4,200 hours over four years full-time, including at least 1,000 supervised clinical hours. Type II is for existing health professionals and is typically about 1,000 hours [source: WHO Benchmarks 2010].

Core idea of how change happens. WHO states three principles [source: WHO Benchmarks 2010]:

• The person is a "dynamic functional unit" whose health is influenced by body, mind and spirit.
• The body has self-regulatory and self-healing mechanisms.
• Structure and function are interrelated.

The American Osteopathic Association's four tenets add that rational treatment rests on these principles. DOs do not treat the tenets as empirical laws [source: Wikipedia]. In this framework, "somatic dysfunction" (formerly the "osteopathic lesion") is found by palpation. Hands-on treatment of that dysfunction is held to restore function and support self-regulation [source: Wikipedia, citing Howell 1999; StatPearls].

These are the profession's own explanatory concepts. Psychotherapists should present them to clients as the osteopath's model, not as established physiology.

2. Framework

The osteopathic episode of care as published:

1. Case history and examination. A thorough history and physical examination come before any OMT [source: StatPearls].
2. Diagnosis and screening. This step checks for contraindications by body region and by technique [source: WHO Benchmarks 2010; StatPearls].
3. Information and valid consent. The osteopath explains risks, benefits and alternatives and records the discussion [source: StatPearls; GOsC Standard A4].
4. Treatment. The practitioner selects techniques from the categories in section 4.
5. Reassessment. The patient is reassessed after manipulation [source: StatPearls].
6. Self-management advice and review. For low back pain, NICE recommends considering manual therapy (spinal manipulation, mobilisation or soft-tissue techniques) "only as part of a treatment package that includes exercise" (NICE NG59, as updated in July 2026) [source: Guideline Central 2026].

Session count and length. No standard number of sessions appears in the regulatory sources, and practice varies [uncertain: not verified]. Ask the osteopath for their planned number of sessions and their review point.

The psychotherapist's parallel phases [synthesis]:

• Phase A, consider. Identify a musculoskeletal complaint that is within accepted scope (see section 4.1). Ask whether medical assessment has already happened.
• Phase B, refer and prepare. Give the client information on regulation and title. Prepare a client with a trauma history for touch, and agree a plan for sharing information.
• Phase C, alongside. Process body experiences in sessions, watch for adverse effects and boundary issues, and keep the two roles distinct.
• Phase D, review. Is the client functionally better, as judged by the client and the osteopath? If not, stop, re-refer or return to GP or physician care.

Criteria for moving between phases [synthesis]:

• A to B: red flags have been ruled out by a medical or osteopathic assessment, and the client has given informed agreement.
• B to C: the client can name their stop signal and their chaperone preference.
• C to D: the osteopath's planned review point is reached, or a new symptom, distress or a boundary concern appears.

NICE change relevant to psychotherapists. The July 2026 NG59 update deleted the recommendations on cognitive-behavioural psychological therapy and on combined physical-psychological programmes for low back pain. The guideline gives retracted evidence as part of the reason [source: Guideline Central 2026; uncertain: NICE text itself not verified]. Psychotherapy for a person with back pain therefore rests on that person's psychological needs, such as distress, trauma or depression, and not on a NICE back-pain recommendation.

3. Guiding principles

Each principle is followed by its practical meaning for the psychotherapist.

• Stay in your own role. Refer, prepare, integrate and monitor, but do not touch. None of the mainstream talk-therapy codes reviewed contains a touch provision: BACP 2018 and 2026, UKCP 2019, BPS 2009, HCPC 2023, APA, AAMFT. All of them prohibit sexual contact and require you to practise within your competence and refer [source: BACP; UKCP; BPS; HCPC; APA; AAMFT]. Body-psychotherapy codes regulate touch directly (USABP section VIII; EABP Principle 7), but they govern body psychotherapy, not osteopathy [source: USABP; EABP].
• Check the title and the register. "Osteopath" in the UK means a GOsC registrant, and in Australia an Osteopathy Board of Australia registrant. In the US, a DO is a physician. Suggest that the client checks the public register before booking [source: The DO; Osteopathy Board of Australia].
• Accept only regulator-accepted claims. In the UK, the ASA/CAP lists the conditions osteopaths may advertise, which are mainly musculoskeletal pain and "tension and inability to relax". Claims for babies, children and pregnancy-specific conditions (e.g. colic, reflux, poor feeding) are unlikely to be acceptable without robust evidence [source: ASA]. Do not refer for physical disease outside these claims.
• Consent before and during, with the right to stop. UK osteopaths must have valid consent for all examination and treatment (Standard A4) [source: GOsC A4]. Consent is "an ongoing process" that the patient may withdraw at any time [source: OCNZ draft 2022]. Before any touch-based referral, rehearse the client's stop signal with them.
• Dignity and chaperones. GOsC Standard A6 says the osteopath must always ask whether the patient would like a chaperone when the treatment involves an intimate area, a patient under 16, an adult lacking capacity, or a home visit. Patients may undress and dress unobserved and may cover areas that need not be exposed [source: GOsC A6].
• Never sexual touch. Sexual or genital touch is never part of osteopathic care. Work in sensitive areas needs separate explanation, consent and a chaperone offer (see 4.3) [source: GOsC A6; OCNZ draft 2022; USABP].
• Screen before referring. The WHO lists absolute and relative contraindications. A contraindication in one body region, or to one technique, does not rule out other regions or techniques [source: WHO Benchmarks 2010]. Your job is to make sure a medical or osteopathic screen happens and that the client discloses their conditions and medicines.
• Attribute contested concepts. Present the following as practitioners' concepts with weak or absent independent support, never as fact: cranial rhythm and the "primary respiratory mechanism", visceral mobility, and "releases" of stored emotion. Visceral techniques lack evidence of reliability or specific efficacy (Guillaud et al. 2018, as cited) [source: Wikipedia].
• Be cautious about memory claims. If a practitioner tells a client that touch released a "body memory" of an event, treat it as an experience to explore, not evidence that the event happened [synthesis, consistent with memory-research cautions].
• Give an honest evidence status. Reviews differ:
  • Franke et al. 2014 report moderate-quality evidence that OMT reduces pain and improves function in non-specific low back pain.
  • Other reviews (Orrock and Myers 2013; Posadzki and Ernst 2011) found insufficient or no compelling evidence.
  • Effectiveness for paediatric conditions was unproven (Posadzki et al. 2013), and evidence for asthma was insufficient (Cochrane, Hondras et al. 2005).
  • All of these reviews are as cited [source: Wikipedia; uncertain: original reviews not verified].
• Children need specific competence. The Osteopathy Board of Australia says osteopaths should not claim to provide, or provide, care for babies and children without appropriate education, training and competence. No osteopath may call themselves a paediatric "specialist" [source: Osteopathy Board of Australia].

4. Intervention inventory

Part 4.1 covers what the psychotherapist does. Part 4.2 describes OMT techniques as the profession publishes them, so you can inform clients and recognise what they report. Part 4.2 does not instruct anyone to perform these techniques. All therapist wording is illustrative.

4.1 The psychotherapist's interventions

4.1.1 Scope check: is osteopathy a sensible suggestion?

• Purpose: match the client's complaint to what regulators accept. Avoid implying osteopathy treats psychological or physical disease.
• When to use: the client reports musculoskeletal pain, stiffness, or "tension and inability to relax", or asks you about osteopathy.
• Steps:
  1. Clarify the complaint: where, how long, and what has been tried.
  2. Compare it with the ASA/CAP list of accepted claims: back pain and sciatica (not from injury or accident), uncomplicated mechanical neck pain (not whiplash), cervicogenic headache and migraine prevention, joint and arthritic pain, shoulder and elbow complaints, minor sports injuries, and tension and inability to relax [source: ASA].
  3. For low back pain, say that NICE positions manual therapy only within a package that includes exercise [source: Guideline Central 2026].
  4. Do not suggest osteopathy for colic, reflux, infections, asthma or other disease [source: ASA; Wikipedia, as cited].
• Example language (illustrative): "Osteopaths mainly work with muscle and joint pain such as back and neck pain. For low back pain, the national guidance is that hands-on treatment sits alongside exercise rather than replacing it. Is that the kind of help you're after?"
• Watch for:
  • hope that touch will "fix" an emotional problem;
  • pressure from a practitioner's marketing;
  • complaints that are not musculoskeletal.
  • Working: the client has realistic, specific goals, such as walking further or sleeping without pain.

4.1.2 Red flags, contraindications and medical clearance

• Purpose: make sure a competent medical or osteopathic screen happens. Do not do the screening yourself.
• When to use: before any referral. Repeat if symptoms change.
• Steps:
  1. Ask whether a GP or physician has assessed the problem.
  2. Ask the client to tell the osteopath about the conditions the WHO lists as contraindications [source: WHO Benchmarks 2010]:
     • bleeding disorders or anticoagulant medicine;
     • osteoporosis or osteopenia;
     • cancer;
     • recent surgery or fracture;
     • connective-tissue disease or rheumatoid disease;
     • known aneurysm or vascular disease;
     • recent head injury;
     • uncontrolled glaucoma or a recent lens implant.
  3. Advise same-day medical help, not osteopathy, for:
     • progressive leg weakness or numbness;
     • new bladder or bowel disturbance or saddle numbness (possible cauda equina syndrome);
     • severe abdominal pain;
     • sudden severe headache or neck pain with neurological symptoms;
     • fever with back pain. The WHO lists these conditions as absolute contraindications. The emergency advice is [synthesis].
  4. Note that the WHO considers anticoagulant therapy an absolute contraindication to direct techniques unless the therapeutic level has been checked recently [source: WHO Benchmarks 2010].
• Example language (illustrative): "Before you book, could you make a list of your medicines and any conditions, especially blood thinners, bone thinning, cancer or recent surgery? The osteopath needs that to choose what's safe for you."
• Watch for:
  • minimising of symptoms;
  • reluctance to see a GP;
  • new neurological or systemic symptoms.
  • Working: the client reports that the osteopath took a full history and examined before treating [source: StatPearls].

4.1.3 Choosing and verifying the practitioner

• Purpose: steer the client to a regulated practitioner with relevant competence.
• Steps:
  1. UK: suggest the client checks the GOsC register. "Dr" or "Doctor" should not be used by an osteopath without a medical qualification [source: ASA].
  2. Australia: suggest the Ahpra register, which covers the Osteopathy Board of Australia [source: Osteopathy Board of Australia].
  3. US: explain that a DO is a physician. A client who wants OMT should ask whether the DO actually provides it [source: The DO; Wikipedia].
  4. Elsewhere: ask the client to identify the national regulator or professional register [uncertain: not verified per country].
  5. For children, ask about paediatric training [source: Osteopathy Board of Australia].
• Example language (illustrative): "In the UK 'osteopath' is a protected title, so you can check anyone on the official register in a minute. Shall we look together?"
• Watch for:
  • practitioners who advertise treating disease or claim specialist paediatric status;
  • a person titled "osteopath" in a country with no title protection.

4.1.4 Preparing a client with a trauma history for touch

• Purpose: make it possible for the client to accept or refuse hands-on care from a position of choice. Reduce the risk of dissociation or re-traumatisation.
• When to use: any client with a history of abuse, medical trauma, assault, or dissociation, or with strong reactions to being touched or undressed.
• Steps:
  1. Explain the client's rights, based on GOsC A4 and A6 [source: GOsC A4; GOsC A6]:
     • valid consent is required for every part of examination and treatment;
     • the client may undress and dress unobserved;
     • they may cover any area that doesn't need to be exposed, wear a gown, or be treated clothed where possible;
     • they may ask for a chaperone, who can be a friend or relative;
     • they may rearrange the appointment if no chaperone is available.
  2. Explain that consent can be withdrawn at any moment and that a sensitive technique can be postponed to a later session [source: OCNZ draft 2022].
  3. Help the client choose a stop signal (a word or a raised hand) and practise saying it aloud with you.
  4. Decide together what, if anything, the client wants the osteopath told in advance, for example "I may freeze. Please check in verbally before each new area."
  5. Plan grounding for before and after the appointment. Steps 3 to 5 are [synthesis].
• Example language (illustrative): "You're allowed to stop anything at any point, even halfway through, and you don't need to give a reason. Shall we practise the words you'd use? 'Please stop' is enough."
• Watch for:
  • fawning or compliance ("I'll just put up with it");
  • dissociation when touch is discussed;
  • a client who cannot imagine saying stop. Postpone the referral until they can.
  • Working: the client can state their rights, their signal and their chaperone choice.

4.1.5 Information about sensitive-area techniques

• Purpose: prepare the client to recognise legitimate sensitive-area work and its safeguards.
• Steps:
  1. Tell the client which areas osteopathic regulators treat as sensitive [source: OCNZ draft 2022]:
     • breast;
     • genitalia, perineum and anal area;
     • gluteal, sacral and coccygeal regions;
     • anterior pelvis and upper inner thigh;
     • culturally, the head.
  2. Explain the safeguards: the aim and process are explained in plain language beforehand; a chaperone is offered [source: GOsC A6]; consent is recorded; and a technique raised for the first time is normally offered at a later appointment [source: OCNZ draft 2022].
  3. Internal techniques (intraoral, intravaginal, intrarectal) need specific training and infection control [source: OCNZ draft 2022]. For pelvic-floor or gynaecological concerns, refer to regulated medical or pelvic-health clinicians [synthesis].
  4. Say plainly that sexual or genital stimulation is never treatment.
• Example language (illustrative): "If an osteopath ever suggests work near an intimate area, they should explain why, offer a chaperone, and normally give you time to think it over. You can always say no."
• Watch for: any account of touch that was not explained or was sexualised. Go to 4.1.9.

4.1.6 Collaboration and information sharing

• Purpose: coordinate care without blurring roles.
• Steps:
  1. With written client consent, agree what you will share: relevant trauma sensitivities, not narrative detail.
  2. Agree how the osteopath tells you about distress during treatment, and how you raise concerns.
  3. If the client is also seeing another body-oriented practitioner, discuss with them how the services fit together to avoid confusion. The EABP code raises this for parallel services [source: EABP]. Steps 1 and 2 are [synthesis].
• Example language (illustrative), to the osteopath: "My client has consented to me letting you know that verbal check-ins before moving to a new area help them stay present."
• Watch for:
  • oversharing;
  • the osteopath offering psychological interpretations;
  • you offering physical ones.

4.1.7 Integrating body experiences in psychotherapy

• Purpose: help the client make sense of sensations, emotions or memories that came up during or after manual treatment.
• Steps [synthesis]:
  1. Invite a description of what happened, in the client's own words.
  2. Separate sensation from interpretation: what they felt, what they made of it, and what the practitioner said it meant.
  3. Track arousal and use usual stabilisation methods if the client becomes activated.
  4. Link the experience to therapy goals, such as trust, safety and body ownership.
  5. Return physical questions to the osteopath or GP.
• Example language (illustrative): "You said your eyes filled up when they worked on your back. What did you notice in your body, and what did it mean to you at the time?"
• Watch for:
  • the client adopting the practitioner's explanations, such as "blocked energy" or "stored trauma";
  • intrusive images. Treat these as material to explore, not as proof of events.
  • Working: the client feels more agency and less shame about bodily reactions.

4.1.8 Recognising and passing on adverse effects

• Purpose: catch harmful reactions early and route them to the right clinician.
• Steps:
  1. Know the common transient effects. Reviews of spinal manipulation most often name headache, increased pain, fatigue, aggravation of symptoms, soreness, stiffness, dizziness and nausea [source: Systematic Reviews 2017, Table 3]. StatPearls describes soreness and temporary flare after thoracic HVLA [source: StatPearls].
  2. Know the rare serious events named in the literature: stroke and vertebral artery dissection, radiculopathy, cauda equina syndrome, disc herniation, vertebral fracture and spinal cord injury [source: Systematic Reviews 2017, Table 3]. Neck manipulation is the context for stroke and artery-dissection concerns. Whether, and how strongly, manipulation causes these events is debated in the literature [uncertain: causal conclusions not verified].
  3. Arrange emergency care at once for:
     • neurological symptoms after neck treatment, such as sudden severe headache or neck pain, dizziness, double vision, slurred speech, unilateral weakness or numbness;
     • new bladder or bowel symptoms or saddle numbness. This advice is [synthesis].
  4. For non-urgent problems, encourage the client to tell the osteopath and their GP. Record what you advised.
• Example language (illustrative): "Soreness for a day or two is commonly reported. But any sudden headache, vision change, slurred speech or weakness means calling emergency services straight away, not waiting to see the osteopath."
• Watch for: the client attributing a new symptom to a "healing crisis" or being told to push through it.

4.1.9 Recognising boundary violations and supporting a complaint

• Purpose: protect the client and support reporting.
• Signs [synthesis, based on GOsC A6 and OCNZ]:
  • touch of intimate areas without prior explanation, consent or a chaperone offer;
  • being watched while undressing without a stated reason and consent;
  • pressure to undress more than needed;
  • comments on the body;
  • secrecy;
  • invitations to social or sexual contact;
  • being told that sexualised touch is therapeutic.
• Steps:
  1. Believe and document the client's account.
  2. Assess immediate safety and whether a crime should be reported to the police.
  3. Explain the routes:
     • UK: a concern to the GOsC;
     • Australia: a notification to Ahpra or the Osteopathy Board, or in NSW and Queensland to the Osteopathy Council of NSW or the Office of the Health Ombudsman [source: Osteopathy Board of Australia];
     • US: the state medical or osteopathic licensing board for DOs [uncertain: board names vary by state].
  4. Offer to support the client through the process. Follow your own code's duties: all the major codes prohibit sexual contact with clients [source: BACP; UKCP; APA; AAMFT].
• Example language (illustrative): "What you're describing isn't part of any legitimate osteopathic treatment. You have the right to report it, and I can help you think through how, at your pace."
• Watch for:
  • self-blame;
  • minimising ("maybe it was a technique");
  • retraumatisation symptoms.

4.1.10 Children and infants

• Purpose: protect children from unsupported claims and make sure valid consent, assent and safeguarding happen.
• Steps:
  1. Parents seeking osteopathy for colic, reflux, feeding, glue ear or infections should consult the child's doctor. The ASA has upheld complaints about such claims [source: ASA].
  2. If a parent still chooses osteopathy, advise them to:
     • choose a practitioner with paediatric training [source: Osteopathy Board of Australia];
     • stay present (a chaperone must be offered for under-16s) [source: GOsC A6];
     • give consent themselves and seek the child's assent [synthesis].
• Example language (illustrative): "For a baby's feeding or crying problems, the regulator's position is that the evidence for osteopathy is limited, so the first stop is your GP or health visitor."
• Watch for:
  • parental exhaustion driving the search for a fix;
  • safeguarding concerns.

4.1.11 Responding to "body memory" or emotional-release claims

• Purpose: prevent iatrogenic belief in events the client does not remember.
• Steps [synthesis]:
  1. Treat statements such as "your tissues are holding trauma" as the practitioner's interpretation.
  2. Do not use bodily reactions as evidence that abuse occurred.
  3. Explore the client's own memory and meaning, without suggestion.
  4. If the practitioner keeps making such claims, discuss changing practitioner.
• Example language (illustrative): "Strong feelings during body treatment are common and worth exploring. They don't on their own tell us what happened in the past."
• Watch for:
  • new "memories" emerging after sessions;
  • growing reliance on the practitioner's interpretations.

4.2 OMT techniques as the profession publishes them

The WHO groups osteopathic techniques into six categories: direct, indirect, balancing, combined, reflex-based and fluid-based [source: WHO Benchmarks 2010]. They are listed here so you can answer client questions and recognise what clients report. Only trained, registered or licensed practitioners deliver them. This section gives no forces, positions or session prescriptions.

Psychotherapist's steps for every technique in 4.2 [synthesis]: (1) ask the client what was done and how it felt; (2) check that consent and the agreed stop signal were honoured (4.1.4); (3) screen for new or worsening symptoms (4.1.8) and pass them on to the practitioner or GP with consent; (4) explore any meanings the client takes from the practitioner's explanations.

4.2.1 Thrust / high-velocity low-amplitude (HVLA) technique (direct)

• Purpose as published:
  • StatPearls describes HVLA as a rapid, brief thrust within the joint's normal range that engages a "restrictive barrier" [source: StatPearls].
  • It is used for palpable somatic dysfunction with a firm barrier, pain or loss of motion.
  • Its proposed mechanism is reflex muscle relaxation [source: StatPearls].
• What the client experiences: brief positioning, then a quick movement, often with a click [uncertain: the click is not described in the sources].
• Contraindications (absolute):
  • local thrust at a site of acute fracture, compromised bone or joint stability (e.g. tumour, infection, rheumatoid disease), haematoma or abscess, or surgical fixation [source: WHO Benchmarks 2010];
  • vertebrobasilar or cervical artery problems [source: StatPearls];
  • cauda equina syndrome or cord compression [source: StatPearls];
  • no diagnosis or no consent [source: StatPearls].
• Contraindications (relative):
  • disc herniation [source: WHO Benchmarks 2010];
  • strained ligaments [source: WHO Benchmarks 2010];
  • acute acceleration-deceleration ("whiplash") neck injury [source: WHO Benchmarks 2010];
  • hypermobility [source: StatPearls];
  • osteoporosis [source: WHO Benchmarks 2010].
• StatPearls advises considering gentler techniques first in older patients [source: StatPearls].
• Example language (illustrative): "If they suggest a quick 'click' technique, especially on your neck, you can ask what the alternatives are. Gentler options exist, and you can say no."
• Watch for: see 4.1.8 for neurological symptoms after neck treatment.

4.2.2 Articulatory, muscle energy and general osteopathic techniques (direct)

• Purpose as published:
  • The WHO classes these as direct techniques [source: WHO Benchmarks 2010].
  • StatPearls lists muscle energy and articulatory techniques among the less forceful alternatives to HVLA [source: StatPearls].
  • In muscle energy technique, the patient actively uses their muscles against the practitioner's resistance [uncertain: not verified in the sources].
• Contraindications:
  • the WHO systemic and local lists for direct techniques: bleeding disorders, anticoagulation without a recent level check, connective-tissue disease, compromised bone, neoplasm, aneurysm, and so on [source: WHO Benchmarks 2010];
  • for muscle energy technique, secondary sources add fracture, dislocation, instability, severe osteoporosis and recent surgery [source: Wikipedia].
• Example language (illustrative): "Some techniques ask you to push gently against their hand. If anything hurts or you want to pause, say so."
• Watch for: clients who keep pushing through pain to "do it right". Explore perfectionism and compliance.

4.2.3 Functional technique and counterstrain (indirect)

• Purpose as published:
  • The WHO classes these as indirect techniques [source: WHO Benchmarks 2010].
  • StatPearls lists counterstrain as a less forceful alternative to HVLA [source: StatPearls].
  • Detailed mechanisms are [uncertain: not verified].
• Contraindications:
  • the WHO list for indirect techniques: acute cerebral bleed or stroke, cerebral aneurysm or arteriovenous malformation, suspected peritonitis or visceral rupture, recent closed head injury [source: WHO Benchmarks 2010];
  • relative: neoplasm and metastatic disease [source: WHO Benchmarks 2010];
  • for counterstrain, secondary sources add severe osteoporosis, vertebral artery pathology, and patients unable to relax [source: Wikipedia].
• Example language (illustrative): "These gentler techniques usually involve being held in a comfortable position for a while. You can still ask to change position or stop."
• Watch for: being held still can bring on feelings of being trapped in trauma survivors. Plan a stop signal (4.1.4).

4.2.4 Balanced ligamentous tension and ligamentous articulatory strain (balancing)

• Purpose as published: the WHO names these as balancing techniques [source: WHO Benchmarks 2010]. A detailed description is [uncertain: not verified].
• Contraindications: the WHO list for indirect, fluid, balancing and reflex techniques [source: WHO Benchmarks 2010].
• Example language (illustrative): "Ask them to explain in plain words what they're doing and why, before they start."
• Watch for: passivity or freezing during slow, held contact.

4.2.5 Myofascial/fascial release and Still technique (combined)

• Purpose as published: the WHO names these as combined techniques [source: WHO Benchmarks 2010]. Detailed methods are [uncertain: not verified].
• Contested concept: treat "fascial memory" or tissue that "stores emotion" as practitioners' claims without established support [synthesis].
• Example language (illustrative): "If you're told your fascia is 'holding' something emotional, that's their way of describing it. We can look at what it means to you here."
• Watch for: see 4.1.11.

4.2.6 Osteopathy in the cranial field / involuntary mechanism (combined)

• Purpose as published: the WHO lists osteopathy in the cranial field and the "involuntary mechanism" among combined techniques [source: WHO Benchmarks 2010]. Practitioners describe gentle contact on the head and sacrum based on a proposed cranial rhythm, called the "primary respiratory mechanism" [uncertain: not verified].
• Evidence status:
  • The cranial rhythm and the reliability of palpating it are contested [uncertain: independent reliability reviews not verified].
  • The ASA has upheld complaints about claims that cranial osteopathy treats infant constipation, infections or "birth stresses" [source: ASA].
• Contraindications: the WHO list for indirect techniques, including acute head injury, intracranial bleed, aneurysm and undiagnosed hydrocephalus [source: WHO Benchmarks 2010].
• Example language (illustrative): "Cranial work is very light touch. The idea of a cranial rhythm is the practitioners' theory, and it isn't well supported. It shouldn't be offered as a treatment for an illness."
• Watch for:
  • parents seeking it for infants (see 4.1.10);
  • the head is a culturally sensitive area for some clients [source: OCNZ draft 2022].

4.2.7 Visceral techniques (combined)

• Purpose as published: the WHO lists visceral techniques as combined techniques [source: WHO Benchmarks 2010]. They are applied to the abdomen and are held to affect organ mobility [uncertain: not verified].
• Evidence status: a 2018 review found no evidence of reliability or specific efficacy for visceral osteopathy (Guillaud et al., as cited) [source: Wikipedia].
• Contraindications: suspected peritonitis, appendicitis, or visceral disease with suspected leakage or rupture. Abdominal pain is an absolute local contraindication to direct techniques [source: WHO Benchmarks 2010].
• Example language (illustrative): "Abdominal pain needs a medical check first. Hands-on abdominal work isn't a substitute for that."
• Watch for:
  • undiagnosed abdominal symptoms;
  • work near the anterior pelvis, which is a sensitive area (see 4.1.5).

4.2.8 Reflex-based techniques: Chapman's reflexes, trigger points, neuromuscular techniques

• Purpose as published: the WHO classes these as reflex-based [source: WHO Benchmarks 2010]. Detailed rationale is [uncertain: not verified].
• Contraindications: the WHO list for indirect, fluid, balancing and reflex techniques [source: WHO Benchmarks 2010].
• Example language (illustrative): "Pressure on tender points can be uncomfortable. You decide how much is too much."
• Watch for: pain tolerated silently, and post-session soreness (4.1.8).

4.2.9 Lymphatic pump techniques (fluid-based)

• Purpose as published: the WHO classes these as fluid-based [source: WHO Benchmarks 2010]. Secondary sources report a Cochrane review: OMT within chest physiotherapy for adult pneumonia did not reduce mortality but slightly shortened hospital stay (Chen et al., as cited) [source: Wikipedia; uncertain: review not verified].
• Contraindications: secondary sources list fractures, local infections and high fever as relative contraindications [source: Wikipedia]. The WHO fluid-technique list also applies [source: WHO Benchmarks 2010].
• Example language (illustrative): "If you're unwell with a fever, check with your doctor before any treatment."
• Watch for: use as a substitute for medical treatment of infection.

5. Handling problems

• Client wants osteopathy for a psychological problem (e.g. anxiety, trauma) [synthesis]:
  • Acknowledge the wish for relief through the body.
  • Explain that the regulator-accepted claims are mainly musculoskeletal, plus "tension and inability to relax" [source: ASA].
  • Keep the psychological work in therapy. Consider body-oriented methods that a trained psychotherapist can deliver within their own code.
• Client is stuck or not improving after several sessions [synthesis]:
  • Revisit the goals.
  • Ask whether exercise is part of the package, as NICE expects for low back pain [source: Guideline Central 2026].
  • Encourage a review with the osteopath and the GP, and consider stopping. Open-ended courses without measurable change are a reason to reassess.
• Dependence on the practitioner or on being "fixed" [synthesis]:
  • Explore the meaning of being cared for through touch.
  • Support self-management and active coping.
  • Be alert to dependency, which the USABP code also highlights for touch-based work [source: USABP].
• Overwhelm, freezing or dissociation during treatment:
  • Before the next appointment, rehearse the stop signal and check-ins again. Agree that a chaperone or support person will attend [source: GOsC A6; OCNZ draft 2022].
  • Consider asking the osteopath to use clothed or gentler techniques, or postpone hands-on care until the client is more stabilised [synthesis].
• Client could not say stop or later regrets consenting:
  • Validate the client. Consent is ongoing and can be withdrawn [source: OCNZ draft 2022].
  • Process the experience. If the practitioner ignored signals, see 4.1.9 [synthesis].
• Non-adherence to exercise or self-care advice [synthesis]:
  • Explore barriers such as fear of movement, pain beliefs, low mood or time.
  • Use your usual motivational methods. Do not prescribe exercises yourself.
• Rupture with you over the referral [synthesis]:
  • If the client hears "see an osteopath" as "it's all physical" or as rejection, name both tracks: bodily pain and its psychological meaning both matter.
  • Repair the rupture, and keep the referral optional.
• Rupture with the osteopath, such as the client feeling dismissed or hurt [synthesis]:
  • Help the client prepare what to say.
  • The client may change practitioner or end treatment.
  • Distinguish ordinary dissatisfaction from a conduct concern.
• Adverse effect reported:
  • Apply the urgency triage in 4.1.8.
  • Record what you advised.
  • Encourage the client to report the effect to the treating practitioner and their GP [synthesis].
• Practitioner makes disease or infant claims [source: ASA]:
  • The ASA has upheld complaints about claims to treat colic, reflux, glue ear, feeding problems, constipation and infections.
  • Share this with the client.
  • A client can complain to the ASA about advertising [synthesis].
• "Body memory" or recovered-memory suggestions:
  • Use 4.1.11.
  • Do not confirm or deny the events. Monitor for growing certainty that arises only from bodily experiences [synthesis].
• Client from a culture or faith with norms about touch, gender or undressing:
  • Help the client ask for a practitioner of a preferred gender, a chaperone, clothed treatment, or no head contact.
  • Regulators expect sensitivity to modesty without making assumptions [source: GOsC A6; OCNZ draft 2022].
• The client asks you to do hands-on work yourself:
  • Decline unless your own code permits touch and you hold recognised training in a touch-based psychotherapy. Body-psychotherapy codes require informed consent, ongoing monitoring and the right to refuse touch [source: USABP; EABP].
  • Never combine OMT with psychotherapy.
• Cross-border confusion, e.g. a US DO versus a European osteopath [synthesis]:
  • Clarify which profession the client means.
  • Explain what that profession can do: a physician can prescribe; a non-physician osteopath cannot [source: The DO].

Sources

Web sources:

• Benchmarks for training in osteopathy (WHO, 2010), copy hosted by the Osteopathic International Alliance
• GOsC: Consent (practice guidance)
• GOsC Osteopathic Practice Standards A6: You must respect your patients' dignity and modesty
• The DO: An ocean away: the story of how osteopathy crossed the Atlantic
• NBOME: Osteopathic Medicine 127 Years Later: Through the Eyes of A.T. Still, MD (2019)
• StatPearls: Osteopathic Manipulative Treatment: HVLA Procedure - Thoracic Vertebrae (Hammell & Null, 2023)
• ASA/CAP: Health: Osteopathy (advice online, 2022)
• Osteopathy Board of Australia: Statement on paediatric care
• [Osteopathic Council of New Zealand: Examination and treatment of sensitive areas (draft, August 2022)](https://www.osteopathiccouncil.org.nz/common/Uploaded files/Publications/Consultations/Draft_Sensitive Areas_Aug22.pdf)
• Guideline Central: NICE low back pain and sciatica in over 16s guideline spotlight (August 2026)
• The risk associated with spinal manipulation: an overview of reviews, Table 3 (Systematic Reviews, 2017)
• Wikipedia: Osteopathy (secondary source for the reviews cited as "as cited")

Reviews cited only via the secondary source above [uncertain: not verified]: Franke, Franke & Fryer 2014 (BMC Musculoskeletal Disorders); Orrock & Myers 2013 (BMC Musculoskeletal Disorders); Posadzki & Ernst 2011 (Clinical Rheumatology); Posadzki, Lee & Ernst 2013 (Pediatrics); Hondras, Linde & Jones 2005 (Cochrane); Chen et al. 2022 (Cochrane); Guillaud et al. 2018 (BMC Complementary and Alternative Medicine); Howell 1999 (NEJM); Gevitz 2006 and 2014 (JAOA).

Web sources (professional codes on touch, sexual contact and referral):

• BACP Ethical Framework 2018
• BACP Ethical Framework 2026
• UKCP Code of Ethics and Professional Practice 2019
• [BPS Code of Ethics and Conduct (2009)](https://www.keele.ac.uk:443/media/keeleuniversity/facnatsci/schpsych/documents/healthandconduct/BPS code_of_ethics_and_conduct.pdf)
• HCPC Standards of Proficiency: Practitioner Psychologists (2023)
• APA, Ethical Principles of Psychologists and Code of Conduct (2002, amended 2010 and 2016)
• AAMFT Code of Ethics (2015)
• USABP Code of Ethics
• EABP Ethics Guidelines (2020)

Sources named but not verified [uncertain: not verified]:

• GOsC Osteopathic Practice Standard A4 (valid consent), whose title and requirement are summarised on the GOsC consent page above;
• NCCIH, Spinal Manipulation: What You Need To Know;
• NICE NG59 (2016, updated 2020 and 2026), described here via Guideline Central.