Origens biomédicas do termo lesão osteopática e seu impacto nas pessoas com dor

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Biomedical origins of the term osteopathic lesion and its impact on people in pain
Monica Noy, Luciana Macedo, Lisa Carlesso
PII: S1746-0689(19)30135-X
DOI: https://doi.org/10.1016/j.ijosm.2020.06.002
Reference: IJOSM 545
To appear in: International Journal of Osteopathic Medicine
Received Date: 1 September 2019
Revised Date: 13 May 2020
Accepted Date: 30 June 2020
Please cite this article as: Noy M, Macedo L, Carlesso L, Biomedical origins of the term osteopathic
lesion and its impact on people in pain, International Journal of Osteopathic Medicine (2020), doi: https://
doi.org/10.1016/j.ijosm.2020.06.002.
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https://doi.org/10.1016/j.ijosm.2020.06.002
https://doi.org/10.1016/j.ijosm.2020.06.002
https://doi.org/10.1016/j.ijosm.2020.06.002
1 
 
Biomedical Origins of The Term Osteopathic Lesion and Its Impact on People in Pain 
 
Monica Noya 
Luciana Macedob macedol@mcmaster.ca 
Lisa Carlessob carlesl@mcmaster.ca 
a. Private Practice - Move Pain Care, 738 Spadina Ave, Toronto, ON, Canada, M5S 2J8 
b. School of Rehabilitation Science, McMaster University, 1400 Main St. W Institute for 
Applied Health Sciences, Hamilton, Canada, L8S 1C7 
Corresponding Author information: 
Monica Noy 
738 Spadina Ave, Suite 200, Toronto, ON M5S 2J8 
Tel: 1-647-981-6871 
E-mail: monicanoy@gmail.com 
 
Declaration of Interest: None 
 
 
 
1 
 
Biomedical Origins of The Term Osteopathic Lesion and Its Impact on People in Pain 
 
 
Declaration of Interest: {Name of author} is a member of the International Advisory Board of 
the Int J Osteopath Med but was not involved in review or editorial decisions regarding this 
manuscript. 
 
 
 
2 
 
Abstract 
 Osteopathic manual practitioners in Canada use, and continue to be educated to use the 
term osteopathic lesion. This term is either derived from or directly drawn from the biomedical 
model; the overarching framework through which most healthcare is delivered. Use of the term 
illustrates the adoption and misappropriation of a biomedical term and follows the same curative 
reasoning processes as in biomedicine. Manual osteopathic practitioners in Canada believe the 
osteopathic lesion to be a palpably detectable entity. Use of the term could arguably be capable 
of eliciting nocebo and iatrogenic symptom effects. The origin of, and potential iatrogenic 
consequences of using the term with patients appears to be largely invisible to osteopathic 
practitioners. Awareness of the origin and use of this term and potential problems for patient-
centred osteopathic care are necessary before comprehensive transformation in education and 
practice standards at the association and educational levels can be adopted. 
 
 
Key words: 
Biomedical, biopsychosocial, iatrogenic, language, lesion, musculoskeletal, osteopathic manual 
practitioner 
 
3 
 
Language has the potential to influence thoughts, beliefs, and actions in positive and 
negative ways(1–3). In healthcare, language ideally provides the patient with knowledge and 
tools for understanding, resolving or managing their symptoms. The words used within patient-
provider interactions are context dependent, and based on a complex interaction of content, 
values, social identity and setting (4). 
The biomedical model is the overarching framework through which most healthcare is 
delivered in Canada and from which the dominant discourse in healthcare arises (5–7). In the 
United States, osteopathy is primarily a medical practice within a biomedical context (8). Manual 
osteopathic practice in most countries, including Canada, is not medical and uses primarily 
hands-on techniques during treatment (8,9). Manual osteopathy was invented in opposition to the 
dominant medical paradigm at the time, but its identity within a larger healthcare context is still 
debated (10–13). However, some of the language used in manual osteopathy is either derived 
from or directly drawn from the dominant biomedical discourse. In Canada, the predominant 
construct of the ‘osteopathic lesion’ has been, and still is being used as an organizing principle of 
osteopathic clinical reasoning (14–18). 
The use of the term lesion in manual osteopathy illustrates the adoption and 
misappropriation of a biomedical term. The term lesion has a shared meaning in medicine and in 
the lay population that is not retained in the manual osteopathic context. Given the potential for 
misunderstanding of common medical terms, use of the same term with an altered definition may 
be problematic for patient understanding and could arguably be capable of eliciting nocebo and 
iatrogenic symptom effects in much the same way as in a medical setting (1,19). 
 
4 
 
The Biomedical Model 
Engel described the biomedical model as a scientific model that accounted for disease on 
a somatic level independent from social, psychological and behavioural influences (7). Though 
Engel argued for replacement of the biomedical model, that did not occur. Instead, Fuller 
proposes that the current or ‘old’ biomedical model described as “physicians cure biological 
disease using biomedical mechanistic reasoning” (p. E640) has been partially influenced by the 
biopsychosocial model, resulting in a blend of old practices mixed with new evidence-based 
clinical guidelines (6,20,21). The biomedical model remains the primary construct under which 
most medical and musculoskeletal practitioners still operate (22,23), and even with the increasing 
influence of the biopsychosocial model, Fuller argues that it maintains many disadvantages such 
as reductionism and fractured care(6). 
The compartmentalization of care in Canada occurs through rationing of patient access to 
one medical issue per visit (24), and with specialization throughout the system(25). This type of 
care keeps the focus of treatment away from the patient’s whole experience of illness and 
sustains the use of metaphors such as ‘medicine is war’ and the ‘body as machine’(26,27). In 
musculoskeletal care these medical metaphors encourage secondary metaphors about being 
mechanical in movement (biomechanics), in structure (alignment), and in our ability to repair 
(correcting or fixing) (26). In osteopathy, these concepts are exemplified in the use of the 
osteopathic lesion as one of the central constructs on which the profession was built. 
 
The Osteopathic Lesion as a Biomedical Construct 
5 
 
The use of the word lesion in osteopathic practice in Canada and in many other countries 
follows the same curative reasoning processes as in biomedicine, mimicking rather than rejecting 
its main premises. The common and easily accessible meaning of the word lesion in a medical 
sense is that of a disruption of tissues due to injury or illness that is visible to either the naked or 
microscopic eye (28,29). Osteopathic use of the term retains the fundamental medical and lay 
definition as that of a disruption of tissues, but changes the focus of this disruption to a non-
visible functional one rather than a demonstrable pathology or injury (17). Though the term 
osteopathic lesion has been changed to somatic dysfunction, the definition is the same: “Impaired 
or altered function of related components of the somatic (body framework) system” (17). It is a 
non-pathological disruption of an otherwisenormal activity of the body that cannot be seen by 
the naked or microscopic eye and is findable only through skilled osteopathic palpation (16,30). 
This alteration of the medical definition for osteopathic use has evolved to include many 
different types of complex and compounding lesions that can affect almost every body part, and 
have cascading effects on every body system (17). Despite the change to somatic dysfunction, in 
Canada use of the term lesion is still commonplace (14,18,31,32). 
 The exact meaning of the term osteopathic lesion remains unclear and is still under 
debate within the global osteopathic community (14,16). Introduction of the term into the medical 
arena in 1935 through a book titled The Osteopathic Lesion was highly criticized by the British 
Journal of Medicine for its lack of scientific validity (33). Recently, Fryer explored the relevance 
of somatic dysfunction of the spine within osteopathic practice and recommended use of the 
label for diagnostic purposes in a practice setting be discontinued (16). Instead, Fryer described a 
confluence and variability of physiological factors that could be considered part of the 
assessment of a somatic dysfunction(16). 
6 
 
 
The Disconnect Between Tradition and Evidence 
A significant number of osteopathic practitioners in Canada are taught traditional 
osteopathic principles, and come to believe that the osteopathic lesion or somatic dysfunction is a 
detectable entity found by osteopathic palpation (14,16,18,34). The lesional construct has 
consistently been questioned, and though attempts have been made to mechanistically explain 
the functional construct, there is no clear consensus of definition or mechanism that has emerged 
(14–16,33,35). Manual and to some degree medical osteopaths have considered their profession 
as distinct from biomedicine (10,36) but the fundamental overlap of the use of the term lesion and 
its biomedical origins has been absent from the discussion around professional identity. The 
impact of the use of the term lesion on patient understanding has not been specifically examined. 
However, studies examining clinician beliefs and patient perceptions of language used in an 
osteopathic setting reveal that patient beliefs about their pain can be negatively influenced by 
words used by the therapist (22,37). 
 
The Iatrogenic Potential of The Osteopathic Lesion 
In clinical healthcare settings the iatrogenic potential of the words used and the impacts 
they may have are often outside of the conscious awareness of both the health professional and 
the patient (3,38–40). Practitioners who provide their patients with osteopathic lesions as causes 
for symptoms are confining themselves to a single reasoning criterion, and are likely unaware of 
broader knowledge contexts for providing a patient-centered healthcare exchange (41). 
7 
 
Moseley and Butler argue that diagnostic language is often metaphorical, almost always 
unhelpful or wrong, and often provided without further clarification of the literal meaning (26). 
For example, in a magnetic resonance imaging study, participants reported negative emotional 
impacts from descriptions of demonstrable lesions such as those found on reports (42). Greater 
understanding, higher satisfaction and usefulness of the information was stated when the reports 
were reworded to an eighth-grade reading level and defining words for the pathology were 
removed. 
Given the lack of clarity around the definition of the term osteopathic lesion, it cannot be 
expected that the meaning will be conveyed with any clarity to the patient. This 
misunderstanding may impact the patient’s perception of their own illness and their beliefs 
around its cause and resolution (43). The labeling of a symptom set as one caused by an 
osteopathic lesion may not be that different to providing a diagnostic label for a condition such 
as disc degeneration. If the language used is not qualified, or if the patient’s health literacy is 
low, the impact of these words will be different from the information that is intended to be 
conveyed. Any further associated pain or tension symptoms may become identified with the 
diagnosis (1,22). The osteopathic lesion label also provides an associated single cause for a 
variety of symptoms that require the patient to seek specialist treatment to find a resolution. This 
construct extends biomedical reasoning outside of appropriate practice settings. For example, 
attributing the cause of low back pain to a perceived anomaly such an osteopathic lesion runs 
contrary to evidence-based best-practice recommendations(20). This single-cause link with pain 
could, in part, contribute to life-long negative associations in a chronic condition with, 
ultimately, inadequate resolution. if the conditions develops into to the development of a chronic 
8 
 
condition that has life-long implications of pain, suffering, and disability with ultimately 
inadequate resolution (23,37,40,44). 
 
For People Living with Pain 
The research evidence for treating people living with pain strongly rejects equating 
structural or functional findings as causal for pain and is becoming more supportive of multi-
practitioner, multimodal, patient-centred and biopsychosocial approaches (20,22,45–49). Yet, 
osteopathic manual practitioners, like most musculoskeletal therapists are still educated using 
outdated, biomedical dualistic concepts that link structure with symptoms, conflating the 
understanding of nociception and pain (50, 51). This conflation is also still sticky within 
biomedicine and is a source of considerable confusion in research, medicine, and 
musculoskeletal therapies, making change more difficult to enact (26,44,52,53). Evidence that 
clearly demonstrable lesions such as disc herniations are common, often found incidentally, and 
cannot be directly correlated to a person’s experience of pain(54) compound the problems 
associated with use of the term osteopathic lesion. If association of a demonstrable lesion has 
been shown to have a non-linear relationship with the symptom of pain, then associating a non-
demonstrable lesion to explain the same symptom potentially adds to the confusion of cause for 
the person in pain. 
Eccleston and Crombez outline a misdirected problem-solving model and perseverance 
loop that occurs when patient symptoms remain unresolved by treatment(55). Patients worry 
about their symptoms and persist in seeking treatment from a variety of therapies that promise to 
resolve them. In the absence of an apparent somatic cause, practitioners continue to search for 
9 
 
something presented through the body that can be used to explain the symptoms. An illustration 
of this might be what the Neuro Orthopaedic Institute calls the Sea of Endless Professionals on 
the road to recovery (56). Though each wave in this sea is its own entity, in this illustration it 
represents a different musculoskeletal profession that has its own way of determining the cause 
and treatment for the persons’ pain. The osteopathic patient who is led to believe a lesion causes 
pain will expect that, if the pain returns with activity, that movement either caused a new lesion 
or activated a recurring lesion. Similar to being provided with a structural cause for low back 
pain, being given an osteopathic lesion could become a permanent negative association leading 
to fear of the movement that recreates the pain (40). As with being given findings of a disc 
herniation, the person may believe that they have and will always have a lesion in the presence of 
an associated pain. 
 
Future Direction for the Profession 
 In the last five years the international osteopathic research community has been prolific 
in exploring, understanding, defining, and addressing the knowledge gaps in evidence that exist 
for osteopathic practitioners to treat people who live with pain(11,22,57–64). The research 
encourages comprehensive questioning of traditional concepts in light of current science, and 
introduces ways of envisioning osteopathic manual practice from an evidence-based perspective. 
There are comparatively fewer Canadian osteopathic researchers who can engage the community 
at this level, and there are insufficient tools for translating the research into practice at the 
association and educational levels. As such, the osteopathic lesion or somatic dysfunction 
remains a primary educational principle of the profession. 
10 
 
 Providing practitioners and institutions with an understanding of the construct of the 
lesion as derived from the biomedical paradigm is a necessary first step for providing the 
community with a logical context to reframe and move on from traditional reasoning and engage 
with emerging research and evidence-based practices. Recognition of the iatrogenic potential of 
the term would encourage educational institutions to remove it from curricula, and associations 
to advocate for discontinued use in a clinical context. The term osteopathic lesion describes a 
confluence and variability of factors that could reasonably be replaced with more specific 
commonly recognized descriptors already used within musculoskeletal practice. Future study 
engaging discussion with the osteopathic community about the basic science evidence and 
current best-practices for persons with pain would be beneficial to reframe the lesional construct 
and provide awareness of the impact of language used for communication. 
 
11 
 
References 
1. Barsky AJ. The iatrogenic potential of the physician’s words. JAMA. 2017 Dec 26;318(24):2425–6. 
2. Stewart M, Loftus S. Sticks and stones: The impact of language in musculoskeletal rehabilitation. J 
Orthop Sports Phys Ther. 2018 Jun 30;48(7):519–22. 
3. Bowman C, Ronch J, Madjaroff G. The power of language to create culture [Internet]. 2012 [cited 
2019 Jan 17]. Available from: https://www.pioneernetwork.net/wp-
content/uploads/2016/10/The-Power-of-Language-to-Create-Culture.pdf 
4. Roberts C, Wass V, Jones R, Sarangi S, Gillett A. A discourse analysis study of ‘good’ and ‘poor’ 
communication in an OSCE: A proposed new framework for teaching students. Medical Education. 
2003;37(3):192–201. 
5. Knyahnytska Y, Williams C, Dale C, Webster F. Changing the conversation: Diabetes management in 
adults with severe mental illnesses and type 2 diabetes. Canadian Journal of Diabetes. 
2018;42(6):595–602. 
6. Fuller J. The new medical model: a renewed challenge for biomedicine. CMAJ. 2017 May 
1;189(17):E640–1. 
7. Engel G. The need for a new medical model: A challenge for biomedicine. Science. 
1977;196(4286):129–36. 
8. Osteopathic Medicine and Osteopathy – Osteopathic International Alliance [Internet]. [cited 2019 
Aug 18]. Available from: https://oialliance.org/about-us/osteopathic-medicine-and-osteopathy/ 
9. Canadian Osteopathic Association [Internet]. Canadian Osteopath. [cited 2019 Aug 18]. Available 
from: https://www.osteopathic.ca 
10. Thomson OP, Petty NJ, Moore AP. Reconsidering the patient-centeredness of osteopathy. 
International Journal of Osteopathic Medicine. 2013 Mar 1;16(1):25–32. 
11. Smith D. Reflecting on new models for osteopathy – it’s time for change. International Journal of 
Osteopathic Medicine [Internet]. 2019 Mar;31:15–20. 
12. Turner PWD, Holroyd E. Holism in osteopathy – bridging the gap between concept and practice: A 
grounded theory study. International Journal of Osteopathic Medicine. 2016 Dec 1;22:40–51. 
13. Lucas NP, Moran RW. Is there a place for science in the definition of osteopathy? International 
Journal of Osteopathic Medicine. 2007 Dec 1;10(4):85–7. 
14. Liem T. A.T. Still’s Osteopathic lesion theory and evidence-based models supporting the emerged 
concept of somatic dysfunction. J Am Osteopath Assoc. 2016 Oct 1;116(10):654–61. 
15. The emerging concept of the osteopathic lesion. 1948. The Journal Of The American Osteopathic 
Association. 2000 Jul 1;100(7):449. 
12 
 
16. Fryer G. Somatic dysfunction: An osteopathic conundrum. International Journal of Osteopathic 
Medicine. 2016 Dec 1;22:52–63. 
17. Glossary of Osteopathic Terminology [Internet]. The American Association of Colleges of 
Osteopathic Medicine; 2011 [cited 2018 Dec 30]. Available from: 
https://www.aacom.org/docs/default-source/insideome/got2011ed.pdf?sfvrsn=2 
18. Jarman S. We do lesions. The Osteopathyst [Internet]. 2016 Sep 25;(8). Available from: 
https://www.osteopathyst.com/issue-8/ 
19. Rossettini G, Carlino E, Testa M. Clinical relevance of contextual factors as triggers of placebo and 
nocebo effects in musculoskeletal pain. (Report). BMC Musculoskeletal Disorders. 2018 Jan 
22;19(1):27. 
20. Toward Optimized Practice (TOP) Low Back Pain Working Group. 2015 December. Evidence-
informed primary care management of low back pain: Clinical practice guideline. [Internet]. 
Edmonton, AB: Toward Optimized Practice; 2015. Available from: 
http://www.topalbertadoctors.org/cpgs/885801 
21. Osteoarthritis: Care for adults with osteoarthritis of the knee, hip, or hand [Internet]. Health 
Quality Ontario; Available from: 
https://www.hqontario.ca/Portals/0/documents/evidence/quality-standards/qs-osteoarthritis-
clinician-guide-en.pdf 
22. Darlow B. Beliefs about back pain: The confluence of client, clinician and community. International 
Journal of Osteopathic Medicine. 2016 Jun 1;20:53–61. 
23. Setchell J, Costa N, Ferreira M, Makovey J, Nielsen M, Hodges PW. Individuals’ explanations for 
their persistent or recurrent low back pain: A cross-sectional survey. BMC Musculoskeletal 
Disorders. 2017 Nov 17;18(1):466. 
24. Canadian health care’s “one issue per visit” problem | CBC News [Internet]. CBC. 2019 [cited 2019 
Jul 6]. Available from: https://www.cbc.ca/news/health/second-opinion-one-problem-visit-
1.5061506 
25. Leatt P, Pink GH, Guerriere M. Towards a Canadian model of integrated healthcare. Healthcare 
Papers. 2000 Mar;1(2):13–35. 
26. Moseley GL, Butler DS. Explain pain supercharged : The clinician’s manual. Adelaide, South 
Australia: Noigroup Publications; 2017. 
27. Hodgkin P. Medicine is war: and other medical metaphors. BMJ. 1985 Dec 21;291(6511):1820–1. 
28. lesion. In: The Free Dictionary [Internet]. [cited 2018 Dec 30]. Available from: https://medical-
dictionary.thefreedictionary.com/lesion 
29. Lesion | Definition of Lesion by Merriam-Webster [Internet]. [cited 2019 Nov 23]. Available from: 
https://www.merriam-webster.com/dictionary/lesion 
13 
 
30. Niemier K, Seidel W, Liefring V, Psczolla M, Beyer L, Ritz W. Von der Funktionsstörung 
zur Funktionskrankheit. Manuelle Medizin. 2018 Jun 1;56(3):253–8. 
31. Postgraduate courses in Osteopathy | Osteopathic Mechanical Link [Internet]. CEO-CCO-SICO-DOK. 
[cited 2019 Aug 18]. Available from: 
https://osteocontinuingeducation.com/Courses/Course%20series/OML/ 
32. Ateliers du Symposium — 36e Symposium de Montréal du CEO [Internet]. Collège d’Études 
Ostéopathiques de Montréal. [cited 2019 Aug 18]. Available from: 
https://www.symposiumceo.ca/Ateliers_header/Ateliers_Sympo/index.php 
33. Shiel J. The osteopathic lesion. The British Medical Journal. 1935;1(3885):1295–1295. 
34. Osteopathic Assessment and Treatment [Internet]. [cited 2019 Aug 18]. Available from: 
http://www.osteopathy-canada.com/osteopathic-manual-practitioner-canada/ 
35. Denslow JS. Analyzing the osteopathic lesion. 1940. The Journal Of The American Osteopathic 
Association. 2001 Feb 1;101(2):99. 
36. Johnson SM, Kurtz ME. Perceptions of philosophic and practice differences between US 
osteopathic physicians and their allopathic counterparts. Social Science and Medicine. 
2002;55(12):2141–8. 
37. Thomson OP, Collyer K. ‘Talking a different language’: a qualitative study of chronic low back pain 
patients’ interpretation of the language used by student osteopaths.International Journal of 
Osteopathic Medicine. 2017 Jun 1;24:3–11. 
38. Loftus S. Pain and its metaphors: A dialogical approach. J Med Humanit. 2011 Sep 1;32(3):213–30. 
39. Vranceanu A-M. The emotive impact of orthopedic words. Journal of Hand Therapy. 
2011;24(2):112–7. 
40. Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what 
clinicians say to people with low back pain. Ann Fam Med. 2013 Nov;11(6):527–34. 
41. Higgs J, editor. Clinical reasoning in the health professions. 3rd ed. Amsterdam ; Boston: Elsevier, 
BH; 2008. 504 p. 
42. Bossen JK, J M, Hageman MG, J, S M, King JD, et al. Does rewording MRI reports improve patient 
understanding and emotional response to a clinical report? Clinical Orthopaedics and Related 
Research; Rosemont. 2013 Nov;471(11):3637–44. 
43. Petrie KJ, Weinman J. Why illness perceptions matter. Clin Med (Lond). 2006 Dec;6(6):536–9. 
44. Quintner J, Cohen M. The challenge of validating the experience of chronic pain: The importance of 
intersubjectivity and reframing. In: van Rysewyk S, editor. Meanings of Pain [Internet]. Cham: 
Springer International Publishing; 2016; 281–93. Available from: https://doi.org/10.1007/978-3-
319-49022-9_17 
14 
 
45. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, et al. Systematic literature 
review of imaging features of spinal degeneration in asymptomatic populations. AJNR American 
journal of neuroradiology. 2015 Apr 1;36(4):811–6. 
46. Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJEM, Ostelo RWJG, Guzman J, et al. 
Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic 
review and meta-analysis. BMJ. 2015;350:h444. 
47. Taccolini Manzoni AC, Bastos de Oliveira NT, Nunes Cabral CM, Aquaroni Ricci N. The role of the 
therapeutic alliance on pain relief in musculoskeletal rehabilitation: A systematic review. 
Physiotherapy Theory and Practice. 2018;34(12):901–15. 
48. Volker G, Vree F, Wolterbeek R, Gestel M, Smeets R, Köke A, et al. Long-term outcomes of 
multidisciplinary rehabilitation for chronic musculoskeletal pain. Musculoskeletal Care. 
2017;15(1):59–68. 
49. Buchanan D, Cohen M, Katz J, Quintner J, Williamson O. Beyond biopsychosocial: A new 
framework for pain medicine. Pain Medicine. 2007;8(7):614–5. 
50. Jull G. Biopsychosocial model of disease: 40 years on. Which way is the pendulum swinging? British 
Journal of Sports Medicine. 2017 Aug;51(16):1187–8. 
51. Wall PD, McMahon SB. The relationship of perceived pain to afferent nerve impulses. Trends in 
Neurosciences. 1986;9:254–5. 
52. Apkarian AV. Nociception, pain, consciousness, and society: A plea for constrained use of pain-
related terminologies. The Journal of Pain. 2018 Nov 1;19(11):1253–5. 
53. Treede R-D, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, et al. Chronic pain as a symptom or a 
disease: the IASP Classification of Chronic Pain for the: International Classification of Diseases: (: 
ICD-11: ). PAIN. 2019 Jan;160(1):19. 
54. Brinjikji W, Diehn FE, Jarvik JG, Carr CM, Kallmes DF, Murad MH, et al. MRI findings of disc 
degeneration are more prevalent in adults with low back pain than in asymptomatic controls: A 
systematic review and meta-analysis. AJNR American Journal of Neuroradiology. 2015 Dec 
1;36(12):2394–9. 
55. Eccleston C, Crombez G. Worry and chronic pain: a misdirected problem solving model. Pain. 2007 
Dec 5;132(3):233–6. 
56. Butler DS, Moseley GL, Sunyata. Explain pain. Adelaide: Noigroup Publications; 2003. 129 p. 
57. Fryer G. Integrating osteopathic approaches based on biopsychosocial therapeutic mechanisms. 
Part 1: The mechanisms. International Journal of Osteopathic Medicine. 2017 Sep;25:30–41. 
58. Fryer G. Integrating osteopathic approaches based on biopsychosocial therapeutic mechanisms. 
Part 2: Clinical approach. International Journal of Osteopathic Medicine. 2017 Dec;26:36–43. 
15 
 
59. Penney JN. The Biopsychosocial model: Redefining osteopathic philosophy? International Journal 
of Osteopathic Medicine. 2013;16(1):33–7. 
60. Fitzgerald K, Vaughan B, Austin P, Grace S, Orchard D, Orrock P, et al. The Lancet low back pain 
series: A call to action for osteopathy? International Journal of Osteopathic Medicine. 2018;28:70–
1. 
61. Roots SA, Niven E, Moran RW. Osteopaths’ clinical reasoning during consultation with patients 
experiencing acute low back pain: A qualitative case study approach. International Journal of 
Osteopathic Medicine. 2016 Mar 1;19:20–34. 
62. Draper-Rodi J, Vogel S, Bishop A. Identification of prognostic factors and assessment methods on 
the evaluation of non-specific low back pain in a biopsychosocial environment: A scoping review. 
International Journal of Osteopathic Medicine. 2018 Dec 1;30:25–34. 
63. Leach MJ, Sundberg T, Fryer G, Austin P, Thomson OP, Adams J. An investigation of Australian 
osteopaths’ attitudes, skills and utilisation of evidence-based practice: a national cross-sectional 
survey. BMC Health Services Research. 2019 Jul 17;19(1):498. 
64. Sundberg T, Leach MJ, Thomson OP, Austin P, Fryer G, Adams J. Attitudes, skills and use of 
evidence-based practice among UK osteopaths: a national cross-sectional survey. BMC 
Musculoskeletal Disorders. 2018 Dec 8;19(1):439. 
 
September 1, 2019 
 
Conflict of Interest: None 
This research did not receive any specific grant from funding agencies in the public, commercial, or not-
for-profit sectors. 
 
 
Monica Noy