A profile of osteopathic care in private practices in the United Kingdom: A national pilot using standardised data collection

Manual Therapy 19 (2014) 125e130

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Original article

A profile of osteopathic care in private practices in the United Kingdom: A national pilot using standardised data collection C.A. Fawkes*, C.M.J. Leach, S. Mathias, A.P. Moore Clinical Research Centre, Aldro Building, University of Brighton, 49, Darley Road, Eastbourne, East Sussex, BN20 7UR, England, UK

a r t i c l e i n f o

a b s t r a c t

Article history: Received 4 June 2013 Received in revised form 2 September 2013 Accepted 5 September 2013

Increasing interest is being shown in osteopathy on a national and international basis. Since little prospective data had been available concerning the day-to-day practice of the profession, a standardised data collection tool was developed to try and address this issue. The tool development process has been described in an earlier paper. The standardised data collection (SDC) tool underwent national piloting between April and July 2009 in United Kingdom private practices. Osteopaths volunteered to participate and collected data on consecutive new patients or patients presenting with a new symptom episode for a period of one month; follow-up data were collected for a further two months. A total of 1630 completed datasets from the SDC pilot were analysed by the project team. Data generated from the national pilot showed that lumbar symptoms were the most commonly presented in patients (36%), followed by cervical spine (15%), sacroiliac/pelvic/groin (7.9%), head/facial area (7%), shoulder (6.8%), and thoracic spine (6%). A total of 48.8% of patients reported comorbidities, the most common being hypertension (11.7%), followed by asthma (6.6%), and arthritis (5.7%). Outcome data were collected looking at the patients’ response to treatment, and any form of treatment reactions. The profiling information collected using the SDC tool provides a contemporary picture of osteopathic practice in the United Kingdom. Ó 2013 Elsevier Ltd. All rights reserved.

Keywords: Osteopathy Osteopathic medicine Standardised data collection Quality of healthcare

1. Introduction Osteopathy now forms part of the provision of musculoskeletal services in the United Kingdom (UK) appearing in national and international guidelines (Hildebrand et al. and the chronic low back pain guideline working group, 2004; van Tulder et al. and the acute low back pain guideline working group, 2004; Department of Health, 2006; Savigny et al. and Guideline Development Group, 2009); however this provision focusses on one particular type of osteopathic technique, i.e. spinal manipulation. The clinical recommendations are most notably for low back pain, a condition representing a significant cost burden to national governments (Maniadakis and Gray, 2000; Dagenais et al., 2008). The information about the wider extent of current osteopathic practice in the UK is limited; some data have been collected from isolated surveys, usually conducted on a single day, in one private or NHS osteopathic practice, or in one clinic attached to an osteopathic educational institution (OEI) (Burton, 1981; Pringle and Tyreman, 1993;

* Corresponding author. National Council for Osteopathic Research, UK. Tel.: þ44 (0) 207 882 6131. E-mail address: [email protected] (C.A. Fawkes). 1356-689X/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.math.2013.09.001

Hinkley and Drysdale, 1995; General Osteopathic Council, 2001; McIlwraith, 2003). While the vast majority of the evidence supporting the use of osteopathy relates to the use of spinal manipulation, this is only one technique among a range of more than 100 different osteopathic techniques or procedures which have been described in the literature (Owens, 1963; Jones, 1981; Heilig, 1986; Still, 1992; Di Giovanna and Schiowitz, 1997; Lesho, 1999; Evans, 2002; Evans and Breen, 2006; ; Furlan et al., 2009). In response to this lack of data regarding osteopathic approaches, the National Council for Osteopathic Research initiated the development of a standardised data collection (SDC) tool to gather baseline data about current osteopathic practice. This was developed by an iterative process using a nominal group technique involving volunteer private practitioners (Fawkes et al., 2009); its development is reported in a separate paper (Fawkes et al., 2014). This paper reports the results of the first large national pilot data collection using the SDC tool. The aims of the study were to test the performance of the newly-developed SDC tool, and gather information to help to describe the scope and range of osteopathic practice in terms of patient demographics, symptom profiles, management strategies, outcomes of care, and the costs associated with treatment.

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2. Methods

3.1. Patient characteristics

The previously developed osteopathic SDC tool was used to gather prospective data on individual patient consultations within a cross section of volunteer osteopathic practices across the UK. It should be stressed that the data analysed represents pilot data from the newly-developed SDC tool.

The socio-demographic information collected from patients is shown in Table 1. The mean age was 44.8 years (SD 19.1 years, range 0e93 years) and was bi-modally distributed with a small secondary peak in the childhood age groups. There were 8.6% (140) patients aged under 20 with more than half of these being under 1 year old. Overall, the majority of patients were in employment (62.1%) including 14% in part time work, or retired (19%). There were 27 patients (1.7%) reported as being in receipt of disability allowance. Patient-reported ethnicity was white (93.9%), using ethnicity descriptors employed by the Office for National Statistics (Office for National Statistics, 2010). The most common referral route to the osteopath was selfreferral (79.9%), with most (69.8%) arranging treatment with a particular osteopath identified via “word of mouth”. The costs of treatment were met by the individual in 89.1% of cases; 6.6% of patients had their treatment funded by insurance schemes, 0.6% by their employer, and 0.6% by the NHS. The reasons for seeking osteopathic care included personal recommendation (64.9%), failure of other treatment(s) (1.9%), wanting a form of manual or hands-on treatment (9.1%), wanting drug-free treatment (9.1%), and waiting for an NHS appointment (1.9%). A total of 59% of the patients were new to osteopathy. The waiting times for access to care was recorded as the first available appointment offered to a patient; these waiting times were short with 16.8% of patients being offered an appointment on the same day, 71% being seen within 3 days of contacting the practice, and 84% being seen with one week of their first contact with the practice. A total of 29% of patients had received NHS treatment or investigations prior to attending an osteopath for this particular episode of symptoms. NHS treatment included prescribed medication (20.1%), imaging (13.9%), hospital outpatient treatment (10.9%), or hospital inpatient treatment (1.3%). A total of 48% of patients reported they had consulted their general practitioner (GP) prior to their osteopathic consultation, and 8.8% had made 4 or more visits. The presenting problem(s) was/were recorded by the anatomical site(s) of the symptom(s). Up to three anatomical sites were permitted, ranked by their importance to the patient. Table 2 shows the distribution of sites ranked most commonly by patients. The lumbar spine was the most frequently reported site of symptoms (36.0%), followed by the cervical spine (15.0%) and pelvic region (11.0%); the other sites all scored less than 10%. The duration of symptoms related to the current problem was reported as chronic (13 weeks or more) by 32.5% of patients; sub-

2.1. Recruitment and sampling All registered osteopaths in private practice in the UK were eligible to participate in the SDC pilot. Recruitment was voluntary, and effected through advertisements at regional osteopathic groups, in the osteopathic press, email networks, and at national osteopathic conferences. 2.2. Intervention Ten copies of the SDC tool complete with guidance notes were distributed to participants; data collection took place over a three month period between April and July, 2009. Data on new patients or returning patients presenting with a new episode were collected by the participants during April; they were followed-up for a further two months or until discharge depending on which event occurred sooner. The tool was semi-structured, recording predominantly quantitative data with some free text. To maintain anonymity and confidentiality, each osteopath was allocated a unique ID code, to which they could add a sequential code (01, 02.) for the patient identifier. Consecutive new patient-episodes were requested for data collection to prevent selection bias. Patients were eligible irrespective of the age, presenting symptoms or reason for consultation. Extra work was involved for the osteopath in completing the six-page SDC tool in addition to the usual practice case-notes at first consultation. Follow-up data relating to outcomes of care were collected during the course of treatment e.g. post treatment reactions within the first 24e48: overall outcome of care data including symptom change were collected by the osteopath after the first visit, and at discharge or the end of the data collection period depending which occurred first. On conclusion of the data collection period, participating osteopaths were asked to post their completed SDC tools back to the research team at the host institution. 2.3. Analysis Data were input into Microsoft Excel and checked for quality. The main analysis was descriptive, using the statistical functions within Excel to summarise the data. 3. Results

Table 1 Patients’ socio-demographic data. Patient characteristic

A total of 394 (9.4%) of the 4198 osteopaths on the GOsC Register of Osteopaths in 2009 volunteered to take part in the project. Among the 394 volunteers, 87% of these osteopaths actively collected data. A total of 1630 completed data sets were returned to the host institution for analysis. Data quality was generally good; there were some missing values in various questions (for example age data were missing for 2.6% of patients) and no datasets had to be excluded because of poor quality data. Data were collected on patients presenting for treatment during the first month of the three month data collection period: due to this discrete time-frame for initial data collection and follow up, some patients (n ¼ 33) had not completed their course of treatment at the end of the data collection period.

Gender Female Male Missing Age range 0e9 years 10e19 years 20e29 years 30e39 years 40e49 years 50e59 years 60e69 years 70e79 years 80þ Missing

No. of patients

%

912 703 15

56 43 1

91 48 143 351 299 293 200 123 39 43

5.6 2.9 8.8 21.5 18.3 18.0 12.3 7.5 2.3 2.6

C.A. Fawkes et al. / Manual Therapy 19 (2014) 125e130 Table 2 Anatomical sites of presenting symptoms. Site of symptoms

Head/facial area Neck Shoulder Upper extremity Thoracic spine Rib cage Lumbar Pelvic region (including sacro-iliac, pelvis, groin, glutaeal, hip Lower extremity Abdomen Other missing Total

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Table 3 Types of treatment and management given at first consultation.

First ranked site

Other sites recorded

N

N

%

Treatment and management type %

121 244 111 37 98 23 587 194

7.4 15.0 6.8 2.3 6.0 1.4 36.0 11.9

127 475 328 247 284 80 774 675

5.9 12.3 8.5 6.4 7.4 2.1 20.0 17.5

136 22 47 47 1630

8.3 1.3 2.9 0.6 100.0

635 53 85 0 3863

16.4 1.4 2.2 0.0 100.0

acute (7e12 weeks) by 14.5% of patients, and acute (six weeks or less) by 51.1%. For the patients with acute symptoms, 15.3% had experienced their symptoms for less than one week. The mode of onset was acute for 37.0% patients with 43.0% of patients experiencing their first onset of any symptoms, while 34.4% had experienced three or more prior episodes. A total of 13% of patients were absent from work at their first appointment, and 1% had been absent from work for 5 weeks or more. Medically diagnosed comorbidity was recorded using the index created by Groll et al. (2005); the most frequently reported diagnoses were hypertension (11.7%), asthma (6.6%), arthritis (5.7%), and upper gastrointestinal disease (5%). If anxiety (3.6%) and depression (3.6%) are considered together, mental health disorders become the second most common comorbidity. 3.2. Osteopathic management Clinicians considered that 97.7% of the patients consulting were suitable for osteopathic treatment; this means that on initial presentation clinicians did not feel that the patients required referral to a medical practitioner for further investigation or treatment, or required intervention from another healthcare professional. The types of treatment given were varied and complex drawing from a wide range of techniques which are acquired at undergraduate level and during postgraduate training; they are shown in Table 3. The question relating to osteopathic management was a multichoice question hence the large number of treatment types described. The most frequent types of treatment were soft tissue techniques (78.0%) and joint articulation (72.7%). This was followed by high velocity low amplitude thrust (HVLA) techniques (37.7%), patient education about their symptoms (35.8%), cranial techniques (25.8%), and exercise (22.6%). The treatments recorded in the “other” section included adjunctive treatments e.g. dry needling, lymphatic drainage, traction, and strapping. Participating osteopaths reported providing 97% of patients with explanations about the possible cause(s) of their symptoms, and how to avoid repetition or recurrence. More than 87% of patients received advice on a wide range of self-management strategies in addition to active treatment (Table 4); these included primarily cryotherapy, rest and relaxation, and exercises. 3.3. Outcomes of care Participating osteopaths reported that at the end of the course of treatment, 39% of patients were discharged and required no further

Number of patients

Manual therapy Soft tissue Articulation HVLA thrust Cranial technique Muscle energy Strain-counterstrain Functional technique Visceral Myofascial release (MFR) General Osteopathic treatment Pain management Relaxation advice Steroid Injection Acupuncture Electrotherapy Ice Orthotics Information and advice Education Dietary advice Exercise OTHER NONE TOTAL

N

%

1272 1185 615 420 299 122 224 42 128 17

78.0 72.7 37.7 25.8 18.3 7.5 13.7 2.6 7.9 1.0

133 0 65 42 19 13

8.2 0.0 4.0 2.6 1.2 0.8

583 52 369 107 38 5745

35.8 3.2 22.6 6.6 2.3

treatment, and 39% had reached the end of their current course of treatment but were recommended to return for episodic care. Episodic care is an option some patients choose, especially if they have a chronic recurrent condition, to maintain on-going contact with the osteopath for advice and support. A further 8% were referred on to another practitioner, most being referred back to their GP for further investigations or treatment, or to a hospital consultant. A further 2% were referred for investigation while remaining under the care of the practice. Data were collected also concerning treatment reactions; this included information about any temporary worsening of symptoms in the first 48 h after treatment (Table 5). Increased stiffness or pain were the most common reactions after the first treatment (18% and 14% respectively). Patients were asked to complete the Clinical Global Improvement Scale (Kemler et al., 2003; Berk et al., 2008) on the SDC form. This scale was used as it is similar to the data osteopaths routinely collect verbally from their patients. A total of 74.3%

Table 4 Self-management strategies recommended at first consultation. Self-management strategy Application of heat Application of cold Contrast bathing Rest Relaxation advice Specific exercise General exercise Naturopathic neuromuscular techniques Use of the Back book Use of the Whiplash book Natural remedies Vitamin or other nutritional supplements Other None Total

N

%

151 569 155 358 145 772 300 7

9.3 34.9 9.5 22.0 8.9 47.4 18.4 0.4

9 4 28 59

0.6 0.2 1.7 3.6

254 201 3012

15.6 12.3

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Table 5 Treatment reactions within 48 h of treatment. Symptom

After first treatment N

None experienced Increased pain Increased stiffness Dizziness Nausea Headache Fatigue Other Not known or not applicable TOTAL

969 238 293 24 12 38 107 9 145

After subsequent treatment(s) %

N

%

59.4 14.6 18.0 1.5 0.7 2.3 6.6 0.6 8.9

1260 61 71 5 4 12 44 4 210

77.3 3.7 4.4 0.3 0.2 0.7 2.7 0.2 12.9

1835

1671

of patients reported they were “improved”, “much improved” or “best ever” after the first treatment. At the final treatment, a small proportion (5.8%) reported they were “not improved but not worse”, and 0.8% of patients reported they felt worse. Four patients in the sample (0.2%) reported being much worse after the first treatment, but there were none in this category at the final followup. The majority of patients (76.3%) with chronic symptoms also reported an improvement by the end of their course of treatment. A small number of patients reported being absent from work at their first appointment (13%), and return to work was possible after two treatments for more than half of those patients. 4. Discussion Completed data sets were returned for 1630 patients; this means information was provided for this number of patients at whatever stage of completion their consultation/treatment reached, and recorded their initial presenting symptoms, and what care was provided as part of their management. This sample size of patients was sufficient for adequate statistics and analysis (Campbell et al., 2007) to provide a profile of current UK osteopathic practice. The face validity of the SDC tool was good, with almost all questions completed unambiguously for the typical osteopathic patient. The dataset produced using the SDC tool provides novel useful and wide-ranging information about patient characteristics, presenting symptoms, osteopathic management, service delivery, and prior use of NHS resources. Earlier work looking at the characteristics of osteopathic patient population is available but their comparison to the SDC dataset is sorely limited due to the differing nature of the data collection, and the varying clinical settings. However, a comparison of most commonly presenting age band, sex, and percentage of low back pain presentation has been obtained from studies where the data are available and is shown in Table 6. The lack of standardised approach underlines the difficulty

of comparing data over time. The creation of a prospective and standardised data collection tool will allow changes in practice and patient populations to be compared in the future thereby allowing clinicians to stay informed about how to develop their skills accordingly. For some minority groups of patients, a modified dataset is likely to be required to understand these patients better: e.g. the 9% of paediatric patients. This cross-sectional profile of osteopathic care in the UK is the most detailed to date. In contrast to earlier work, the patients in this pilot data collection process were all commencing treatment for a new symptom episode, the data about management were quite detailed including details of the “package of care” provided by participating osteopaths, and patients were followed-up for a short period of time (two months) to provide some outcome data. The results support the view that osteopaths predominantly treat musculoskeletal conditions, and a wide range of treatment types are delivered accompanied by selfcare advice and education. The data also described the provision of osteopathic care for infants among the volunteering osteopaths who collected data. This diversity of the range of care delivered to all ages has the advantage of offering patient choice, but may also be a source of confusion for members of the public when consulting an osteopath for the first time without personal recommendation. A range of service delivery data was collected and demonstrated that waiting times for treatment were short. The consultation duration was flexible but most appointments lasted 30 min or more. The findings of short waiting times, and choice in both treatment approach and after-care were consistent with research comparing osteopathic care with a hospital-based intervention (Chown et al., 2008). Chown et al., 2008 suggested that fewer patients dropped out in the osteopathy arm of their study for a variety of reasons which included the more flexible schedule of the osteopath, patients’ preference for hands-on therapy and views on its effectiveness compared with the more exercise-based approach of physiotherapy, personal characteristics, or past experience within private practice. Outcome data were collected including immediate reactions to treatment, and whether those initial treatment reactions were longer lasting. From the collected data, it was found that treatment delivered was safe with no serious or moderate adverse events, as described in the work by Carnes and Underwood (2008), being reported. Although short term pain and stiffness were common after treatment, this was consistent with the literature (Ernst, 2007; Froud et al., 2008; Rajendran et al., 2009; Carnes et al., 2010). Identifying that patients are suitable for treatment is a key requirement of osteopathic care; appropriate referral is a core requirement of the GOsC Code of Professional Practice (General Osteopathic Council, 2005). In this dataset 8% patients were referred by osteopaths to other healthcare professionals, mainly to their GP. Symptom improvement as an outcome was collected also using the SDC tool. A total of 39% of patients were reported as being discharged with satisfactory resolution of symptoms; a proportion

Table 6 Patient data compared between existing data collection studies.

Age band for highest number of presenting patients Percentage of female patients Percentage of male patients Percentage of patients in which lumbar spine symptoms were reported N/A data not available. a 1% of patients declined to answer.

SDC data (Fawkes et al., 2009)

McIlwraith, (2003)

GOsC (2001)

Pringle and Tyreman (1993)

Hinkley and Drysdale (1995)

Burton (1981)

30e39

40e49

36e45

41e60

20e29

35e54

37 63 68

48 52 46.2

48 52 N/A

60.5 39.5 49

49.8 50.2 52

a

43 56a 36

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of patients (39%) were recommended to return for “episodic care” i.e. treatment at longer intervals, at some point in the future. A longer follow-up period would be required to identify how many patients did follow this advice, and what effect this had on their long term outcome. Symptom improvement data was collected using the Clinical Global Improvement (CGI) scale; 80.7% of all patients reported some improvement, with 76.3% improvement in chronic patients. However, these data were not collected independently from patients away from the practice venue and this is an amendment which would be undertaken in future data collection exercises. The positive findings of osteopathic care are consistent with the evidence underpinning the recommendations of osteopathic care as a first line option in the NICE guidelines for early management of chronic non-specific low back pain (Savigny et al. and Guideline Development Group, 2009). Finally, the under-representation of certain sectors of the population in the patient sample was evident. For those with low income, whether associated with unemployment, disability, poor health or age, this may be due to the lack of sessions paid for by the NHS, lack of awareness about osteopathy itself, or simply a reflection of the areas from which participating practices were located. The data collection process was the final stage within a larger study to develop and pilot a standardised data collection tool, and provide some prospective baseline data concerning the profession. However, there were limitations in the process and the quality of the data collected which the pilot process identified. The sample of patients though substantial in number cannot be considered fully representative of the whole population of osteopathic patients due to the volunteer nature of the participating osteopaths, and the non-random selection of practices. Further, it could be argued that more motivated clinicians are more likely to participate in data collection processes which could have an impact on the types of patient recruited, the types of treatment delivered, and the supportive care provided underpinned by evidence-informed practice. The role of patient selection bias cannot be discounted fully even though clinicians were asked to collect data on ten consecutive new symptom presentations or new patients. The sample size of osteopaths collecting data would ideally have been larger. This may have been due to the fact that the national pilot was a new initiative for the profession. In future, participation could be increased by demonstrating to osteopaths the use to which previous data have been put, and demonstrating the value that data collection has to individual clinicians and their practices. Alternatively, osteopaths could be randomly selected to take part in a data collection project. The collection of outcome data is one area requiring further attention. The CGI scale was used to collect outcome data, but a more widely used scale e.g. a numerical rating scale was regarded as a more suitable alternative for future use allowing a quantitative measure of change to be recorded. Ideally outcome data would be collected by an independent person external to the practice so that the patient is less likely to be influenced by the notion that the treating clinician will review their outcome data. Inherent in this issue is the tension between a clinician wishing to view outcome data so that it can inform further treatment, and amend it if this is required, to gaining robust feedback from patients who may be reluctant to report that symptoms are not improving. The use of Patient Reported Outcome Measures is being promoted within UK healthcare to allow more effective measurement of change, but the issue of response bias needs consideration. In response to this, the National Council for Osteopathic Research is developing an online system that will allow patients to submit outcome data after osteopathic treatment which will be independently analysed allowing summary data to be reported to osteopaths about their patients collectively whose details will be anonymised. The use of a wider cross-section of the profession selected at random to

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participate in such data collection initiatives would also give a wider profile of professional activity. Collecting data about patients’ experiences of care in an anonymised manner is being explored also to allow patients to contribute data on any treatment reactions and other experiences of care to provide further insight for the osteopathic profession to that already identified from other work (Leach et al., 2011). 5. Conclusions The national pilot of the SDC tool developed in a previous study provided evidence of the face validity and relevance of the dataset, and delivered a detailed profile of care provided in UK osteopathic private practices. Examination of pilot data showed a small number of questions required amendment, and additional facilities would be required for collecting certain types of data e.g. outcome data. These changes notwithstanding, a valid, fit-for-purpose dataset for further snapshot surveys within osteopathy now exists. The data collected using the SDC tool has highlighted areas for future work. Further development of the tool is indicated for paediatric patients. Further research could explore questions arising from the data, e.g. the types of exercise prescribed by osteopaths; previous research identified little training in exercise prescription within the osteopathic curriculum (Zamani et al., 2007, 2008), the outcomes for “episodic care” despite insurers/health commissioners not advocating its use (AXA PPP Healthcare, 2010; BUPA, 2010), and the interactions and referral patterns by osteopaths to other healthcare professionals. Ethics Ethical review was provided by the Research Ethics and Governance Committee of the host institution. Funding Funding for this project was provided by the General Osteopathic Council. Acknowledgements We are grateful to the General Osteopathic Council (GOsC) for awarding funding for the development and national piloting of a standardised data collection (SDC) tool. We are grateful also to Mr Michael Watson and Mr Kelston Chorley of the British Osteopathic Association, Dr Jorge Esteves of the British School of Osteopathy, and Mr Bryan McIlwraith, a private practitioner with experience in practice-based data collection, for acting as the steering committee for this project, and all of the osteopaths who were involved in the development of the SDC tool and data collection process. References AXA PPP Healthcarehttp://www.axappphealthcare.co.uk/assest/documents/handbooks/ personal/cash-plan/cashback-handbook-15.pdf; 2010. accessed 12.05.10. Berk M, Ng F, Dodd S, Callaly T, Campbell S, Bernardo M, et al. The validity of the CGI severity and improvement scales as measures of clinical effectiveness suitable for routine clinical use. J Eval Clin Pract 2008;14(6):979e83. BUPA. BUPA Healthcover. http://www.bupa.co.uk/individuals/health-life-cover/ health-insurance/healthcare-select-1; 2010. accessed 12.05.10. Burton AK. Back pain in osteopathic practice. Rheumatol Rehabil 1981;20(4): 239e46. Campbell M, Machin D, Walters SJ. Medical Statistics: a textbook for the health sciences. 4th ed. Chichester: Wiley; 2007. p. 1e344. Carnes D, Underwood M. Defining adverse events in manual therapies. Int J Osteopathic Med 2008;11(4):145e54.

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