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. 2021 Dec 22;28:49–59. doi: 10.1016/j.echu.2021.09.001

Osteopathic Models Integration Radar Plot: A Proposed Framework for Osteopathic Diagnostic Clinical Reasoning

Carmine Castagna a, Giacomo Consorti a,b,⁎, Matteo Turinetto a, Christian Lunghi b
PMCID: PMC8720649  PMID: 35002577

Abstract

Objective

The purpose of this article is to propose a tool to assist with clinical reasoning to select and integrate different osteopathic models and evidence-based actions into clinical practice.

Discussion

The authors adopted the guidelines for writing a commentary as a reporting framework for the present article. The proposed Osteopathic Models Integration Radar Plot has potential for integration into clinical practice and the educational environment. This framework may enable clinicians to manage complex clinical phenomena, such as musculoskeletal disorders related to allostatic load.

Conclusion

This proposed framework may be helpful to communicate the outcome of osteopathic evaluations to other healthcare professionals. This proposed model will need to be tested to determine feasibility.

Key Indexing Terms: Osteopathic Medicine; Manipulation, Osteopathic; Models, Educational; Models, Theoretical; Clinical Decision-Making; Decision Making, Shared

Introduction

The Osteopathic International Alliance recognized the renovated principles and structure-function models as commonly used approaches to osteopathic patient care worldwide; however, their implementation in practice differs across countries.1 Despite reports by the Benchmark of the World Health Organization2 that the structure-function models are part of training in osteopathy, European osteopaths consider other approaches as more pertinent shared concepts: Parietal-Structural, Visceral, and Craniosacral.3 Fryer highlighted these mechanical “pillars” as a cause–effect model of osteopathic hands-on techniques that could have contributed to moving osteopathic manipulative therapy away from a person-centered care approach.3 The structure-function models appeared just recently in the core competencies of a European country: the Italian proposal.4

Yet, the osteopathic conceptual models need updating. Structure-function models were recently mentioned as an example of theoretical frameworks that require robust assessment, revision, and consensus.5 Esteves et al's commentary5 provided valuable steps to put in place for the identification of strengths and limitations of each model of care in osteopathic education and practice. It is undeniable that most of the aspects considered central to osteopathic practice are ready to be updated in a shared process with the community of practice to foster a stronger professional identity and to enhance the recognition of osteopathic manipulative therapy as a mainstream healthcare discipline.

A recently published commentary6 highlighted the prevailing trend in the osteopathic field toward an uneven focus in practice. On the one hand, there are proposals shifting practice toward the biopsychosocial model, favoring a hands-off treatment more oriented to a psychosocial, educational approach.6 On the other hand, more biomechanically focused ideas are considered more operator-centered.6 The unique palpatory element that is considered by the osteopath may not necessarily be shared with the patient or with other healthcare professionals. Smith6 called on osteopaths to reflect further, advising that it is now time to support integrated models where hands-on care is adequately implemented by science to better address the patient's condition. Nevertheless, in the essential common core competencies of osteopaths,1 it is reported that each practitioner, in addition to evidence-based health care, should demonstrate an understanding of the structure-function models.

There is a great opportunity to balance biological and psychosocial elements considering a biopsychosocial approach where the part “bio” refers to neurologic-mechanical-circulatory-respiratory-metabolic processes that are considered associated with psychological responsiveness to manage social-environmental demand.7 The integration of the various models could better define person-centered osteopathy, as could addressing the management of all 3 ways of understanding and relating to unhealth/disease (the biomedical perspective), illness (the phenomenological perspective), and sickness (the social perspective).7 Although the issue of the reference models of osteopathic clinical reasoning is much discussed, standardized osteopathic evaluation and treatment procedures are still lacking, especially concerning clinical reasoning.7

Walton and Elliot8 introduced a new clinical reasoning framework that could be applied in pain management through the use of a radar plot and conceptual triangulation; it represents a useful tool for the interpretation of complex pain patterns. The authors encouraged other researchers to substitute the domains in their proposal with those that are relevant for fields other than pain to help clinicians across disciplines make sense of highly complex and often confusing areas of clinical practice, education, and research.

Therefore, the purpose of this article was to propose a clinical reasoning framework to include osteopathic interpretations of complex clinical patterns in adaptive load needs, using adaptability across patient populations to define personalized treatment. In this model, we propose concepts of individual adaptive clinical typing (eg, identifying observable characteristics of an individual resulting from the interaction of his/her adaptive and self-regulative processes to environmental challenge) and triangulation, as well as the radar plot tool. We propose a framework for the selection and integration of structure-function models in clinical practice.

Methods

We used the guidelines of Berterö as reporting framework to develop and report this model.9 Our goal is to discuss new and distinctive perspectives on current issues related to the application of structure-function models in the osteopathic clinical practice.

Discussion

We propose the following framework could be useful to align the methodology used by the osteopaths in the interpretation of the patient's presentation in relation to their adaptation capabilities to allostatic challenges. To the best of our knowledge, up to date, there are no available tools to support a common interpretative framework of the clinical presentation in an osteopathic perspective. Moreover, the framework proposed in the present commentary might help conceptualize philosophical concepts common to several health professions' clinical settings and communicate the osteopathic evaluation and outcomes to other healthcare professionals.

Overview of Osteopathic Structure Function Models

Osteopathic structure-function models have been developed to promote the understanding of the patient's complex health functioning.6 The assessment of body systems’ activities helps to develop differential diagnoses of the most likely causes of the symptoms and conditions presented.7 The models also contribute to designing a comprehensive management plan that helps patients restore and maintain their maximal health potential7,10 (Table 1).

Table 1.

Osteopathic Structure/Function Models

Model Osteopathic Focus
Biomechanical To enhance the movement function of the myofascial and skeletal system11, 12, 13, 14, 15 and confront pain.12
Respiratory-circulatory To improve ventilatory function,13, 14, 15 enhance circulation in the entire body,16, 17, 18 including cerebral perfusion,19 and the stiffening or hardening of the vessel.20
Metabolic To enhance immunity,21, 22, 23, 24, 25 endocrine, 26 and visceral activities, also including gastrointestinal function.27, 28, 29, 30, 31
Neurologic To balance central and peripheral autonomic nervous activities,32,33 including exteroceptive, proprioceptive, and interoceptive processes,19,34,35 and pain.27,28,33
Biopsychosocial model The Biopsychosocial model, first proposed by Engel in 1977,36 can be considered both a clinical care philosophy and a practical guide to individual patient management. In recent years, the osteopathic biopsychosocial model was updated37,38 and discussed in light of the body-mind-spirit and environment unity39 principle, the enactive model,5,39 as well as psychoneuroimmunology29 to enhance patients’ sense of agency and responsiveness to allostatic load.40
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Structure-function models are typically based on basic scientific observations of systemic physiology, musculoskeletal movement, body fluids and gas exchanges, metabolic processes, neurologic activities, and biological and psychological patterns of interaction with the environment: the adaptive homeostatic-allostatic processes (Table 2).17,41

Table 2.

Adaptation Processes—Concepts Related to Human Coping Strategies and Stress Response42

Adaptation Process Definition
Homeostasis Physiological processes are stable and important for life: body temperature, pH, glucose, and oxygen voltage are maintained within the optimum range.
Allostasis The mechanism of keeping physiological processes in equilibrium and achieving homeostasis as environments and/or life history changes includes interoceptive and intrinsic network communication activities, and key mediators include the HPA axis, catecholamines, and cytokines.
Allostatic load Cumulative consequence of allostatic disease. Can be adaptive in the brief period but may rise over time or in the influence of environmental stress factors.
Allostatic overload Allostatic load affects the individual's ability to cope, contributes to secondary outcomes (neural-metabolic-immunological overload and musculoskeletal-fascial system alterations), and raises the incidence of illness.
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HPA, hypothalamic-pituitary-adrenal.

Structure-function models have been developed to extend the renovated osteopathic tenets into pragmatic, comprehensive patient-centered care;7 qualitative research has reported that structure-function model is also employed in Australia, New Zealand, and the United Kingdom to achieve an osteopathic multidisciplinary decision-making and reasoning process41; clinical reasoning focused on the 5 osteopathic models was reported as consistent and distinctive patient-centered osteopathic care.4,41

In the Glossary of Osteopathic Terminology,43 the 5 osteopathic models are described as treatment approaches to address physiological functions that maintain health and play a central role in adaptation to stressors as well as in recovery and repair from illness and disease.

Clinical Osteopathic Assessment Hypothesis: The Radar Plot and Triangulation

The Radar Plot is proposed to select and integrate structure-function models in clinical practice. It results in a person-centered approach to improve the patient's self-regulation and ability to cope with the allostatic load. Osteopathic treatment plans and every single session are composed of a mixed approach, that is, combining a tailored person-centered approach with a symptom-based approach.40,44 Person-centered approaches are tailored hands-on strategies. They aim to improve self-regulative systems and allostatic load associated with fascial patterns of the entire body (maximalist methods) or localized tissue alterations, also considered areas of interest by both the patient and the practitioner (minimalist methods). Maximalist and minimalist methods are combined with the patient's active strategies, such as exercise, mindfulness, and other lifestyle-related activities. To administer symptom-based approaches, osteopaths must consider evidence-based reports for similar clinical contexts, selecting appropriate procedures according to the research findings: the techniques and the areas of the body that resulted helpful in research articles conducted in the field.40,44

The treatment plan needs to be elaborated in a shared decision-making process between the patient and the osteopath.40,44,45 The osteopathic shared decision-making process is based on the integration of narrative of the patient, clinical history, and objective examination of patient presentation, as in the other health professions. The osteopaths, and other manual therapists, consider different related multidimensional aspects, such as allostatic load index, self-regulation system functionalities (ie, biomechanical, neurologic, respiratory-circulatory, metabolic, psychologic), and palpatory findings (ie, somatic dysfunction and/or fascial pattern for the osteopathic practitioners).40,44,46 During the clinical encounter, especially during patient interviews, both patient and practitioner can share a high-value experience, which can be investigated through the patient's narrative and can be understood by decoding multilevel communication: not just what the patient says but also what the patient does not say and what the patient's body language communicates. The clinician review of the clinical history allows the patient to give meaning and value to the multiple aspects of his clinical conditions and general health status.

The anamnestic phase is directed to generate a hypothesis by decoding individual adaptive capacity, as well as body system functioning. The patient's present, remote, and familiar clinical history, lifestyle, and environmental interactions were assessed to verify their impact on the patient's presentation and state of health (Table 3).

Table 3.

Assessment of the Self-Regulative Systems

Allostatic load index Biomarkers: blood pressure, metabolic parameters (glucose, insulin, lipid profiles, and waist circumference), markers of inflammation (interleukin 6, C-reactive protein, and fibrinogen), heart rate variability, sympathetic nervous system activity (12-hour urinary norepinephrine and epinephrine), and hypothalamic-pituitary-adrenal axis activity (diurnal salivary free cortisol)47
Psychomarkers: Allostatic load assessment48
Life markers: Social Readjustment Rating Scale49
Self-regulative systems Biomechanical Neurologic Circulatory/Respiratory Metabolic Biopsychosocial
Clinical history Myalgia, tendonitis, capsulitis, arthralgia, chondropathies, postural control alteration, work-related musculoskeletal injury, etc. Neuralgia, radiculopathies, autonomic disorders (hyperthermia, perspiration, etc.), disorders of the sense organs, changes in sensation (paresthesia, dysesthesia, allodynia, etc.), headache, migraine, etc. Mucosal congestion, lymphatic, venous, inflammation, or infection of the respiratory tract, heart disease, circulatory failure, etc. Fatigue, infections, toxicity, poor ability to repair tissue, sleep disorders, thyroid disorders, etc. Occupational musculoskeletal disorders, chronic pain; functional disorders, such as irritable bowel syndrome, fibromyalgia, and chronic fatigue syndrome associated with pain, cognitive impairments, and sleep disturbance; chronic illness and long-term conditions associated with biopsychosocial processes leading to health problems, for example, depression and anxiety; medically unexplained symptoms, sickness behavior, frequent feeling of general tiredness, difficulty concentrating, irritability, panic attacks, crying, sleep disorders, change in body mass not associated with nutritional changes (metabolic alterations), high levels of perceived stress; failure in family support, social and health systems, environmental impacts, etc.
Standardized self-report evaluation Short musculoskeletal function assessment questionnaire50 Musculoskeletal functional limitations index51 Central Sensitization Inventory (CSI)52
Body Perception Questionnaire -short form (BPQ) 53
-Postural awareness scale (PAS) 54 		Brief adult respiratory system health status scale-community version (BARSHSS-CV)55 Gastrointestinal Symptoms Rating Scale (GSRS)56 Short Form - Profile of Mood States (POMS-SF)57
STarT back screening tool58
Depression, anxiety and stress scales59
Functional objective examination Postural control test60 Manual assessment tests of central sensitization 61 and of autonomic nervous system tone62 Examination of the amplitude of the peripheral pulses, considering its relationship with arterial stiffness62
Manual assessment of respiratory motion63 		Gastrointestinal distress signs62 Waddell signs64
Effect of provocation tests on physiological functions Emergent hypothesis of clinically relevant osteopathic palpatory findings:
- somatic dysfunctions
- fascial patterns		 Emergent hypothesis of clinically relevant osteopathic palpatory findings:
- somatic dysfunctions
- fascial patterns		 Emergent hypothesis of clinically relevant osteopathic palpatory findings:
- somatic dysfunctions
- fascial patterns		 Emergent hypothesis of clinically relevant osteopathic palpatory findings:
- somatic dysfunctions
- fascial patterns		 Emergent hypothesis of clinically relevant osteopathic palpatory findings:
- somatic dysfunctions
- fascial patterns
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Sample indicators for each domain of a patient's self-regulative system status. Consequently, the generated hypothesis is to be verified into a collaborative patient-osteopath decision-making process.

The moderators are criteria that are used to monitor the patient's health levels during the treatment plan. For example, the allostatic load index was proposed as one of the tools to be considered a decision-making moderator to assess treatment progress, especially in chronic conditions. The drivers are criteria that guide the practitioner into and out of a clinical decision. For example, body systems’ functional examinations, behind objective examination tests (both appropriate for the patient presentation), and patient subjective responsiveness to provocation tests were proposed as tools to guide decisions about the tailored treatment to be administered.

Five domains are considered potential maladaptive drivers; in other words, they represent a self-regulative system failure correlated with allostatic load and associated with patient presentation. An example of the multidimensional aspects collected by patient encounters to define the 5 domains is shown in Table 3.

The 5 points are represented by the osteopathic structure-function models, in other words, 5 self-regulative systems involved in the adaptation processes, in health and consequently in illness and disease. They are as follows: (1) biomechanical processes involved in musculoskeletal motion,65,66 postural balance 67,68 and pain12; (2) respiratory-circulatory activities such as breathing patterns,13, 14, 15 body fluids supply, and drainage,16, 17, 18 involved in various musculoskeletal and systemic clinical conditions; (3) metabolic function concerning immune,21, 22, 23, 24, 25 endocrine,26 and organ activities, such as gastrointestinal absorption and disposal69, 70, 71, 72, 73; (4) neurologic voluntary and autonomic pathways involved in cortical attentional processing, proprioceptive and interoceptive pathways related to pain19,27,28,32, 33, 34, 35,74; and (5) biopsychosocial components of the health spectrum of the person and the community, as well as nocebic beliefs and unhealthy lifestyles, are highly considered better to understand disease, illness, and sickness behaviors.37,38

The authors support the hypothesis in which diagnostic procedures can no longer be considered emerging from the operator's palpation ability alone. The intuition, observation, and palpation of changes in the tissue exercised by the osteopath must be processed in light of the patient's responses and related sensory awareness.

The patient's perception derived from the practitioner's palpation becomes a powerful interface between the operator and patient. It favors patient embodiment and body awareness, the way the body is felt, visualized, and positioned, and recognizing that the particular shape and nature of one's physical, temporal, and social immersion is what makes meaningful experience possible. It allows both patients and osteopaths to reflect on patient presentation, on individual perception, on the process of care, and give a shared sense to them.75

The impact of palpatory findings on a patient's perception (eg, provocation test or inhibitory test76) guides the osteopath in the selection of the different types of touch (eg, affective touch, interoceptive touch, etc.), delivered through different osteopathic techniques, or movement (suggested during a patient's active approaches). The improvement of motion ability or pain, while the osteopath is administering a specific touch on somatic dysfunction area, or while positioning the patient facilitating a fascial pattern, become indications for the osteopaths to identify the appropriate techniques.

The provocation tests are tools to design a tailored treatment in a shared decision-making process. Osteopaths administer different types of touch—using provocation tests—to assess pleasant stimulation for the patient, which also represents the proper one to be focused on somatic dysfunction or fascial patterns, according to the patient's preferences (Table 4).

Table 4.

Selection of Osteopathic Touch Based on the Impact of Osteopathic Palpatory Findings and on Multidimensional Nature of the Patient's Complaint

Examples of Some Clinical Hypothesis of Tissue Alterations Involved in Maintaining Somatic Dysfunction or Fascial Pattern Hypothesis of Mechanoreceptors Mostly Involved in the Dysfunctional Pattern Provocation Tests (Touch or Movement) to Evocate Patient Responsiveness Type of Touch (Applied by the Practitioner) in Osteopathic Approaches Movement (used by the Patient) in Osteopathic Approaches Functional Response Expected After Treatment
Myofascial tissue Muscle spindle Compressional moves toward muscle mass Soft-tissue technique Micromovements, coordination, and precision Tonus decrease in related myofibers
Myotendinous junction
Joint capsules		 Golgi receptor Slow elongation of related collagen fibers above a certain strain threshold (a post-isometric relaxation could be requested) Muscle energy technique Hanna's Pandiculation techniques
Active resistant stretches		 Tonus decrease in related myofibers
Spinal ligaments
Joint capsule		 Pacini corpuscle Rapid pressure changes and vibration High-velocity techniques
Recoil techniques
Harmonic techniques		 Rapid stimulation and vibratory tools exercise Enhancement of local proprioception and improvement in local neuromuscular self-regulation
Joint capsule Ruffini endings Slow deformation along tangential vectors Myofascial release
Balanced ligamentous tension or ligamentous articular strain		 Slow movements with myotatic reflex activation
Melting stretches		 Inhibition of sympathetic activity
Epidermis Free nerve endings Antalgic positioning associate to light and slow touch, affective touch Interoceptive osteopathic approaches (ie, positional release techniques) Meditative movements
Experiential bodywork
Intentional breathing
Intrinsic myofascial
vibration exercises		 Tactile C-fibers afferent: affiliation, pain inhibition, well-being
Relieving pain: orienting response, pain desensitization
Visceral tissue Piezo 2 Antalgic positioning associate to light and slow touch, affective and vibratory touch Harmonic and vibration technique Low-frequency vibratory exercise
Intrinsic myofascial vibration exercises		 Affiliation, pain inhibition, well-being
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Reprinted with permission from Baroni et al.45

The radar plot and related principle of triangulation are introduced as a method for defining the nature of an illness experience's primary driver(s), showing 5 domains as potential faults of the self-regulating system. Figure 1 demonstrates these 5 allostatic overload drivers. While not exhaustive, the 5 points reflect specific aspects of a patient's illness-related context, providing far greater granularity for clinical decision-making than current osteopathic treatment models do.

Fig 1.

Fig 1

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Osteopathic Models Integration Radar Plot. BPS, biopsychosocial.

The aim of the radar plot tool is to provide guidance for clinical decisions related to treatment planning. In each domain, the status levels are limited to homeostatic, allostatic, allostatic load, and allostatic overload qualitative ranges. The diagrammatic representation of relative self-regulative requests on each of the 5 systems will promote care decisions by easily defining the primary drivers of the perception of the patient's illness (see the example in Table 5, Fig 2).

Table 5.

Example of Data Collection and Integration to Design the Osteopathic Models Integration Radar Plot

Item Finding
Clinical history Age: 55; Sex: F; Profession: retired (work officer).
Chief complaint: Chronic left shoulder pain and altered ROM. Medical diagnosis: adhesive capsulitis, also known as frozen shoulder.
Onset 2 years before, without trauma. The patient came for pain radiating below the shoulder.
Subjective symptoms: site: left shoulder pain (the patient is left-handed); onset: Started insidiously 6-week before and had not diminished in intensity with medications; character: Insidious pain, allodynia in the thoracic outlet (bilateral); radiation: gradual onset 2 years before, without trauma; associations: tension-type headache; sleep disorders; anxiety; the onset was in the early stage of menopause; a frequent urge to swallow was reported by the patient. Time course: no changes during the day, nor by night at the first onset. The precedent secondary events improve by night after mindfulness exercise. Exacerbating/relieving factors: no exacerbating factors, nor relieving factors at the first onset. The precedent secondary events improve by relaxation, mindfulness exercise, and osteopathic manipulative therapy. Various constrained head postures were reported as exacerbating symptoms. Severity: 8 of 10 in severity level of pain that affected daily living habits resulted in Shoulder Pain and Disability Index (SPADI).77
Objective examination findings related to the chief complaint: positive Neer's, Hawkins’, and Yocum's tests.
Multidimensional aspects of patient perception: the patient reported feeling uncomfortable and pain in the left shoulder while styling her hair. Thanks to osteopathic evaluation, the patient became aware that she felt uncomfortable and pain bilateral on the shoulders and the neck, and radiation in both the upper limbs while putting on a shirt.
Allostatic load index Biomarkers: no alteration; psycho-markers: allostatic load clinimetric criteria and assessment pointed out an allostatic overload;48 life-markers: the patient reported on the Social Readjustment Rating Scale the loss of her husband 3 years earlier, the transfer abroad of his only daughter 2 years earlier, and the change of house in progress.49
Models selection Neurologic Biopsychosocial
Standardized self-report evaluation Body awareness alterations were highlighted by high scores level registered at body perception questionnaire-short form; 53 the Central Sensitization Inventory (CSI) showed a probable central sensitization state.52 The psychological distress reported by the patient was highlighted by the Short Form - Profile of Mood States (POMS-SF).57
Functional Objective Examination Five positive tests to 8 were registered at the manual assessment tests of central sensitization;61 that confirmed the central sensitization characteristic signs and symptoms manifested by the patient. Symptom magnification and sickness behavior were shown by 4 positive tests to 5 were registered at the Waddell signs,64 which confirmed the physiological distress reported by the patient.
Effect of provocation tests on physiological functions The following osteopathic palpatory findings were identified as more relevant with respect to the others detected:
M99.09 (ICD-1078) fascial pattern (decompensated according to Zink model43 associated with TART signs43 generalized in all the posterior midline); M99.07 (ICD-1078) Upper Extremity; M99.08 (ICD-1078) rib cage. Different provocation tests showed a positive impact of palpatory findings: improvement at manual assessment tests of central sensitization and on Waddell signs.
Models integration The emergent clinical outcomes guide the osteopathic on integrating osteopathic neurologic and biopsychosocial models to design a tailored treatment. The process also drives the selection of the most appropriate somatic dysfunction and fascial pattern to administer the osteopathic approach. The emergent pattern clarifies also the proper types of touch (employed in the osteopathic manipulative techniques) or movement (suggested during a patient's active approaches) to be used to address the compromised self-regulative failure related to patient's health condition (ie neurologic and psychosocial) and chief complaint (ie adhesive capsulitis). The entire process is represented into the Osteopathic Models Integration Radar Plot (Fig 2).
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ROM, range of motion.

Fig 2.

Fig 2

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Osteopathic Models Integration Radar Plot filled using information derived from the clinical example in Table 5.

The Radar Plot has been composed using the following methodology: There are 5 levels on each osteopathic model. To acquire one level on a specific osteopathic model within the Radar Plot, it is necessary to obtain a positivity in one of the items of the Table 3 for that specific model (ie, clinical history, standardized self-reported evaluation, functional objective examination, effect of provocation tests on physiological functions). The only exception is represented by the item “allostatic load index.” Indeed, if positive, it gives one level to all the osteopathic models due to its nonspecificity.

During the clinical encounter, the amount of time required to complete the radar plot could represent a limitation on its use. Future research could address a synthesis of different scales and tests used to collect the radar plot. Other authors reported their synthesis of previously validated instruments.48 Clinimetrics is used to indicate a domain concerned with indexes, rating scales, and other expressions used to describe or measure symptoms, physical signs, and other distinctly clinical phenomena, which do not find room in the customary taxonomy.48 The researchers developed a new clinical assessment and clinimetric criteria of allostatic load. They suggested criteria and areas that need to be explored for the determination of allostatic overload. The proposed criteria for the determination of allostatic overload are based on insights derived from research and clinical experience.48

The Osteopathic Models Integration Radar Plot could represent one of the first steps needed to collect clinical prediction rules (CPRs) customized for osteopathic care settings. The osteopathic approach is mostly tailored to the person's self-regulative processes with health and disease rather than focusing on a specific condition. Clinical prediction rules are tools designed to guide practitioners in their everyday clinical decision-making.79 Additionally, provide practitioners with an evidence-informed tool to assist in patient management when determining a particular diagnosis or prognosis (eg, somatic dysfunction) or when predicting a response to a particular intervention (osteopathic approaches). Osteopathic CPRs could represent strategies that successfully subgroup or distinguish types of the allostatic load manifested by the patient as related to the illness condition.80 That targeted approach or stratified care is considered better than a more general approach that offers similar treatment to a large group of people.80

Limitations

The model uses a simple scoring algorithm, which could lead to an excessive simplification of complex systems such as patients. Thus, the simplification of complexity to make operational decisions based on its interpretation risks flattening and excessively reducing some aspects that it would be good to keep complex. Secondly, the proposed model would benefit from implementation and experimentation. It is a model with solid theoretical foundations; however, it lacks evidence in its clinical use as a whole. Every single item/test/scale presented in the model has been validated and used in clinical research, but to the best of the authors’ knowledge, there are no studies that used all the reported tools to compose a single score.

Future Research

Different steps of future research will be involved to incorporate the best available evidence (including CPRs) combined with clinical expertise and patient preference to improve the overall quality of care provided to individual patients.81 For the development and validation of CPRs in the osteopathic field, a second step should be aimed at validating the CPRs. A “test set” or “validation set” is needed to ensure that results are replicated in a different population of patients or a different healthcare setting.81 The third step should be focused on an impact analysis to verify whether CPRs can improve clinically relevant outcomes, increase patient satisfaction, and decrease costs once implemented in the realities of busy clinical practice.81

The authors support a less linear model of integrating the research results into practice. Using a circular model rather than a hierarchy or pyramid allows clinicians to take into account their experience, patients’ values, and preferences, as well as evidence to design complex interventions such as osteopathic manipulative therapy.80 Future studies should be carried out to try out the feasibility of presenting osteopathic shared decision-making, particularly osteopathic model selection and integration processes, to design a tailored treatment using radar plots.

Conclusion

We propose this new framework to facilitate clinical reasoning for the selection and integration of different osteopathic models in clinical practice. We believe that the radar plot is easy to build, that it enables understanding of complex clinical patterns, and that it can be generalized through populations of patients with different musculoskeletal conditions related to allostatic load and self-regulative impairments.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

Design (planned the methods to generate the results): C.C., G.C., C.L.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): M.T., C.L.

Literature search (performed the literature search): C.C., G.C., M.T., C.L.

Writing (responsible for writing a substantive part of the manuscript): C.C., G.C., C.L.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): M.T., C.L.

Practical Applications.

  • •

    A radar plot framework for osteopathic clinical reasoning is presented.

  • •

    The radar plot uses triangulation for complex clinical patterns recognition.

  • •

    Patient's adaptive load is assessed to define personalized treatment.

  • •

    The framework guides clinical decision-making for osteopathic models selection and integration.

  • •

    The new framework requires formal empirical study to determine its overall usefulness.

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