Tradition-Dismissive vs. Tradition Reconceptualization Approaches in Musculoskeletal Care: The Example of Osteopathic Care

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This study focuses on the debate between traditional and modern concepts in musculoskeletal care and explores the feasibility of integrating traditional principles with modern scientific approaches using Osteopathic Care (OC) as an example.

The research methodology section does not clearly describe how the literature was selected, whether expert interviews followed a standardized process, and how the data was analyzed. It is recommended to provide more details and improve this section.

The discussion section involves multiple frameworks (such as the Neuroaesthetic-Enactive Paradigm and Functional Neuromyofascial Activity) but fails to systematically explain how these theories are interconnected. It is recommended to use diagrams or charts to further illustrate their relationships.

It is recommended to incorporate real-world cases or preliminary experimental data to demonstrate the clinical feasibility of the framework. Additionally, the discussion section could explore how this framework can be adapted and applied in different healthcare settings to highlight its practical value.

Author Response

Thank you very much for taking the time to review this manuscript. Please note that in the new version of the manuscript, the changes made following your suggestions are highlighted in red to enhance readability. Thanks to the valuable feedback from the reviewers, we have had the opportunity to enhance the methodology of the perspective paper by incorporating "Materials and Methods," "Results," and "Discussion" sections, as well as a "Limitations and Future Directions" subsection. The word count has increased significantly, from 1,887 words in the initial version (excluding the 4 tables) to around 5,930 words (excluding the 4 tables). Additionally, we have added a "Clinical Scenario" subsection, complemented by Figure 2, to demonstrate how the four-step framework for patient-osteopathic practitioner-environment synchronization can be adapted and applied in real-world clinical practice. Lastly, we expanded the reference list, increasing the number of citations from 32 in the original version to 74 in the revised manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.

# Reviewer 1

Comment 1: This study focuses on the debate between traditional and modern concepts in musculoskeletal care and explores the feasibility of integrating traditional principles with modern scientific approaches using Osteopathic Care (OC) as an example. The research methodology section does not clearly describe how the literature was selected, whether expert interviews followed a standardized process, and how the data was analyzed. It is recommended to provide more details and improve this section.

Response 1:  Thank you for your valuable feedback. We appreciate the opportunity to clarify and enhance the description of our research methodology. In response to your concerns, we have included the Materials and Methods section (lines 173-225), detailing the Research Question, the  Study Design and Theoretical Framework, the Literature Search Strategy, the Eligibility Criteria and Selection Process, and the structured Reflective process employed for synthesizing key insights. Please find below the added Materials and Methods section:

“ 2. Materials and Methods

2.1 Research Question. This perspective paper explores the following research question:  "How can an integrative conceptual and practical framework that reconciles osteopathic tradition-dismissive and tradition-reconceptualization approaches, while incorporating osteopathic principles informed by enactivism and related biobehavioral synchrony strategies, contribute to the development of a patient-centered osteopathic model that enhances the clinical application of bodily, cognitive, and existential domains, optimizes musculoskeletal health outcomes, and fosters interprofessional collaboration in clinical practice?"

2.2 Study Design and Theoretical Framework. This perspective paper was developed following established guidelines for writing commentaries, a methodological approach commonly used to explore emerging areas of inquiry in the absence of extensive empirical data [27]. To address the study objectives, the authors examined existing literature on consciousness and body representation to bridge the academic divide between materialistic and non-materialistic perspectives in manual therapy. The theoretical framework was developed through a collaborative brainstorming process among a team of experts (G.D’A., F.B., C.L., and  R.Z-P.), each with over 10,000 hours of experience in education, scientific research, and clinical osteopathic practice [28]. This process was grounded in clinical observations and informed by the best available evidence.

2.3 Literature Search Strategy. A comprehensive literature search was conducted between July and December 2024 using MEDLINE (PubMed). To identify relevant search terms, the research team reviewed Medical Subject Headings (MeSH) and their corresponding subheadings related to osteopathic care (OC) and other manual therapies [29]. Eleven MeSH terms were deemed effective in retrieving literature on manual therapy research: manipulation, osteopathic; osteopathic medicine; chiropractic; exercise movement techniques; exercise therapy; manipulation, orthopedic; massage; muscle relaxation; muscle stretching exercises; musculoskeletal manipulations; and traction. These MeSH terms were supplemented with additional keywords relevant to the study’s focus, including professional identity, interprofessional relations, medical rationalities, shared decision-making, therapeutic alliance, enactivism, allostasis, touch, synchrony, interoception, autonomic nervous system, traditional medicine, person-centered care, and evidence-based practice. The search was limited to articles published in English, with no restrictions on study design, population, outcomes, or publication date.

2.4 Eligibility Criteria and Selection Process. No formal validity or quality assessments were performed to ensure a comprehensive exploration of the available literature. The selection process followed a two-stage approach, conducted independently by the authors (G.D’A., F.B., C.L., and  R.Z-P). First, article abstracts were screened to assess their relevance to the research question. Second, full-text versions of the selected studies were reviewed using the same criteria. Additionally, reference lists of the identified articles were examined, and a snowball sampling approach was employed to identify further relevant studies.

2.5 Reflective and Conceptual Framework Development. To facilitate the systematic development of a practical and shareable conceptual framework, the authors applied Driscoll’s reflective model [30] during a structured brainstorming process grounded in the literature research findings and clinical experience. This process comprised three key stages: 1) What? – Identifying and summarizing key themes and insights from the literature; 2) So What? – Analyzing the significance of these findings and assessing their relevance for developing a practical framework; 3) Now What? – Outlining practical applications and implications for clinical practice and future research. The brainstorming sessions were conducted by a team of experts (all authors), drawing on their combined expertise in education, scientific research, and clinical osteopathic practice, with over 10,000 hours of collective experience [28].”

                       

Comment 2: The discussion section involves multiple frameworks (such as the Neuroaesthetic-Enactive Paradigm and Functional Neuromyofascial Activity) but fails to systematically explain how these theories are interconnected. It is recommended to use diagrams or charts to further illustrate their relationships.

Response 2: Thank you for your insightful comment. In response, we have included two paragraphs:

One paragraph in lines 116-127  to introduce the neuroaesthetic-enactive paradigm (NEP): “The application of the NEP in OC establishes an integrative approach that incorporates principles from neuroaesthetics and enactivism into the therapeutic interaction between osteopathic practitioners and patients. This paradigm highlights the significance of multisensory perception, embodied cognition, and aesthetic experience in shaping the therapeutic process. It reframes OMT as more than a biomechanical intervention, emphasizing its dynamic and interactive nature, where the patient and practitioner collaboratively create meaning, regulate physiological responses, and adapt through touch, movement, and sensory engagement. By applying NEP principles, the OP acknowledges how aesthetic perceptions—such as the patient’s sense of coherence between the delivered OMT and their embodied agency—enhance the patient experience, strengthen the therapeutic alliance, and optimize clinical outcomes through embodied sense-making and active inference [19].”

Another paragraph was included in lines 320-335 to introduce Patient Active-Participatory Osteopathic Approach and Functional Neuromyofascial Activity (FNA): “PAOA integrates OMT with various motor, cognitive, and behavioral strategies [41]. It includes FNA, in which the patient performs a movement body scan—focusing on bodily sensations—to assess and self-assess functional motor abilities. This approach enables both the patient (as an active agent) and the OP (along with other healthcare professionals) to recognize local and global compensatory movement patterns characterized by dysfunctional movements in specific body regions or across the entire body [42].

The structure of FNA is designed to make somatic aspects associated with alterations in motor function—such as SD—perceptible and comprehensible not only to patients but also to healthcare professionals who are not trained in the osteopathic palpatory diagnostic process (OPDP). Additionally, FNA provides valuable insights into the rationale for applying different types of OMT, including interventions in distant areas of the body, even while the patient is in motion, actively performing an FNA routine. A key component of the proposed method is the inclusion of "FNA-snacks," a time-efficient and well-tolerated routine performed periodically or daily, to promote the integration of smooth and effortless movement into the patient’s everyday life [42]. ” Moreover we have included a formal results section in which we describe the theoretical and practical foundations of the four-step framework for patient-osteopathic practitioner-environment synchronization. This section incorporates the Neuroaesthetic-Enactive Paradigm and Patient active-participatory approaches, such as Functional Neuromyofascial Activity. We believe this will provide a clearer understanding of how these theories interrelate within the framework. We also appreciate the suggestion to use diagrams and we incorporated them in a clinical scenario section with a figure to further illustrate the practical application of each of the proposed four step.

 

Comment 3: It is recommended to incorporate real-world cases or preliminary experimental data to demonstrate the clinical feasibility of the framework. Additionally, the discussion section could explore how this framework can be adapted and applied in different healthcare settings to highlight its practical value.

Response 3: Thank you for your valuable suggestion. In response, we have incorporated a subsection “3.3 Clinical scenario” in the section “3.Results” to better outlines the progression and further illustrate by text and Figure 2 the practical application of each of the proposed four steps. This addition aims to demonstrate the clinical feasibility of the framework in a real-world context. Furthermore, in response to your comment, we have included a formal "Discussion" section (lines 474-578), which provides additional insight into how the framework can be adapted and applied across various healthcare settings. This section emphasizes the practical value of the framework by discussing it in the context of the existing literature. To support this expanded discussion, we have incorporated 24 additional references. Finally, we have included a subsection addressing the limitations of the framework and potential future directions (line 579-618).

 

 

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

REVIEW REPORT (applsci-3546376)

Tradition-Dismissive vs. Tradition-Reconceptualization Approaches in Musculoskeletal Care: The Example of Osteopathic Care.

- “This article aims to examine the clinical significance and implications of the 81 patient's bodily, cognitive, and existential domains, with particular emphasis on their 82 clinical assessment and practical applications in everyday healthcare practice, using OP 83 experiences as an example.” This sentence suggests that the manuscript will focus on clinical and existential aspects of the patient within the osteopathic context. But what theoreticl gaps will be explored? And what is the justification for investigating the need for the proposed model? Should the authors explicitly define the objectives of the article and further justfy the need for the proposed model?

- Authors must explicitly compare the proposed model with other existing frameworks to highlight its originality, because even though the proposed model is inovative, its differentiation in relation to other existing frameworks is not explored.

- The connection between the concepts discussed and clinical applicability seems confusing. Can the authors make it clear how this model translates into better outcomes for patients? If possible, include practical examples of its application in osteopathy.

- The clinical implications were adequately presented, but the authors did not discuss the potential challenges and barriers to implementing the suggested model. Would it be possible to include another topic to address this point and make the manuscript more complete? The authors could even address the limitations of the model, such as possible difficulties in clinical adoption and resistance from professionals in the field, since the implementation of new approaches in osteopathy may face resistance, especially among professionals who follow more traditional models.

- I read the document a few times and I had a question in my mind that the manuscript did not answer: what will be the next steps to validate this approach in clinical practice?

Comments for author File: Comments.pdf

Author Response

## Reviewer 2

 

Comment 1: “This article aims to examine the clinical significance and implications of the  patient's bodily, cognitive, and existential domains, with particular emphasis on their clinical assessment and practical applications in everyday healthcare practice, using OP  experiences as an example.” This sentence suggests that the manuscript will focus on clinical and existential aspects of the patient within the osteopathic context. But what theoretical gaps will be explored? And what is the justification for investigating the need for the proposed model? Should the authors explicitly define the objectives of the article and further justfy the need for the proposed model?

Response 1: Thank you for your thoughtful comment. In response, we have revised the introduction to better clarify the theoretical gaps and the justification for the proposed model. Specifically, we highlighted two key needs:

1. There is a significant gap between the advancements in technological tools for musculoskeletal rehabilitation and their practical application in routine clinical settings. Additionally, there is a need to enhance patient understanding of these technologies and standardized interventions, while also addressing the importance of maintaining face-to-face interactions in clinical encounters to strengthen the patient-practitioner relationship.
   
   
2. The ongoing debate within the osteopathic community underscores the need for reconciliation between tradition-dismissive and tradition-reconceptualization approaches. This reconciliation, addressing challenges related to outdated theories, mechanistic models, and the integration of diverse paradigms in contemporary osteopathic care, could converge into a practical, renovated person-centered framework that improves the therapeutic alliance and, consequently, rehabilitation outcomes.
   
   

Furthermore, we have refined the aim of the perspective as follows (lines 146-159): "The present perspective aims to develop a distinctive osteopathic framework that integrates neurocognitive and social sciences with foundational osteopathic principles, promoting a holistic and inclusive approach to musculoskeletal health. This framework will be informed by enactivism and emphasize patient engagement and biobehavioral synchronization. Additionally, it seeks to create a practical, integrated model that combines Osteopathic Manipulative Treatment (OMT) with Patient Active-participatory Osteopathic Approaches (PAOA), reinforcing a person-centered care approach to complement technological musculoskeletal rehabilitation. This framework aims to provide valuable support for all healthcare professionals involved in the patient's overall management plan, including physicians, nurses, occupational therapists, and physiotherapists. It will also incorporate verbal and nonverbal narratives, considering patient complexity, body representation, and sociocultural factors, while fostering shared decision-making to optimize therapeutic outcomes in musculoskeletal care."

We hope this revision better addresses the theoretical gaps and justifies the need for the proposed model.

 

Comment 2: Authors must explicitly compare the proposed model with other existing frameworks to highlight its originality, because even though the proposed model is inovative, its differentiation in relation to other existing frameworks is not explored.

Response 2: Thank you, your comment stimulated us to add the first part of paragraph 3.1 (lines 236-252) to sum-up the already present framework with intrinsic (namely, non-osteopathic) limitations. Secondly, to give some practical outcome-witnessed insights, in the Discussion we critically compared RCTs’ outcomes taken from the already published literature (14 out of 15 included in two Systematic Reviews with Meta-Analysis). In our opinion, taken together, these literature glimpses suggest the potential role of OC performed in a fashion practically formalized by our framework. (lines 505-578).

Comment 3: The connection between the concepts discussed and clinical applicability seems confusing. Can the authors make it clear how this model translates into better outcomes for patients? If possible, include practical examples of its application in osteopathy.

Response 3: Thank you for your valuable feedback. In response to your comment, we have included a clinical scenario that demonstrates examples of the practical applications of the 4 steps of the framework. This scenario is presented in Table 5 of the Results section and highlights how the model can be directly translated into better outcomes for patients, showcasing its real-world applicability in osteopathy. We hope this addition clarifies the connection between the discussed concepts and their clinical relevance.

Comment 4: The clinical implications were adequately presented, but the authors did not discuss the potential challenges and barriers to implementing the suggested model. Would it be possible to include another topic to address this point and make the manuscript more complete? The authors could even address the limitations of the model, such as possible difficulties in clinical adoption and resistance from professionals in the field, since the implementation of new approaches in osteopathy may face resistance, especially among professionals who follow more traditional models.

Response 4: We sincerely appreciate the reviewer’s valuable suggestion regarding the need to discuss potential challenges and barriers to implementing the proposed model. In response, we have added the following Limitations and Future Directions subsection to the discussion, addressing possible difficulties in clinical adoption, resistance from professionals adhering to traditional models, and the necessity of strong organizational support and training. Additionally, we highlight the importance of further research to inform policymakers and healthcare decision-makers, ensuring the sustainable adoption of person-centered care.

“4.2 Limitations and Future Directions. In line with policy recommendations to enhance person-centred care, the Four-Step Framework for Patient-Osteopathic Practitioner-Environment Synchronization proposed in this perspective aims to empower patients and improve care quality. However, we acknowledge potential challenges in disseminating and implementing this framework in real-world settings, as existing patient-centred models continue to emphasize the prioritization of individual needs and preferences [38]. As with other healthcare professionals, we recognize key barriers to person-centred care, including entrenched traditional healthcare structures resistant to change, skeptical and stereotypical professional attitudes, and challenges in developing effective interventions [38]. Addressing these obstacles requires strong organizational support, leadership, training, and active engagement from both professionals and patients to ensure successful integration into routine clinical practice [38]. A comprehensive investigation is essential for designing the implementation of the proposed framework. This research will help inform policymakers and health system decision-makers, fostering the sustainable adoption of person-centered care.”

 

Comment 5: I read the document a few times and I had a question in my mind that the manuscript did not answer: what will be the next steps to validate this approach in clinical practice?

Response 5: Thank you for your insightful feedback. We appreciate your suggestion regarding the next steps for validating the approach in clinical practice. Firstly, We have included a formal "Discussion" section (lines 474-578), which provides additional insight into how the framework can be adapted and applied across various healthcare settings. This section emphasizes the practical value of the framework by discussing it in the context of the existing literature. To support this expanded discussion, we have incorporated 24 additional references. Moreover, in response, we have expanded on this aspect in the manuscript by providing a research road map in the subsection "4.2 Limitations and Future Directions" of the Discussion.  This addition addresses the critical considerations for future work and helps clarify the path forward for clinical validation. We hope this enhances the manuscript and adequately addresses your concern. It follows the additional five steps research road map (lines 591-618): “A comprehensive investigation is essential for designing the implementation of the proposed framework. This research will help inform policymakers and health system decision-makers, fostering the sustainable adoption of person-centered care. This perspective article highlights the need for a future research roadmap to advance osteopathic biobehavioral synchronization by integrating early professional skills with evidence-based knowledge to foster innovative clinical approaches. The first step in this roadmap aims to define the unique contributions of OC by outlining the proposed framework and reviewing existing research. This will be achieved through a scoping review and the development of an integrative hypothesis paper. The second step seeks to expand current knowledge by observing real-world clinical practices, focusing on accurate data collection, hypothesis generation, and the enhancement of individualized OC. This will be accomplished through case reports following CARE guidelines, which help reduce bias, increase transparency, and identify early indicators of effective treatments tailored to specific patients. The third step involves exploring the clinical value of the proposed practical framework for prevention at multiple levels, including primary, secondary, tertiary, and quaternary prevention. This will be assessed through a range of epidemiological studies, including case reports, ecological studies, cross-sectional studies, case-control studies, cohort studies, and experimental studies. The fourth step focuses on investigating the physiological mechanisms underlying biobehavioral synchronization, utilizing both real-world and lab-based observational studies. To preserve the distinctiveness of the osteopathic patient biobehavioral synchronization framework, the fifth step will involve employing a Delphi panel and consensus conference. Mentorship, consensus workshops, and continuing professional development will also be integral in teaching and implementing this framework within the professional community.

Through these five steps, the roadmap will guide the future development and clinical application of osteopathic biobehavioral synchronization.”

 

 

 

 

 

Author Response File: Author Response.docx