Alvarez Bustins et al.

BMC Complementary and Alternative Medicine (2018) 18:129

https://doi.org/10.1186/s12906-018-2190-0

RESEARCH ARTICLE Open Access

Profile of osteopathic practice in Spain:

results from a standardized data collection
study
Gerard Alvarez Bustins1,2,4*, Pedro-Victor López Plaza3,4 and Sonia Roura Carvajal1,4

Abstract
Background: There is limited research regarding patients’ profiles and consumer attitudes and habits of osteopathy
in Spain. The purpose of this study was to profile patients who regularly receive osteopathic care in Spain using an
internationally developed standardized data collection tool.
Method: During the period between April 2014 and December 2015, a UK-developed standardized data collection
tool was distributed to Spanish osteopaths who voluntarily agreed to participate in this cross-sectional study.
Results: Thirty-six osteopaths participated in this study and returned a total of 314 completed datasets. Of 314
patients, 61% were women and 39% were men, with a mean age of 40 years (SD 17.02 years, range 0 to 83 years).
Forty-four percent were full-time salaried workers, and in 78% of cases, receiving osteopathic treatment was the
patient’s own choice. Chronic spinal pain presentations were the most frequent reasons for consultation. Seventy-
five percent of patients presented with a coexisting condition, mainly gastrointestinal disorders and headaches. The
main treatment approach consisted of mobilization techniques, followed by soft tissue, cranial and high velocity
thrust techniques. Improvement or resolution of the complaint was experienced by 93% of patients after a small
number of sessions. Adverse events were minor and occurred in 7% of all cases.
Conclusion: This is the first study carried out in Spain analyzing the profile of patients who receive osteopathic
care. The typical patient who receives osteopathic care in Spain is middle-aged, presents mainly with chronic spinal
pain, and voluntarily seeks osteopathic treatment. Osteopathic treatment produces a significant improvement in the
majority of cases with a low rate of minor adverse events reported.
Keywords: Osteopathy, Osteopathic medicine, Cross-sectional survey, Standardized data collection, Scope of
practice, Clinical presentations

Background (LOPS 44/2003). In the other hand, the Ministerial

Osteopaths first started practicing in Spain in the Order (2135/2008) that establish the educational cur-
1980s. Since then, the practice of osteopathy in Spain riculum of the physiotherapy degree mention osteop-
has significantly developed. The first professional athy as a technique that undergraduates shall know.
training and education programs in osteopathy began However, both the standards and scope of practice of
in 1987 and were taught by French and Belgian in- osteopathy in Spain lack formal recognition in the
structors [1]. Osteopathy is not regulated in Spain as regulatory and legislative domains [2]. This situation
a healthcare profession as it’s not included on the has resulted in the co-existence of two recognized
Law of Arrangement of the Sanitary Professions groups including ‘osteopaths’ (i.e., practitioners with-
out prior health science degrees), and osteopath-
* Correspondence: gerardalv@gmail.com physiotherapists (i.e., practitioners with prior health
1
Centre for Osteopathic Medicine – C.O.ME. Collaboration, Spain National science degrees, typically in physiotherapy). Although
Center, Clinical-based Human Research Department, Barcelona, Spain
2
Iberoamerican Cochrane Centre – Biomedical Research Institute Sant Pau, IIB
the osteopath-physiotherapist group represents the
Sant Pau, Barcelona, Spain majority of osteopaths practicing in Spain, there are
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Alvarez Bustins et al. BMC Complementary and Alternative Medicine (2018) 18:129 Page 2 of 10

other groups of practitioners with very diverse training through a parallel survey designed specifically for this
and educational backgrounds. This ‘lawless’ situation has purpose.
thereby fostered the emergence of numerous qualifica-
tions and professional associations representing different Methods
groups of osteopaths. Participants
Additionally, there is limited research regarding the pro- During the period between April 2014 and December
files of people who seek osteopathic treatment in Spain. In 2015, the SDC tool was distributed to all osteopaths
May 2008, the Observatory of Natural Therapies pub- who voluntarily agreed to participate in this cross-
lished an independent study, sponsored by three natural sectional study. The pragmatic eligibility criteria in-
therapy organizations, on the use and habits of consumers cluded any professional who named their practice as
of natural therapies in Spain [3] (Additional file 1). In this osteopathy. For participant recruitment, a three-step
study, 2000 people aged between 16 and 65 years were process was established. First, the cooperation of all as-
interviewed. The results showed that osteopathy was sociations, Registers and schools of osteopathy in Spain
known by 32% of the population and that 8.2% used it country was required. At the same time, the research
regularly. In 2011, the Spanish Ministry of Health, Social team launched an internet-based information and aware-
Policy and Equality published the report “Analysis of the ness campaign on social networks (Twitter and Face-
situation of natural therapies” [4], which analyzed 139 book) specially focused on Spanish osteopathic
techniques carried out within the natural therapies scope community groups. An explanatory video on how to
by assessing the existing scientific evidence, use and legal participate and complete the form was also distributed
framework associated with these techniques in Spain and (https://vimeo.com/105709291). Through these chan-
other countries. This report, which received expert contri- nels, a contact email address and a specific acceptation
butions from several professional registers and organiza- form to participate was provided. When acceptance
tions, profiled osteopathy as a complementary and forms were received, the research team provided osteo-
alternative medicine and classified it under the category paths with a study information sheet and instructions to
“Manipulative and body based therapies”; however, this re- provide to their patients so that they would be fully in-
port failed to provide additional data regarding natural formed about the purpose of the study (Additional file 2).
therapy consumer use and habits beyond that submitted Two reminders were scheduled for those osteopaths
in 2008 by the Natural Therapies Observatory [3]. who did not return any completed survey after having
In 2009, the National Council for Osteopathic Re- agreed to participate. To maintain anonymity and confi-
search (NCOR) in the United Kingdom (UK) devel- dentiality, each osteopath was allocated a unique ID
oped and piloted a Standardized Data Collection tool code to which they could add a sequential code (01, 02.)
(SDC) to profile the demographics and clinical pre- for the patient identifier. The Institutional Review Board
sentations of patients receiving osteopathic care [5]. of Barcelona Osteopathic Foundation approved the study
The study characterized osteopathic practice in the (FOB04140001). Informed consent was assumed by par-
UK to establish standards for audit activities, obtain ticipation in the study.
relevant information for the profession and develop a
resource for research purposes. The study demon- The questionnaire
strated that the SDC tool was able to generate a sub- Once authorized by NCOR, the extended version of the
stantial amount of high quality information and was SDC tool was translated and cross-culturally adapted to
suitable for widespread use. For example, it was able Spanish. The translation process involved all members
to provide information about patients’ demographic of the research team and was completed in 4 steps. i)
characteristics, presenting symptoms, patient manage- forward translation into Spanish (PP) ii) backward trans-
ment and treatment, and results obtained. In the last lation into English verifying equivalency to the original
few years, some studies have been conducted in dif- meanings (GA & SR) iii) and piloting the questions on a
ferent countries to trace the profiles of both the pro- sample of 5 osteopaths and iv) modification of the forward
fessionals and patients who receive osteopathic care translation after pilot feedback (SR). The questionnaire
[6–10]. The SDC tool was used in some of these was uploaded to an internet-based survey platform (Sur-
studies. veyMonkey® Europe – Dublin, Ireland) (Additional file 3).
The primary objective of this study was to profile The study form had three parts, those corresponding
patients who regularly receive osteopathic care in to the 1st and 2nd consultations and the last consult-
Spain using the “SDC tool” developed by Fawkes and ation in the data collection phase. The modified SDC
colleagues, which has been modified for a Spanish Tool consisted of 47 items separated in different blocks
population. A secondary objective was to describe the that covered information about healthcare quality and
professional profile of active osteopaths in Spain treatment during the osteopathic intervention process.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Alvarez Bustins et al. BMC Complementary and Alternative Medicine (2018) 18:129 Page 3 of 10

I. Initial consultation for a new episode: Comprised of Results

23 questions related to the patient’s medical history, Of the 61 osteopaths who agreed to participate in the
lifestyle, previous treatments, presence of pain, study, 36 returned the questionnaires from which a total
anatomical location of their symptoms and reasons of 314 datasets/patients were analyzed (8.7 patients for
for consulting an osteopath. each osteopath on average). Eighty-three percent of the
II. Management and Treatment: Comprised of 2 compiled questionnaires originated from the same re-
questions regarding the initial treatment and gion of the country (Catalonia). Two hundred forty-five
management of the patient and included treatment patients completed treatment during the data collection
approaches used after the first consultation. period, and 75 (24%) did not finish the plan of care for
III. Information and consent: Comprised of 7 questions unknown reasons. Among the three parts of the SDC
covering information regarding consent and its tool, we collected information about the first visit from
associated characteristics. 314 patients, about the second visit from 266 (85%) pa-
IV. Second Consultation: Comprised of 5 questions tients and regarding the last visit from 248 (79%) pa-
about the outcomes and approach of subsequent tients. Concerning the quality of the responses, some of
appointments regarding the treatment and the the forms were delivered incomplete (partially filled).
duration of the visit. Notwithstanding this, the unanswered questions did not
V. Last consultation for the treatment of the episode: follow a specific pattern that can suggest lack of interest
Comprised of 10 questions related to the state of the or insufficient training methods.
patient at the end of the data collection period, total
number of treatments received, and the evolution
and quantification of the initial symptoms. Patients’ demographic information
Patient demographic data are shown on Table 1. From
The symptom area(s) where the patient reported their 314 datasets, 61% (n = 192) were women versus 39%
complaints was considered the reason for consultation, and men (n = 122), and all participants had a mean age of
multiple sites were allowed. The osteopath chose a max- 40 years (SD 17.02 years, range 0 to 83 years). The ma-
imum of 4 symptom areas ranked by importance to the pa- jority of patients (77%, n = 241) were adults (> 18 years),
tient (considered as the clinical presentation). For pain whereas 15% (n = 47) were children (< 18 years), of
reporting, a numerical rating scale (NRS) was used [11]. Pa- whom 10% (n = 15) were under the age of 1.
tients were asked to range their pain in a 0–10 scale, with 0 Regarding the patient employment profile, 44% (n =
representing the absence of pain and 10 the worst pain pos- 137) of the respondents were full-time salaried workers.
sible. A self-reported improvement was also recorded. In 78% (n = 244) of the cases, receiving osteopathic treat-
For those osteopaths who requested the survey in paper ment was the patient’s own choice. The findings of this
format, it was sent along with detailed return instructions study reflected that the remaining 22% (n = 68) of refer-
and a prepaid envelope. Osteopaths recorded information rals were provided by other health professionals includ-
from 10 new consecutive patients to avoid selection bias. In ing 23% from general practitioners, 18% from
addition, the osteopaths received a second survey with 20 physiotherapists, 16% from orthopedic consultants, 7%
questions covering their professional profile. These 20 from podiatrists and a minor percentage from other pro-
questions collected data among the following 3 blocks: pre- fessionals such as gynecologists, optometrists, physical
training, osteopathic studies, and workplace location and trainers, pediatricians, neurologists, psychologists, acu-
characteristics (Additional file 4). puncturists, osteopaths, internal medicine specialists,
dentists and insurance companies. Notwithstanding this,
the main source of referrals for patients was in most
Data management and statistical analysis cases attributed to word-of-mouth recommendations
Data obtained from the on-line survey were automatic- (76%, n = 239). The patient paid out of pocket for treat-
ally exported to a spreadsheet (Microsoft Excel® version ment in 91% (n = 284) of the cases.
15.21.1 – Microsoft Ibérica, Madrid -Spain). Data ob- Seventy-three percent (n = 229) of the cases had not
tained in paper format were manually entered into the previously received osteopathic treatment, and the main
same spreadsheet by SR who was also responsible of the reasons to initiate treatment were personal recommen-
data analysis. All of the information collected (either dation or direct referral (75%, n = 235), previous unsuc-
from complete and incomplete forms) were analyzed. cessful treatments (34%, n = 108) or an individual choice
The responses were coded quantitatively to enable a to receive osteopathic treatment (30%, n = 93) (Table 1).
simple descriptive statistical analysis. The total number Eleven percent of patients reported that they had already
of answers available for each question are reported in received prior treatment for the same complaint; includ-
the following sections. ing chiropractic, massage, physiotherapy, acupuncture,

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Alvarez Bustins et al. BMC Complementary and Alternative Medicine (2018) 18:129 Page 4 of 10

Table 1 Patients socio-demographic Characteristics Reason for consultation (clinical presentation)

% n The three most frequent complaints reported were
Sex 314 symptoms in the cervical area (20%) followed by the
Female 61% 192
lumbar area (13%) and the head and facial area
(13%) (Table 2). Eighty-three percent of patients in-
Male 39% 122
cluded in the study expressed multiple complaints at
Age (years) 40 (mean) their first consultation (55% presented two co-morbid
Employment situation 314 conditions and 31% presented more than 3). Co-
Full-time employee 44% 137 morbidities followed the same distribution and in-
Student 17% 54 cluded cervical (25%), lumbar (18%) and head and fa-
Self-employed 14% 43
cial area (11%) conditions.
Thirty-eight percent (n = 119) of patients reported
Retirement 8% 27
suffering from their complaint for over a year, 9% (n =
Unemployed 5% 16 27) between 6 and 12 months, 27% (n = 84) between 1
Other (Employee temporary 12% 37 and 6 months and 27% (n = 83) less than one month.
part-time, domestic
employment, pensioner)
Forty-nine percent (n = 152) of patients reported that it
was the first time they had suffered from their com-
Referral Source 313
plaint, whereas 35% (n = 111) had experienced it on 4
Patient’s own choice 78% 244 or more occasions. Eighty-nine percent (n = 278) had
Health care professional 21% 68 not taken time off from work despite the problem. The
Other 1% 1 mean value of the degree of pain reported at the start
Previous Osteopathic treatment 313 of treatment was of 6 points (SD 2.2) on the pain as-
No 73% 229
sessment scale (NRS).
Seventy-five percent of patients had medical history ac-
Yes 27% 84
counts (n = 234) vs. 25% (n = 79) without accounts. The
Osteopathic reason for consultation most frequent medical history conditions were gastro-
Recommendation or Reference 75% 235 intestinal (12%, n = 29), migraines (11%, n = 25), anxiety
Previous unsuccessful treatment 34% 108 (9%, n = 22) and arterial hypertension (9%, n = 21).
Their choice to receive 30% 93
osteopathic treatment
Treatment options other 26% 81 Therapeutic approaches
than medication In 96% (n = 301) of patients included in the study, osteo-
Manual treatment search 20% 64 pathic treatment was considered appropriate. The most
Personal search 16% 49
frequently used techniques during the first consultation
were mobilization techniques (60%), soft tissue techniques
Previous Osteopathic 10% 31
treatment experience (57%), high velocity technique (HVT - thrust techniques)
(52%) and cranial techniques (46%). At the follow-up con-
Alternative to surgery 5% 16
sultations, the most commonly used techniques were
Do not desire treatment 4% 12
programmes from
mobilization techniques (61%), cranial techniques (54%),
Social Security services soft tissue techniques (52%), and functional techniques
Awaiting for rehabilitation 2% 7 (42%) (Table 3).
covered by the The time spent on each treatment session was divided
Social Security service
between visits of < 30 min, between 30 and 45, between
Other 2% 7 45 and 60 or > 60 min. The frequency of each session dur-
ation is shown in Table 4.
In 80% of the cases, the therapists asked for patient con-
Bach flower remedies, neural therapy, diathermy, podia- sent before providing osteopathic treatment. Of the
try, optometry, speech therapy and steroid injections. consent-based cases, 33% were performed verbally, 21%
The waiting time to be examined by an osteopath did were written and 46% were both verbal and written.
not exceed one week as reported by 75% (n = 236) of pa- In the majority of cases, patients were informed about
tients. The remaining 25% (n = 76) had to wait more the different treatment options (70%), the possible risks and
than 8 days. The median number of medical consulta- side effects of the treatment (85%), the expected response
tions patients had undergone before receiving osteo- to treatment (4%), the approximate number of sessions re-
pathic treatment was 2 visits. quired (72%), ways to avoid relapse in the future (66%) and

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Alvarez Bustins et al. BMC Complementary and Alternative Medicine (2018) 18:129 Page 5 of 10

Table 2 Reason for consultation (clinical presentation location) 39% of the cases, 6–9 in 2% of the cases and > 9 in 2% of the
n = 311 cases. The median number of consultations per patient was 3
% consultations, and the treatment duration ranged from 1 to
Neck-cervical 20% 3 months in 54% of cases, less than one month in 31% of
Lumbar 13% cases and more than 4 months in 15% of cases.
Sixty-eight percent (n = 168) of patients completed
Head- Face areas 13%
treatment during the time period in which the study was
SI/pelvis/groin 9%
conducted. Seventeen percent (n = 42) were still receiving
Shoulder 7% osteopathic care upon completion of the study, and 15%
Knee 5% (n = 38) abandoned or terminated their plan of care for
Thoracic spine 5% various reasons (e.g., illness, funding problems).
Chest, Rib cage 4% Upon the patients’ last visits within the study period, 25%
had completed the treatment plan, 35% voluntarily chose to
Hip 4%
return for a check-up, 17% continued treatment, and 23%
Foot 3%
were referred to some further diagnostic process or re-
Abdomen 3% sumed previous treatments.
Ankle 3%
Gluteal region 3%
Osteopaths demographics
Elbow 2% The mean age of the osteopaths participating in the
Hand 1% study was 36.6 years (SD 7.65 years, range 27 to
TMJ 1% 70 years), and all held university qualifications prior to
Other 1% their osteopathy studies. The demographic and academic
characteristics of the osteopaths are shown in Table 6. In
Wrist 1%
reference to the participants’ osteopathy education and
Arm 1%
training, 61% (n = 22) had more than 1500 h, 36% (n =
Muscle 0% 13) had between 1000 and 1500 training hours, and 3%
Calf 0% (n = 1) had less than 500 h. Ninety-seven percent (n =
Forearm 0% 35) of the osteopaths worked in a private practice of
SI Sacroiliac joint, TMJ Temporomandibular joint which 71% (n = 25) did so in their own practice. Sixty-
four percent (n = 23) worked with other osteopaths, and
61% (n = 22) were part of a multidisciplinary team.
Eighty percent (n = 29) of osteopaths worked exclusively
an explanation of the clinical problem they presented
as an osteopath, and 20% (n = 7) of the therapists com-
(97%). In most cases, patients received counseling on their
bined their activity with other professional activities.
lifestyle habits, diet, and physical activity (66%), and only in
Ninety-four percent of the participants reported to treat
few cases (9%) were other aspects were recommended.
patients with musculoskeletal complaints, 47% pediatric
patients, 39% obstetric patients, 33% gynecological prob-
Treatment results
lems and 11% sport related injuries (Table 6).
After the first consultation, patients reported that they felt
Fifty-five percent of osteopaths were registered to
“much better” in 25% of cases, “improving” in 52% and
some osteopathic register or professional association.
“no better or worse” in 15%. At the end of treatment, 72%
All of these osteopaths were from Registro de los
of patient datasets included in the study reported being
Osteopatas Españoles (ROE) except one from the
“much better” or “better than ever”, as described in
General Osteopathic Council (GOsC).
Table 5. The mean value on the NRS at the end of treat-
ment was of 1.6 (SD 1.8) (Table 5).
Seventy-three percent (n = 194) of patients did not re- Discussion
port any side effects to the treatment after the first visit, To the best of our knowledge, this is the first study
whereas the remaining 27% (n = 99) mainly experienced attempting to describe the profile of osteopathic practice
fatigue and / or increased pain-related side effects. At the in Spain. The main aim was to determine not only the
end of treatment, 93% (n = 224) of patients did not have profile of patients who receive osteopathic care in Spain
any adverse effects. but also the main features of the service provided. Fur-
Among the 248 patients who finished their plan of care thermore, it was of interest to record the profile of the
during the study period, the number of treatment sessions professionals who participated in the study. The SDC
provided ranged between 1 and 3 in 57% of the cases, 3–6 in tool offers extensive information about the patients’

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Alvarez Bustins et al. BMC Complementary and Alternative Medicine (2018) 18:129 Page 6 of 10

Table 3 Techniques Approaches

First Visit n = 301 Follow-up visits n = 266
mobilization techniques 60% mobilization techniques 61%
Soft tissues 57% Cranial Techniques 54%
HVT 52% Soft tissues 52%
Cranial Techniques 46% Functional Techniques 42%
Functional Techniques 38% HVT 39%
Counseling on daily lifestyle and habits 31% Visceral Techniques 29%
Visceral Techniques 28% Counseling on daily lifestyle and habits 24%
Patient education 23% Patient education 20%
Counterstrain 19% Muscle Energy technique 12%
Muscle Energy technique 9% Counterstrain 11%
Contraction/Relaxation/Stretching 8% Contraction/Relaxation/Stretching 10%
Physical activity 7% Relaxation techniques 7%
Other 6% Physical activity 7%
Diet 4% Other 6%
Acupuncture 3% Diet 4%
Relaxation techniques 2% Acupuncture 2%
Hands off 1% Hands off 1%
Orthopedic equipment 1% Orthopedic equipment 0%
Infiltration 0% Infiltration 0%
HVT high velocity technique

demographic characteristics, their reported symptoms, patients under 14 years of age, showing the interest and
the osteopathic management plan derived therefrom and use of parents in Complementary and Alternative Medi-
the way in which the service is provided. cine (CAM) in Europe [14–17].
The socioeconomic profile of the patient seeking The results revealed that a large population of patients
osteopathic care in Spain mostly corresponds to people included in this study had never received osteopathic care.
(women> men) of middle age (mean = 40 years) who are The proportion of referrals from other healthcare profes-
full-time employees. These results agree with the only sionals was found to be small. The choice to seek and
study previously published in Spain [3] and the studies undergo osteopathic treatment is usually personal and pur-
by Burke et al. [6] and Fawkes et al. [7] performed in sued as an alternative to previous unsuccessful treatments.
Australia and UK, respectively (Table 7). This profile has This finding is supported by research focusing specifically
also been reported in patients who receive complemen- on CAM use by pain sufferers, which described patients’
tary and / or alternative medicines and other self-care opinions as dissatisfaction with their general practitioners’
activities [12, 13]. (GPs) availability, wait time, or lack of benefit from con-
In Spain, osteopathy is mainly provided within the pri- ventional medical treatments for back pain [13].
vate healthcare sector and generally is a health service The main reason for receiving osteopathic care in Spain
not covered either by the National Health System or by is related to musculoskeletal problems, mainly in the cer-
most health insurance companies. It was noted that al- vical and lumbar spine. These outcomes were also noted
though the majority of patients were adults, 15% were in similar studies conducted in other countries [6–10].

Table 4 Time spent in consultation

1st Visit n = 312 Successive visits n = 263
Less than 30 minuts 1% 3 Less than 30 minuts 5% 14
Between 30 and 45 minuts 15% 47 Between 30 and 45 minuts 25% 67
Between 45 and 60 minuts 58% 180 Between 45 and 60 minuts 68% 179
More than 60 minuts 26% 82 More than 60 minuts 1% 3

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Alvarez Bustins et al. BMC Complementary and Alternative Medicine (2018) 18:129 Page 7 of 10

Table 5 Results obtained & NRS scale However, more than one-third of patients treated in the
2nd
Visit results n = 266 Last Visit results n = 244 Spanish public Health System for non-specific low back
Better than ever 5% 13 Better than ever 17% 42 pain continue to suffer from pain 2 months after their
Much better 25% 66 Much better 55% 134
first visit and in up to 10% of these individuals, the pain
becomes worse [20]. In addition, the probability of re-
Improved 52% 137 Improved 21% 52
ferral to physical therapy or rehabilitation in Spain is
No better or worse 15% 43 No better or worse 6% 14 greater when low back pain is more intense (acute and
Worst 2% 5 Worst 0% 1 subacute cases) [20]. Given this situation, along with
Far worse 1% 2 Far worse 0% 1 the perception of the usefulness of manipulative therap-
Worse than ever 0% 0 Worse than ever 0% 0 ies in the treatment of back pain [13, 21], it may ex-
Average score on NRS scale
plain why this distress is the main cause for seeking
osteopathic care (both in Spain and in other countries),
Pretreatment 6
and moreover, most patients included in our study re-
Post-treatment 1,6 ported chronicity in their complaints. This finding is
contrary to what Burke et al. [6] and Fawkes et al. [7]
The use of CAM for back pain was recently extensively reported, as they noted that acute cases (less than 4–
evaluated by Murthy et al. [13] Osteopathy was among 6 weeks) were mostly treated. This difference in the
the 4 CAM modalities assessed in that study along with early care environment may be related to the lack of a
acupuncture, chiropractic and massage. According to specific regulation the osteopathic scope of practice
Murthy and colleagues [13], the prevalence of osteopathic within the Spanish population.
treatment for back pain ranged from 4.1 to 48.4% (mean: Despite spine-related clinical problems, patients with
17.3%; median: 8.4%) as reported by four population stud- headaches, facial-related pain and other symptoms are
ies drawing on fieldwork with large samples. commonly seen by osteopaths [9, 10]. In our survey,
Recent research on the prevalence of spinal pain in headaches were the 3rd most common reason for seek-
Spain demonstrated that, after a period of stability be- ing osteopathic care (13%). Some studies have shown
tween the years 2004/5 and 2008/9 [18], there was in- preliminary positive results about the effectiveness of
crease in the prevalence during between 2008/9 and osteopathic manipulative treatment (OMT) in migraine
2011/12, with values of 5.4% for neck pain and 8.56% patients [22–25]. Moreover, there is some evidence that
for low back pain [19].According to Palacios-Ceña and OMT may lower the cost of the treatment regimen for
colleagues [19], this increase can be partially explained patients with migraine headaches [26]. Notwithstanding
by the economic crisis suffered in Spain in recent years. this, according to the available literature, there is a low
level of evidence that OMT is effective in the manage-
Table 6 Therapists socio-demographic Characteristics ment of headache [27].
% n In our study, 69% of patients had previously visited a
Sex 36 medical physician for the same complaint, with an aver-
Male 53% 19 age number of consultations before the start of the
Female 47% 17 osteopathic treatment of 2.8. Actually, the pattern of
Age (years) 36.7 (mean) - 7.65 SD
CAM use for back pain supplementary to conventional
care was evident across back pain–specific population
Previous Studies 100%
studies from North America, Europe, and Australia,
Physiotherapy 88.5% 31 thereby suggesting that back pain sufferers did not
Other 11.5% 5 choose CAM instead of conventional medicine [13].
School of Osteopathy The data obtained regarding the reduction of pain
Spanish 94% 34 both after the first consultation and at the end of the
Other 6% 2
treatment indicate that osteopathic care is a good ap-
proach to relieve patients’ pain. Although the effective-
Experience (years) 7 (mean) - 4.45 SD
ness of osteopathy for musculoskeletal pain has been
Type of patients disputed [28], several studies have shown its effective-
Musculoskeletal 94% 34 ness in patients with both acute and chronic lower back
Pediatrics 47% 17 pain [29–32], neck pain [33] and in other clinical pre-
Obstetrics 38.8% 14 sentations [24, 27, 34–39]. It is also worth highlighting
Gynecologists 33.3% 12
the low percentage of adverse effects reported by the pa-
tients (7%) at the end of treatment. These results
Sports 11.1% 4
reinforce those reported by Fawkes et al. [7] and Burke

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Alvarez Bustins et al. BMC Complementary and Alternative Medicine (2018) 18:129 Page 8 of 10

Table 7 Patients data compared to available literature data

Cofenat et al. Burke et al. Fawkes et al. Wilkinson et al. van Dun et al. Alvarez Bustins et al.
(2008) [3] (2013) [6] (2013) [7] (2015) [9] (2016) [10] (2018) (current study)
Average 36–45 30–50 44.8 40.3 45 40
age
Percentage >Women 67.6% 56% 63% 61%
of women
Percentage <Men 32.4% 43% 37% 39%
of men
Reason for – Lumbar, cervical, Lumbar, cervical, Lumbar, Head-area, Cervical and Cervical, lumbar,
consultation EEII pelvis facial, Cervical spine lumbar, Head and facial
headache, area
Cervical
brachialgia
Techniques Acupuncture, Soft tissue, Muscle Soft tissue, mobilization Cranial, soft tissue, Visceral, cranial Mobilization
used yoga, Homeopathy, Energy technique, techniques, HVT, mobilization techniques, soft
preferably massage mobilization education, cranial, techniques, tissue techniques,
techniques, Muscle Energy functional, HVT, cranial
education technique, functional counterstrain, techniques

et al. [6] and other studies evaluating other manual ther- included (n = 314) enables obtaining, at least, reliable
apies [40, 41] and are consistent with systematic reviews associated indicators about the profile of patients
assessing the adverse effects of manual therapies [42]. treated with osteopathy in Spain.
The average number of visits per patient was 3.6 Likewise, 83% of the datasets originated from a sin-
visits, plus in more than half of the cases, treatment did gle region of the country (Catalonia) leading to a
not exceed 2 months. In light of these results, osteo- demographic bias of the results. Consequently, the
pathic care appears to be effective over a short period data obtained on the professionals’ profile (secondary
of time and with a relatively low number of sessions. aim) may not be fully representative and should
Despite these results, the clinical effectiveness and eco- therefore be analyzed and interpreted with caution.
nomic assessment of osteopathic care has not been Despite some unpublished studies addressing this
established by our study. Furthermore, a lack of evi- issue [49–51], there is still a lack of evidence regard-
dence in the literature showing the cost-effectiveness of ing the professional profile in Spain. A new study to
osteopathic treatment remains [43, 44]. However, the identify the professional profiles of Spanish osteopaths
results note a high degree of patient satisfaction with is currently being conducted based on previous experiences
osteopathic treatment. Beyond clinical outcomes, in Benelux [10] and Italy (in process).
patient-centered care, which is also a key aspect within Some other limitations arise from the methodology
the osteopathic approach, has been proven to be one of used to obtain the data. The SDC tool was developed
the most promising and effective scopes within health and piloted in the UK and was used as faithfully as pos-
care [45–47] for its major relevance towards the estab- sible to the original version. The choice of the SDC tool
lished therapeutic relationship, application of a holistic responds to the will of using a validated tool, however,
approach to solve patients’ distress and tailoring of a the osteopathic scope of practice in the Spain is different
patient’s treatment based on their context [48]. from that of UK and some questions may have different
interpretation in the Spanish context. Additionally, the
Limitations translation process of the questionnaire did not involve
The main limitation of this study is the low response professional translators and only included a small pilot
rate. Although a total of 61 professionals decided to sample for testing of the final translation.
participate, in only 59% (n = 36) of the cases were Finally, practitioners, rather than patients, were respon-
data collected. The great heterogeneity of professional sible for the data collection. Although written specific in-
profiles and the undefined legal situation of the pro- structions were given to osteopaths (Additional file 2), no
fession in Spain leads to poor cohesion in this sector. in-person training or quality control checks were per-
Moreover, the absence of a single official institution formed to assure that the forms were completed accur-
representing the professionals’ interest and scope of ately. This could be a source of potential bias towards
practice, together with the differences among stake- favorable outcomes rather than all outcomes. Moreover,
holders, hinder the development of the profession specifically those answers concerning ethics, good prac-
and the performance of studies at population scale. tices and patients’ satisfaction should be considered under
Nonetheless, the significant number of patients the light of potential reporting bias.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Alvarez Bustins et al. BMC Complementary and Alternative Medicine (2018) 18:129 Page 9 of 10

Conclusion Ethics approval and consent to participate

This study describes the profile of patients who receive osteo- The Institutional Review Board of Barcelona Osteopathic Foundation
approved the study (FOB04140001). Informed consent was assumed by
pathic care in Spain. By using a modified UK-developed SDC participation in the study.
tool, data on the socio-demographic characteristics, popula-
tion use habits, clinical characteristics and therapeutic experi- Consent for publication
ence of patients seeking osteopathic care in Spain were Not applicable.

collected. Secondarily, information was obtained regarding Competing interests

the osteopathic management of patients and the way in The authors declare that they have no competing interests.
which this service is provided. This is the first study con-
ducted in Spain to analyze the profile of patients who receive Publisher’s Note
osteopathic treatment. This information can help to increase Springer Nature remains neutral with regard to jurisdictional claims in
public awareness of the profession, aid the decision-making published maps and institutional affiliations.
process of patients regarding their care, and contribute to an Author details
understanding of the value that osteopathy may have in 1
Centre for Osteopathic Medicine – C.O.ME. Collaboration, Spain National
Spanish healthcare. Center, Clinical-based Human Research Department, Barcelona, Spain.
2
Iberoamerican Cochrane Centre – Biomedical Research Institute Sant Pau, IIB
Sant Pau, Barcelona, Spain. 3Blanquerna School of Health Sciences, Ramon
Additional files Llull University, Barcelona, Spain. 4Fundació d’Osteopatia de Barcelona, Grup
de Recerca en Osteopatia de Barcelona, Sant Just Desvern, Barcelona, Spain.

Additional file 1: Supplementary file. Observatorio de las Terapias Received: 12 May 2017 Accepted: 26 March 2018
Naturales. (PDF 293 kb)
Additional file 2: Instructions to inform patients clearly and
comprehensively about the purpose of the study. (ZIP 166 kb) References
Additional file 3: Extended version of the SDC Tool, which was 1. Tricot P, Puig JB. OSTEOPATÍA. una Terapia Por Descubrir. Editorial
translated and cross-culturally adapted into Spanish. (ZIP 384 kb) Paidotribo; 2006.
2. van Dun P, Wagner C. Die Identität der Osteopathie in Europa.
Additional file 4: Professional survey. A Survey containing 20 questions
Osteopathische Medizin. 2012;13(4):22–6. https://doi.org/10.1016/S1615-
covering osteopaths’ professional profile. (ZIP 172 kb)
9071(12)60062-8.
3. COFENAT, CONAMAD, TENACAT. Observatorio de las Terapias Naturales.
Abbreviations Published May 1, 2008. Accessed 6 May 2017.
CAM: Complementary and alternative medicines; GPs: General practitioners; 4. Ministerio de Sanidad, Política Social e Igualdad. Análisis de la situación de las
HVT: High Velocity technique/s; NCOR: National Council of Osteopathic terapias naturales. http://www.mspsi.gob.es/novedades/docs/
Research; NRS: Numerical rating scale; SDC tool: Standardized data collection analisisSituacionTNatu.pdf. Published December 19, 2011. Accessed 6 May 2017.
tool; SI: Sacro-ilíac joint; TMJ: Temporo-mandibular joint 5. Fawkes C, Leach J, Matias S, Moore A. The standardised data collection
project. Standardised data collection within osteopathic practice in the UK:
Acknowledgements development and first use of a tool to profile osteopathic care in 2009. East
The authors would like to thank NCOR for allowing us to use the SDC tool. Sussex: National Council for osteopathic research (NCOR) university of
We would also like to thank all of the participants who contributed their Brighton; 2010.
time to completing the surveys and the Registro de Osteópatas de España 6. Burke SR, Myers R, Zhang AL. A profile of osteopathic practice in Australia
for their financial support. 2010-2011: a cross sectional survey. BMC Musculoskelet Disord. 2013;14(1):
The authors sincerely thank Francesco Cerritelli, Dr. Oliver Thomson and Dr. 227. https://doi.org/10.1186/1471-2474-14-227.
Jorge Esteves for reviewing the article as well as Albert Paredes for 7. Fawkes CA, Leach CMJ, Mathias S, Moore AP. A Profile of osteopathic care
contributions during the early stages of the project. in private practices in the United Kingdom: a national pilot using
standardised data collection. Man Ther. 2013;19(2):125–30. https://doi.org/
10.1016/j.math.2013.09.001.
Funding
8. Morin C, Aubin A. Primary reasons for osteopathic consultation: a
Funding for this project was provided by the Registro de Osteópatas de
prospective survey in Quebec. PLoS One. 2014;9(9):e106259. https://doi.org/
España (ROE) grant program.
10.1371/journal.pone.0106259.
9. Wilkinson J, Thomas KJ, Freeman JV. Day-to-day practice of osteopaths
Availability of data and materials using osteopathy in the cranial field, who are affiliated with the
The datasets used and/or analyzed during the current study are available Sutherland Cranial College of Osteopathy (SCCO): a national survey.
from the corresponding author on reasonable request. Int J Osteopath Med. 2015;18(1):13–21. https://doi.org/10.1016/j.ijosm.
2014.04.008.
Authors’ contributions 10. van Dun P, Nicolaie MA, Van Messem A. State of affairs of osteopathy in the
GA conceptualized and designed the study. All of the authors were Benelux: Benelux Osteosurvey 2013. Int J Osteopath Med. 2016;20:3–17.
responsible for adapting the SDC tool for the Spanish context and for data https://doi.org/10.1016/j.ijosm.2016.01.003.
collection and interpretation. SR was responsible for data analysis. GA and SR 11. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: visual
contributed to data analysis and interpretation as well as critical review and analog scale for pain (VAS pain), numeric rating scale for pain (NRS pain),
revision of the manuscript. All of the authors contributed to drafting and McGill pain questionnaire (MPQ), short-form McGill pain questionnaire (SF-
critically revising the paper and agree to be accountable for all aspects of MPQ), chronic pain grade scale (CPGS), short Form-36 bodily pain scale (SF-
the work. All authors read and approved the final manuscript. 36 BPS), and measure of intermittent and constant osteoarthritis pain
(ICOAP). Arthritis Care Res (Hoboken). 2011;63(Suppl 11):S240–52. https://doi.
Author’s information org/10.1002/acr.20543.
Gerard Alvarez - PhD student on Biomedical Research Methodology and 12. Ryan A, Wilson S, Taylor A, Greenfield S. Factors associated with self-care
Public Health in the Medical Department of the Universitat Autònoma de activities among adults in the United Kingdom: a systematic review. BMC
Barcelona. (Barcelona (Spain)). Public Health. 2009;9:96. https://doi.org/10.1186/1471-2458-9-96.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Alvarez Bustins et al. BMC Complementary and Alternative Medicine (2018) 18:129 Page 10 of 10

13. Murthy V, Sibbritt DW, Adams J. An integrative review of complementary 33. Franke H, Franke J-D, Fryer G. Osteopathic manipulative treatment for chronic
and alternative medicine use for back pain: a focus on prevalence, reasons nonspecific neck pain: a systematic review and meta-analysis. Int J Osteopath
for use, influential factors, self-perceived effectiveness, and communication. Med. 2015;18(4):255–67. https://doi.org/10.1016/j.ijosm.2015.05.003.
Spine J. 2015;15(8):1870–83. https://doi.org/10.1016/j.spinee.2015.04.049. 34. Dunning JR, Butts R, Mourad F, et al. Upper cervical and upper thoracic
14. Vlieger AM, van de Putte EM, Hoeksma H. The use of complementary and manipulation versus mobilization and exercise in patients with cervicogenic
alternative medicine in children at a general paediatric clinic and parental headache: a multi-center randomized clinical trial. BMC Musculoskelet
reasons for use. Ned Tijdschr Geneeskd. 2006;150(11):625-30. Disord. 2016;17(1):64. https://doi.org/10.1186/s12891-016-0912-3.
15. Low E, Murray DM, O'Mahony O, O'B Hourihane J. Complementary and 35. Hubert D, Soubeiran L, Gourmelon F, et al. Impact of osteopathic treatment
alternative medicine use in Irish paediatric patients. Ir J Med Sci. 2008;177(2): on pain in adult patients with cystic fibrosis–a pilot randomized controlled
147–50. https://doi.org/10.1007/s11845-008-0152-0. study. PLoS One. 2014;9(7):e102465.
16. Hameen-Anttila KP, Niskala UR, Siponen SM, Ahonen RS. The use of 36. Muller A, Franke H, Resch K-L, Fryer G. Effectiveness of osteopathic
complementary and alternative medicine products in preceding two days manipulative therapy for managing symptoms of irritable bowel syndrome:
among Finnish parents - a population survey. BMC Complement Altern a systematic review. J Am Osteopath Assoc. 2014;114(6):470–9. https://doi.
Med. 2011;11(1):107. https://doi.org/10.1186/1472-6882-11-107. org/10.7556/jaoa.2014.098.
17. Posadzki P, Watson L, Alotaibi A, Ernst E. Prevalence of complementary and 37. Swender DA, Thompson G, Schneider K, McCoy K, Patel A. Osteopathic
alternative medicine (CAM)-use in UK paediatric patients: a systematic manipulative treatment for inpatients with pulmonary exacerbations of
review of surveys. Complement Ther Med. 2013;21(3):224–31. https://doi. cystic fibrosis: effects on spirometry findings and patient assessments of
org/10.1016/j.ctim.2012.11.006. breathing, anxiety, and pain. J Am Osteopath Assoc. 2014;114(6):450–8.
18. Fernández-de-las-Peñas C, Alonso-Blanco C, Hernández-Barrera V, Palacios- https://doi.org/10.7556/jaoa.2014.095.
Ceña D, Jiménez-García R, Carrasco-Garrido P. Has the prevalence of neck 38. Cerritelli F, Pizzolorusso G, Renzetti C, et al. A multicenter, randomized,
pain and low back pain changed over the last 5 years? A population-based controlled trial of osteopathic manipulative treatment on preterms. Rubens
national study in Spain. Spine J. 2013;13(9):1069–76. https://doi.org/10.1016/ C. PLoS One. 2015;10(5):e0127370. https://doi.org/10.1371/journal.pone.
j.spinee.2013.02.064. 0127370.
19. Palacios-Ceña D, Alonso-Blanco C, Hernández-Barrera V, Carrasco-Garrido P, 39. Ruffini N, D'Alessandro G, Cardinali L, Frondaroli F, Cerritelli F. Osteopathic
Jiménez-García R, Fernández-de-las-Peñas C. Prevalence of neck and low manipulative treatment in gynecology and obstetrics: a systematic review.
back pain in community-dwelling adults in Spain: an updated population- Complement Ther Med. 2016;26:72–8. https://doi.org/10.1016/j.ctim.2016.03.005.
based national study (2009/10-2011/12). Eur Spine J. 2015;24(3):482–92. 40. Paanalahti K, Holm LW, Nordin M, Asker M, Lyander J, Skillgate E. Adverse
https://doi.org/10.1007/s00586-014-3567-5. events after manual therapy among patients seeking care for neck and/or
20. Kovacs FM, Fernández C, Cordero A, et al. Non-specific low back pain in back pain: a randomized controlled trial. BMC Musculoskelet Disord. 2014;
primary care in the Spanish National Health Service: a prospective study on 15(1):1–10.
clinical outcomes and determinants of management. BMC Health Serv Res. 41. Todd AJ, Carroll MT, Robinson A, Mitchell EKL. Adverse events due to
2006;6:57. https://doi.org/10.1186/1472-6963-6-57. chiropractic and other manual therapies for infants and children: a review
21. Ong C-K, Doll H, Bodeker G, Stewart-Brown S. Use of osteopathic or of the literature. J Manip Physiol Ther. 2015;38(9):699–712.
chiropractic services among people with back pain: a UK population survey. 42. Carnes D, Mars TS, Mullinger B, Froud R, Underwood M. Adverse events and
Health Soc Care Community. 2004;12(3):265–73. manual therapy: a systematic review. Man Ther. 2010;15(4):355–63. https://
22. Voigt K, Liebnitzky J, Burmeister U, et al. Efficacy of osteopathic doi.org/10.1016/j.math.2009.12.006.
manipulative treatment of female patients with migraine: results of a 43. Steel A, Sundberg T, Reid R, et al. Osteopathic manipulative treatment: a
randomized controlled trial. J Altern Complement Med. 2011;17(3):225–30. systematic review and critical appraisal of comparative effectiveness and
https://doi.org/10.1089/acm.2009.0673. health economics research. Musculoskelet Sci Pract. 2017;27:165–75. https://
23. Adragna V, Bertino AS, Carano M, Soru A, Taranto G, Desideri R. O052. doi.org/10.1016/j.math.2016.10.067.
Migraine without aura and osteopathic medicine, a non-pharmacological 44. Licciardone JC. Systematic review of comparative effectiveness and health
approach to pain and quality of life: open pilot study. J Headache Pain. economics research relating to osteopathic manipulative treatment. Musculoskelet
2015;16(S1):127. https://doi.org/10.1186/1129-2377-16-S1-A180. Sci Pract. 2017;29:e16–7. https://doi.org/10.1016/j.msksp.2017.01.006.
24. Cerritelli F, Ginevri L, Messi G, et al. Clinical effectiveness of osteopathic treatment 45. Parsons S, Harding G, Breen A, et al. The influence of patients“ and primary
in chronic migraine: 3-armed randomized controlled trial. Complement Ther care practitioners” beliefs and expectations about chronic musculoskeletal
Med. 2015;23(2):149–56. https://doi.org/10.1016/j.ctim.2015.01.011. pain on the process of care: a systematic review of qualitative studies. Clin J
25. D'Ippolito M, Tramontano M, Buzzi MG. Effects of osteopathic manipulative Pain. 2007;23(1):91–8.
therapy on pain and mood disorders in patients with high-frequency migraine. J 46. Luxford K, Safran DG, Delbanco T. Promoting patient-centered care: a
Am Osteopath Assoc. 2017;117(6):365–9. https://doi.org/10.7556/jaoa.2017.074. qualitative study of facilitators and barriers in healthcare organizations with
a reputation for improving the patient experience. Int J Qual Health Care.
26. Schabert E, Crow WT. Impact of osteopathic manipulative treatment on cost
2011;23(5):510–5. https://doi.org/10.1093/intqhc/mzr024.
of care for patients with migraine headache: a retrospective review of
47. Dwamena F, Holmes-Rovner M, Gaulden CM, et al. Interventions for
patient records. J Am Osteopath Assoc. 2009;109(8):403–7.
providers to promote a patient-centred approach in clinical consultations.
27. Cerritelli F, Lacorte E, Ruffini N, Vanacore N. Osteopathy for primary
Cochrane Database Syst Rev. 2012;12:CD003267. https://doi.org/10.1002/
headache patients: a systematic review. JPR. 2017;Volume 10:601–11.
14651858.CD003267.pub2.
https://doi.org/10.2147/JPR.S130501.
48. Orrock PJ. The patient experience of osteopathic healthcare. Man Ther.
28. Posadzki P, Ernst E. Osteopathy for musculoskeletal pain patients: a
2016;22(C:131–7. https://doi.org/10.1016/j.math.2015.11.003.
systematic review of randomized controlled trials. Clin Rheumatol. 2011;
49. Alzuri AG. Osteopaths in Spain: a survey of training and practice patterns.
30(2):285–91. https://doi.org/10.1007/s10067-010-1600-6.
(thesis dissertation) European School of Osteopathy. 2003.
29. Franke H, Franke J-D, Fryer G. Osteopathic manipulative treatment for
50. Brea JV. Exploring the identity of the osteopaths in Spain. A survey study.
nonspecific low back pain: a systematic review and meta-analysis. BMC
(thesis dissertation) European School of Osteopathy. 2012.
Musculoskelet Disord. 2014;15(1):286–18.
51. Cano S. Osteopathy in Spain: a survey to explore the practice characteristics,
30. Majchrzycki M, Wolski H, Seremak-Mrozikiewicz A, et al. Application of
training, and attitudes towards regulation. (thesis dissertation) London
osteopathic manipulative technique in the treatment of back pain during
School of Osteopathy. 2014.
pregnancy. Ginekol Pol. 2015;86(3):224–8.
31. Schwerla F, Rother K, Rother D, Ruetz M, Resch K-L. Osteopathic
manipulative therapy in women with postpartum low back pain and
disability: a pragmatic randomized controlled trial. J Am Osteopath Assoc.
2015;115(7):416–25. https://doi.org/10.7556/jaoa.2015.087.
32. Licciardone JC, Gatchel RJ, Aryal S. Recovery from chronic low back pain
after osteopathic manipulative treatment: a randomized controlled trial. J
Am Osteopath Assoc. 2016;116(3):144–55.

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:

1. use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
2. use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
3. falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
4. use bots or other automated methods to access the content or redirect messages
5. override any security feature or exclusionary protocol; or
6. share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at

onlineservice@springernature.com