Osteopathy aims to holistically improve and support all health aspects. Worldwide, osteopathy has no consistent regulation, education and practice standards. Supply and demand steadily increase, and the question arises whether the public sector should pay for those services in future. Therefore, the evidence on the effectiveness and safety of osteopathy in treating musculoskeletal pain is summarised (part 1), and current training and quality requirements and regulations of the osteopathic profession in Europe are described (part 2).

For part 1, a systematic literature search for randomised controlled trials was conducted in five databases. From the 964 studies found, 35 studies were identified as relevant, and the best available evidence (n=15) was selected for each body region. Additionally, we summarised a recent systematic review for chronic low-back pain. All studies were critically appraised. According to the current evidence, osteopathy can improve neck and low back pain in the short- and mid-term and possibly reduce shoulder and foot pain, while there is uncertainty about its effectiveness for pain in other body regions and diseases analysed (knee, osteoporosis, fibromyalgia). No statistically or clinically significant deteriorations occurred due to osteopathic interventions, and only very few patients reported minor adverse events. The risk of bias in the included studies was unclear to high. Serious limitations of the studies were given due to the lack of blinding. However, the nature of osteopathy hardly allows blinding of those who deliver or receive it. Heterogeneity (e.g. professions involved, comparison, outcome measurements, treatment periods, follow-up) might have influenced the results.

For part 2, ten countries were selected according to predefined inclusion criteria. A targeted manual search for training and quality requirements for osteopaths was conducted in different sources. Experts were contacted to further identify and complete the countries' information. A legal regulation exists in seven countries, and the title 'osteopath' is fully protected in six countries. However, different training options for osteopathy exist in the included countries, varying in their curricula.

Future randomised controlled trials should be designed to have a lower risk of bias and allow for long-term follow-ups so that more high-quality evidence of effectiveness can be conducted to inform clinical practice and health policy. A regulation regarding education, practice and training is needed before a possible financial reimbursement. It is essential to orientate on international standards and adapt those for Austria.