The Use of Exercise Prescription in Australian Osteopathy Practice: Secondary Analysis of a Nationally Representative Sample of the Profession

Introduction Exercise is beneficial for improving general health, wellbeing, and specific medical conditions. In musculoskeletal conditions such as chronic low back and neck pain, prescribed exercise has been found to be moderately effective in decreasing pain and improving function. Osteopaths are primary contact health professionals who manage predominantly musculoskeletal complaints. This work presents a secondary data analysis of the Australian osteopathy practice-based research network and profiles the characteristics of osteopaths who often use exercise prescription in patient care. Methodology. Secondary analysis of a cross-sectional survey of 992 osteopaths was registered with the Osteopathy Research and Innovation Network, an Australian practice-based research network. Demographics, practice, and treatment characteristics of Australian osteopaths who “often” use exercise prescription in patient care were examined. Results Seven-hundred and thirty-three Australian osteopaths (74%) indicated that they use exercise prescription “often” in patient care. Australian osteopaths who often use exercise prescription are more likely to be colocated with another osteopath (ORa 1.54) and send referrals to an exercise physiologist (ORa 1.94) and a specialist medical practitioner (ORa 1.72). Those osteopaths who often used exercise prescription were also more likely to discuss physical activity (ORa 5.61) and nutrition (ORa 1.90). Australian osteopaths who use exercise prescription often were more likely to treat patients with sports injuries (ORa 2.43) and use soft tissue techniques (ORa 1.92), trigger point techniques (ORa 2.72), and sports taping (ORa 1.78). Conclusion Osteopaths who utilise exercise prescription were more likely to discuss physical activity, diet, and nutrition and utilise referral networks with specialist medical practitioners and exercise physiologists. Australian osteopaths who often use exercise prescriptions were also more likely to treat patients with sport injury. The results suggest that most Australian osteopaths use exercise prescription and have referral networks with other health professionals for patient management. Further work is required to explore the type of exercise prescription used and for what conditions.


Introduction.
Exercise is benefcial for improving general health, wellbeing, and specifc medical conditions.In musculoskeletal conditions such as chronic low back and neck pain, prescribed exercise has been found to be moderately efective in decreasing pain and improving function.Osteopaths are primary contact health professionals who manage predominantly musculoskeletal complaints.Tis work presents a secondary data analysis of the Australian osteopathy practice-based research network and profles the characteristics of osteopaths who often use exercise prescription in patient care.Methodology.Secondary analysis of a cross-sectional survey of 992 osteopaths was registered with the Osteopathy Research and Innovation Network, an Australian practice-based research network.Demographics, practice, and treatment characteristics of Australian osteopaths who "often" use exercise prescription in patient care were examined.Results.Seven-hundred and thirty-three Australian osteopaths (74%) indicated that they use exercise prescription "often" in patient care.Australian osteopaths who often use exercise prescription are more likely to be colocated with another osteopath (ORa 1.54) and send referrals to an exercise physiologist (ORa 1.94) and a specialist medical practitioner (ORa 1.72).Tose osteopaths who often used exercise prescription were also more likely to discuss physical activity (ORa 5.61) and nutrition (ORa 1.90).Australian osteopaths who use exercise prescription often were more likely to treat patients with sports injuries (ORa 2.43) and use soft tissue techniques (ORa 1.92), trigger point techniques (ORa 2.72), and sports taping (ORa 1.78).Conclusion.Osteopaths who utilise exercise prescription were more likely to discuss physical activity, diet, and nutrition and utilise referral networks with specialist medical practitioners and exercise physiologists.Australian osteopaths who often use exercise prescriptions were also more likely to treat patients with sport injury.Te results suggest that most Australian osteopaths use exercise prescription and have referral networks with other health professionals for patient management.Further work is required to explore the type of exercise prescription used and for what conditions.

Introduction
Research highlights the benefts of exercise including improving general health and wellbeing and being part of the management of specifc medical conditions such as stroke and osteoporosis [1].Although general exercise is benefcial for an individual's quality of life [2] and from a public health perspective [3], more specifc or targeted exercise can be of beneft in the management of various complaints, particularly those that are musculoskeletal in nature.For chronic low back pain (LBP) and neck pain, prescribed exercise has been demonstrated to be moderately efective in decreasing pain and improving function [4,5].Prescribing exercise within management plans for musculoskeletal conditions is strongly advocated in both clinical practice guidelines [6][7][8][9] and biopsychosocial approaches to patient care [10].
Tere are a range of prescribed exercise approaches that can be utilised as part of the management of musculoskeletal complaints such as low back pain.Tese include resistance training, aerobic-based exercise, motor control exercises, and other exercise approaches including yoga and Pilates [11].Walking [12] and aquatic-based exercise [13] are also reported to be of beneft as an exercise for musculoskeletal complaints.However, a signifcant challenge with the inclusion of exercise as part of the management plan is adherence, both from a patient and research defnition perspective [14].Tat said, these exercise interventions are relatively easily incorporated into a management plan based on patient preference(s) and benefcial from a public health and health promotion perspective.
Exercise prescription is frequently used by allied health professionals with the aim of improving physiological wellbeing, functional ability, capacity, mobility, and pain relief [15][16][17].Tese allied healthcare professions include physiotherapy [18], chiropractic [18,19], occupational therapy [20], and osteopathy [21].Te type of exercise prescription provided typically includes activity recommendations, progressive general exercise, and more specifc exercise interventions including stretching, range of motion activities, and stabilisation exercises to specifc body regions [22].
Osteopaths are primary contact health professionals who manage predominantly musculoskeletal complaints [23].In the Australian context, patients predominantly access osteopathy services privately.Patients may also access care through third-party payment schemes associated with worker's compensation, trafc accident, and war veteran schemes.Although the dominant therapeutic approach used by Australian osteopaths is manual therapy [24], patient education [25,26] and exercise are also incorporated.Orrock [27] explored osteopathic practice in Australia in 2009 and found that approximately 55% of practitioners often or always prescribe therapeutic exercise.In 2018, Adams, Sibbritt, Steel, and Peng [23] reported 74% of Australian osteopaths utilise exercise prescription, as do 78% of New Zealand osteopaths.Tese increases over time in the reported use of exercise prescription may be related to an increase in the visibility of this approach within osteopathy pre-professional curricula.
Data from the United Kingdom (UK) show that approximately 23% of osteopaths used exercise prescription as part of their patient management [28].In contrast, a crosssectional study of Australian osteopaths in 2013 reported approximately 6% only of patient records examined in 2011 and 2012 contained a form of exercise prescription [29].As highlighted above, the lower rate in this older work by Burke, Myers, and Zhang [29] compared to more contemporary research refects an increasing utilisation in practice, likely based on the education of osteopaths and emphasis on exercise as an efective management strategy for musculoskeletal complaints.
Several case studies have also reported osteopaths prescribing exercise as a form of therapy or where it has been incorporated into the patients' broader management plan [30][31][32].Te use of exercise outside the immediate osteopathy practice environment has also been investigated with home exercise programmes featured in various manual therapy research studies [33].However, there is limited higher quality research about the use of exercise prescription by osteopaths in the literature, suggesting that further research is needed to efectively capture the use of exercise prescription by the profession.Our work presents a secondary data analysis of the Australian osteopathy practicebased research network [23,24] to profle the characteristics of osteopaths who often use exercise prescriptions in patient care [34].In profling the practice of Australian osteopaths and their use of exercise, it is possible to develop a more informed understanding of which practitioners are using exercise prescription in practice.Furthermore, the current analysis also allows for an initial exploration as to whether the practice of Australian osteopaths refects contemporary evidence-based approaches using combined manual therapy and exercise prescription for the management of musculoskeletal complaints.[23] was used to recruit participants from July to December 2016.Potential participants were required to be a registered osteopath at the time of data collection.Participants who consented were invited to complete an online questionnaire.Responses to the ORION questionnaire were received from 992 osteopaths, a 49.1% response rate.Adams and colleagues [23] reported the respondents to be nationally representative of the Australian osteopathy profession at the time of data collection.

2.2.
Questionnaire.A 27-item questionnaire was developed to collect data from the PRBN participants using dichotomous, frequency, and Likert-type responses [23].Te questionnaire invited participants to provide data on individual practitioner demographics (i.e., age, gender, and number of years in private osteopathy practice), participants' practice characteristics (i.e., patient care hours and patient visits per week, practice location, and interactions with other health professionals either through colocation or referrals), and patient management (i.e., body regions treated, manual therapy technique use, and advice to patients).Additional items also explored practitioner opinions on expanded practice rights and use of research in osteopathy practice.Patient management characteristics included the frequency of patient presentations, discussion of lifestyle behaviors, frequency of treating specifc patient groups, and frequency of osteopathy technique use.

Outcome Variables and Exposure Variables.
Participants were asked to indicate their frequency of use of exercise prescription in patient care ("never," "rarely," "sometimes," and "often"), the outcome variable.Te outcome variable was dichotomized to "not often" (combining never, rarely, and sometimes) or "often" [35].Te exposure variables were 2 Te Scientifc World Journal the practitioner and practice characteristics described in the Questionnaire section above.Variables with frequency or Likert-type responses were dichotomized for the analysis (often and not often ("never," "rarely," and "sometimes")) and attitude (defnitely and not defnitely ("no," "unsure," "maybe")).Age, average patient numbers per week, average patient care hours per week, and years in clinical practice were analysed as continuous variables.All other variables included in our analysis are reported in binary form (yes/ no).

Statistical Analyses.
Analyses were performed using SPSS (version 25).Descriptive statistics were generated for each variable on the questionnaire.Inferential statistics were used to explore the association between the outcome variable and dichotomized variables.Alpha was set at p < 0.05, and unadjusted odds ratios ORc (with 95% confdence intervals) calculated where signifcant.Continuous data were analysed using independent measures t-tests with alpha set at p < 0.05, and efects sizes (Cohen's d) calculated where signifcant.Variables with p < 0.20 were entered into a binary logistic regression analysis.Backward elimination was used to determine the signifcant predictors of osteopaths who "often" use exercise prescriptions [23].Adjusted odds ratios (ORa) with 95% confdence intervals (CI) and p values were calculated from this regression modelling.Variables were signifcantly associated with the outcome variable at p < 0.05.

Results
Seven-hundred and thirty-three Australian osteopaths (73.9%) indicated that they use exercise prescription "often" in patient care.Tere was no statistically signifcant difference of gender for Australian osteopaths who use exercise prescription often compared to osteopaths who do not use it often (p > 0.05) (Table 1).Australian osteopaths who often use exercise prescription were younger in both age and time in practice (p < 0.05) and reported a higher number of patient visits and care hours per week (p < 0.05) all with small-to-medium efect sizes.Tose Australian osteopaths with a postgraduate qualifcation, and those who reported being a member of Sports Medicine Australia, were also more likely to use exercise prescription often, compared to those who did not report these characteristics (Table 1).
For patient assessment, Australian osteopaths who use exercise prescription often were more than twice as likely to refer for diagnostic imaging and six times more likely to use orthopaedic assessment in patient examination, compared to those who do not often use exercise prescription (Table 2).Australian osteopaths who often use exercise prescription were approximately 50% more likely to be colocated with other osteopaths (ORc 1.48) and nearly twice as likely to send referrals to exercise physiologists (ORc 1.90) (Table 2).
Australian osteopaths who often use exercise prescription in patient care were more than eight times as likely to discuss physical activity with their patients compared with osteopaths who do not often use exercise prescription (Table 3).Medication and occupational health and safety were more than twice as likely to be discussed with patients by osteopaths who reported the use of exercise prescription often in patient care (Table 3).Australian osteopaths who often use exercise prescription were almost twice as likely to discuss a range of other clinical management strategies with patients compared with osteopaths who do not often use exercise prescription (Table 3).
Osteopaths who often use exercise prescription were more than twice as likely to treat postural disorders (ORc 2.13) and tendinopathies (ORc 2.28) and compared to those who do not often use exercise prescription in patient care (Table 3).Australian osteopaths who often use exercise prescription were three times more likely to treat patients with sport injuries (ORc 3.37) and twice as likely to report treating compensable work injury patients (ORc 2.40) (Table 3).
Osteopaths who often used exercise prescription were more than twice as likely to use muscle energy technique and dry needling and three times more likely to more than 3x more likely to use soft tissue technique and trigger point therapy (Table 3).Tose osteopaths who often used exercise prescription were also nearly six times more likely to use sports taping compared with colleagues who did not often use exercise prescription (Table 3).However, osteopaths who often use exercise prescription were less likely to use autonomic balancing, balanced ligamentous tension, biodynamics, and osteopathy in the cranial feld techniques in patient care (Table 3).
Australian osteopaths who often use exercise prescription in patient care were nearly twice as likely to indicate expanded practice with respect to prescribing rights (ORc 1.92) and twice as likely to seek expanded referral rights to Sports Medicine specialists (ORc 2.37) (Table 3).
Adjusted odds ratios (ORa) for variables that were identifed as being statistically signifcant in the backward binary logistic regression model are described in Table 4. Australian osteopaths who often use exercise prescription were over fve times more likely to discuss physical activity with patients compared with those who do not often use exercise prescription in patient care.

Discussion
Our secondary analysis of the Australian osteopathy PBRN data provides a novel insight into the practice characteristics of practitioners who often use exercise prescription as part of the care of patients with musculoskeletal complaints.Approximately three-quarters of Australian osteopaths often prescribe exercise in patient care.Tis fnding is consistent with previous data for New Zealand osteopaths [24] suggesting that exercise prescription is a signifcant component of Australasian osteopathy practice.
Our data show that Australian osteopaths who often use exercise prescriptions are also more likely to engage in referrals with other health professionals.Osteopaths who use exercise prescription often were almost twice as likely to send referrals to an exercise physiologist and to specialist medical practitioners.Approximately 5% of referrals from Te Scientifc World Journal Australian osteopaths are reported to be specialist medical practitioners [27].Tese fndings are encouraging, and it may indicate that these osteopaths are more likely to use a multidisciplinary approach to their patient management, particularly where exercise prescription is involved.It is possible that Australian osteopaths are working with exercise physiologists for individual patient care.Tere are opportunities for these two health professional groups to work together through the Australian government-funded chronic disease management plan scheme [36] and also in the care of private paying patients.Combined with the current fndings, there is an increasing evidence base with respect to referrals to and from osteopaths [27,29].We are not able to comment on the nature of the referrals; however, these fndings warrant additional exploration to better understand how Australian osteopaths work with other health professionals for the beneft of their patients.
Te practice of osteopathy intersects with exercise and physical activity and well-being from several perspectives.Australian osteopaths who often use exercise prescriptions in patient care were over fve times more likely to report discussing physical activity with their patients compared with osteopaths who do not.Our results suggest that osteopaths who discuss physical activity and use of exercise prescription form a signifcant part of Australian osteopathic practice [26].Tis result is encouraging from a health promotion perspective and may indicate that Australian osteopaths, who incorporate exercise prescription into patient care, also recognise the value of physical activity for overall health.Activities such as walking and swimming are examples of physical activity that are benefcial for managing musculoskeletal complaints [12,37], and it may be that osteopaths are encouraging patients to engage in these or other forms of physical activity.Further, these fndings suggest that osteopaths may be playing an important role in promoting public health messaging around physical activity for general health.However, these assertions require further research through practice audits or practitioner interviews.
Our data suggest that osteopaths who report often using exercise prescription were more than twice as likely to treat sports injuries and 50% more likely to use sports taping.Injuries related to sport are common presentations to Australian osteopaths with approximately half of Australian osteopaths treating sport-related injuries [23].Te association observed between using exercise prescription and treating sport-related injuries is likely related to Australian osteopaths using targeted and sport-specifc exercise to facilitate an individuals' return to sport post-injury [38].However, exercise prescription for sports injuries in the context of osteopathy care is underexplored.Several case studies [39,40] have described the use of exercise prescription in the context of osteopaths managing sportrelated injuries, with positive outcomes.However, there are also opportunities to develop higher level evidence to support patient outcomes and cost-efectiveness.With respect to the use of sports taping, there is evidence to support its use for the management of musculoskeletal complaints, particularly in short term or for acute presentations [41][42][43].Sports taping was also used by Australian osteopaths, and the association in the current works suggests that this forms part of their management exercise prescription for patient care.Tere is an evidence base for the use of taping for the management of a wide variety of musculoskeletal complaints [44] or to support athletic performance [45].It may be that Australian osteopaths recognise the value of sports taping, combined with exercise prescription, for patient care.Further, the increased likelihood of sports taping use by osteopaths who often use exercise prescription suggests they may be combining these modalities in patient care; however, more exploration is needed.Nutritional supplement advice was also more likely to be used by Australian osteopaths who often use exercise prescriptions, compared to those who do not.Tis is a consistent fnding with the chiropractic profession [46] suggesting that this advice forms part of the scope of manual therapy practice in Australia.From a health promotion perspective, few Australian adults meet the fruit and vegetable intake guidelines [47], instead consuming a dominance of excessive calorie dense, ultraprocessed food intake, posing a risk for heart disease, type 2 diabetes, and several cancers [48].Te nature of the nutritional supplement advice provided by Australian osteopaths requires exploration, particularly whether this advice relates to specifc supplements for the management of musculoskeletal complaints or is more broadly applicable to overall health and wellbeing.
Previous research has shown that a variety of manual therapy techniques are the dominant intervention strategy for Australian osteopaths [23,27,29].Although the use of manual therapy by Australian osteopaths is common [23,27,29], our work highlights some techniques (soft tissue techniques and trigger point therapy) that are more  Te Scientifc World Journal commonly utilised by osteopaths who often use exercise prescription compared to those who do not.Soft tissue techniques have been shown to be efective in the management of upper and lower extremity musculoskeletal complaints [49][50][51].As such, the use of soft tissue techniques by Australian osteopaths may facilitate the ability of a patient to undertake their prescribed exercises or potentially related to patient expectation with respect to the interventions provided.
Te cross-sectional and self-report nature of the design of the ORION survey is a limitation when interpreting the results of the study.It is known that cross-sectional selfreport designs are potentially susceptible to social desirability bias [52] and recall bias [53].How practitioners defned exercise prescription when completing the questionnaire is open to interpretation and may have skewed the results.Lastly, the design of the survey does not allow for analysis of the type of exercise prescription (e.g., whether in the clinic or home) and whether osteopaths use exercise prescription for some presenting complaints only.It is probable that practitioners approach diferent conditions in diferent ways and this clinical reasoning would be valuable to explore.
Our analyses ofer opportunities for future research to develop a greater understanding of how Australian osteopaths use exercise prescription in their practice.Barriers and enablers for the use of exercise prescription, the type of exercises being prescribed and for what presenting complaints, as well as the clinical reasoning for exercise prescription and outcomes from care where exercise prescription forms part of the management, could be explored.Tis research, combined with the current work, has the potential to inform pre-and postprofessional education (including professional development) and health policy.

Conclusion
Our work sought to identify the prevalence of exercise prescription used by osteopaths for patient management and to profle the clinical management characteristics of osteopaths who often use it.Tis work from a nationally representative practice-based research network (PBRN) profles the characteristics of the 74% of Australian osteopaths who often use exercise prescription in patient management.We identifed several patients and clinical management characteristics associated with the use of exercise prescription often in osteopathy patient care.Tese included discussion of physical activity, diet, and nutrition, often treating patients with sports injuries, and use of health professional referral networks.Whether these strategies are consistent with the best available evidence requires additional investigation, but the results support the conclusion that a signifcant proportion of Australian osteopaths often use exercise prescription in patient care.

Table 1 :
Practitioner characteristics of Australian osteopaths who often versus not often use exercise prescription in patient care.

Table 2 :
Practice characteristics of Australian osteopaths who often use exercise prescription in patient care.

Table 3 :
Clinical management characteristics of Australian osteopaths who often use exercise prescription in patient care.

Table 4 :
Adjusted odds ratios for signifcant practitioners and clinical management characteristics of Australian osteopaths who often use exercise prescription in patient care.