MANUAL THERAPY AND OSTEOPATHY - COM-PARATIVE ANALYSIS

Purpose: to study and analyze the commonalities and differences between manual therapy and osteopathy. Material and methods: a content analysis of bibliographic descriptions and relevant articles on manual techniques and their application in patients with acute and chronic problems; historical method for studying the world practices in manual therapy and osteopathy; a documentary method for the legal regulation of the considered problem is studied in the normative acts, strategic and ethical documents. Results : a review of the literature and regulations reveals the commonalities between OP and MT: both use manual techniques for spinal dysfunction to reduce pain and improve movement in the affected joints but are not recognized as independent professions. The available differences relate mainly to the lack of a legal framework for training and practice in osteopathy and legal regulation of manual therapy as a specific field in the specialty “Physical and Rehabilitation Medicine”. Conclusion: The retrospective analysis clearly shows the place and role of manual therapy and osteopa-thy in the world. Despite the shared roots between MT and OP in Bulgaria, we find many differences in the leg-islative framework, training and practice. There is still no procedure for separating manual medicine into an independent medical profession in Bulgaria.


INTRODUCTION
A historical overview of the problem of how manual therapy and osteopathy differ reveals their common roots. It is believed that manual techniques were practiced in prehistoric times by hunters due to frequent injuries and sprains during hunting. It is known that manual techniques were also used in Ancient Greece, evidence of which is found in Plato's philosophical treatise "The State" (380 BC, in Greek: Πολιτεια, Polythea). With the help of manual techniques, Hippocrates helped patients with complaints of back pain and symptoms of internal organs [1]. In his work "on joints", he described traction techniques for the spine, as well as techniques for peripheral joints in luxations and subluxations, which according to modern understandings is close to the concept of "chiropractic" and manual therapy [2]. Interesting is the opinion of Hippocrates that the condition of the spine is extremely important because the cause of many diseases is related to its pathology and by improving the "joint play" of the vertebrae is possible to achieve a cure of the disease naturally. Hippocrates believed that the relaxing, shock and traction techniques of manual therapy are effective in the treatment of pathologies of the spine and complaints from the internal organs [3].

MATERIAL AND METHODS
The study was conducted during the period -January-February 2021, and its purpose was to study and analyze the commonalities and differences between manual therapy and osteopathy. The study uses a meaningful analysis of bibliographic descriptions and relevant articles on manual techniques and their application in patients with acute and chronic problems. A historical method is used to study the world practices in manual therapy and osteopathy. A documentary method in connection with the legal regulation of the considered problem is studied in the normative acts, strategic and ethical documents.

RESULTS
The review of world practices found that schools for therapists practicing manual techniques existed mainly in the United States, as teachers had no medical education and teaching was based on empirical, practical experience. Subsequently, it became possible to study osteopathy and manual therapy at universities, where the course of study gradually increased from 14 days to four years. At university, manual therapists, or chiropractors as they are called in the United States, and osteopaths studied all the sciences intended to train physicians except pharmacology.
Manual therapy (MT)is as old as the world and is an integral part of physiotherapy, but especially scientific development has been observed in the last 40 years.MT deals with the diagnosis, therapy and prevention of pain-related functional disorders of the musculoskeletal system [4,5]. The manual medicine specialist performs an examination that includes neurological status, but manual diagnosis may also be included. MT is aimed at eliminating pain restoring the functions of the spine and bone and joint apparatus in degenerative-dystrophic injuries [6]. In the mid-1950s, representatives of conventional medicine, using the methods of osteopathy and chiropractic in their medical activities, founded their own new school, in which only doctors could be members. To distinguish it from chiropractors and osteopaths, the medical field is called "manual medicine". The name comes from the Latin word manus = hand, and the semantic translation of the specialty is treatment through physical impact on the patient by the hands of the doctor. The experts have organized several congresses, which are held every three years. At the Third Congress, it was decided to establish in September 1965 in London the International Society of Manual Medicine. Currently, despite the presence of the International Federation of Manual Medicine (FIMM), there are numerous centers for manual therapy and osteopathy in the world (USA, England) [7]. It is necessary to mention one of the deans of manual medicine, the doctor and teacher Carl Levitt, who spread his experience in Czechoslovakia, Poland, Switzerland, incl. and in Bulgaria.
In Russia, in 1992, AA Barvinchenko published "Atlas of Manual Medicine", and in 1993 the monograph of AB Sittel "Manual Medicine" was published. Manual therapy began to be used in Moscow, Kiev, Kharkov, Sochi and other cities. In 1989, the first All-Union Symposium on Manual Therapy (Moscow) was held. In pursuance of his decisions, the All-Union Association of Manual Medicine (WAMM) was organized in 1990, and later the Russian Federal Association of Manual Medicine (RFAMM), which has numerous regional branches [8].
Manual therapy in Bulgaria is a specific field in the medical specialty "Physical and Rehabilitation Medicine". Assoc. Prof. Todor Todorov and Assoc. Prof. Iliya Todorov have a special contribution to the development of manual medicine in Bulgaria. In his dissertation, Assoc. Prof. I. Todorov gives accurate information and a clear idea of the benefits of manual therapy on the sacroiliac joint, which deepens the knowledge in this area and puts the foundations of sacred manipulative therapy. [9] Historically, the foundations of manual medicine in our country were laid in 1976 with the establishment of the Reference Center for Manual Medicine was established in Alexandrovska Hospital yet (although not named literally in this way). Then in the Clinic of Neurology of the hospital was created the first office for manual therapy, and Assoc. Prof. Mulchanova was the first doctor to work in it. Assoc. Prof. Mulchanova has started conducting courses for doctors in the Department of Neurology under the French program and with the schedule, according to which European standards will be guided to a large extent now. This unit has had different names over the years. In 2005, it grew into an independent manual therapy center at the hospital, then was a ward and lasted until the end of 2011, when it was gradually "assimilated" by the Clinic of Neurology. When the President of the International Federation of Manual Medicine, Dr Wolfgang von Heinmann, and the President of the European Scientific Society of Manual Medicine visited the center during the XI Scientific and Practical Conference, they were briefly demonstrated some manual techniques. The experts are pleasantly surprised by the good training of the specialists in Bulgaria and recommend the creation of this European reference center [10]. In Bulgaria, a society for manual medicine of vertebrogenic diseases is established and functioning to this day with honorary chairman Assoc. Prof. Mulchanova and chairman Dr Marieta Karadjova (Clinic of Nervous Diseases), who talks about the research foundations of manual medicine in our country. A commission is being formed in the Union of European Medical Specialists to develop standards for manual medicine -as well as for the theory, practice and certification of specialists.
Osteopathy (OP) is a holistic manual system for the prevention, diagnosis, treatment and rehabilitation of somatic dysfunctions caused by musculoskeletal problems [11]. A specific object of osteopathic influence is somatic dysfunction, which by its nature is a reversible disorder. Somatic dysfunctions expand the clinical possibilities of osteopathy, allow to trace their spread, and on the basis of the principles of evidence-based medicine to confirm the clinical effectiveness of osteopathic effects in various pathological conditions of the body [12, 13]. The OP uses the so-called "long lever technique", which affects the spine through the patient's limbs and torso, although it also applies to individual segments. Osteopaths practice "gentle" mobilization and massage techniques and attach great importance to functional disabilities. They consider the changes in the spine as osteopathic hypermobility -"relaxation" [14].
Modern osteopathy originated in the second half of the twentieth century in the United States. Andrew Taylor Steele (1828-1917) is considered to be the founder of the OP.His engineering education and subsequent medical education allowed him to build his own view of the mechanics of the human body. Style studied manual methods from antiquity, explaining their application from the point of view of modern science. Steele believes that osteopathy is a system of scientific knowledge in anatomy and physiology, with which a responsible and trained specialist works, applying this knowledge for the benefit of the sick and traumatized patient (E. Still, 1892).In 1892, Steele founded the world's first osteopathic school in Kirksville (Missouri). In Europe, the first osteopathic school was established in 1917 in London by his student John M. Littlejon . More than 20 years later, William Garner Sutherland (1873-1954) published the book "The cranial bowl", in which he presented his observations. W. Sutherland's followers, Viola M. Freeman, Harold Magun, and Tom Schulei, began teaching cranial osteopathy in France in 1964 [15].
In Russia, the OP entered St. Petersburg in 1991 through the osteopath Viola M. Freeman, who founded the first private osteopathic school (1994). In 1997, a register of osteopaths was established in St. Petersburg, which today includes dozens of graduates. In 2000, on the basis of the St. Petersburg Medical Academy, the postgraduate training in the "Training and Research Center for Osteopathic Medicine" began to function. In 2003, the Ministry of Health of the Russian Federation approved the methodological recommendations ¹2003 / 74 "Osteopathy", which set out the main provisions, principles, methods, indications and contraindications for the use of OP in clinical practice. An important feature of this normative act is that they are intended for doctors of all specialties, and not only for neurologists and orthopedists, as in manual therapy. In 2006, the Institute of Osteopathy was opened at the Medical Faculty of the State University of St. Petersburg, and in 2012 osteopathy was established as a profession and became a specialty in the field of higher education (cipher 31.08.52) [16].
The review of the normative acts in the Bulgarian legislation does not reveal legal regulation of the profession "osteopath", as well as the availability of training in OP in the higher medical schools. An Eastern European School of Osteopathy was founded in Bulgaria with Dr Erohov Alexandrovich as a leading teacher. The training program is structured in three levels aimed at joint and muscle pathologies in the field of the spine, but this does not contribute to the regulation of osteopathy as a specialty in the health care system and profession in our country [17].
A review of the literature and regulations reveals the commonalities between OP and MT: both use manual techniques for spinal dysfunction in order to reduce pain and improve range of motion in the affected joints, as well as other methods and means of kinesitherapy (massage, healing gymnastics, positional treatment), through which they affect not only the musculoskeletal problem but also the general health [18].
Despite differences in views on the mechanism of pain, manual therapists and osteopaths have developed their own methods of manual therapy over time, leading to their separation and sometimes even opposition. Table  1 shows (as a comparative characteristic) the differences that we find in our study between OP and MT in Bulgarian conditions: The available differences relate, on the one hand, to the lack of a legal framework for training and practice in osteopathy, and on the other hand -the lack of legal regulation of manual therapy as a specific area in the specialty "Physical and Rehabilitation Medicine". In Bulgaria, there is still no procedure for separating Manual therapy into a separate medical profession.

CONCLUSION
The analysis of osteopathy and manual therapy in the available literature and regulations makes it possible to establish their unifying goal -improving individual and public health. Despite this general similarity and their common roots in their historical development, we find many differences in their legislative framework, education Removal of blockages of joints of the musculoskeletal system, leading to hypomobility Clinical method -electroneuromyography, neurological and orthopedic status, examination, etc.
High High-energy techniques predominate Short procedures included in the scheme -basic examination-control examination to validate the result 6 years "Master of Medicine" + 4 years of specialization + continuing education in the healthcare system and practice. The main difference between the two practices is in the preparation of the performers of this medical service: manual therapy is practiced by certified doctors who have passed the relevant postgraduate education, and osteopathy -by persons with non-medical education. In Bulgarian conditions, manual therapy to date is legally regulated as education and is practiced by doctors in the specialties "Physical and Rehabilitation Medicine", "Orthopedics", "Rheumatology" and "Neurology" after special and continuous training in postgraduate education at higher medical schools. In this sense, osteopaths do not meet the standards for accredited education and license, which implies a rethinking of their place in the health and education system.