Osteopathy for Musculoskeletal Pain: A Systematic and Umbrella Review of Effectiveness and Safety

Background: Musculoskeletal pain affects an estimated 1.7 billion people worldwide and ranks among the leading causes of global disability. This review evaluates the effectiveness and safety of osteopathy in treating musculoskeletal pain across multiple body regions and conditions. Methods: A systematic literature review following PRISMA guidelines was conducted across five databases (Embase, Medline via Ovid, The Cochrane Library, PEDro, and INAHTA), yielding 964 citations. Eligible studies were RCTs published in English or German up to May 2022; conference abstracts were excluded. A hybrid design was employed: a systematic review of RCTs for neck, shoulder, knee, foot, osteoporosis, and fibromyalgia was combined with a pre-specified umbrella review component for chronic non-specific low back pain (registered in PROSPERO) to avoid duplication of an existing high-confidence evidence synthesis. From 35 critically appraised articles, the best available evidence (n = 15) was selected per body region based on a risk of bias (RoB) assessment (Cochrane Collaboration tool, version 1); the existing review was appraised with AMSTAR 2. An updated search (2022-July 2025) was performed without a RoB assessment. Data were synthesised qualitatively and reported narratively. Results: Fifteen RCTs and one systematic review were included, covering eight body regions and conditions (2408 participants). Pain improved immediately post-treatment in most regions; statistically significant between-group differences were less consistent at mid- and long-term follow-ups. Key findings: neck pain (n = four RCTs)-improvement in three of four studies immediately post-treatment; shoulder pain (n = two RCTs)-improvements across all follow-up points in one study; low back pain (n = one systematic review, 10 RCTs, 1160 participants)-pain reduced immediately and at mid-term follow-up; knee pain (n = two RCTs)-significant reduction in one study; foot pain (n = two RCTs)-improvement in both studies post-treatment and at mid-term follow-up; osteoporosis (n = one RCT)-no improvement immediately post-treatment; fibromyalgia (n = two RCTs)-significant between-group differences in one study post-treatment and at mid-term follow-up. Functional outcomes were heterogeneous across regions. Adverse events were minor and transient; no serious side effects were reported across any included study. The updated search (2022-July 2025) identified 12 additional RCTs across five regions, with findings broadly consistent with the primary analysis, though results for the neck region were marginally less favourable. Discussion: Based on current evidence, osteopathy can improve neck and low back pain for up to three months and may reduce shoulder and foot pain; evidence for other body regions remains inconclusive. RoB was unclear to high across studies, largely due to the inherent inability to blind patients and practitioners in manual therapy trials. Substantial heterogeneity in interventions, outcome measures, and study designs limits comparability. Overall certainty of evidence was low to moderate, warranting cautious interpretation. The consistent absence of serious adverse events across all included studies supports osteopathy as a safe therapeutic option. High-quality research with standardised interventions, rigorous designs, long-term follow-ups, and a focus on technique, dosage, and safety is needed to inform clinical practice and healthcare policy. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sector.