Rethinking causation and mechanisms in osteopathy and physical intervention trial design: the positivist-realist continuum

Banton, Amanda, McIntyre, C, Ellwood, J, MacMillan, A, Hohenschurz-Schmidt, D and Vogel, Steven (2026) Rethinking causation and mechanisms in osteopathy and physical intervention trial design: the positivist-realist continuum. International Journal of Osteopathic Medicine, 60 (100820). ISSN 1746-0689

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Abstract

There has been renewed interest in mechanistic theory within osteopathy and the associated musculoskeletal professions, particularly regarding the role mechanisms play in osteopathic, manual and other physical interventions. Evidence-Based Medicine which commits to evidential pluralism (explicit incorporation of mechanistic evidence to inform trial design, through the selection of more meaningful controls and measuring more relevant outcomes) is known as Evidence-Based Medicine Plus (EBM+). This position paper introduces the concept of EBM+ to the osteopathy and MSK research community, and proposes the evolution of a theory of mechanisms that borrows from both positivist and realist traditions to better account for the mechanistic effects of physical interventions that are described in trials as specific, non-specific and contextual effects, and which have a relevance for clinical practice and education. This position paper contributes an overview of the philosophy of causality, a summary of scientific models of causation, and an account of how different theories of causation can be used to frame mechanisms, contextual factors and both specific and non-specific effects of physical interventions in trial design and clinical practice. What is novel is the positivist-realist continuum as a framework for accounting for different categories of treatment effects within explanatory, pragmatic and mechanistic trial design. We conclude with recommendations towards refining physical intervention trial design and reporting, encouraging researchers to make explicit the mechanistic theory and causal assumptions that support their methodological choices.

Item Type:	Article
Keywords:	Research design, Randomized controlled trials, Musculoskeletal manipulations, Physical therapy modalities, Evidence-based medicine, Causality, Philosophy, medical, Realism EBM+
Schools:	UCO School of Osteopathy
Depositing User:	Jessica Tovey
Date Deposited:	29 May 2026 08:43
Last Modified:	29 May 2026 08:43
URI:	https://hsu.repository.guildhe.ac.uk/id/eprint/657

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