Osteopathic Care as (En)active Inference: A Theoretical Framework for Developing an Integrative Hypothesis in Osteopathy

Abstract

Osteopathy is a person-centred healthcare discipline that emphasizes the body's structure-function interrelationship-and its self-regulatory mechanisms-to inform a whole-person approach to health and wellbeing. This paper aims to provide a theoretical framework for developing an integrative hypothesis in osteopathy, which is based on the enactivist and active inference accounts. We propose that osteopathic care can be reconceptualised under (En)active inference as a unifying framework. Active inference suggests that action-perception cycles operate to minimize uncertainty and optimize an individual's internal model of the lived world and, crucially, the consequences of their behaviour. We argue that (En)active inference offers an integrative framework for osteopathy, which can evince the mechanisms underlying dyadic and triadic (e.g., in paediatric care) exchanges and osteopathic care outcomes. We propose that this theoretical framework can underpin osteopathic care across the lifespan, from preterm infants to the elderly and those with persistent pain and other physical symptoms. In situations of chronicity, as an ecological niche, the patient-practitioner dyad provides the osteopath and the patient with a set of affordances, i.e., possibilities for action provided by the environment, that through shared intentionally, can promote adaptations and restoration of productive agency. Through a dyadic therapeutic relationship, as they engage with their ecological niche's affordances-a structured set of affordances shared by agents-osteopath and patient actively construct a shared sense-making narrative and realise a shared generative model of their relation to the niche. In general, touch plays a critical role in developing a robust therapeutic alliance, mental state alignment, and biobehavioural synchrony between patient and practitioner. However, its role is particularly crucial in the fields of neonatology and paediatrics, where it becomes central in regulating allostasis and restoring homeostasis. We argue that from an active inference standpoint, the dyadic shared ecological niche underwrites a robust therapeutic alliance, which is crucial to the effectiveness of osteopathic care. Considerations and implications of this model-to clinical practice and research, both within- and outside osteopathy-are critically discussed.

Keywords: active inference; affective touch; chronic pain; enactivism; free-energy principle; osteopathy; predictive processing; therapeutic alliance.

FIGURE 1

Multilevel representation of human selfhood according to Seth (2021). Embodied self—the sense of having a body, perspectival self—the ability to perceive the world from a first-person perspective, volitional self—the sense of agency, narrative self—the sense of personal identity, social self—linked to the way in which we are perceived by, and interact with others.

FIGURE 2

Active inference. This Figure depicts the coupling of an agent’s internal states (the dynamics of which entail predictions or beliefs about the niche) to its external states (the dynamics of the agent’s niche). Adapted with permission from Vasil et al. (2020).

FIGURE 3

Thinking through other minds. The agent osteopath and the agent patient build shared expectations through engagement with the clinical encounter social and material affordances, allowing adaptive niche construction by thinking through other minds. In the context of communication in clinical practice, coupled dynamics are strengthened by an adaptive prior for alignment. The adaptive prior for alignment specifies the characteristically enhanced precision of the hypothesis that “we” exist. This prior motivates similar agents to actively couple their respective actions and perceptions. The coupling of perception and action enables the osteopath and patient to reliably align with (i.e., infer) the hidden states of the other. This circular process brings about a process of cultural niche construction that creates, maintains, and modifies a set of predictable epistemic resources. These specify a set of high value (i.e., predictable) observation-policy mappings, which are used to disambiguate the mental states of conspecifics. Effective communication plays a crucial role in enabling agents with an adaptive prior for alignment to effectively disambiguate external states. An agent’s external states are constituted, in part, by the internal, mental states of another agent (and vice versa). This follows from the fact that external states cause sensation; for an agent equipped with an adaptive prior for alignment, inferring external states entails inferring other agents’ hidden states. Adapted with permission from Vasil et al. (2020).