## 4 Discussion
By critically analyzing the osteopathic literature published so far, it is found that there are four main examples that demonstrate this concept. In a very recent systematic review and meta-analysis including nine randomized clinical trials, [PERSON] et al., 2024 [54] found that OMT was not superior to a sham or placebo in patients with neck or low back pain. There were several methodological flaws in the review, such the lack of coherence between the inclusion criteria and the included studies and the arbitrary choice to not consider the inclusion of a more objective outcome, namely the number of co-interventions required to reduce the pain. However, after carefully re-reviewing the nine included studies, it is found that only one out of nine studies [55] considered all three of the above-presented main aspects that are at the basis of our paradigm. Five out of nine studies [56; 57; 58; 59; 60] performed OC by only relying on one aspect (SD/OPF), without implementing holistic approach and without performing individualized OC; three out of nine studies [61; 62; 63] did not use any of the three main aspects. According to the forest plot presented by the authors of the meta-analysis, [PERSON] et al., 2008 [55] was the most effective study, demonstrating the intrinsic value of OC. A second example is another meta-analysis [64] that analyzed the length of stay and the costs of preterms undergoing OC compared to preterms receiving only the usual care. Five RCTs (four Italian and one Austrian) were included. The results showed that all four Italian studies [65; 66; 67; 68] reduced the preterms' length of stay. Unfortunately, the Austrian study [69] showed that, in the OMT group, the preterms' length of stay was 34 days greater compared to the control group (100 vs. 66 days). The difference in performing OC in the Italian vs. Austrian studies is clear, but both are noteworthy. In the four Italian studies, OC was conducted according to the three main aspects (SD/OPF, holistic approach derived from osteopathic principles, and individualization). In contrast, in the Austrian study, a visceral treatment was performed in a standardized way for each preterm. It is worth noting that the author referenced SD; however, there appeared to be a misinterpretation of the concept: \"In the present study, delayed meconium excretion of the preterm infant was defined as the SD to be treated\". A third example is [PERSON] et al., 2004 [70], who added OC in a cohort of 30 elderly patients (mean age 69.2 years) who underwent surgery for knee or hip fractures alongside conventional rehabilitation. Comparing the osteopathy cohort with a cohort of matched patients undergoing only rehabilitation, the osteopathy group showed a worsened length of stay (15.4 days for the OC group vs. 12.3 days for the control group, \(p=0.09\); considering all osteoarthritis patients, 14.9 days for the OC group vs. 9.3 days for the control group, \(p=0.001\)). Furthermore, there was a statistically significantly better outcome in favor of the control group regarding the mental health subscale of the SF-36 and the locomotion subscale of the Functional Independence Measure. Finally, the rehabilitation efficiency was found to be better in the control group compared to the OC group (2.6 vs. 2.0, respectively, \(p=0.01\)). Despite the strong methodological basis of the RCT, which made it coherent with the very recent suggestion regarding the placebo control [71], it did not include a genuine \"osteopathic\" counterpart. The authors of the above study write, \"Participants were evaluated by an OMT specialist to identify areas of SD [...] Treatments were performed by undergraduate fellows\" [70]. This represents a form of fragmented practice in which the practitioner remains disengaged from the evaluation and diagnostic process, thereby losing the significant aspect of biogeochemical synchronization. Furthermore, the protocol established that only locoregionally operated somatic regions would be treated, referring to poorly specified \"surrounding areas\".