Exercise based interventions are common in the treatment of musculoskeletal disorders. These interventions have been investigated in other manual therapy disciplines, but little empirical data exists about. osteopathic approaches to exercise. There is a need to examine the role of exercise in osteopathic undergraduate education and the osteopathic treatment and management of patients in order to identify, clarify and develop upon educational and professional needs of the practising osteopath. The aims of this thesis were to explore the integration of exercise therapy in the undergraduate osteopathic curriculum, gain an understanding of the interpretation and uses of exercise therapy in osteopathic practice and explore potential concordance between education and practice. To provide context for the studies in the thesis, preparatory work included . examining the historical and philosophical developments within osteopathy and the utilisation of exercise therapy and physical activity in wider health care provision. Curriculum evaluation of the intended (content analysis of course documents) delivered (faculty member perspective) and received (student perspective) undergraduate osteopathic curricula revealed the idiosyncratic and sporadic nature of documented and delivered exercise content. The intended curriculum was seen to pertain to academic education whilst the delivered and received curriculum was reflective of clinical education. There was evidence of shared desires from osteopathic students and faculty members who suggested that they would welcome a standardised, experiential, patient centred approach to exercise therapy. The interview study with practitioners revealed a patient centred approach to the use of exercise therapy. However there remains some confusion over the use and understanding of exercise terminology. Paradoxically with the stated patient centred approaches practitioners expressed exercise delivery using paternalistic language. Favoured modes of exercise showed common trends with other manual therapies such as the use of 'core stability' programmes, but bore little resemblance to those delivered during undergraduate education. Exercise therapy and its potential for use is a substantial issue for osteopaths and for education providers in the UK. There is some dissonance between clinicians reported patient centred care approaches and actual delivery of exercise advice. Exercise education in osteopathy and clinical practice are not concordant and clinical aspects of undergraduate education are not documented clearly and are largely opportunistic. There is a need for further consensus about the role of exercise therapy in osteopathic practice and this should be a driver for a more coherent approach across education and practice.

Purpose: This study explored therapeutic processes associated with developing a course for patients with persistent pain which integrated osteopathic treatment with Acceptance and Commitment Therapy (ACT). This 'third wave’ cognitive behavioural approach is effective for a range of physical and psychological problems, including persistent pain, and congruent with osteopathic principles of holism, function and agency, which provided a theoretical basis for developing an integrated intervention to promote resilience and well-being. A qualitative case study was conducted as part of a developmental research programme to explore how ACT could be integrated with osteopathic treatment for individual patients, and with what effects on processes and outcomes. Method: Linguistic ethnography was used to explore links between pain-related discourses, clinical decisions and responses to pain. Treatments were audio-recorded, transcribed, and coded. Extracts referring to discourses about pain experienced during manual therapy were subjected to micro-level conversation analysis, sociolinguistic analysis of participants’ roles, and macro-level analysis of links to broader healthcare discourses. A reflective diary was used to explore experiential learning and integrate auto-ethnographic information. Results: Two distinctive forms of mechanistic and facilitative pain discourse were identified. In predominantly mechanistic discourses, agency and expertise were located with the osteopath, and intention was focused on fixing ‘broken’ parts and relieving pain using ‘familiar’ osteopathic techniques. In facilitative discourses, the osteopath adopted a more collaborative role, focused on developing the patient's body and self-awareness to promote more flexible, active pain responses. Practitioner challenges included learning how to shift intention between mechanistic and facilitative interventions, a process that was enabled by mindfulness and willingness to tolerate uncertainty. Conclusions: In this study, ACT-informed osteopathy involved facilitative discourses, associated with increased patient agency and flexibility in response to pain. Further research is needed to explore whether this pattern of discourse is robust in other clinical settings; relationships between mechanistic and facilitative discourses and therapeutic outcomes; and effects of ACT training on practitioner mindfulness and attitude towards clinical uncertainty. Findings suggest that this integrated approach could expand the scope of osteopathic care for patients with persistent pain, and is worth further investigation.