The treatment method of osteopathy and the occupational profile of osteopaths have been discussed more often in recent times. However, there is still no uniform international regulation on who is allowed to practice as an osteopath and what qualification he or she requires. Osteopathy has been defined by the European Committee for Standardization as a whole-person, patient-centered, manual health care discipline that emphasizes on the interrelationship of structure and function of the body and facilitates the body’s innate ability to heal itself [1].

An increasing number of European countries, such as Italy and Luxembourg, are developing professional regulations for osteopaths [2]. Thus far, eight countries in Europe (England, Finland, France, Iceland, Lichtenstein, Malta, Portugal, and Switzerland) have legal regulations concerning osteopathy [3].

In Germany, however, osteopathy is not an independent profession. Currently, three different professional groups are practicing osteopathy: physicians, natural health professionals, and physiotherapists [4]. However, there is no legal basis for practicing osteopathy and for its rank in health care treatment. Hence, different jurisdictions and the interpretation of osteopathy during the past years have, in practice, resulted in confusion among professionals practicing osteopathy. The Higher Regional Court Düsseldorf, for example, prohibited a physiotherapist from practicing osteopathy at his facility, as long as the treating person had not been appointed as a physician or had received permission to practice healing arts pursuant to § 1 HeilPrG (German law on natural health professionals) [5]. In contrast, in the course of another matter, the Higher Regional Court Frankfurt decided that practicing healing arts will only be reserved for physicians and natural health professionals if the patient’s health is at risk. Such an indirect risk for the patient resulting from an osteopathic intervention could, however, be excluded by order of the treating physician [6].

Austria does not have any current legal regulation for the occupational profile either. Physicians trained in osteopathy and physiotherapists are practicing osteopathy in Austria [7]. During a complete survey in the framework of a master’s thesis, the Austrian standard osteopath was described as being female, aged between 30 and 49 years, and primarily qualified as a physiotherapist. Moreover, 77.8% of the interviewees indicated that they did not practice osteopathy exclusively, but mostly in combination with their original profession [8].

In contrast, the term osteopath has been protected in Switzerland since 2013 and was acknowledged as a medical profession in 2016 [9].

Research concerning the effectiveness of osteopathic treatment methods has advanced lately [10-12]; however, there is only little research about the profession as an osteopath. Therefore, the Characteristics, Opportunities, and Challenges of Osteopathy (COCO) study is supposed to provide clarification on how osteopaths define themselves in comparison with other occupational profiles. The COCO study will examine the characteristics of the osteopathic profession, in addition to the possibilities and challenges, for osteopaths in Germany, Austria, and Switzerland.

Comparable research has already been conducted in other countries. In the framework of the study “Challenges and opportunities for Australian osteopathy: A qualitative study of the perceptions of registered osteopaths,” published in 2018 in the International Journal of Osteopathic Medicine, Blaich et al [13] interviewed osteopaths, questioning them about the osteopathic profession. The authors concluded that future osteopathic research and uniform training can strengthen the profession’s position within the health care system. They classified their results as being mostly specific for the Australian context; the results may not transfer to other countries. The qualitative study design is formulated as a potential restriction because the results were acquired from a small sample. With respect to a German-speaking country, this study might be a typical example of a qualitative partial study in the framework of the COCO study. The results of the study by Cerritelli et al [14] provide essential insights into the osteopathic profession in Italy. On the basis of a Web-based survey, the professional profile of an Italian osteopath could be described as that of a freelance, young, and male adult working on his own and having received his training part-time; his original profession is in the fields of sport science or physiotherapy. Concerning the implementation of a license or registration procedure in their country, the authors have pointed out that the different types of professional training must especially be accounted for. This study might be a typical example of a quantitative partial study in the framework of the COCO study.

If we consider both of the indicated studies more closely, the combination of different study designs appears to make sense; therefore, we will be able to examine any data acquired within the intended examination directly with respect to their generality.

The objective of the COCO study is to examine how osteopaths define themselves in comparison with other occupational profiles and how they describe the characteristics of their work.

As the intended research project is very comprehensive, superordinate planning will be required. The objective of this study is to prepare a detailed study design for the more extensive comprehensive study.

This study employed a mixed methods design. The research topic will be examined based on qualitative and quantitative partial studies that will be conducted in parallel as well as sequentially.

The parallel form comprises several partial studies during the same period, which will be evaluated subsequently. In contrast, different studies are finally conducted in a sequential form. Thus, evaluation of the qualitative studies will influence the later implementation of the quantitative studies in the planned study: Technically, this is an exploratory design. First, hypotheses can be developed on the grounds of the results from the qualitative study projects, which are then examined in a second step on the generality of the projects. This kind of sequential planning allows for differentiated questioning. In contrast, a parallel design allows for implementation of different study designs without reciprocal influence [15].

Before the study, intensive literature research was conducted. We searched databases for publications referring to the research topic. On the basis of an overview of the current research situation, qualitative partial studies will be implemented as a first step, for example, interviews with osteopaths in Germany, Austria, and Switzerland. Following analytical evaluation of the study contents, questionnaires will be developed with the resulting data. In the second step, the quantitative partial studies will be conducted by standardized questionnaires. These will be filled in by osteopaths working in Germany, Austria, and Switzerland. After conclusion of the survey, meta-integration of the qualitative and quantitative study results will be conducted in a separate partial study. At the end of the integrative work, a quantitative study will be performed to evaluate the entire study project.

We primarily looked for osteopathic final papers describing the work area of osteopathy in the broadest sense. A search was performed using the internet search engines Google and Google Scholar as well as via the portals Osteopathicresearch.com, Ostemed-dr, Pubmed, EMBASE, and Pedro. Keywords used for the search were, for example, Abschlussarbeit Osteopathie, Fragebogen Osteopathie, Berufsbild Osteopathie, dissertation/thesis osteopathy, questionnaire osteopathy, and occupational profile osteopathy. In addition, we particularly searched for papers published on the websites of individual training institutions and universities offering osteopathic education.

To avoid falsifying the current situation of osteopathy by inclusion of older surveys, only studies published ≤10 years ago have been accounted for. In addition, the full text of the used studies must be available to the authors.

All participants of the individual qualitative and quantitative studies must have attended at least 4 years of training as osteopaths and must be practicing as osteopaths (for humans). Participants are enrolled via the lists of therapists of the professional associations or interest groups. As such, it is guaranteed that the criterion of a comprehensive training in osteopathy will be fulfilled; otherwise, the participants cannot be members of such associations.

Another criterion for the entire group of participants is a balanced gender distribution (as balanced as possible). In addition, participants in the individual countries should be subject to a topographic spread as wide as possible, so that district-specific phenomena can be excluded. In Germany and Austria, osteopathy is not an independent profession; therefore, different professional groups practicing osteopathy in both countries should be represented among the participants of the study.

For the partial studies, each study is conducted by an individual study co-ordinator who has access to the literature, the study protocol, and the datasets resulting from other partial studies.

Several aspects must be accounted for with regard to the conception of the measuring instruments. For example, the questions should be short and concrete and formulated in simple words. Hypothetic or leading questions should be avoided [26]. To review the questionnaires developed later with respect to comprehensibility and unambiguity of the questions, as well as concerning the completeness of the possible answers, the execution of a pretest is recommended [27]. The basis of a representative result is also a questionnaire response rate as high as possible. In the case of questionnaire administered in writing, a response rate of 52% (SD 24%) is expected [28]. To increase the motivation of the study’s potential participants, it is possible to offer shopping vouchers or any similar incentive to the study participants.

Participation in all the studies conducted within this project will be voluntary. Participants will be informed about their right to refuse participation [29]. Participation based on remuneration will also be excluded. For participants of questionnaires administered in writing, this information can be handled, for example, by including the conditions of participation in an annex of the questionnaire, which the participants approve by sending back the survey. All the interview partners will be informed and must have expressed their consent in writing. The anonymity of all the participants will be guaranteed at all times.