Jorge Esteves | British School of Osteopathy (original) (raw)

Papers by Jorge Esteves

Background: Osteopathic pre-registration education aims to produce competent autonomous practitio... more Background: Osteopathic pre-registration education aims to produce competent autonomous practitioners who are capable of dealing with and mastering the uncertainty of clinical practice. The students’ preparedness for clinical practice is typically assessed using high-fidelity long case exams, i.e., clinical competence assessments using real patients in a real clinical setting. Summary of work: In this presentation, we describe the development, implementation and initial critical evaluation of the Script Concordance Test (SCT) in the osteopathy programme at Oxford Brookes University. The SCT was used to complement the long case exam in assessing final year students’ ability to effectively operate in situations of clinical and professional uncertainty. To our knowledge, this was the first use of the SCT in osteopathy. The development and implementation of this assessment strategy was informed by available research literature. Student feedback was used to evaluate the effectiveness and...

International Journal of Osteopathic Medicine, 2008

avoid direct painful contraction of a muscle that requires lengthening, such as in the case of pi... more avoid direct painful contraction of a muscle that requires lengthening, such as in the case of piriformis, but there is little published research into these techniques, their relative effectiveness or therapeutic comfort. Design: A randomised controlled trial was performed on 30 asymptomatic male subjects, who were randomly allocated into one of 2 groups (PIR and RI) each of 15 subjects. The study was designed to establish any significant change in hip internal rotation range of movement following application of either PIR or RI muscle energy technique compared to control. Comparative outcome differences between the techniques were also assessed. Methods: One group received a post-isometric relaxation muscle energy technique, the other received a reciprocal inhibition muscle energy technique, both involving subsequent stretch to piriformis. Internal rotation of the hip was measured at 3 stages: control prior to treatment, after a sham treatment, and after the relevant intervention. Prone position was used throughout, and the measurements taken using a digital handheld inclinometer applied to the tibia. The data was analysed using Graphpad Prism 4 software; intra-group results were treated as one-way ANOVA comparisons of range of motion (control vs sham vs intervention), and inter-group results were treated as unpaired t tests comparing range of motion and change in range of motion. Results: Significant increases were found within both groups when comparing range of motion before and after treatment (P<0.0001). When comparing the groups, no significant differences were found either in range of motion, or change in range of motion after treatment. Conclusion: The study found that both techniques resulted in statistically and clinically significant increases in internal rotation range of motion of the hip, but found no statistical or clinically significant difference between the techniques. A larger study would be required to establish the strength of this finding.

http://digital.turn-page.com/i/576658-september-2015/12

PLoS ONE, Jun 24, 2015

Objective 1) to assess the preparedness to practice and satisfaction in learning environment amo... more Objective

to assess the preparedness to practice and satisfaction in learning environment amongst new graduates from European osteopathic institutions; 2) to compare the results of preparedness to practice and satisfaction in learning environment between and within countries where osteopathy is regulated and where regulation is still to be achieved; 3) to identify possible correlations between learning environment and preparedness to practice.

Method
Osteopathic education providers of full-time education located in Europe were enrolled, and their final year students were contacted to complete a survey. Measures used were: Dundee Ready Educational Environment Measure (DREEM), the Association of American Medical Colleges (AAMC) and a demographic questionnaire. Scores were compared across institutions using one-way ANOVA and generalised linear model.

Results
Nine European osteopathic education institutions participated in the study (4 located in Italy, 2 in the UK, 1 in France, 1 in Belgium and 1 in the Netherlands) and 243 (77%) of their final-year students completed the survey. The DREEM total score mean was 121.4 (SEM: 1.66) whilst the AAMC was 17.58 (SEM:0.35). A generalised linear model found a significant association between not-regulated countries and total score as well as subscales DREEM scores (p<0.001). Learning environment and preparedness to practice were significantly positively correlated (r=0.76; p<0.01).

Discussion
A perceived higher level of preparedness and satisfaction was found amongst students from osteopathic institutions located in countries without regulation compared to those located in countries where osteopathy is regulated; however, all institutions obtained a ‘more positive than negative’ result. Moreover, in general, cohorts with fewer than 20 students scored significantly higher compared to larger student cohorts. Finally, an overall positive correlation between students’ preparedness and satisfaction were found across all institutions recruited.

International Journal Osteopathic Medicine, Aug 19, 2014

Background Chronic pain remains an unresolved issue in clinical practice despite the extensive r... more Background
Chronic pain remains an unresolved issue in clinical practice despite the extensive research investigating its behavioural and neural correlates. Evidence demonstrates that chronic pain results in altered representation of the body in the brain. Arguably, this impacts on the perception of the self and its associated processes; namely, interoceptive awareness and body awareness. However, there is minimal research investigating the links between interoceptive awareness, body awareness and chronic pain.

Objectives and Method
This case-control study investigated the relationship between chronic pain and interoceptive awareness; and the links between interoceptive awareness and body awareness. A sample of 59 participants comprising of 22 patients with chronic pain and 37 individuals without a history of chronic pain were assessed using a heartbeat monitoring task (HBMT) and the Body Awareness Questionnaire (BAQ). The HBMT was used to measure interoceptive awareness; and the BAQ to measure body awareness. Data from variables regarded as potential confounders, were also collected.

Results
The findings did not reveal a statistical significant difference in interoceptive awareness and body awareness across the groups. Moreover, activities likely to enhance proprioception or mindfulness based practice did not influence interoceptive awareness. Notwithstanding this, a positive trend was identified between body awareness and mindfulness based activities.

Conclusions
Several limitations of this study suggest scope for further research investigating putative changes in interoceptive awareness in the presence of chronic pain and the effect of osteopathic treatment on the perception of the self. The role of mindfulness based activities in the management of chronic pain is also discussed.

Russian Osteopathic Journal, Jul 1, 2014

Принятие клинических решений в остеопатии в значительной степени зависит от пальпаторных диагност... more Принятие клинических решений в остеопатии в значительной степени зависит от пальпаторных диагностических данных. Несмотря на имеющиеся доказательства эффективности остеопатия при лечении проблем опорно-двигательного аппарата, надежность пальпации в качестве диагностического инструмента остается спорной. Исследования, посвященные воспроизводимости диагностической пальпации, последовательно демонстрируют, у нее отсутствует клинически приемлемый уровень надежности. Эти данные можно объяснить тем, как производятся индивидуальные перцепционные суждения о характере повреждения или дисфункции, а также уровнем профессионального опыта. Предварительные результаты нашего исследования показывают, что приобретение опыта в диагностической пальпации связано с изменениями в когнитивной обработке данных. В то время как на диагностические суждения опытных врачей оказывает значительное влияние неаналитическая обработка данных, направленная сверху вниз, студенты, в основном полагаются на сенсорную обработку данных, направленную снизу вверх - от зрения и тактильных ощущений. Постоянное обучение и клиническая практика могут привести к изменениям в нейрокогнитивной архитектуре остеопата. В данной работе предлагается нейрокогнитивная модель опыта диагностической пальпации, имеющая большое значение для остеопатического обучения и клинической практики. Мы утверждаем, что студентам и врачам необходимо повышать достоверность различных сенсорных сигналов в контексте клинического обследования, объединять сенсорные сигналы, поступающие по различным каналам и стремиться к применению как аналитического, так и неаналитического мышления при принятии решений. Важно, чтобы студенты развивали свои навыки критического мышления, а также анализа своего практического опыта.

Russian Osteopathic Journal, Jul 1, 2014

Clinical decision making in osteopathy is heavily reliant on palpatory diagnostic findings. Altho... more Clinical decision making in osteopathy is heavily reliant on palpatory diagnostic findings. Although there is evidence that osteopathy is effective in the management of musculoskeletal conditions; the reliability of palpation as a diagnostic tool remains controversial. Research examining the reproducibility of diagnostic palpation consistently demonstrates that it lacks clinically acceptable levels of reliability. These findings might be explained by how individual perceptual judgments regarding the nature of the lesion or dysfunction are made and by the clinician’s level of professional expertise. Preliminary results from our research indicate that the development of expertise in diagnostic palpation is associated with changes in cognitive processing. Whereas the experts’ diagnostic judgments are heavily influenced by top-down, non-analytical processing; students rely primarily on bottom-up sensory processing from vision and haptics. Ongoing training and clinical practice are, arguably, likely to lead to changes in the osteopath’s neurocognitive architecture. This paper proposes a neurocognitive model of expertise in diagnostic palpation that has implications for osteopathic education and clinical practice. We argue that students and clinicians should be encouraged to appraise the reliability of different sensory cues in the context of clinical examination, combine sensory data from different channels, and consider using both analytical and non-analytical reasoning in their decision making. Importantly, they should develop their skills of criticality and their ability to reflect on, and analyse their practice experiences in and on action.

International Journal of Osteopathic Medicine

Background Decision-making and reflective thinking are fundamental aspects of clinical reasoning... more Background
Decision-making and reflective thinking are fundamental aspects of clinical reasoning. How osteopathy students think and make decisions will therefore have far-reaching implications throughout their professional lives. Models of decision-making are firmly established in cognitive science literature and their application is universal, yet the decision-making processes and thinking dispositions of osteopathy students remain relatively unexplored.

Objectives and Method
Using the Cognitive Reflection Test (CRT) to measure decision-making preferences and the 41-item Actively Open-minded Thinking disposition scale (AOT), this study set out to explore how osteopathy students at the start (novice; n=44) and end (intermediate; n=32) of their pre-professional training make decisions and how reflectively they think.

Results
Intermediate level practitioners demonstrate significantly more analytical decision-making than their novice peers (p = 0.007; effect size = 0.31); however, reflective thinking dispositions do not change as participants progress through their training (p = 0.07). No significant association was found between analytical decision-making and reflective thinking (p = 0.85).

Conclusions
The trend for intermediate level practitioners to demonstrate more analytical decision-making than novices, without significant differences in reflective thinking processes, supports other research that suggests osteopathic education promotes deductive over inductive reasoning in its graduates and that reasoning and thinking dispositions may develop independently of
each other, given the skills and knowledge-based requirements of osteopathic education.""

International Journal of Osteopathic Medicine, Jul 2013

"Palpation plays a central role in osteopathic clinical decision making, yet it is one of the ha... more "Palpation plays a central role in osteopathic clinical decision making, yet it is one of the hardest clinical skills to develop, teach, and assess. In fact, it could be argued that osteopaths literally diagnose with most of their senses. Information conveyed by the osteopath’s different senses is processed and interpreted in his/her brain, taking into consideration the relevant anatomical, physiological, and pathological knowledge, osteopathic models of care, and the osteopath’s own clinical experience. It has been claimed that expert clinicians demonstrate palpatory literacy to the extent that they often speak of having ‘listening’ or ‘seeing’ hands. Considering the plastic nature of the human brain, we argue that that the development of palpatory diagnostic expertise is likely to be associated with behavioural, neuroanatomical, and neurophysiological adaptive changes. Building upon the initial findings of our ongoing research examining the neural and behavioural correlates of diagnostic expertise in osteopathy and on evidence from the fields of cognitive neuroscience, experimental psychology, and medical cognition, this paper
proposes ways in which the development of competence in diagnostic palpation can be optimised. We propose that as students progress through their programme of study, they should be encouraged to use available opportunities to experience normal and altered patterns of structure and function; and reflect on the validity and reliability of their diagnostic judgements. "

International Journal Osteopathic Medicine, Jul 2013

Osteopathic pre-registration education aims to produce competent autonomous practitioners who are... more Osteopathic pre-registration education aims to produce competent autonomous practitioners who are capable of dealing with and mastering the uncer- tainty of clinical practice. The students’ preparedness for clinical practice is typi- cally assessed using high fidelity long case exams, i.e., clinical competence assessments using real patients in a real clinical setting. In this paper, we critically review relevant literature concerning the validity, reliability and underpinning educational theory of the Script Concordance Test (SCT), and describe the develop- ment, implementation and initial critical evaluation of this assessment tool in the osteopathy programme at Oxford Brookes University. The SCT is an assessment tool aimed at assessing clinical reasoning in the context of uncertainty, which is being increasingly used as an assessment strategy in the field of medical education. Despite its limitations, we believe that the SCT is a useful addition to assessing clin- ical reasoning in osteopathy, particularly in situations of clinical uncertainty. It has the potential to effectively assess the students’ diagnostic reasoning, evaluation of risk and patient safety, and ethical aspects of osteopathic care. Critically, it pro- vides an important vehicle to assess the students’ preparedness for autonomous clinical practice using a standardised format.

Manual Therapy, Dec 5, 2013

"Chronic low back pain (CLBP) is a common, yet challenging condition for both patients and clinic... more "Chronic low back pain (CLBP) is a common, yet challenging condition for both patients and clinicians. Several studies have demonstrated a strong association between CLBP and psychological factors such as anxiety, fear-avoidance, self-efficacy, catastrophizing and depression. These factors are closely linked with emotional states; however, it is unknown whether CLBP patients process their emotions differently from asymptomatic individuals. The aim of this case-control study was to investigate the relationship between CLBP and emotional processing. A sample of 110 participants comprising of 55 patients with chronic back pain and 55 individuals without a history of CLBP were assessed using the Emotional Processing Scale (EPS-25). The EPS-25 generates an overall score, and also scores pertaining to five individual emotional processing factors – avoidance, suppression, unregulated emotion, impoverished emotional experience and signs of unprocessed emotion.

Chronic back pain patients scored significantly higher in the overall EPS-25 score (p < 0.001) with an effect size of 0.33. In addition, there were significant differences in four factors – impoverished emotional experience, unregulated emotion, unprocessed emotion, and suppression, with effect sizes ranging from 0.20 to 0.44. The results suggest that dysfunctional emotional processing, particularly with regard to the suppression of emotions, is associated with CLBP. Clinicians should critically consider the role of emotional processing in their patients' evaluation and management. Future research using a prospective cohort should assess the role of emotional processing as a predictor in the development of chronic back pain."

International Journal Osteopathic Medicine, Aug 2013

Background: Many osteopathic educational institutions (OEIs) require students to complete researc... more Background: Many osteopathic educational institutions (OEIs) require students to complete research projects, which normally involve external assurance of academic standards. Different academic factors can lead to tension between teaching approaches and attitudes to criticality as a necessary competency for effective practice in evidence-informed healthcare. Lack of clarity about different purposes of student research can lead to varying interpretations of assessment
criteria and inconsistent marking.
Objective: A new card sorting was designed to enable analysis of opinions about appropriate standards of criticality in student research reports.
Methods: Data was obtained from a convenience sample (n ¼ 50) of participants attending four conference workshops. Participants read an abstract from a hypothetical student project and sorted cards containing project extracts into ‘unacceptable’, ‘acceptable’ or ‘good’ examples of criticality and recorded scores on marking grids.
Results: Scores demonstrated poor inter-rater agreement (kappa < 0.20), especially for cards expected to show ‘acceptable’ levels of criticality, although participants in one workshop achieved ‘fair’ levels of agreement (k ¼ 0.22e0.39).
Conclusions: The workshops promoted discussion about the challenges of encouraging students to question underlying osteopathic principles but there was poor inter-rater agreement about appropriate levels of criticality. Heterogeneous workshop
groups and anonymised data meant that differences between OEIs and confounding factors such as linguistic variables and levels of experience could not be assessed. Further studies should explore different pedagogical approaches and assessment values to address inequalities in assessments, develop agreed standards
for academic practice, enhance research education outcomes and support the long term development of a credible evidence base for osteopathic practice.

Books by Jorge Esteves

Esteves JE de J (2011). Diagnostic Palpation in Osteopathic Medicine: A Putative Neurocognitive Model of Expertise. Oxford Brookes University. Oxford, UK.

"This thesis examines the extent to which the development of expertise in diagnostic palpation in... more "This thesis examines the extent to which the development of expertise in diagnostic palpation in osteopathic medicine is associated with changes in cognitive processing. Chapter 2 and Chapter 3 review, respectively, the literature on the role of analytical and non-analytical processing in osteopathic and medical clinical decision making; and the relevant research on the use of vision and haptics and the development of expertise within the context of an osteopathic clinical examination.

The two studies reported in Chapter 4 examined the mental representation of knowledge and the role of analogical reasoning in osteopathic clinical decision making. The results reported there demonstrate that the development of expertise in osteopathic medicine is associated with the processes of knowledge encapsulation and script formation. The four studies reported in Chapters 5 and 6 investigate the way in which expert osteopaths use their visual and haptic systems in the diagnosis of somatic dysfunction. The results suggest that ongoing clinical practice enables osteopaths to combine visual and haptic sensory signals in a more efficient manner. Such visuo-haptic sensory integration is likely to be facilitated by top-down processing associated with visual, tactile, and kinaesthetic mental imagery.

Taken together, the results of the six studies reported in this thesis indicate that the development of expertise in diagnostic palpation in osteopathic medicine is associated with changes in cognitive processing. Whereas the experts’ diagnostic judgments are heavily influenced by top-down, non-analytical processing; students rely, primarily, on bottom-up sensory processing from vision and haptics. Ongoing training and clinical practice are likely to lead to changes in the clinician’s neurocognitive architecture.

This thesis proposes an original model of expertise in diagnostic palpation which has implications for osteopathic education. Students and clinicians should be encouraged to appraise the reliability of different sensory cues in the context of clinical examination, combine sensory data from different channels, and consider using both analytical and non-analytical reasoning in their decision making. Importantly, they should develop their skills of criticality and their ability to reflect on, and analyse their practice experiences in and on action."

Talks by Jorge Esteves

Osteopaths operate as primary contact practitioners. At the point of graduation, students are req... more Osteopaths operate as primary contact practitioners. At the point of graduation, students are required to possess a clinical competence profile which enables them to operate as autonomous health care practitioners. This competence profile is evidenced by a well-developed clinical reasoning. Recent evidence from the field of cognitive science proposes that everyday’s’ decision making is underpinned by two distinct systems of judgment: a fast, intuitive, tacit and largely unconscious mode of processing (System 1), and a slow, analytical, deliberate and conscious mode of reasoning (System 2). Despite its claimed unique philosophy of care, clinical decisions about patient’s diagnosis and care in osteopathy are, arguably, likely to be either intuitive or analytical. Although intuitive judgments are highly effective and essential in everyday’s clinical practice, they are also more likely to fail. In contrast, analytical processes are more reliable and robust; however, they are cognitively demanding and require appropriate training and individual disposition. Clinical decision making is highly influenced by our tendency as humans towards cognitive biases and by, for example, context, fatigue, affective state, gender and rationality. In this presentation, I will present evidence from the fields of educational and cognitive sciences and critically appraise its relevance to osteopathic clinical decision making. I will argue that as educators, we need to ensure students develop strategies that enable them to self-monitor for bias and be critically aware of sub-standard clinical decisions in complex or challenging situations, and for the risk of over-relying on intuitive judgments without further reflection.

Touch plays a central role in osteopathic diagnosis and care and in the development of therapeuti... more Touch plays a central role in osteopathic diagnosis and care and in the development of therapeutic relationships. Evolutionarily, touch is the most elementary form of human communication, which plays an important role in child development and adult relationships. Recently, we have found that osteopaths believe touch plays an important role in reassurance, placebo, proprioceptive awareness, pain modulation and in restoring tissue physiology; its role in non-verbal communication is also believed to be central to both treatment and diagnosis. Although there is evidence that osteopathic treatment is effective in the management of musculoskeletal conditions such as low back pain, little is known regarding the effects of therapeutic touch on the nervous system and its impact on pain modulation, emotional processing and in the perception of self. In particular, the role of touch in the management of chronic pain is largely under-researched. There is growing evidence that chronic pain causes cortical reorganisation and sensitisation of the central nervous system. Moreover, chronic pain is associated with a disruption of the integrity of body schema leading to a decrease in body awareness, to the extent of alienation from one’s body. In my presentation, I will explore the putative mechanisms of touch in osteopathic care and their impact on the patient’s perception of self, particularly on body schema and body awareness. I will argue that touch is likely to have an important role on body representation and awareness and in the modulation of pain.

Chronic low back pain (CLBP) is a common, yet challenging condition for both patients and clinici... more Chronic low back pain (CLBP) is a common, yet challenging condition for both patients and clinicians. Several studies have demonstrated a strong association between CLBP and psychological factors such as anxiety, fear-avoidance, self-efficacy, catastrophizing and depression. These factors are closely linked with emotional states; however, it is unknown whether CLBP patients process their emotions differently from asymptomatic individuals. The aim of this case-control study was to investigate the relationship between CLBP and emotional processing. A sample of 110 participants comprising of 55 patients with chronic back pain and 55 individuals without a history of CLBP were assessed using the Emotional Processing Scale (EPS-25). The EPS-25 generates an overall score, and also scores pertaining to five individual emotional processing factors – avoidance, suppression, unregulated emotion, impoverished emotional experience and signs of unprocessed emotion.

Palpō ergo sum – “I palpate, therefore I am” – Diagnostic palpation and decision making in osteop... more Palpō ergo sum – “I palpate, therefore I am” – Diagnostic palpation and decision making in osteopathy

Clinical decision making in osteopathy is heavily reliant on palpatory diagnostic findings. Although there is evidence that osteopathy is effective in the management of musculoskeletal conditions; the reliability of palpation as a diagnostic tool remains controversial. Studies that have investigated the reproducibility of diagnostic palpation demonstrated that, in general, it lacks clinically acceptable levels of reliability. These findings might be explained by how individual perceptual judgments regarding the nature of the lesion or dysfunction are made and by the clinician’s level of professional expertise. However, the perceptual and behavioural aspects of diagnostic palpation in osteopathy are largely unknown. Preliminary results from my research indicate that the development of expertise in diagnostic palpation is associated with changes in cognitive processing style. Whereas the experts’ diagnostic judgments are heavily influenced by top-down, non-analytical processing; students rely, primarily, on bottom-up sensory processing from vision and haptics. Ongoing training and clinical practice are, arguably, likely to lead to changes in the osteopath’s neurocognitive architecture. Building upon my preliminary results and on a putative neurocognitive model of expertise, I will go further to propose an embodied model of clinical decision making, which is based on ongoing research and newly available evidence. Damasio (2010) has recently proposed that mental images used in the perception of objects are the result of changes that occur in the body and brain during the physical interaction of an object with the body. Arguably, the perception of tissue dysfunction is likely to be influenced by the osteopath’s sense of self and dependent on the integration of exteroceptive and interoceptive sensory input, feelings of emotion and on interactions with the patient and external environment. The implications of this model for research, clinical practice and education will be discussed.

International Journal of Osteopathic Medicine, 2008

http://digital.turn-page.com/i/576658-september-2015/12

PLoS ONE, Jun 24, 2015

Objective 1) to assess the preparedness to practice and satisfaction in learning environment amo... more Objective

to assess the preparedness to practice and satisfaction in learning environment amongst new graduates from European osteopathic institutions; 2) to compare the results of preparedness to practice and satisfaction in learning environment between and within countries where osteopathy is regulated and where regulation is still to be achieved; 3) to identify possible correlations between learning environment and preparedness to practice.

International Journal Osteopathic Medicine, Aug 19, 2014

Russian Osteopathic Journal, Jul 1, 2014

International Journal of Osteopathic Medicine

International Journal of Osteopathic Medicine, Jul 2013

International Journal Osteopathic Medicine, Jul 2013

Manual Therapy, Dec 5, 2013

International Journal Osteopathic Medicine, Aug 2013

Esteves JE de J (2011). Diagnostic Palpation in Osteopathic Medicine: A Putative Neurocognitive Model of Expertise. Oxford Brookes University. Oxford, UK.

Osteopaths make perceptual judgments regarding the presence of somatic dysfunctions based on info... more Osteopaths make perceptual judgments regarding the presence of somatic dysfunctions based on information conveyed by their senses. Notwithstanding this, in the diagnosis of somatic dysfunction, osteopaths engage in a series of other cognitive processes such as the encoding and retrieval of diagnostic information, mental imagery, reasoning, and decision making. These cognitive processes are all likely to play important and synergistic roles in their diagnostic decision making.

Here, I report on the findings from my doctoral thesis, which examined the extent to which the development of expertise in diagnostic palpation in osteopathic medicine is associated with changes in cognitive processing. Moreover, I propose a putative neurocognitive model of expertise in diagnostic palpation, which has implications for osteopathic education.

The results from the six conducted studies indicate that the development of expertise in diagnostic palpation is associated with changes in cognitive processing. Whereas the experts’ diagnostic judgments are heavily influenced by top-down, non-analytical processing; students rely, primarily, on bottom-up sensory processing from vision and haptics. Ongoing training and clinical practice are likely to lead to changes in the clinician’s neurocognitive architecture.

As educators, we should encourage students and clinicians to appraise the reliability of different sensory cues in the context of clinical examination, combine sensory data from different channels, and consider using both analytical and non-analytical reasoning in their decision making. Importantly, students and clinicians should develop their skills of criticality and their ability to reflect on, and analyse their practice experiences in and on action.

Osteopaths make perceptual judgments regarding the presence of soft tissue changes based on infor... more Osteopaths make perceptual judgments regarding the presence of soft tissue changes based on information conveyed by their senses. Previously, we have shown a link between the development of expertise in osteopathy and the integration of visuo-haptic diagnostic information. Here, we report findings from two studies. In a first study, we investigated whether the simultaneous use of vision and haptics reduces diagnostic variability. We also explored the effects of having one’s eyes closed or open during the haptic exploration of tissue dysfunction. Nine participants at different levels of expertise examined the lumbar spine of eighteen participants on six separate occasions under conditions of unimodal [haptics-eyes-closed; haptics-eyes open] and bimodal testing [visuo-haptic]. Experts demonstrated lower levels of intra-observer variability in the haptic-eyes closed and visuo-haptic conditions. Novices were considerably better in the haptic-eyes open condition. In a second study, we surveyed 95 clinicians and students on the role of mental imagery and visuo-haptic integration. Experts’ levels of agreement to all mental imagery and visuo-haptic integration questions were significantly higher. We speculate that ongoing clinical practice enables osteopaths to combine information from vision and haptics more efficiently. Mental imagery may facilitate this process by enabling experts to access representations of tissue states from their long-term memory.