The global health and wellness industry has an estimated value of $4 trillion USD [1] of which traditional and complementary medicine (osteopathy included) represent $359.7 billion USD (almost 9%) [2].

Some European countries are gradually recognizing osteopathy as an independent health profession [3] and regulating it in a timely manner [4], [5]. Other countries have carried out validated surveys (e.g., the Osteopathic Practitioners Estimates and Rates [OPERA] study) to describe the traits of osteopathic practitioners, their professional profiles, and elements of their clinical practices [6], [7], [8], [9]. The insights gained from such surveys may impact how the profession develops and may eventually assist stakeholders in the recognition of the profession and subsequent regulatory process.

Osteopathy is currently regulated in 12 European countries: Cyprus, Denmark, Finland, France, Iceland, Lichtenstein, Luxembourg, Malta, Norway, Portugal, Switzerland, and the United Kingdom [3]. In Italy, a law to recognize osteopathy as a health profession has been approved and is in the final stage of the regulation process before its adoption [10]. In the USA, where osteopathy has always followed a distinct training path [11], there is an increasingly close collaboration between osteopathic and so-called allopathic medical schools. In contrast, the situation in Spain is characterized by a lack of consensus within the professional community itself and the lack of regulation [12]. There is no official qualification for osteopathy and it is not considered a healthcare activity by the Royal Decree 1277/2003 of October 10, 2003 [13]. Law 44/2003 on the organisation of health professions [14] does not list it among the university and vocational training qualifications that correspond to regulated health activities. The characteristics of Spanish osteopaths and their practices are summarized in Table 1.

Osteopathy in Spain continues to exist in a state of regulatory stagnation or even regression. In February 2019, the Government of Spain launched a campaign (#coNprueba) [15] that was part of the "Plan against pseudotherapies and pseudosciences". The campaign listed 73 techniques described as pseudotherapy, and another 66 practices described as having minimal evidence to support their efficacy and safety. Very common techniques such as auriculotherapy, acupuncture, manual lymphatic drainage, pilates, yoga, naturopathy, and osteopathy itself among others were in included in the 2019 #coNprueba campaign.

Although there are lobby groups and associations created to oppose pseudotherapy [16], listening to a single voice on such complex and controversial issues is a potential danger to society [17], and a wider debate in defence of those therapies with scientific evidence (e.g., osteopathy) would be appropriate. If the work being done at the European level (both at the regulatory and academic levels) does not happen in Spain, there is a serious possibility that osteopathy will be banned in this country. Furthermore, if it continues to be considered “professional” practice instead of an “evidence-based or evidence-informed” practice, there is the possibility of a hybrid outcome in which osteopathy would be recognized and regulated as a subspecialization of other health professions (e.g., of physiotherapy) [18]. This possibility would risk bringing osteopathy dangerously closer to patient care based on signs and symptoms rather than centred around the whole person who is active and empowered in the achievement of their health goals [19], [20]. This could set a dangerous precedent for those countries where osteopathy is in the process of being recognized, as it could paralyze such implementation. Furthermore, this would contravene the existing national laws mentioned above (RD 1277/2003 and Law 44/2003).

The current objective in Spain must be to bring the state of the art of osteopathy to the international level and then, through specific regulation, to encourage both the training of new osteopaths according to international standards [21] and the development of research. Spain's efforts could help the international osteopathy community to find its therapeutic niche and professional identity, and find ways to combine the values of tradition and modern science.