This blog is the result of many months, even years, of reading literature on pain science, physiotherapy and osteopathy culminating in this summary article. I hope that it will open up discussion with colleagues so that together we can have a vision for the future of osteopathy.
It has felt as though a ‘Jenga’ type scenario has been taking place with blocks of evidence, skills and knowledge which were the foundation of my osteopathic education and practice being removed leaving what felt like a very unstable foundation for osteopathy. I have to confess that this has led to a period of deep reflection, and at times disillusionment with osteopathy.
I am thankful that my despair is now developing into hope primarily based on some extremely insightful articles by Gary Fryer and Eyal Ledermann. However this is a fundamental change in the basis of osteopathic understanding and practice. As all practitioners will be aware it is not easy to make changes in practice. So this is an ongoing and very bumpy journey which still leaves me with many questions. I have been working on this article for several weeks. I am delighted to see that the 2017 IO convention will have seminars on the osteopathic approaches discussed in this article.
I appreciate that not everyone will be willing to embrace this model of change. Change is never easy. It is an ongoing process and I am simply sharing progress so far. For ease of reading some of this article is in note form – the reading list has full details of all the sources of information that have shaped these views so far, if you want the full story read the articles, this article is merely to serve as a summary resource and foundation for discussion.
Taking down the foundations
This subject is starting with the negative, deconstructing many of the beliefs underpinning osteopathy. Research has highlighted and dispelled many myths in musculoskeletal medicine. These are just some examples, see the reference list to look into the evidence in more detail:
- Posture doesn’t influence pain and reliability of assessment is poor
- People with no pain have disc bulges, osteoarthritic changes, rotator cuff tears
- Core stability training is no better than other exercise
- Palpation cannot be relied upon
- Trigger points are questionable what they are and whether they actually exist
- Trigger points – there is a lack of evidence for their presence and treatment is not demonstrably effective
- Special tests have poor sensitivity and specificity
- Stretching causes little change in stiffness or length but possibly more stretch load tolerance
- Soft tissue techniques have little effect on tissue healing
- Facilitated segments have poor evidence
- Manual therapy does not produce a long-term increase in mobility.
- It is not possible to accurately determine tissues involved in a pain episode
- Asymmetry, imbalances and postural deviations are normal biological deviations
- Musculoskeletal symptoms are not explained by biomechanics, structure or posture so structural modifications are unlikely to be helpful
- Not possible by manual means to produce physiological load required to make structural changes
More and more evidence is being produced demonstrating that the biomechanical approach lacks evidence of accuracy and efficacy. There are myths and traditions in every profession but it is important we challenge these beliefs to ensure we continue to provide best care to patients. You may have read the recent article in the Guardian with a surgeon challenging his profession about the worth of their interventions over placebo.
Rebuilding the model
I have found the work of Mary O’Keefe, Kieran O’Sullivan and Peter O’Sullivan invaluable in informing and understanding aetiology and treatment efficacy. The Chartered Society of Physiotherapy has also been producing some excellent, informative patient education resources. However, these are all physiotherapists and many osteopaths may object to relying on their views alone.
This is where the work of Gary Fryer and Eyal Ledermann have enabled me to rebuild my view of treatment from an osteopathic perspective.
There are two evidence-based models that can form the basis for reconstructing our osteopathic approach, as proposed by Eyal Lederman – process based approach and Gary Fryer – integrated osteopathic approach:
- A process based approach
The process based approach aims at supporting repair, adaptation and alleviation of symptoms rather than removing structural and biomechanical obstacles impeding recovery.
Aiming to identify which process the patient is in:
Repair – acute injuries, sprains and strains and muscles tears – heal in fixed time frames
Adaptation – chronic conditions – movement loss due to tissue and motor control changes
Symptomatic recovery – pain OA, tendinopathies, stiffness, paraesthesia, anxiety and depression
Repair – repetitive loading, passive/active mobilisation, active movement challenges – post surgery, muscle, joint and tissue injuries, discs, acute
Adaptation – treatment uses active movements similar to functional goals
Symptoms – maintain daily activities, progressive physical challenges – overloading and repetition using own movement repetoire; support, reassurance, empowering. Touch, caregiving, reassurance. Inform, plan, goals
Educator and facilitator rather than mechanic.
2. Integrated Osteopathic approach
Identify pain process:
Neuropathic – central or peripheral lesion, radicular, burning, shooting, pricking
Nociceptive – proportionate to injury and localised
Central sensitisation – pain widespread, hyperalgesia and allodynia
- Pain not widespread – sensitivity to bright lights, noise, temp, stress
Yellow flags – risk for chronicity – belief back pain harmful or severely disabling, fear-avoidance behaviours, reduced activity, low mood, reliance on passive, not active treatment
Acute pain and movement impairment
Movement impairment = voluntary guarding to limit load on pain sensitive structures and fear-avoidance behaviour
Treat tissues and reassure no serious injury or pathology and encourage to be active
-promote tissue healing, fluid drainage and mobility
Gentle extensibility and stretching forces – progressively increased
Passive – promote movement and reduce pain, reassurance and pain education
Active and passive movement – trans-synovial fluid flow
MET – drain fluid, mechano-receptor stimulation
HVLA – possibly
Chronic pain and movement impairment
More neurological and psychological approaches
Movement impairment = guarding and avoidance of movement in direction that provokes pain, may become habitual
Aim – reassure and reduce fear of pain, pain education, identify and correct inappropriate beliefs – encourage activity and confidence in movement
Manual therapy – activates descending mechanisms and aids sensorimotor and proprioceptive processing, promote mobility and flexibility.
HVLA – not clinically relevant
MET – passive to active bridge
Exercise programmes – functional goals
3.A combined approach
Combining these models which have obvious common themes results in a process like this:
On presentation decide which of the 5 categories the pain falls into neuropathic, nociceptive, central sensitisation and acute or chronic, it can be multiple or transitional. It should be at least one from the top three and acute or chronic.
There will be symptomatic recovery in all categories – the central box. Treatments should then be planned according to either the acute repair model or the chronic adaptation model.
Pain is a complex process
There are further evidence based insights which assist understanding of the pain process and enable us to educate patients.
Kieran O’Sullivan is a firm believer that back pain needs to be considered an ordinary part of life with more than 90% likely to experience symptoms during their life. It should be put in the category with tiredness, constipation, sick bugs – all normal but inconveniencing and unpleasant conditions which last a few days. The problem is when pain doesn’t get better. From clinical experience we know many patients report episodes of self-resolving back pain.
In communication we should avoid medical jargon which can disempower by being interpreted as serious impairments with long-term consequences, requiring ongoing passive treatment. Positional nomenclature can lead to thoughts of a structural disorder with catastrophising, fear avoidance and unnecessary dependence. Implying that symptoms need to be kept an eye on can also induce fear and dependence on passive treatment. The words that practitioners use can have a nocebo effect.
Pain is influenced by:
- Training load – sudden increase or decrease
- Past pain experiences
- Gender, socio-economic status
- General well-being
- Expectations, fear, anger, frustration
Fear and depression and anger make pain worse and are associated with poorer outcomes and more disability.
Hypervigilance –> notice more pain, neutral signals become threatening –> avoidance
Catastrophic thinking –> overwhelming, seeking help with no injury or change in pain
These two effects can be summarised as attention bias and interpretation bias.
STRESS is influenced by:
- fears – future, present
- health/illness – yourself, others
- bereavement/loss – out of time, loss of control, transition
- busyness – positive and negative
Helps with communication
These questions have been pulled out of different pieces of research and podcasts as suggested approaches to empowering patients.
What could you do that’s different?
Make a list of good for me/bad for me
‘Tell me your story’
Make a plan – write it down.
Key positive messages
Summarise what has happened
Tell me how your pain is affecting you?
What do you think will help?
Anything you are afraid of? Any movements you are afraid of?
“Keeping flexible, active and strong will help keep your back healthy and reduce pain.”
Education about pain and emotions is important. No pain without psychology.
Anti-depressants alone not effective – need talking therapies
Pain à low mood à tired, listless à decreased fitness
Majority with chronic pain have low mood
Not complex, long explanations, bite-size education patients can cope with.
Helplessness, loss, worry – not liking themselves, not clinical depression
Doesn’t reduce pain but improves function
Patients are challenged but patient remains in charge
– working to address values
– find starting point happy with – works toward goal
Patient needs to discover the truth re. psychological, not be told.
Depression and avoidance behaviours remain after pain removed so therefore need addressing
Pain interacts with who you are at a given time – pain is worse when life is bad
Pain in front of face and can’t see anything else. Pushing it away – exhausting and can’t do anything else. Look beyond the problem – can see it but can look up at world and continue to function.
– listened to, pain credible, relationship building, understand, care
– Generic – trust me, seen before, no need to worry, it’s going to be ok
– Cognitive – education, info, cause, programs, treatment plan, feelings, obstacles – most important for impowering patient
Need positive messages, education, reduced fear, empower to take an active role. Confirm understanding of what has been said.
Patient assessment and records
Having embraced this model of change, the next challenge is to use this model in patient records and change our diagnostic approach and record keeping. A thorough examination is still necessary to form a foundation for monitoring change and improvement and to provide reassurance to patients about what works well and form goals of treatment.
Alongside this approach lies the premise that the goals of treatment should not be focussed on pain reduction but functional goals. How is the patient being affected by the pain and how can improvement be monitored?
I don’t know how much pain science is filtering through into osteopathic education as it is not an area I am involved in currently. However, speaking to new graduates it is certainly something there is increasing awareness of this research evidence but the approach to patients and recording in the case history appears to continue to be a biomedical, traditional osteopathic approach. The BSO appears to be at the forefront of change with its Osteomap approach and much of the research they are producing.
What’s the future?
The future is obviously unknown. It feels as though there could be a greater divide developing in osteopathy between those committed to the traditions and historic foundations of osteopathy and those embracing the evidence-based approach. Osteopathy has always been a diverse profession. With the ongoing threat that healthcare regulators will merge there is a danger that osteopaths will have to fight to retain their identity. Osteopathy and physiotherapy are arguably becoming more integrated in their approach which is not surprising as both professions rely on the same evidence base. Perhaps the future will be a combined profession of Physical Therapists providing access to the best of both professions. Having three approaches to musculoskeletal conditions at times seems merely to confuse the public as to which profession they should approach for treatment. I remain passionate about the high quality of education and clinical skills of osteopaths and am excited to see the developments within the profession led by the Osteopathic Development Group. Defining the evidence based USP of osteopathy is going to be the key to its long-term survival as a key component of the healthcare system.
It would be great to hear your views, please share below or email me firstname.lastname@example.org
References and reading
Darnall, B. (May, 2017) Reducing catastrophizing to treat and prevent chronic pain. Canadian Institute for the Relief of Pain and Disability Live Webinar.
Fryer, G. (2017) Integrating Osteopathic approaches based on biopsychosocial therapeutic mechanisms – Parts 1 and 2. International Journal of Osteopathic Medicine, In press: July 2017
Gifford, L. (2014) Aches and Pains CNS Press
Lederman, E. (2015) A process approach in manual and physical therapies: beyond the structural model. Available at www.cpdo.net
O’Sullivan, K. (2016) BMJ Talk Medicine: 7 habits of highly effective clinicians. Available at: https://soundcloud.com/bmjpodcasts/dr-kieran-osullivan-on-managing-back-pain-7-habits-of-highly-effective-clinicians-part-2-2016
O’Sullivan, P. (March, 2017) Reconceptualising pain. Healthy, Wealthy and Smart podcast, available at: http://podcast.healthywealthysmart.com/2017/03/262-prof-peter-osullivan-reconceptualizing-pain/
Pincus, T. (2017) Pain and Me. Available at: https://www.youtube.com/watch?v=ZUXPqphwp2U
Pincus, T. (2015) Psychology and Back Pain. Podcast Mechanical Care Forum Episode 88. Available at: http://www.mechanicalcareforum.com/podcast/88
Stewart, M. (2016) Know Pain Course
Article: Myths and misconceptions in Physio https://tpmpstudents.wordpress.com/2017/04/20/myths-and-misconceptions-in-physio/