Research evidence has eroded the foundations of much of osteopathic and manual therapy clinical reasoning:
Inaccuracy of palpation
Unreliability of postural, tissue-based diagnosis
Ineffectiveness of manual therapy techniques to achieve significant changes in posture, tension and mobility.
Many postural and structural diagnostic explanations have been found to be invalid,
There is an increasing evidence of the importance of the biopsychosocial model. You may consider this to be nothing new. Osteopathic has always emphasised a holistic approach. However, if you were to consider the diagnostic reasoning, treatment methods and treatment records of the majority of osteopaths they would be primarily biomedical.
While evidence is showing it is very difficult to justify purely biomedical reasoning for pain problems there is also another issue. Structural diagnoses often have a nocebo effect which affects patient beliefs and behaviour. How many patients have come to you still living in the shadow of their ‘slipped disc’ diagnosed 20 years ago.
We know that clinical encounters in themselves can have a placebo effect. Positive clinical language can improve patient self-efficacy and placebo treatment modalities can be effective. The clinical environment also has a placebo effect.
Complexity of Pain
The biopsychosocial model should not be used in a dichotic sense. It is not possible to label a problem as biomedical or psychosocial. Pain is a complex multifactorial behaviour pattern which cannot be divided into physical and psychosocial concepts.
Experientially pain is an assessment of the danger of a nociceptive input – based on intensity, prior experience and beliefs and context. The patient’s experience of pain is unique.
The biopsychosocial approach has many elements – Encompassing historical and current risk factors from previous physical and psychosocial trauma, social dysfunction, gender and environmental and alterations in psychological processes – pain cognition, hypervigilance, catastrophizing, self-efficacy, fear-avoidance and distress alongside biological factors in pain.
Values based practice is also very important in successful clinical encounters. Therapeutic approaches need to be personalised according to patient values or goals.
Pain is multi-dimensional, multi-faceted, biopsychosocial process unique to each patient and therefore requires a unique approach tailored to each patient.
How does osteopathy work?
This may seem complex having stated how much of our structural reasoning lacks evidence and the need to encompass so many other factors – biopsychosocial reasoning, placebo, values. You might be wondering how manual therapy can have any impact?
Although we know that manual therapy has very little influence on the tissues and certainly doesn’t cause lasting changes in mobility or muscle length it does make a difference. These are the changes identified:
- reduction in inflammatory markers
- decreased spinal excitability and pain sensitivity
- modification to cortical areas involved in pain processing
- excitation of sympathetic nervous system
Patient and practitioner expectations and explanations need to be framed within this context and both need to be aligned. There must be a therapeutic alliance for effectiveness. The context of interventions also heavily influences clinical outcomes. Psychological factors will also interact with technique provision enhancing or reducing benefit.
Like pain, treatment is complex and multifactorial. We need to challenge our understanding in the light of evidence to make sure we are maximising treatment effectiveness. We’ll be looking into many more aspects of osteopathy in the treatment of pain in the next few weeks.
References for statements made in this article can be found in my article published in IJOM: https://www.journalofosteopathicmedicine.com/article/S1746-0689(18)30037-3/abstract