Reconceptualising an osteopathic approach to pain, Part 1

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,

Biopsychosocial?

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.

Placebo

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

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

2 Comments

Dan Graham

I too think this is the most fascinating topic in so many ways. probably primarily because I want to think that I can make a difference. One of the things that comes to mind reading your post is Eyal Lederman., although I appreciate Eyal Lederman is not a thing.

We need to, I need to, nail this topic, and I would be very glad to work together with others on this.
There is some wonderful evidence supporting and not supporting manual therapy, but imo it is all wonderful, supporting or not supporting, because we have some evidence.
And for me having been in practice for 20 years I would say that the evidence supports a lot of my misgivings about what I have done, and to some extent still do.

Maybe if we could make the patient the priority , then this would foster a good foundation.

I am very skeptical that osteopathy does work, how can we say it works when we all practice in different ways, what is it that works in this ‘osteopathy’? Can we really say there is such a thing as ‘osteopathy’, when we all have different definitions and ways of practicing?

When you point to the physiological benefits of manual treatment, what conditions does this refer to? What phase in the process of a condition do these physiological benefits refer to?

Re our CPD, does not your very question form the basis of the ‘ professionalism’ referred to in the CPD and which surely should be the foundation of practice?

For our CPD, for our peace of mind, for our patients, I very much welcome this discussion we could have.
Thank you

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Mint

Thanks for your comments Dan. You ask some very insightful questions. I think you will find some of them are addressed as I continue through the series this month. I am looking at clinical reasoning models and some of the difficulties with clinical reasoning and will conclude with proposing an osteopathic model to encompass many of these thoughts. You can read more about the physiological benefits of manual treatment from the work of Eyal Lederman and Gary Fryer and Jorge Esteves has been doing some interesting work on touch. The physiological benefits are to do with the influence on the nervous system and reducing sensitisation or stimulating autonomics. This is one summary, although there are many more along similar lines: https://www.facebook.com/modernpaincare/photos/pcb.2336267349991203/2336267156657889/?type=3&theater

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