Approach to Low Back Pain – Osteopathy

Case

A man aged 42 years, who works as a police officer, presented with severe lower back pain, which he had experienced for 24 hours after spending the previous day helping his brother to move house. He had difficulty ambulating and most movements aggravated the pain. There were no lower limb symptoms and no red flags present on history or examination. He was otherwise well and was not taking any regular medications.

Osteopaths are registered health professionals who work mainly in private clinics and manage various musculoskeletal complaints.1 ..with major studies in anatomy, physiology, pathology, research methods, and osteopathic philosophy and technique. There are similarities with other manual therapies, such as chiropractic and manipulative physiotherapy, but the differences in underlying philosophy, approach to diagnosis, and frequency and duration of consultations provide distinctive practice styles to each discipline.

Osteopathic approach and philosophy

The osteopathic approach to patient care is characterised by holism and places emphasis on the reciprocal relationship between anatomical and physiological structures. The holistic approach also acknowledges psychosocial, environmental and ergonomic factors2 that influence pain and disability. To reach a diagnosis, osteopaths assess symptomatic tissues and other related areas of the body that may influence optimal biomechanical function. Treatment includes manual techniques and patient education.

Research and osteopathy

Although there is a paucity of high-quality research investigating the effectiveness of osteopathic management for many conditions, limited but growing evidence offers support for treatment of low back pain (LBP).3–7 Isolated manual techniques, such as spinal manipulation, have been most thoroughly examined by researchers, but seem to have only a modest benefit for LBP.8 An integrated treatment approach using an eclectic set of manual techniques and advice – as commonly used in osteopathic practice – may be of greater benefit in LBP and a number of randomised controlled trials (RCT) have found improvements in LBP after osteopathic treatment.3–7 Recent RCTs reported that osteopathic treatment was more effective than placebo for chronic LBP interventions,5 more effective than usual medical care for acute LBP,3 and helpful for LBP in pregnant women.4

Initial assessment

Initial osteopathic consultations are up to 60 minutes in duration. The consultation includes obtaining a case history and other relevant medical and health information,9 assessment of red flags10 and gaining patient consent for treatment. If a red flag is identified, patients are immediately referred to their GP for assessment, and in more urgent cases (eg. cauda equina syndrome) referred directly to hospital emergency units. The patient completes a self-report pain questionnaire (eg. visual analogue pain scale) and assessment of changes in activities of daily living (ADLs) to assess pain and functional disability.

The information provided in this case scenario suggests differential diagnoses of lumbar facet joint sprain, lumbar disc pathology or sacroiliac joint (SIJ) sprain. The osteopathic physical examination is informed by the case history and aims to support or exclude differential diagnoses.

Physical examination for the case presented

A physical examination would include the following:

• observation of standing posture
• active and passive range of motion of lumbopelvic, hip and thoracic regions
• occupation and ADL-oriented functional movement testing
• assessment of lumbar and thoracic segmental mobility and tenderness
• palpation of lumbar spine, abdomen and hip soft tissues
• orthopedic tests, including straight leg raise, active straight leg raise test and SIJ pain provocation tests.

Management strategies

Immediate (at initial presentation as stated in the case scenario)

For the case presented here, the osteopath would address restricted and painful areas identified in the examination. Treatment may involve mobilisation or articulation of lumbar and thoracic facet joints, soft tissue massage and stretching of lumbar and hip musculature, and the use of gentle isometric contraction techniques (‘muscle energy’) to encourage better motion, muscle recruitment and decrease pain.11,12 Gentle application of spinal manipulation may be used for the lumbar and/or thoracic spine,13 but suspected intervertebral disc pathology would be a contraindication. The patient would be advised to consult their general practitioner (GP) or pharmacist for appropriate short-term pain relief medications and advised to keep moving within pain limits.

An advantage of the osteopathic consultation is the time available to educate patients and discuss concerns. In this case, the osteopath would explain the likely cause and prognosis, and offer reassurance to the patient that nothing serious was evident, that most acute back pain resolves without the need for ongoing treatment or surgery, and that the patient should aim to be active and return to work as soon as possible.14 The osteopath would discuss sick leave for 2–3 days and schedule a review consultation.

Short term (days to weeks)

Some improvement in symptoms would be expected due to the natural history of acute musculoskeletal conditions. Further manual therapy would be provided, advice given on ADLs, and approaches to return to work within a short period of time would be encouraged. Recommendations for alternative work duties may also be appropriate.

Medium term (up to 6 months)

It is unlikely that this patient would need treatment for more than a few weeks. In the case of other factors being present (ie. yellow, black or blue flags) or re-injury, treatment may include manual therapy, the focus being directed towards active treatment approaches, such as rehabilitation exercises. The implementation of additional outcome measures may be helpful for identification of patients requiring psychological intervention.

Long term (years, including prevention and maintenance strategies)

It is highly unlikely that the patient in this case would require long-term osteopathic treatment. Osteopaths encourage patients to invest time and effort into keeping muscles strong and joints mobile, either though occasional osteopathic manual treatment, ergonomic awareness, their own exercise and rehabilitation program, or a combination of all.

Conflict of interests: None
Provenance and peer reviewed: Commissioned; externally peer reviewed.

References

1. Burke SR, Myers R, Zhang AL. A profile of osteopathic practice in Australia 2010–2011: a cross sectional survey. BMC Musculoskelet Disord 2013;14:227. Search PubMed
2. Fryer G. Special issue: Osteopathic principles. Int J Osteopath Med 2013;16:1–2. Search PubMed
3. Cruser dA, Maurer D, Hensel K, Brown SK, White K, Stoll ST. A randomized, controlled trial of osteopathic manipulative treatment for acute low back pain in active duty military personnel. J Man Manip Ther 2012;20:5–15. Search PubMed
4. Licciardone JC, Buchanan S, Hensel KL, King HH, Fulda KG, Stoll ST. Osteopathic manipulative treatment of back pain and related symptoms during pregnancy: a randomized controlled trial. Am J Obstet Gynecol 2010;202:43–48. Search PubMed
5. Licciardone JC, Minotti DE, Gatchel RJ, Kearns CM, Singh KP. Osteopathic manual treatment and ultrasound therapy for chronic low back pain: a randomized controlled trial. Ann Fam Med 2013;11:122–29. Search PubMed
6. Vismara L, Cimolin V, Menegoni F, et al. Osteopathic manipulative treatment in obese patients with chronic low back pain: a pilot study. Man Ther 2012;17:451–55. Search PubMed
7. Williams NH, Wilkinson C, Russell I, et al. Randomized osteopathic manipulation study (ROMANS): pragmatic trial for spinal pain in primary care. Fam Pract 2003;20:662–69. Search PubMed
8. Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review. Spine 2011;36:E825–46. Search PubMed
9. Orrock P. Profile of members of the Australian Osteopathic Association: Part 1 - The practitioners. Int J Osteopath Med 2009;12:14–24. Search PubMed
10. Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ 2013;347. Search PubMed
11. Degenhardt BF, Johnson JC, Hagan C. Osteopathic manipulation reduces pain and improves quality of life. Int J Osteopath Med 2013;16:e11–12. Search PubMed
12. Greenman PE. Principles of Manual Medicine. 3rd edn. Philadelphia: Lippincott William & Wilkins, 2003. Search PubMed
13. de Oliveira RF, Liebano RE, Costa LdCM, Rissato LL, Costa LOP. Immediate effects of region-specific and non-region-specific spinal manipulative therapy in patients with chronic low back pain: a randomized controlled trial. Physical Therapy 2013;93:748–56. Search PubMed
14. Brooks P, March L, Bogduk N, et al. Evidence-based management of acute musculoskeletal pain. Australian Acute Musculoskeletal Pain Guidelines Group. Brisbane: Australian Academic Press, 2003. Search PubMed

This article originally appeared on racgp.org.au and was written by Brett Vaughan, Tracy Morrison, Della Buttigieg, Chris Macfarlane and Gary Fryer.

What does Osteopathic Manual Therapy Help?

Osteopathy is a form of drug-free non-invasive manual medicine that focuses on total body health by treating and strengthening the musculoskeletal framework, which includes the joints, muscles and spine. Its aim is to positively affect the body's nervous, circulatory and lymphatic systems.

This therapy is a unique holistic (whole body) approach to health care. Osteopaths do not simply concentrate on treating the problem area, but use manual techniques to balance all the systems of the body, to provide overall good health and wellbeing.

Dr. Andrew Taylor Still established the practice of Osteopathy in the late 1800s in the United States of America, with the aim of using manual 'hands on' techniques to improve circulation and correct altered biomechanics, without the use of drugs.

What does osteopathy treat?

Osteopaths treat more than you think. Many patients present with complaints of aches in the head, back, neck, and heel/ foot pain; sciatica; shin splints; tennis elbow and repetitive strain injury. Other patients suffer from asthma; arthritis; digestive problems; carpal tunnel syndrome; whiplash and postural problems.

Osteopaths also deal regularly with patients who have been injured in the workplace, at home or while playing sport.

What are the qualities of Osteopathy

The philosophy of Osteopathy is what sets it apart from other medical disciplines. The key principles are based on all parts of the body functioning together in an integrated manner. If one part of the body is restricted, then the rest of the body must adapt and compensate for this, eventually leading to inflammation, pain, stiffness and other health conditions. When the body is free of restrictions in movement, Osteopathic treatment assists the body with pain minimisation, reduced stress and greater mobility providing the body with the opportunity to heal itself.

Osteopaths use a broad range of gentle hands-on techniques including soft tissue stretching, deep tactile pressure, and mobilisation or manipulation of joints.

In some cases, Osteopaths can complement the advice given by GPs. For example, people who suffer from arthritis are often prescribed medication by their GP. In addition to that, Osteopaths can ease the pain caused by joint and muscle stiffness, by improving joint mobility and the flow of blood to the joints, and show arthritis sufferers how to prevent causing injury to themselves.

Osteopathy is a five-year university course, which includes a degree and masters qualification. Senior Osteopathy students complete clinical training under the supervision of registered Osteopaths at student teaching clinics.

Osteopaths believe in working as part of a health system of health providers and often refer back to the G.P. or another allied health professional where appropriate.

Benefits of Osteopathy

Osteopathic treatment in itself is not 'preventative'. Osteopaths respect the body's natural ability as a self-regulating mechanism and only intervene when pain or discomfort is present. The benefits of osteopathy are the general improvement in mobility and structural stability of the body. In turn, other systems of the body such as the circulatory, nervous and lymphatic systems function more effectively and for a number of general conditions, minimal treatment is required.

Osteopathy and sleep

A key indicator of pain or discomfort is lack of sleep or restless nights. An effective osteopathic treatment outcome often reflects the first signs of recovery with a good night's sleep. Poor sleep patterns only serve to magnify the body's inability to function adequately and reduce our psychosomatic (Psychosomatic illnesses are those in which physical symptoms are caused or aggravated by emotional factors) ability to cope with pain.

Osteopathy and the nervous, circulatory and lymphatic systems

Osteopathic treatment positively affects the nervous, circulatory and lymphatic systems, to deliver a more balanced body and better health overall. This combined with good dietary and /or exercise prescription can enhance a patient's well being and often leads to a positive approach to individual health responsibility.

Osteopathy and back pain

With our lives becoming increasingly busy, yet more sedentary, Osteopaths can offer prevention advice such as stretching exercises, lifting techniques, posture, breathing and stress reduction which is a great way for individuals to maintain their own health. In addition some lifestyle changes including diet or workplace ergonomics can dramatically improve ones health and reduce ongoing health costs.

Early intervention by an Osteopath means you can be aware of potential sources of referred pain, and how you can make changes to your lifestyle now, so you won't have to deal with the pain later on.

Preventing injuries means less time off work and therefore more time keeping active and enjoying the benefits of general good health. It is vitally important for all people to be aware of how injuries can occur and what we can all do to avoid them.

What does osteopathic treatment involve?

The first visit to an osteopath will run along the same lines as an initial visit to a GP. A complete medical history is taken and questions asked about lifestyle, diet and emotional status. The osteopath will want to hear about all symptoms, as well as details of any past accidents or traumas, even if they may seem unrelated to the patient's current problem.

The patient may be asked to remove some outer clothing and to perform some simple movements. This is so the osteopath can observe how the patient is using their body, identify any obvious mobility impairment and evaluate posture. Neurological and orthopaedic tests help the osteopath to eliminate possible underlying pathologies and differentiate the basis of the patient's complaint.

Osteopaths are highly trained to manually locate points of restriction or excessive strain in various parts of the body. Using a finely tuned sense of touch or palpation, the osteopath will assess the spine, joints, muscles and tendons. An osteopath may also refer for blood tests or X-rays to confirm findings, or review existing diagnostic results where available.

The initial consultation will take around 45 minutes to complete, after which the osteopath will be able to offer a diagnosis and discuss a treatment program. Treatment could include such techniques as soft tissue stretching, to increase blood flow and improve flexibility of joints and muscles; articulation to mobilise joints by being passively taken through their range of motion; and muscle energy, to release tightness on the muscles by alternatively being stretched and made to work against resistance.

If the diagnosis is one that requires further investigation or specialist intervention, an osteopath will suggest a referral to an appropriate practitioner. Osteopaths often treat in conjunction with a GP, dentist, podiatrist or other health care professional.

Because osteopathy emphasises self-healing, an osteopath may also advise dietary changes, home exercise programs and lifestyle adjustments. All treatment programs are highly individualised and depend on the patient's current condition, past history, and ability to adapt to change. Most simple problems often require only 3-4 treatments.

Why you shouldn't ignore the pain

If you ignore the signs of back pain, this can develop into other forms of referred pain around the body, such as neck, shoulder or leg pain. Longer term this can have deep psychological ramifications which makes it harder for a patient to accept recovery as an achievable goal and like most long term health conditions can lead to depression.

According to osteopathic philosophy, all parts of the body are interconnected and affect each other. However, if someone experiencing back pain does visit an Osteopath, this means the back pain can be treated and potential referred pain can be avoided. Of course, this improves your overall health and wellbeing, allowing you to lead a more active and healthy lifestyle.

This article originally appeared on http://www.medicalnewstoday.com/articles/70381.php?page=2 and was Written by Christian Nordqvist