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 IBS, Crohn's Disease & GI Disorders Have To Do With Coping Skills

Health psychologists have begun treating gastrointestinal disorders that are strongly affected by stress, including irritable bowel syndrome (IBS), Crohn's disease, functional heartburn, functional dyspepsia and ulcerative colitis.

Biochemical signaling between the brain and the GI tract, known as the brain-gut axis, can have a major effect on gastrointestinal disorders. The normal stress of everyday life can aggravate certain GI conditions. And in a vicious cycle, worrying about or dwelling on severe pain, constipation, diarrhea and other GI symptoms can make the symptoms worse, which in turn increases the stress, said Sarah Kinsinger, PhD, ABPP, a Loyola Medicine health psychologist who specializes in treating GI disorders.

Dr. Kinsinger offers behavioral treatments specifically designed to target brain-gut pathways. These treatments teach patients coping strategies to manage symptoms and reduce stress. She provides cognitive-behavioral therapy, an evidence-based treatment for irritable bowel syndrome. She also offers behavioral relaxation techniques, including diaphragmatic breathing (also known as belly breathing or deep breathing) and gut-directed hypnotherapy.

In many patients, psychological or behavioral interventions can be more effective than medications, Dr. Kinsinger said. She usually sees patients for five to seven sessions, and the treatments typically are covered by insurance.

"It is very gratifying to see patients get better after in some cases suffering for many years," Dr. Kinsinger said. "Psychological and behavioral interventions do not cure their disease, but the treatments can provide patients with safe and effective coping mechanisms and greatly reduce the severity of their symptoms."

For some conditions, such as IBS, psychological and behavioral treatments can be the primary treatments. For other conditions for which there are effective drugs, such as Crohn's disease and ulcerative colitis, psychological and behavioral treatments can be effective adjuncts to medications.

Dr. Kinsinger earned a PhD degree in clinical psychology from the University of Miami and completed a health psychology fellowship at the University of Illinois Medical Center at Chicago. She is board certified in clinical health psychology by the American Board of Professional Psychology.

This article originally appeared on Science Daily.

A Must Read For People in Pain: 'Explain Pain'

If I could make only one recommendation to individuals living with chronic pain, it would be to read the book Explain Pain by David Butler and Lorimer Moseley.

Directed at both clinicians who work with chronic pain patients and patients who live with chronic pain, Explain Pain shows how the discoveries of modern pain science can be put to practical use. Written in understandable language with a touch of lighthearted humor, Butler and Moseley take a complex subject and make it possible for the average person to understand and use. One client remarked that she thought it would be hard to read and was delighted that she did not find it difficult at all. 

Pain education can help

Research has demonstrated that pain education can help to reduce chronic pain. For instance, a recent study by the army followed 4,325 soldiers over a two year period and found that one session of pain education could help lower the incidence of low back pain. Understanding how pain works is not a magic bullet that will make pain go away immediately, but it can help to take some of the fear and anxiety out of the experience which can then begin to help alter the experience. With time, thinking a little differently about pain can lead to more successful strategies for reducing, limiting, and eliminating pain.  

Pain is useful and should not be ignored. Pain is a protective mechanism generated by the brain in response to perceived threat. However, when pain is chronic and there is no direct or immediate threat to the body, understanding how the body can get "stuck" in pain can suggest ways to help it get "unstuck." 

Butler and Moseley provide some amazing stories to illustrate the surprising discovery that pain is not directly related to tissue damage. While this concept may, at first, seem odd and difficult to grasp, they produce convincing evidence to support this idea. Consider this: a paper cut produces very little tissue damage, yet can cause a lot of pain. A soldier can get shot in battle, yet not realize he is injured until he is off the battlefield. Amputees may experience phantom limb pain in tissue that no longer exists. How does that happen? The part of the brain that corresponded to the amputated limb can still generate the sensation of pain, even after the limb is gone.

Pain can be influenced by context. If everyone around us seems to be in pain, we may also expect to be in pain. Athletes involved in vigorous sports ignore impacts that would upset most of us because to them it's all part of the game. In that context, it is expected and not a threat. 

Butler and Moseley describe how pain is generated by the nervous system. Understanding that pain is generated by the brain, rather than by damaged tissues, does not mean that pain is "all in your head" and should be ignored or dismissed as imaginary. In fact, understanding that pain is the body's alarm system highlights the importance of treating pain so that the alarm system does not become oversensitive. 

The book describes what happens in different systems of the body and how they may be affected by pain. Normal responses to painful stimuli are contrasted with what happens when the responses become altered. The influence of our thoughts and beliefs is examined for the role it can play in chronic pain.

Practical suggestions

The last few chapters of Explain Pain suggest practical tools that can be used to manage chronic pain. Using "the virtual body" is explained, as is the use of graded exposure to break the association between particular movements and pain and to cultivate successful movement without pain. 

Pain education should be part of every client or patient's rehabilitation.Explain Pain provides an excellent model for pain education.

One of my clients suffered for many years with a painful chronic condition and found this book immensely helpful. Although she had seen many doctors and therapists, she had never been given any pain education. After reading this book, she asked, "Why didn't anyone tell me this?" My response was, "They didn't know." Although Explain Pain was first published in 2003, pain science is still only slowly finding its way to practitioners. 

Since I've begun studying pain science, I've incorporated information the information presented in Explain Pain into my practice. It has been a useful tool for helping clients get out of pain and feel in control of their lives once again.

Additional resources

I've posted a fifteen minute TED Talk by Lorimer Moseley on Why Pain Hurts in a previous post. There is also, in the same article, a forty-five minute lecture to a professional audience for those geeky folks who want to understand details about the biology of pain. Recently, I've found a twenty-five minute video by Moseleywhich has become a favorite because he addresses how we think about conditions like herniated discs and how our thinking can feed and perpetuate fear, anxiety, and pain. If you watch only one of these videos, this is the one I recommend. These videos are educational and entertaining. Moseley, who is both researcher and clinician, has a charming Australian accent and a great sense of humor. Imagine Crocodile Dundee giving an introduction to pain science and you'll get the picture.

For more information about understanding pain, I also suggest the following: 

Painful Yarns by Lorimer Moseley (stories to help understand the biology of pain)

Also, check out this article about understanding how pain works by Paul Ingraham of SaveYourself.ca. 

Cory Blickenstaff, PT, has put together some useful videos of "novel movements." Here are links to the ones on the low back, neck, and hand, wrist, forearm, and elbow. 

This article originally appeared massage-stloius.com and was written by 'Ask the Massage Therapist'.