Osteopathy and Low Back Pain. Article for Medical Professionals
by Alan Szmelskyj DO, MSc, MISMA, FRSH
Introduction to, and context of article
At the beginning of 1995, Mr Greg Sharpe, who was the Chairman of the Education Department of the General Council and Register of Osteopaths, asked me if I would be willing to write about how osteopaths would manage low back pain. Having agreed to do so, I was then commissioned by Dr David Wilson of the Nuffield Orthopaedic Centre, Oxford, to write this paper. The paper would be published, along with other articles, in a mini-symposium on the spine. The article was published in December 1995 (Volume 7 part 4) in a journal called ‘Imaging – An International Journal of Clinical-radiological Practice’. The aim of the article was to inform consultant radiologists and radiographers about osteopathy and low back pain and when osteopaths would consider using imaging techniques. Other contributors to the published symposium were a chiropractor, a consultant in pain management and two consultant radiologists.
What is Osteopathy?
Osteopathy is a discipline which uses a variety of techniques in an attempt to alter a patient's abnormal psycho-social physiological-biomechanical-ergonomic functions to a more balanced level. The holistic osteopath will attempt to help the person manage as many of the exogenous and endogenous stresses that predispose, maintain and contribute to the problem.
Osteopaths view each person as a unique individual. Contemporary medical science recognises each persons unique genetic make up. In clinical osteopathic practice osteopaths also recognise this individuality. Osteopaths tend not to favour standardised prescriptive osteopathic treatment for their patients; since such prescriptive standardised approaches have an inherent risk of ignoring each persons potential response to treatment. This is not to say that osteopaths do not use standardised techniques, but that these procedures are constantly modified in response to the patient's changing conditions, both during a treatment session, and also over the course of several treatments.
In clinical practice it is difficult to construct an accurate multifactorial model which can completely account for a patient's problem. Thus only an approximate holistic evaluation and treatment plan can be achieved in the 30-45 minutes per consultation that most osteopaths spend with their patients. The aim of osteopathic management is to mobilise, with the minimum degree of damage, the body's own self healing and reparative processes (1).
In attempting to restore homeostasis, the osteopath will use a variety of approaches. For example, manual techniques will be used to deal with the physical aspects of the problem. Psychotherapeutic counselling advice will aim to deal with psycho-social aspects.
The epidemiology of back pain in osteopathic practice
In a recent 'snapshot survey' of osteopathic practice undertaken during one day in June of 1994, and encompassing 35% (n=508) of the membership of the Register of Osteopaths, it was found that 74.25% of the patients presenting were self referring, with the majority complaining of low back pain. 23.07% were either referred by their GPs or attended with their doctor's knowledge or permission, and 1.41% were referred by consultants. In the United Kingdom, nearly 20,000 patients consult osteopaths every working day. Of these about 3,350 are consulting an osteopath for the first time (2).
Low back pain accounts for between a half and two thirds of the typical osteopath's case load. The remaining patients present predominantly with other spinal or musculoskeletal problems, (2,3). The majority of patients with low back complaints presenting to osteopaths (63.5%) will have been in pain for over a month, and 36.9% will have had their symptoms for more than a year (4).
The Clinical Standards Advisory Group report into the management of back pain found that osteopaths are by far the largest private providers of treatment for back pain. Osteopaths see about 700,000 new back pain patients each year, for which they provide about 3,300,000 treatment sessions. Typically Britain's 2,500 osteopaths spend 67% of their time treating back pain (3).
The osteopathic clinical encounter
Osteopaths try to identify as far as is practicable each individual patient's exogenous and endogenous stressor profile. Thus osteopathic diagnostic procedures make use of a combination of clinical history and thorough examination to determine the appropriate balance of treatment (5). It is important to find out as much information as possible about the patient's presenting complaint including details about the onset, the prelude to the symptoms, the extent of pain, its distribution, severity, type, location, radiation, aggravating and relieving factors, presence of any sensori-motor phenomena, medication, history of back pain, time off work, nutrition and smoking habits, general medical history including operations, illness, hospital admissions, tests or investigations. Information will also be sought about the patient's occupational history, domestic demands, social and sporting pastimes.
The examination typically consists of observing the patients standing posture, particularly in the anteroposterior and lateral planes; determining the extent of any unlevelling of the sacral base plane leading to scoliosis; changes in muscle tone, location of the presenting complaints, assessment of gross active movements to discover any asymmetry in coupled joint motion, and examination of sitting postures. Recumbent examination would include an assessment of the function of the lower limb joints and of the cause and amount of any lower limb asymmetry. The feedback from palpatory examination of the lumbar and thoracic spine is used to assess the degree of intervertebral joint motion and function, as well as elucidating the limitation to movement from paraspinal soft tissues. Palpatory assessment is the most frequent method osteopaths use to assess their patient's musculoskeletal system. Osteopathic diagnostic tests are summarised in table 1. In addition other orthodox clinical methods in particular orthopaedic and neurological testing procedures, are used when indicated (5,6). Ultimately the osteopath will arrive at a working hypothesis about the aetiology and pathology of the patient's problem.
Thus osteopathic diagnosis in low back pain will pay particular attention to: the vulnerable aspects of the individual, the physical stresses involved and their sources, and the dysfunction produced. This is because the usual osteopathic hypothesis is that most spinal complaints follow some form of spinal dysfunction. It is the effect of mechanical forces imposed on components of the musculoskeletal system expressed in distinct patterns of abnormal function which reflect the particular vulnerabilities of the individual (6). The holistic diagnostic process encompasses investigation of the elements of figure 1. The frequency of particular broadly categorised diagnoses are shown in table 2.
Following the diagnostic evaluation the osteopath can estimate the contribution that his or her brand of practice can make to the overall health and welfare of the patient. This contribution may be primarily osteopathic, or in overtly pathological cases complementary to that of the general practitioner or consultant.
In deciding to accept a patient for treatment the osteopath will determine which factors are acute and which are chronic. The practitioner will choose the appropriate techniques for short term management, for example techniques for effective relief of the presenting complaint, including pure symptomatic relief. This would normally consist of a cocktail of manual medicine techniques. The types and frequency of physical treatment techniques that osteopaths use are shown in table 3. In choosing the appropriate hands on treatment the practitioner will usually consider which methods he favours and the patient's likely response to such techniques, considering the frequency, quantity and strength of the treatment. Once the short term objectives have been achieved then the osteopath will devise an appropriate longer term management strategy to return the person's neuromusculoskeletal system to a homeostatically healthier, optimally functioning level, and will encourage the patient to adopt appropriate life style changes.
Osteopaths' use of spinal imaging
Osteopaths largely use radiological studies in a medical context as an aid to any suspected medical diagnosis rather than using them as an aid to an osteopathic evaluation. One study indicated that osteopaths refer about 12% of their back pain patients for radiological investigation (4). Given the clinical procedures that osteopaths use for assessing spinal function, they do not consider that standard radiological films provide them with any additional information that would normally modify their management of the patient. When osteopaths request spinal imaging it is usually because they feel the information will alter their treatment protocol, or because they suspect a particular disease. Such pathologies could include: spondylolysthesis, spondylolysis, osteoporosis, spinal osteochondritis, inflammatory problems such as sacroilitis, traumatic injuries or suspected fracture, for example, from high impact, or extra loading or repetitive stress on the spine leading to axial compression. Other reasons why X-rays might be requested include atypical non resolving back pain, night time pain, or pain worse at night.
There are however occasions when an osteopath might request radiological confirmation as an aid to management, for example, in the treatment of lumbar spondylosis. The extent of degenerative changes particularly when they conform with clinical and in particular palpatory findings, such as the presence of ligamentous shortening, can help determine the advice that is given to the patient on postures and activities to avoid. For example, with the results of radiological studies, I would be more emphatic in discouraging such a patient swimming the breast stroke, or painting ceilings or carrying any heavy weights, as well as in encouraging the more obese patient to lose weight.
An osteopath may use radiography to determine the degree of slippage in a case of suspected spondylolysthesis. This is useful information since it helps the practitioner to decide on the extent and type of manual treatment and exercises. For example, with radiological confirmation of spondylolysthesis I would still encourage the patient to continue with abdominal strengthening exercises but would recommend supine isometric exercises with knees bent. These would eliminate unnecessarily forceful repetitive flexion and leverage onto the lumbar spine.
With the advent of CT, MRI and radionuclide scintigraphy scans some osteopaths are using these newer imaging methods as an aid to their diagnosis of disc disease or in some cases tumours. However, most osteopaths would probably seek another opinion from orthopaedic colleagues before requesting such imaging studies. Most osteopaths request radiological studies via the patient's GP. Some osteopaths have arrangements with radiology departments of local hospitals to refer patients directly. In a small number of cases this arrangement also applies to requests for high technology imaging.
The education and professional training of osteopaths
In order to be competent in diagnostic and clinical abilities osteopaths can undertake a course of study at a number of osteopathic educational establishments (8). Most practising osteopaths have undergone a four year full time course of study (9). Most courses are degree validated. The courses of study at osteopathic colleges combine a mixture of clinical medical science with osteopathic medicine and health care. For example, at the British School of Osteopathy the largest osteopathic school, the major course components during the first year are normal human anatomy, physiology, psychology, and the principles of osteopathic practice. The second year builds on the first with particular emphasis on the anatomy and physiology of the musculoskeletal and nervous system. A great deal of time is also spent on clinical reasoning and diagnosis. The third year emphasises closely supervised development of clinical skills, diagnostic methods and the acquisition of osteopathic techniques. The fourth year allows students more responsibility in the clinics and greater opportunity to gain experience in non-neuromusculoskeletal disorders of the body and in radiology (10).
With the attainment of statutory regulation in August 1993 the osteopathic profession has been deemed to have reached an acceptable level of academic and clinical maturity. Osteopaths are major providers of care for the nation's back pain sufferers. Osteopaths have a unique viewpoint which provides the context against which management of their patients is undertaken. Whilst there is a growing body of literature about osteopathy in the treatment of low back pain, neuromusculoskeletal and other disorders, the most respected book for further reading remains Alan Stoddard's Manual of Osteopathic Practice (11).
I would like to thank Will Podmore for his proof reading and editing of the manuscript.
1 Szmelskyj AO. The difference between holistic osteopathic practice and manipulation. Hol Med 1990; 5(2): 67-79.
2 General Council and Register of Osteopaths. Osteopaths snapshot Survey 199 GCR 16/94. Reading: General Council and Register of Osteopaths, 1994 .
3 Clinical Standards Advisory Group. Epidemiology review: The epidemiology and cost of back pain. London: HMSO, 1994.
4 Burton AK. Back pain in osteopathic practice. Rheumat Rehab 1981; 20: 239-246.
5 Dove C. The patient as an individual and a statistic: Osteopathy. Com Med Res 1987; 2(1): 73-76.
6 Szmelskyj AO, Are you better? Clinical judgements of outcome and their implications 4. Osteopathy. Com Med Res 1988; 2(3): 36-42.
7 McDonald RS. Osteopathic diagnosis of low back pain. Manual Medicine 1988; 3:110-113.
8 General Council and Register of osteopaths. Competencies required for osteopathic practice. Reading: General Council and Register of Osteopaths, 1993.
9 Szmelskyj AO. The qualifications and geographical distribution of practising osteopaths in England, Scotland and Wales. Com Med Res 1992; 6(1): 1-8.
10 Edwards D. The development of a course in osteopathy in the UK. Com Med Res 1990; 4(1):32-45.
11 Stoddard A. Manual of osteopathic practice. London: Hutchinson and Co, 1983.