These pages are intended to convey something of the scope of osteopathic care and my particular approaches to treatment.
Occupational overuse injuries/syndrome
‘The tyrannies of labor’ produce distinct patterns and types of overuse injury. Computer based office workers develop different issues to plasterers and butchers. Within occupational groups there is enormous variability to developing OOIs.
Because peoples’ livelihood often depends on the very activity producing the injury, sufferers often remain silent and endure often debilitating injury rather that seek prompt assessment and intervention. Delay can drive transient inflammation into chronic tissue disorganisation, nervous system sensitisation and chronic pain.
OOIs can develop in any musculoskeletal tissue. Some of the more common regions/locations and tissue involved are:
- Shoulder- (girdle) and neck muscles – upper trapezius, supraspinatus, levator scapulae seem particularly vulnerable
- Forearms flexors and extensors
- Thumb extensor tendons
- Low back muscles, fascia, discs and ligamentous structures.
To describe an osteopathic approach to OOIs I will focus on shoulder pain. This region is complex, dynamic and highly mobile – consisting of multiple joints and a myofascial articulation, the scapulothoracic joint. This arrangement is collectively referred to as the shoulder girdle. OOI and traumatic injury are common as are issues of postural overload – arguably a form of overuse. The shoulder girdle represents a convergence of function – shoulder movement, neck and thoracic function, breathing and mastication (chewing) all tie onto this region.
The overlap and multiple functions of muscles through the shoulder-neck region is of particular interest, particularly in patients with chronic pain associated with an OOI. Sustained pain can produce hyperventilation leading to respiratory alkalosis with further implications for pain regulation, autonomic function and sensitivity-excitability of motor and sensory neurons – particularly those with a postural-respiratory function. These include trapezius, sternocleidomastoid, the scalenes and pectoral muscles. This adaptive scenario can develop insidiously in response to and will amplify the symptoms of a primary shoulder injury. Common shoulder injuries include:
- Tendinosis, tendonitis, +/- bursitis
- Rotator cuff tears
- Capsular injury.
Interestingly there is a poor correlation between diagnostic imaging (ultrasound) of these injuries and clinical symptoms/functional limitations in patients. For this reason I tend not to focus on and harass a particular tissue. Instead treatment and rehabilitation emphasise the restoration of regional function which indirectly influences the local ‘identified’ pathology. Engaging in a process of shoulder girdle rehabilitation through movement practices invariably helps also to resolve thoracic and cervical spine issues.
Low back and pelvic girdle pain
These are two discrete but functionally related issues. During the last twenty years there have been majors advances in our anatomical, biomechanical and therapeutic understanding of these interrelated diagnostic entities. Low back pain is typically experienced locally and can extend beyond but not include the buttock into the thigh and leg. By contrast, pelvic girdle pain tends to produce focal pain in sacral ligaments and referred pain below the sacroiliac joint as well as pubic symphysis (typically in pregnancy). The region is a meetingplace between the upper and lower limbs involving the coordinated function of superficial regional muscular slings, deeper local muscles, ligaments & fascia. The sacroiliac joints are nested in the middle of this confluence.
Historically osteopaths were amongst the first modern musculoskeletal practitioners to assess and treat sacroiliac dysfunction. Osteopaths developed some consensus around diagnosis and build a model that sought to describe the relationships between movement, motion and other functional characteristics of the hip joint, lumbar spine, sacral ligaments and the sacroiliac joint. These early attempts to codify the significance and perceived interactions between anatomical landmarks, apparent leg lengths, passive and active motion, dysfunction and compensations to prioritise treatment based on a clear diagnosis. These diagnostic methods by necessity were based on the prevailing biomechanics as well as osteopathic theories of sacroiliac motion. Some of the biomechanical assumptions underlying these osteopathic diagnostic approaches have been superseded by recent anatomical, biomechanical and functional insights.
The development of visualisation technologies and subsequent biomedical focus on disc bulges led to the erroneous assumption that most back pain was disc related and could be corrected with spinal surgery. We now understand that less than 10% of back pain is caused by disc injury.
Recurrent and chronic low back and pelvis pain are complex issues that have an even more tenuous relationship to diagnostic imaging. In this context the acronym VOMIT (care of Andry Vleeming) seems appropriate to mention – Victims of Medical Imaging Technology. These are patients suffering a chronic-recurrent condition who have be convinced that the source of their pain is located in ‘abnormal’ imaging signs. The observed and reported efficacy of standardised lumbar rotational resistance training combined with general training in the treatment of low back pain, irrespective of imaging-based diagnosis, demonstrates the poor correlation between imaging, diagnosis and therapeutic outcome.
The influence of motor control and stabilisation in lumbar and pelvic function has been elucidated over the last 20 years. In essence pain elicits a ridged motor control strategy which has the potential to perpetuate maladaptive movement patterns and apprehensive pain behaviour. I tend to situate my work in this space where pain meets behaviour and psychological wellbeing. I work with patients to promote coupled and relaxed movement throughout the region using both osteopathic treatment and movement practices.
It is often quoted that acute low back pain resolves in 4-6 weeks in 75-90% of individuals. This assertion is based on insurance industry disability data and has lead to the common practice of symptomatic (analgesia, NSAIDS and rest) treatment for acute low back pain. Numerous primary care and prospective studies dispute this proposition and clinical approach. It has been shown that it is more effective to prevent chronicity rather than wait for chronic issues to develop. The natural history of acute low back pain, in contrast to insurance data, runs a more complex course. Typically the original episode of acute low back pain last up to 3 months and is characterised by rapid but incomplete resolution interspersed by flare-ups. In this respect low back pain is a chronic issue with intermittent exacerbations, akin to asthma rather than an acute disease that can be cured.
Sporting and traumatic injury
Some common sporting and traumatic injuries osteopaths treat are
- ankle inversion (sprained ankle)
- patello-femoral pain
- ilio tibial band ‘syndrome’
- rotator cuff injuries – both chronic degenerative and sudden traumatic tears
- motor vehicle related injuries including whiplash
- manual handling accidents
- low back and pelvic girdle injuries
- achillies tendonitis (-osis)
- midfoot and plantar fascia pain
- muscle strain and tear
Beyond locating and specifying tissue(s) involved in these injuries, osteopaths assess and treat the network of interconnected tissues (lesion field). Osteopaths tend to regard both insidious and even some seemingly sudden traumatic injury as being influenced by and predisposed to dysfunction across multiple structures and functions. Treatment in both instances involves delineating the extend of the lesion field and where necessary honing in on particular tissues. A comprehensive therapeutic response is one in which the injured part seamlessly blends back into the fabric of the whole.
In some case of trauma and degeneration, surgical restoration is sought by patients. Patients seek osteopathic treatment to manage the strain and adaptation of altered post-surgical function as well as improve the functional limitations caused by surgery. Ankle, knee and shoulder reconstruction and repair are very responsive to osteopathic treatment as are laminectomies and other neurosurgical interventions.
Headache can represent a complex diagnostic challenge. The biomedical response to headache tends to be either symptomatic relief with increasingly powerful pain relievers or referral for MRI to rule intracranial nasties. This bipolar response means that many patients experiencing tension-type and migraine headaches do not receive prompt and effective hands-on treatment. The absence of new neurological or systemic symptoms provides osteopaths with a safe opening to assess and treat these primary headaches.
Patients are often unaware of common headache trigger that might include:
- Chemical and environmental sensitivities
- Food sensitivities and intolerances
- Underlying hormonal imbalance (elevated oestrogen is very common)
- Stress & tension – this may be associated with clenching and grinding
- Dental issues like malocclusion
Osteopathic approaches to the treatment of headache vary enormously. Treatment is influenced by differential diagnosis and suspected causation. In some cases multiple factors intersect to produce a headache.
Readers interested in headache diagnosis and classification are directed to the International Headache Society.
Asthma and Breathing Pattern Disorders
Osteopathic patients are often surprised by the tenderness and tension of their respiratory diaphragm. Reducing the resting tone and improving the quality and range of the diaphragms excursions can have far reaching overall health benefits. Re-education of a patients breathing pattern leads to a gradual prolongation and retention of breath as well as less accessory muscle use. Informing and teaching patients about respiration is central to my practice.
Breathing pattern disorders (BPD) are very common in the general population and more common in individuals experiencing musculoskeletal pain. In BPD breathing mechanics are altered, engaging secondary respiratory muscles leading to a thoracic pattern that can lead to hyperventilation. Sustained hyperventilation produces respiratory alkalosis and hypoxia – a reduction of O2 supply to the brain and to tissues with subsequent fatigue. Therapeutically addressing the interplay between BPD, musculoskeletal pain and other psychogenic and environmental triggers is central to osteopathic care.
Asthma is commonly misdiagnosed. Thirty percent of cases of asthma are induced by emotion or exercise and many symptoms are common to hyperventilation and asthma – it has been shown that around 30% of diagnosed adult asthmatics display symptoms associated with functional breathing disorders. BPD influence emotions, balance, motor control, musculoskeletal function and performance, pain sensitivity, resting muscle tone and spinal stability.
Somatic therapies have long been known to be effective in managing these common affective states. We tend to regard these states as adaptive and highly organised responses that influence and are supported by the autonomic nervous system. Rather than necessarily talking about stuff and naming internal states, osteopaths support mental health by reorienting our patients towards autonomic balance. Treatment reacquaints patients with neutral states and transparency behind the clatter and buzz of sympathetic dominance. This process can open up pathways towards mindfulness that can alleviate and permanently change these states.
Sustained anxiety, stress or depression produce characteristic changes throughout the body – impacting on musculoskeletal and neuroendocrine health through multiple pathways.
Arthritis is not one entity and people with the same diagnosis experience varied symptoms and trajectories. Historically particular immunological proteins were associated with different arthritic conditions. The reality is that these conditions are associated with highly variable combinations of altered genomes, proteomes, transcriptomes and metabolomes.
The experience and disease process in arthritis can range from mild and localised joint stiffness and skin lesions to systemic organ involvement requiring complex pharmacological and surgical intervention.
Most patients who seek osteopathic treatment for arthritis have osteoarthritis, otherwise known as degenerative joint disease. Degeneration can be severe and debilitating – sometimes necessitating joint replacement. Post-surgical rehabilitation following joint replacement or less invasive procedures is a rewarding aspect of osteopathic practice. Conversely I work with patients to manage the symptoms of osteoarthritis through osteopathic treatment and even hope to avert or delay ‘inevitable’ orthopaedic surgery. Prospective patients should be aware that the correlation between diagnostic imaging and symptoms in osteoarthritis is very poor. To ascribe a complex symptom picture to radiographically identified arthritic structures can be inaccurate and undermine a patient’s otherwise buoyant expectations of osteopathic treatment.
I routinely work with patients with rheumatoid arthritis, SLE, infectious arthritis and polymyalgia rheumatica. Osteopaths work with motion and function present as well as assisting and maintaining the patients ability to adapt and compensate for arthritic change. My experience in treating arthritis is that a little functional improvement can influence overall comfort and movement integration. Because fatigue is often a major complaint in arthritis, any improvement in economy and ease of motion can be helpful. There is a substantial evidence that gentle osteopathic treatment reduces the inflammatory milieux of the body. Patients with arthritis often benefit dietary change and supplementation that support better regulation of inflammation.
These can range from simple mechanical obstruction to debilitating erosive inflammatory states. Osteopathic visceral manipulation can be applied throughout the gastrointestinal system and may alleviate symptoms like bloating, sluggishness and localised pain associated with a myriad of conditions including gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS).
Osteopathic manipulation of transitional zones like the iliocaecal and gastroesophageal junctions as well as visceral ligaments like the mesentery and the livers extensive connections to the diaphragm can be very productive.
Osteopaths have long recognised the interplay between the organs (viscera) and musculoskeletal system (soma). These interactions are mediated by neurological pathways – the autonomic viscerosomatic and somatovisceral pathways. These collections of autonomic nerves originate and are distributed from bundles deep in the abdomen – they are amenable to osteopathic treatment. Musculoskeletal issues can sometimes be caused or perpetuated by underlying gastrointestinal issues. Because the traffic in these autonomic pathways is bidirectional, working on either the soma or viscera can be beneficial.
Undiagnosed food sensitivities coupled to stress and other psychosocial factors are regarded as common underlying causes of IBS. Osteopaths engage these underlying causes and thereby influence the severity of IBS. It is widely recognised that gluten sensitivity is another frequently contributing factor in IBS (as well as producing celiac disease in 1% of the population). Through abdominal examination and palpation osteopaths are often the first primary heath carer to pick up signs of gluten sensitivity. Sensitivity to fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) is emerging as both a separate entity and contributing factor to the symptoms of IBS.