What can we do with low back pain?
The osteopath Dr. Lederman (2011) states that the mechanical model is outdated for low back pain. Major systematic reviews have shown that there is not enough evidence for mechanical causes of low back pain. The oblique positions, leg length differences, joint blockages, etc. do not appear to have any causal influence on the complaints. The muscular part (core stability, etc.) does not appear to be the cause. Lederman therefore advocates a treatment aimed at reducing the sensitivity of the low back. If the complaints persist for more than eight weeks and become chronic, they have a neurological origin, he says. In this newsletter we will discuss the incidence of low back pain, the etiology from the regular and complementary perspective and what we can do with it as osteopaths.
Table of contents:
Can low back pain also be explained from the neurological model? What do we know and what can we do for patients?
Four relevant studies provide more insight. Mahan first looked in a review of the phenomenon of stretch on peripheral nerves and the contradictions in visions and studies. His finding was that the exact boundary between safe and damaging elongation is still unclear.
Testing and diagnostics
The straight leg raise test (SLR) is the most widely used physical test for measuring the mechanosensitivity and limitation of the mechanical function of the sciatic nerve or lumbar nerve roots in people with low back pain with and without radiating pain. Bueno-Gracia conducted cadaver research to differentiate between hamstring and sciatic nerve problems. As a result, only dorsiflexion at different degrees of hip flexion during SLR produced significant changes in tension and distal displacement of the sciatic nerve in the thigh. This in contrast to the biceps femoris, which showed no significant changes. This indicates that dorsiflexion of the ankle during SLR can be used to differentiate between the muscle and nerve in dorsal hip pain.
Treatment options for the peripheral nervous system:
Sliding and stretching techniques
Coppieters and Butler conducted a cadaveric study of longitudinal displacement and tension in the median and ulnar nerves at the wrist and proximal to the elbow during different types of nerve gliding exercises. They looked at combinations of movements, in which extension of the nerve bed at one joint is simultaneously compensated by shortening the nerve bed at the next joint (‘sliding technique’) or by moving one or more joints in such a way that the nerve bed is extended (‘ stretching technique ‘). The results confirmed the clinical assumption that sliding techniques produce a substantially greater displacement of the nerve than stretching techniques (median nerve at the wrist: 12.6 versus 6.1 mm, ulnar nerve at the elbow: 8.3 versus 3.8 mm), and that this greater displacement is associated with a much smaller change in tension (median nerve at the wrist: 0.8% (sliding) versus 6.8% (stretch)).
The osteopathic treatment of the fascial system of the peripheral nerve has no basis in scientific research but is mainly based on the clinical experience of individual practitioners (Bordoni). The fascial osteopathic technique is the application of a low load, long-term stretch to the myofascial complex, with the aim of restoring the optimal length of this complex. The practitioner places the hand / fingers on the fascial restriction, previously established by means of palpation, until the resistance found disappears or is greatly reduced, thereby inducing or holding back the preferred direction of the tissue. There are reports in the literature that improve the sliding of the different layers of the fascia by manual manipulation, reduce pain and reduce local inflammation. Further research should clarify what happens in the nerve when fascial osteopathy techniques are used, along with quantifying the benefit to the patient. (JtB)
Originele title: Nerve stretching: a history of tension
Auteur: Mark A. Mahan, MD
Gepubliceerd in: J Neurosurg January 11, 2019
Originele title: Do ‘sliders’ slide and ‘tensioners’ tension? An analysis of neurodynamic techniques and considerations regarding their application.
Auteurs: Michel W. Coppieters, David S. Butler
Gepubliceerd in: Manual Therapy 13 (2008) 213–221
Originele title: Differential movement of the sciatic nerve and hamstrings during the straight leg raise with ankle dorsiflexion: Implications for diagnosis of neural aspect to hamstring disorders
Auteurs: Elena Bueno-Gracia, Albert Pérez-Bellmunt, Elena Estébanez-de-Miguel, Carlos López-de-Celis, Michael Shacklock, Santos Caudevilla-Polo, Vanesa González-Rueda
Gepubliceerd in: Musculoskeletal Science and Practice 43 (2019) 91–95
Originele title: Reflections on osteopathic fascia treatment in the peripheral nervous system
Auteurs: Bruno Bordoni, Giovanni Bordoni
Gepubliceerd in: Journal of Pain Research 2015:8 735–740
Chronic low back complaints are common. From the holistic view of osteopathy, more attention should be paid to the influence of psychological causes or central sensitization in chronic low back pain.
According to Driscoll et al. (2010), work-related low back pain led to 21.7 million DALYs worldwide in 2010: disability-adjusted life years. This is a sum of the number of years that people live less due to illness and the loss of quality of life due to illness. The greatest burden of disease was experienced in the 35-55 age group, and men made up the largest share with 61.9% of the total. Chronic low back pain is therefore one of the most common complaints that the osteopath treats.
There are indications that the osteopathic manipulative techniques can effectively treat chronic low back pain (Licciardone & Aryal, 2014 & Licciardone & Gatchel, 2020). Within osteopathy it is also generally accepted that pain complaints are accompanied by physiological, psychological and behavioral changes. Nevertheless, the skills of foreign osteopaths to research and treat the psychosocial causes of pain complaints appear to be limited (Biesen et al., 2020). The vision sometimes appears to differ from the generally accepted guidelines for the treatment of (chronic) low back complaints (Pincus et al., 2006; Figg-Latham & Rajendran, 2007). As a result, guidelines are sometimes not used and patients are not referred for psychological complaints or central sensitization. Many practitioners still feel responsible for the patient’s complaints. Treatment processes take longer, so that a relationship of trust can develop. This in order to ultimately be able to discuss psychosocial complaints, other treatments or treatment goals. The idea behind this is partly justified, but patients may not receive the most effective and / or most appropriate care (Pincus et al., 2006).
More and more is being discovered how central sensitization and psychosocial complaints have effect on all types of (chronic) low back pain. Nijs et al. (2015) indicate that too little account is taken of this. Ultimately, pain perception begins in the brain. They therefore insist that, regardless of the underlying mechanical cause of the back pain, always undergo a psychosocial screening. This is to see if there are any psychological characteristics, negative illness behavior and / or central sensitization. Various tips are given on how to screen for this in practice. Early identification, advice and referral to the most appropriate care is therefore important. This is interesting because there is currently limited evidence for the treatment of peripheral complaints to influence central sensitization in chronic low back complaints. (JV)
Driscoll, T., Jacklyn, G., Orchard, J., Passmore, E., Vos, T., Freedman, G., Lim, S., & Punnett, L. (2014). The global burden of occupationally related low back pain: estimates from the Global Burden of Disease 2010 study. Annals of the Rheumatic Diseases, 73(6), 975–981.
Figg-Latham, J., & Rajendran, D. (2017). Quiet dissent: The attitudes, beliefs and behaviours of UK osteopaths who reject low back pain guidance – A qualitative study. Musculoskeletal Science and Practice, 27, 97–105.
Licciardone, J. C., & Aryal, S. (2014). Clinical response and relapse in patients with chronic low back pain following osteopathic manual treatment: Results from the OSTEOPATHIC Trial. Manual Therapy, 19(6), 541–548.
Licciardone, J. C., & Gatchel, R. J. (2020). Osteopathic Medical Care With and Without Osteopathic Manipulative Treatment in Patients With Chronic Low Back Pain: A Pain Registry–Based Study. The Journal of the American Osteopathic Association, 120(2), 64.
Nijs, J., Apeldoorn, A., Hallegraeff, H., Clark, J., Smeets, R., Malfliet, A., L Girbes, E., De Kooning, M. & Ickmans, K. (2015). Low back pain: guidelines for the clinical classification of predominant neuropathic, nociceptive, or central sensitization pain. Pain physician, 18(3), E333-46.
Pincus, T., Vogel, S., Breen, A., Foster, N., & Underwood, M. (2006). Persistent back pain – why do physical therapy clinicians continue treatment? A mixed methods study of chiropractors, osteopaths and physiotherapists. European Journal of Pain, 10(1), 67.
Van Biesen, T., & Alvarez, G. (2020). Beliefs about chronic low back pain amongst osteopaths registered in Spain: A cross-sectional survey. International Journal of Osteopathic Medicine, 36, 3–10.
Recent systematic reviews have found reasonable evidence that lumbar mobilization and manipulation techniques are effective in treating low back pain. However, knowledge about optimal techniques and dosages and their clinical reasoning is often lacking.
Two systematic reviews have been published on the effect of osteopathic manipulation on low back pain. Franke (2014) wrote that in chronic nonspecific low back pain (LBP) there is evidence for a significant effect of manipulations, both in the reduction of pain and in functioning. Also, when examining non-specific LBP during pregnancy, a significant difference was found in favor of manipulation. This mainly had an effect on the experienced pain. However, the studies conducted on this were of poor quality.
Verhaeghe (2017) concluded that there is some evidence to suggest that osteopathic care may be effective for people with back problems. Further studies with a large group of participants and long-term impact assessment are required to build more evidence-based knowledge.
A study by de Oliveira Meirelles et al (2019) investigated the effect of manipulation in comparison to exercise therapy. In both groups, the therapy appeared to be effective, but the efficacy of the manipulation treatment appeared to be greater. De Toledo’s study (2020) looked at the effect on the iliosacral joint before and after a manipulation, performed on healthy men. There was no change in mobility here.
But how targeted are our manipulations really?
Frantzis (2015) investigated this. He found that osteopathic techniques used in research are similar to chiropractic techniques in manipulation accuracy. Average error made is one segment away from the target segment.
Dewitte (2015) looked at the dosage and when which manipulation technique to use. Physical examination for mechanical nociceptive pain consists of stretching or compression pain. The stretch can be referred to as a divergence pattern, the compression as a convergence pattern. This leads to different treatment strategies.
In addition to the effect of the manipulation alone, the recovery of chronic low back pain after treatment with manipulations was also examined in comparison to cortisone injections, surgery and other forms of treatment for low back pain. It has been found that an osteopathic manipulation can be useful before switching to other, more expensive interventions in the treatment of patients with chronic back pain (Licciardone et al, 2016).
How we manipulate, which dosage we use has been taught to us all through models at school. However, recent research by Smith (2019) undermines much of the biomechanical reasoning of osteopathy. Diagnostic reasoning must go beyond tissue-based diagnoses, he argues. Identifying the process patients are in and which psychosocial factors can play a role are ways to change practice. This has led to much debate about the future of osteopathic discernment. More attention will have to be paid to the biopsychosocial aspect and how this can be applied in practice. (NB)
Originele titel: Osteopathic manipulation treatment versustherapeutic exercises in patients with chronicnonspecific low back pain: A randomized,controlled and double-blind study
Auteurs: de Oliveira Meirellesa,F., de Oliveira Muniz Cunhaa JC., da Silvab E.B.
Verschenen in: Journal of Back and Musculoskeletal Rehabilitation -1 (2019) 1–11
Originele titel: High-velocity, low-amplitude manipulation (HVLA) does not alterthree-dimensional position of sacroiliac joint in healthy men: A quasi-experimental study
Auteurs: de Toledoa D., Kochem B.F., Silva G.
Verschenen in: Journal of Bodywork & Movement Therapies 2019
Originele titel: Articular dysfunction patterns in patients with mechanical low back pain: A clinicalalgorithm to guide specific mobilization and manipulation techniques
Auteurs: Dewitte V., Cagnie B., Barbe T., Beernaert A., Vanthillo B., Danneels L.
Verschenen in: Manual Therapy, 2014
Originele titel: American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients With Low Back Pain
Auteurs: Franke S.
Verschenen in: The Journal of the American Osteopathic Association August 2016 Vol 116 No. 8
Originele titel: The accuracy of osteopathic manipulations of the lumbar Spine:A Pilot study
Auteurs: Frantzis E., Druelle P., Ross K., McGill S.
Verschenen in: International Journal of Osteopathic Medicine, 2014
Originele titel: Recovery From Chronic Low Back Pain After Osteopathic Manipulative Treatment: A Randomized Controlled Trial
Auteurs: Licciardone J.C., Gatchel R., Aryal S.
Verschenen in: J Am Osteopath Assoc. 2016;116(3):144-155
Originele titel: Reflecting on new models for osteopathy–it’s time for change
Auteurs: Smith D.
Verschenen in: The Journal of the American Osteopathic Association Vol 31, P15-20, March 01, 2019
Originele titel: Osteopathic care for spinal complaints: Asystematic literature review
Auteurs: Verhaeghe N., Schepers J., van Dun P., Annemans L.
Verschenen in: PLoSONE13(11)
There are two approaches to assessing low back pain and the influence of the viscera. What influences what now?
- The influence of the viscera on the lower back pain (viscero-somatic) in the diagnosis
- The influence of the lower back on the visceral complaints (somatovisceral) in the treatment.
When assessing the visceral impact on back pain, it is good to look more broadly at the impact of the viscera on spinal pain. Several recent studies have looked into this.
Oliva (2019) found in the systematic review of 309 articles that only 20% of comorbidities of visceral origin were included. Visceral referred pain (VRP) should be looked at more frequently when assessing neck pain, they argue. Interventions that have been investigated can therefore be insufficiently assessed for value. It is suspected that the same applies to lower back complaints.
To what extent can pelvic pain be related to pelvic organ functions? Goeschen (2020) studied the influence of pelvic small organs (prolapse) in chronic pelvic pain (CBP). This has only been a literature review of possible etiology. Several factors are indicated (standing upright, bipedal, pelvic angle changes with age and the fixation of the pelvic organs is flexible, which allows for delivery.They state that the endopelvic fascia is continuously connected to the musculoskeletal system (think piriformis), provides an extra support function Pelvic complaints should therefore be examined for comorbidity of pelvic organ laxity.
Postpartum low back pain often develops. There is little evidence that this has a mechanical musculoskeletal cause (Lederman, 2018), so this may be a visceral cause. In the study by Schwerla (2015), eighty women were randomized within 3 months post partum into a treatment group (4 times in 12 weeks) and a control group. Treatment consisted of OMT as stated in the Glossary of Osteopathic Terminology. The treatment was adapted to the patient. The outcome measures were VAS and Oswetry Disability Index (ODI). There was a significant difference in pain and reduction in disability in the treatment group. However, this study does not take into account which co-morbidities existed. The study reported several co-morbidities (urinary, faecal incontinence, dyspareunia, and haemorrhoids) that obviously determine the outcome of the LBP.
What influences does the osteopath have on scar tissue? Riquet (2019) investigated the treatment of abdominal scars with osteopathy. Twelve subjects were examined with an infrared camera before the treatment of the scar (significant difference in temperature between scar and surrounding area) and after the treatment (no significant difference anymore). From this they conclude that there is a modification of connective tissue function. This can possibly lead to an improvement of function. Wasserman (2016) investigated scar tissue (viscerosomatic pain) after caesarean section as an influence on pelvic pain. The scar was treated in two women with pelvic and abdominal complaints. Outcome measures were pain (algometer), scar flexibility (adherometer) and a pain scale (NPRS). Treatment was weekly for 4 weeks. Both women reported significantly less pain after treatment. Of course, the number is too low for good evidence.
Then there is the influence of the lower back on visceral complaints. Muller (2014) carried out a systematic review of the effects of parietal techniques on Irritable Bowel Syndrome (IBS). Of the ten studies she found, five met the inclusion criteria. She concluded that there is a favorable outcome for OMT compared to the standard interventions and control treatment of IBS. The therapy usually also includes treatment of the musculoskeletal system in addition to the visceral system. Here there is also a somato-visceral influence.
Constipation in children
Visceral physiotherapist Blanco Diaz and colleagues divided 47 children aged 2-14 years into treatment and control groups. The treatment group received visceral and parietal manual techniques according to an established protocol, weekly for 9 weeks. Outcome measures were IBS-SS (Irritable Bowel Symptom Severity Score), BSFS (Bristol Stool Form Scale) and DF (defecation frequency). The result did not show a significant difference between the treatment and control group. The limitations of this study were the lack of multiple diagnostic criteria (e.g. constipation, IBS) and there was only one practitioner conducting the study. (SK)
Table Müller et al: Effectiveness of osteopathic manipulative therapy for managing symptoms of irritable bowel syndrome: a systematic review
Table taken from The Journal of the American Osteopathic Association, 114 (6), 470-479
Oliva-Pascual-Vaca, Á., González-González, C., Oliva-Pascual-Vaca, J., Piña-Pozo, F., Ferragut-Garcías, A., Fernández-Domínguez, J. C., & Heredia-Rizo, A. M. (2019). Visceral Origin: An Underestimated Source of Neck Pain. A Systematic Scoping Review. Diagnostics, 9(4), 186.
Goeschen, K., & Liedl, B., 2020, Chronic pelvic pain and pelvic organ prolapse: a consequence of upright position? Pelviperineology. DOI: 10.34057/PPj
Schwerla, F., Rother, K., Rother, D., Ruetz, M., & Resch, K. L. (2015). Osteopathic manipulative therapy in women with postpartum low back pain and disability: a pragmatic randomized controlled trial. J Am Osteopath Assoc, 115(7), 416-25.
Riquet, D., Houel, N., & Bodnar, J. L. (2019). Effect of osteopathic treatment on a scar assessed by thermal infrared camera, pilot study. Complementary therapies in medicine, 45, 130-135.
Wasserman, J.B., Steele-Thornborrow, J.L., Yuen, J.S., Halkiotis, M., Riggins, E.M., Chronic Caesarian section scar pain Treated with fascial scar release techniques: A case series, Journal of Bodywork & Movement Therapies (2016), doi: 10.1016/j.jbmt.2016.02.011.
Müller, A., Franke, H., Resch, K. L., & Fryer, G. (2014). Effectiveness of osteopathic manipulative therapy for managing symptoms of irritable bowel syndrome: a systematic review. The Journal of the American Osteopathic Association, 114(6), 470-479.
Blanco Díaz, M., Bousoño García, C., Segura Ramírez, D. K., & Rodríguez Rodriguez, Á. M. (2020). Manual Physical Therapy in the Treatment of Functional Constipation in Children: A Pilot Randomized Controlled Trial. The Journal of Alternative and Complementary Medicine, 26(7), 620-627.