Kategori av blogposter som publiceras som forskningsartiklar

Brain connectivity changes after osteopathy

Summary

Use of fMRI to reveal neurophysiological effects following Osteopathic Manual Treatment (OMT) showed significant changes compared to placebo treatment. OMT influences connectivity in cen- tres involved in emotion, behaviour, sensorimotor integration and motor control.

Keywords

Osteopathic Manual Treatment; Neurophysiological effects; Functional brain connectivity; fMRI; Treatment Effects; Manual therapy;

Whilst the effectiveness of osteopathic treatment may not be questionable, the exact mechanisms of its effect have long been under debate. Models have frequently included neurophysiological mechanisms but this recent paper is one of the first to provide a direct investigation of brain mechanisms following OMT.

Neural functional connectivity refers to how brain areas become active and communicate with each other, and can be calculated using functional MRI (fMRI) scans. Such patterns of communi- cation are important to dynamically drive behaviour and cognition: the brain organising as a whole, rather than viewing specific areas of function in isolation.

This randomised manual placebo-controlled trial of 30 healthy, pain-free, osteopathy-naive sub- jects involved two groups: Osteopathic Manual Treatment and Placebo Group. fMRI scans were taken before, immediately after, and three days after a 45-minute treatment. All subjects were ex- amined osteopathically before treatment. The osteopathic group received a treatment based on examination findings and included variably: visceral techniques; myofascial release; cranial treat- ment; indirect techniques; manipulations. Subjects in the placebo group were also examined but received a set procedure of “passive touch” to different body areas without mobilisation.

Results showed an increase in activity and connectiveness in areas related to motor control im- mediately after OMT treatment yet activity decreased in the same area following placebo treat- ment. 3 days later, activity decreased significantly in the caudate area (an area involved in control of movements and muscle tone but also activated during stress) for the OMT group yet increased in the placebo group. There was also a change in activity and connections in the amygdala both immediately (decreased) and 3-days (increased) after OMT but again, the opposite was found in the placebo group. The amygdala integrates multiple emotional, behavioural and motivational in- puts, and helps activate appropriate behaviour after processing fear or threat stimuli. Similar changes were found in the other sensorimotor areas including the cerebellar vermis III (posture, locomotion). There was no significant change between scans taken before treatment and 3-days later implying a reversible treatment effect.

The changes in neural connectivity after OMT, with the opposite effects in the placebo group, was striking. This type of study could well be an emerging area of osteopathic research: use of the rapidly developing neurophysiological investigative field to highlight some of the mechanisms of Osteopathy. It is in line with other studies demonstrating functional brain connectivity changes following chiropractic, therapeutic touch, spinal manipulation. It should be noted, however, the broad variety of osteopathic techniques utilised makes it difficult to interpret which, and what as- pect of the osteopathic encounter, had what effect. Overall, it is encouraging to see a study using fMRI that specifically looks at osteopathy.

Reference: Tramontano M, Cerritelli F, Piras F, Spanò B, Tamburella F, Piras F, Caltagirone C, Gili T. Brain Connectivity Changes after Osteopathic Manipulative Treatment: A Randomized Manual Placebo-Controlled Trial. Brain Sciences. 2020; 10(12):969. https://doi.org/10.3390/brain- sci10120969

Manual Therapy and cervical artery dysfunction

Brief summary: Cervical artery dysfunction (CeAD) may mimic many musculoskeletal presentations. This paper provides a comprehensive review of the best available evidence for risk assessment prior to manipulation of the cervical and upper thoracic spine. Consider CeAD with the following presentation: An uncharacteristic headache, and a neck trauma in the past month.

Key words: Cervical Artery Dysfunction (CeAD), High Velocity Thrust Techniques (HVT), Mobilisation, Dissection, Vertebral Artery, Internal carotid artery, Osteopathic Medicine.

This is an extensive review of the current literature and provides an excellent summary of key fndings and recommendations, for an important aspect of osteopathic practice. This is a good example of a literature review research method to help guide best practice.

The authors describe cervical artery dysfunction (CeAD) to include range of disorders. The link between cervical spine (CSp), high velocity thrust techniques (HVT) and CeAD, is an association, not a clear causal relationship.

CSp movement not just HVT are important factors and an increased length of the styloid process may be a risk factor to CeAD, together with trauma to the CSp.

The peak incidence of CeAD is between 34-54 years of age, and 61% of cases are spontaneous.

There is a risk of misdiagnosis with lack of clinical reasoning being a main factor, with reported adverse efects from manual therapy.

CeAD may mimic musculoskeletal complaints for example acute onset CSp pain.

Headaches associated with CeAD are typically unilateral, frontal-temporal and often with occipital pain. They tend to be throbbing and sharp, but most importantly, unlike anything experienced by the patient before.

The pain is often less than a week in onset, and if associated with ptosis, facial numbness and unsteadiness then immediate referral to the medical services is recommended.

Around 12-34% of cases are the result of trivial trauma e.g. sneezing or sport related injury. The authors strongly recommend considering CeAD for all trauma to the neck in the frst month, and check for the above signs and symptoms.

This article contains much useful information, but much is summarised in clear tables e.g., table 3 potential signs and symptoms of CeAD, table 4 Red Flags, and table 5 Clinical tests.

In summary, if patients complain of an uncharacteristic headache, and have had a neck trauma in the past month, consider the possibility of CeAD.

References

Vaughan, B, Moran, R, Tehan, P, Fryer, G, Holmes, M, Vogel, S & Taylor, A (2016) Manual Therapy and cervical artery dysfunction: Identifcation of potential risk factors in clinical encounters, International Journal of Osteopathic Medicine, vol 21: 40-50

Osteopathy and Tension-type Headaches

Summary

Osteopathy, specifically manual joint mobilisation, may have a positive effect on quality of life and headache frequency for adults with tension-type headaches.

Keywords

Tension-type Headache (TTH), Osteopathy, Manual Joint mobilisation techniques, Headache frequency, Quality of life, systematic review, meta analysis.

Overview

Tension type Headache (TTH) is ranked as the second most prevalent health condition worldwide. There has been a lack of evidence for the effectiveness of manual therapy for TTH but this latest review suggests that Manual Joint mobilisation techniques may decrease frequency of headache occurance and improve quality of life.

A systematic literature review was conducted in february 2020 based on the PICO framework (Population, Intervention, Comparison and Outcome) and adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Methodology followed the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. Six relevant Randomised Controlled Trials (RCT) were found after a searching databases EMBASE, PsycINFO, MEDLINE, CINAHL and PEDRO.

Only RCTs of sufficient quality were included in the review. Patients,18 years or older, diagnosed with TTH according to the International Classification of Headache disorder were included. Manual joint mobilisation techniques were compared to no mobilisation technique, other treatment, treatment as usual, placebo or sham intervention. Headache Frequency was measured in days per month of headache. Both Quality of Life and Headache frequency were assessed at the end of treatment.

Manual joint mobilisation techniques were defined as any manual technique, mobilisation or manipulation within normal range of motion of the joint, aimed at affecting the joints, muscles and connective tissues of the neck, chest and lower back.

Results found that manual joint mobilisation had a positive effect on both headache frequency and quality of life. However, the certainty of evidence was very low due to risk of bias, inconsistency and imprecision. A weak recommendation is therefore made by the review for manual joint mobilisation techniques as a supplement to medical treatment for adult patients with
TTH.

The review also assessed the effectivness of supervised physical activity, psychological treatment, acupuncture and patient education on TTH.Patient education was defined as information about the TTH, treatment, medication over use, self care, lifestyle, physical activity, regular diet and sleep. The review found that no RCTs had been conducted for Patient education but that clinical experience suggests that patient education may have a positive effect on the patients ability to manage their disease. Supervised physical activity was defined as planned, repeated and structured physical activity. Two RCTs were found and results showed potential effect of reducing headache intensity. However, the risk of bias and imprecision was high so the certainty of evidence is very low.

All non-pharmacological interventions were found to be safe. The certainty of evidence was found to be low or very low due to risk of bias and imprecision.

From an osteopathic perspective it is interesting that patient education, supervised physical activity and manual jount mobilisation, as well as being safe for patients, may positivly affect frequency of tension type headaches as well as improve quality of life.

Reference:

Krøll, L.S., Callesen, H.E., Carlsen, L.N. et al. Manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture and patient education for patients with tension-type headache. A systematic review and meta- analysis. J Headache Pain 22, 96 (2021). https://doi.org/10.1186/ s10194-021-01298-4

Caroline Frost September 2021

A Long or short game? Psychosocial predictors of chronic low back pain 

Summary: Psychosocial factors are known to be important in the development of low back pain. This 2020 study analysed the predictive value of specific types of psychosocial stress and self efficacy in development of chronic low back pain. It is relevant for Osteopaths to understand the possible influence of particular types of psychosocial stress such as work or social stress, and self-efficacy on “chronification” of low back pain since they may need to be addressed differentially in the treatment plan.

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Keywords: Psychosocial stress; Low back pain; Chronic pain; Self Efficacy

The link between stress and chronic low back pain is indisputable. In this 2020 study, from Journal of Pain  Research, psychosocial stressors and self-efficacy were assessed as predictors for the development of chronic low back pain over 2 years.

Particular types of stress (eg social or lack-of-control factors), repeated stressful events or long-lasting stressful  situations can lead to an over-activated stress response.  Not only does this result in depleted energy, poor repair and general wear and tear of body resources (“allostatic load”) but ultimately may result in dysfunctional reactions to acute stressors: depression, fatigue, increased pain. These are all familiar in a chronic pain patient presentation. 

Self efficacy is a “person’s belief to be able to deal with upcoming challenges”. It is associated with putting more effort into achieving goals and feeling more capable, all relevant for those in pain. It is regarded as one of the most important psychological protective factors for prevention of chronic pain, or reduced disability in those with chronic pain.

The study method was a prospective observational study over 2 years of 1071 subjects with low back pain at baseline. Psychosocial stress factors (perceived stress, work stress experiences, social stress experiences, vital exhaustion/stress fatigue, life event stress) and self efficacy were assessed using 5 questionnaires and regression analysis was used to identify specific predictors of pain intensity and pain-related disability at 1 year and 2 years.

A tendency to worry and social isolation predicted both back pain and disability 1 and 2 years later. Prior stressful life events, vital exhaustion and work discontent also predicted pain and/or disability 1 year later, and social conflicts, lack of recognition at work, work discontent and perceived stress predicted pain and/or disability 2 years later. Self efficacy showed a predictive effect for having back pain that was stronger for 2 years later than 1 year later.   

The study admits moderate prediction errors so the factors above provide some predictive value but do not reflect the whole story.  This is no surprise, back pain is very complex with multiple interactions so encapsulating some sort of linear predictive model or finding a predominant predictor is unrealistic.  The role of other factors such as depression, pain related beliefs and other yellow flags must also be considered. However, it is useful for Osteopaths to recognise different psychosocial stressors and promote self efficacy in order to moderate potential drivers and protectors for chronic low back pain.  This is relevant both for treating patients with chronic low back pain, and preventing low back pain from becoming chronic. Notably, stressors tendency to worry, social isolation and others are particularly  relevant in the current pandemic, for which undoubtedly patients  in osteopathic clinic will be experiencing additional psychosocial stress load. Osteopaths should be vigilant to this and address them appropriately in the treatment plan. 

References:

Puschmann A-K, Drießlein D, Beck H, Arampatzis A, Catala AM, Schiltenwolf M, Mayer F, Wippert P-M. Stress and Self-Efficacy as Long0Term Predictors for Chronic low Back Pain: A Prospective Longitudinal Study. Journal  of Pain Research 2020:13 613-621

https://pubmed.ncbi.nlm.nih.gov/32280264/

 

Hazel Mansfield

June 2021

Hazel is an Osteopath of 15 years’ experience with a background in neuropsychology, and a renowned lecturer of osteopaths and other manual therapists at both undergraduate and post-graduate levels. 

Hazel studied Natural Sciences at Cambridge University, specialising in neuropsychology before training as an osteopath at the British College of Osteopathy in London.

She consults in private practice in Stockholm, with a special interest in back pain, stress, and using the best available knowledge to elevate standards of patient care.

 

European wide Neck and Low Back Pain Treatment Recommendations 2020

Brief Summary

In clinic, osteopathic treatment together with reassurance, exercises and specific advice for physical activity are the keys to helping your patients with low back pain and neck pain. 

However, electrotherapy, shortwave, laser and more than a couple of days bed rest are not recommended.

Summary of European-wide, evidence-based National and professional Guidelines 2020.

Key words

Low back pain, neck pain, evidence based, European Guidelines.

Background

Back pain causes the highest rate of years lived with disability globally out of 354 conditions, with neck pain ranked in the top 15 (GBD 2017 Disease and Injury Incidence and Prevalence Collaborators, 2018).

In this evidence based and European wide systematic review thirteen databases were searched for National and Professional Guidelines for the clinical management of low back pain and neck pain. The guidelines were issued between 2013-2020. Inclusion criteria: the guidelines were evidence-based, European and issued by professional bodies and organisations; the guidelines were for an adult population over 18; Treatment needed to be deliverable within primary care; treatments were included that aimed to reduce pain, improve function, and support return to work. 

National and Professional Guidelines from Belgium, Denmark, France, Germany, Italy, The Netherlands, Poland and UK were included.

Seventeen guidelines were systematically identified, synthesised and graded using the AGREE II reporting checklist. Of these seven were identified to be of high quality, two guidelines for neck pain and five for low back pain. 3,941 unique citations were identified and analysed. The degree of evidence for or against a treatment was ranked as strong, moderate, weak, inconsistent/consistent or inconclusive.

The Results of the study found that:

Back Pain -there is evidence (both strong and weak) for: 

reassurance, advice, education with specific advice for physical activity, manual therapy combined with exercise, exercise programme and work, group exercise programmes, work-based rehabilitation, and return to work programmes. 

Back pain -there is evidence (strong) against: 

electrotherapy, shortwave, laser, more than a couple of days bed rest, use of paracetamol, anti-depressants, anticonvulsants, muscle relaxants, spinal injections for non-specific low back pain, traction, and orthoses.

Referral for imaging is only recommended for those with red flags -Risk of fracture, infection, metastatic cancer, neurological emergencies including cauda equina, aortic aneurysm or systemic inflammatory arthritis, or deterioration of symptoms.

Psychological therapies are mainly recommended for subgroups of patients with psychosocial risk, complex mood problems or persistent back pain. Surgery is only recommended where there is a specific pathology.

There is inconsistent or inconclusive evidence for: manual therapy without additional active treatment, traction, NSAID’s, opioids, steroid injections, acupuncture, postural therapies. The guidelines recommend entirely non-pharmacological treatments for low back pain. 

Neck Pain -there is evidence (moderate or weak) for: reassurance, advice, education, manual therapy combined with exercise, exercise programme, oral analgesics, topical medications, and psychological therapies. Multidisciplinary treatment for those with psychosocial risk or persistent neck pain or disability. 

Neck Pain– there is inconsistent or inconclusive evidence for manual therapy without additional active treatment, traction, electrotherapies, thermotherapies, cervical orthoses, acupuncture/dry needling and referral for imaging.

This paper gives an up-to-date European wide analysis of National and Professional Guidelines for the treatment of neck and low back pain. It provides highly relevant informative evidence-based recommendations which osteopaths should apply in clinic.

References:

Corp N. et.al. 2020 Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines. European Journal of Pain Vol 25 (2) 275-295

https://pubmed.ncbi.nlm.nih.gov/33064878/

GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018 Nov 10;392(10159):1789-1858. doi: 10.1016/S0140-6736(18)32279-7. Epub 2018 Nov 8. Erratum in: Lancet. 2019 Jun 22;393(10190):e44. PMID: 30496104; PMCID: PMC6227754.

https://pubmed.ncbi.nlm.nih.gov/30496104/

 

Caroline Frost

Juni 2021

Caroline är utbildad som D.O. på British College of Osteopathic Medicine, London, 1989-1993 och blev legitimerad Osteopat i UK 1999. Osteopatiutbildningen bestod av fyra års heltidsstudier. Hon har genomfört en masters i osteopati (MSc) genom Osteopathie Schule Deutschland/ Dresden International University.

Hon är också KBT-terapeut (kognitiv beteendeterapeut) efter att ha genomfört Steg 1 (grundutbldning) i KBT-kognitiv beteendeterapi år 2012. KBT-utbildningen är godkänd av Socialstyrelsen och motsvarar den av ”Svenska föreningen för kognitiva och beteendeinriktade terapier” fastställda normen för grundutbildningen. Jag har även en fil.kand. i biologi.

I England jobbade Caroline på ett hälsocenter i Bethnal Green, London, tillsammans med andra osteopater. Hon samarbetade också med den lokala vårdcentralen där hon erbjöd osteopatiska behandlingar via motsvarigheten till landstinget i Storbritannien. Hon arbetade också som volontär på OCC (osteopathic centre for children) under en tid. År 2004 flyttade Caroline till Sverige från Storbritannien och hennes osteopati- och kbt-mottagning är baserad i centrala Stockholm.

Somatic Dysfunction: past its sell by date!

Brief summary

Somatic dysfunction (SD) is considered a key idea within the theory and practice of osteopathy.  However, a closer inspection of this concept reveals it is outdated, and bears little relevance to the paradigms of person-centred care and evidence-informed practice.  It is time to re-evaluate such key terms and concepts within osteopathic discourse, and make them compatible with 

modern day healthcare.

Key words

Somatic dysfunction, diagnosis, facilitated-segment

Somatic dysfunction: an osteopathic conundrum (Fryer, 2016)

Gary Fryer has been engaged in osteopathic education and research since 1997. He has published extensively, and has a  particular interest in advocating an evidenced informed approach to the teaching and practice of osteopathy.  

 

This master-class paper suggests that the central concept of somatic dysfunction (SD) within osteopathy is no longer relevant.  The conceptual framework of  SD is critiqued in relation to “its unclear pathophysiology and poor reliability of detection.”  Palpation as a diagnostic tool is critiqued and found to be wanting.  Fryer provides a brief historical summary including Korr’s facilitated segment theory which attempted to explain the neurological basis for SD.  However, a thorough review of Korr’s research has revealed serious flaws, and that it cannot validate the notion of SD.  A more compelling explanation for palpatory findings and patient experience of pain in the osteopathic setting is the one of central sensitisation, in which all pain is perceived in the higher centres, not the local tissues.  Fryer urges us as a profession to widen our perspectives and integrate the ever increasing knowledge from current pain and chronic pain research. He suggests a more plausible explanation for the palpable findings, we as osteopaths experience on a daily basis, could be attributable to “nociceptive-driven functional changes.”  These produce changes in tissue quality, texture and alter pain sensitivity.

It is suggested that SD now lacks relevance within modern day health studies. As a theory it is too unspecific, lacks reliability and validity, and dramatically undermines the claim that it is a useful concept in health and disease. Fryer deepens his critique by suggesting that the term dysfunction is also unhelpful, potentially producing a negative picture of the body for the patient (see also Darlow, 2016).  He particularly points to Fryette’s biomechanical model which perpetuates the “bone out of place” concept, which may leave the patient believing they have a serious structural problem.  Fryer states quite clearly “positional terminology is anachronistic and potentially harmful.

The use of this type of negative language is also heavily critiqued in the placebo research literature (Benedetti and Amanzio, 2011) and may induce a nocebo response.  The words and concepts we use with are patients are highly loaded with meanings both positive and negative.  It is therefore important that our language should be considered with care.

The article also provides an alternative model for understanding the palpatory findings without referring to SD, which he suggests we as a profession need to rethink in the light of current research findings on the nature of pain.  The paper ends with a clear message that as a profession we need to examine our theoretical concepts in the light of the best available evidence.

References

Benedetti, F. and Amanzio, M., 2011. The placebo response: How words and rituals change the patient’s brain. Patient Education and Counseling, 84(3), pp.413-419. 

https://pubmed.ncbi.nlm.nih.gov/21621366/

Fryer, G., 2016. Somatic dysfunction: An osteopathic conundrum. International Journal of Osteopathic Medicine, 22, pp.52-63. 

https://www.journalofosteopathicmedicine.com/article/S1746-0689(16)30002-5/pdf

Darlow, B., 2016. Beliefs about back pain: The confluence of client, clinician and community. International Journal of Osteopathic Medicine, 20, pp.53-61. 

https://www.sciencedirect.com/science/article/abs/pii/S1746068916000067

 

Robert Shaw PhD

June 2021

Robert has worked as an osteopath for over 30 years and a psychotherapist for over 25 years. He obtained his PhD in 2000 exploring the concept of embodiment within the therapeutic encounter. He has written many journal articles, a book, and lectured throughout Europe on the subject.

He has a specialised training in dealing with the physical and psychological aspects of post traumatic stress disorder. He moved to Sweden in 2010 and currently has a private practice as an osteopath, integrative psychotherapist, and supervisor, and is the program leader for the Skandinaviska Osteopathögskolan.

He is on the international editorial board for The International Journal of Osteopathic Medicine, and a member of the European School of Osteopathy International faculty. He is an Honorary Research Fellow at University of Technology Sidney (ATS), Australia, which has organised the first International Osteopathy Research Leadership and Capacity Building Program for osteopathy.

Bajsa bättre med Osteopati!

Osteopati kan hjälpa mot förstoppning.

Behandlingsfrekvensen som har fungerat är 1-5 kortare behandlingar i veckan under 2-8 veckor.

Osteopatiska metoder som användes var mobilisering, direkt visceral mobilisering, manipulation av T 9-L2, high velocity low amplitude thrust, myofasciella tekniker, balanced ligamentous tension techniques, massage, träning, MET, mjukdelsbehandling, strain counter-strain, samt bindvävshinne-behandling av lumbosakral, thoracic scapula och cervical området.

OBS!  I kliniken är det viktigt att utesluta underliggande allvarliga sjukdom om en patient har förstoppning.

Nyckelord:

  • Funktionell förstoppning
  • Osteopati
  • Visceral mobilisering

Sammanfattning:

Funktionell förstoppning har höga prevalensnivåer världen över. Vid funktionell förstoppning finns ingen bakomliggande sjukdom. Förstoppning påverkar livskvalitet och kräver mycket resurser av sjukvården.

Förstoppning betyder att det är svårt att bajsa och att frekvensen är lägre än tre gånger i veckan. Förstoppningen kan ge ont i magen och ont i ändtarmsöppningen. Bajset kan vara trögt att få ut och lämna en känsla av att tarmen inte har tömts efter ett toalettbesöket.

Oftast är rekommendationen att dricka mer vätska eller att äta lösande och fiberrik mat och se till att röra på sig.

I den här systematiska översikten granskades sju olika studier som handlade om behandling av förstoppning med manuell terapi inklusive osteopati.

Funktionell förstoppning är sannolikt kopplat till stress och dysfunktion av det autonoma nervsystemet. Hypotesen är att osteopatisk behandling stimulerar det autonoma nervsystemet via det sympatiska, parasympatiska och enteriska nervsystemet. Effekten blir att förbättra visceral rörlighet, blodcirkulation och stimulerar peristaltik. Exakt hur den här mekanism fungerar är ännu okänt men hypotesen är att behandlingen triggar en interaktion mellan det perifera nervsystemet och centrala nervsystemet som resulterar i en kedjereaktion av neurofysiologiska effekter. Det påverkar smärt reglering och inflammatorisk respons som är kopplad till förstoppningen.

Det har gjorts tidigare studier som har tittat på effekten av manuell terapi mot förstoppning men den här studien är den första att granska så många artiklar och använder en pålitliga granskningsmall, Down and Blacks tool.

I fyra olika databaser användes sökorden ”förstoppning” och ”osteopati”,”kiropraktik”,” fysioterapi”och ”manuell terapi”. 533 studier hittades och av dessa var sju relevanta. En av dessa var av hög metodologisk kvalitet, fem måttliga och en av låg kvalitet. Det var 236 deltagare totalt och den genomsnittliga åldern var 43.2 år.

Behandlingen var semi-standardiserad och förutom osteopati användes massage, fysioterapi och Maitland Orthopedic Manual Therapy. I sex av sju studier fanns en kontroll- eller jämförelsegrupp. Olika verktyg inklusive Knowles-Eccersley-Scott-Symtom (KESS) score användes för att mäta graden av förstoppningen innan och efter behandlingen.

Alla sju studier rapporterade ett statistiskt signifikant resultat av manuell terapeutisk behandling mot förstoppning. Detta i jämförelse med kontrollgrupperna. Manuell terapi inklusive osteopati ser ut att vara en effektiv intervention för behandling av förstoppning.

Erdrich L., Reid D., Mason J., 2020. Does a manual therapy approach improve the symptoms of functional constipation? A systematic review of the literature. International Journal of Osteopathic Medicine 36, pp. 26-35.

Caroline Frost

Januari 2021

Caroline är utbildad som D.O. på British College of Osteopathic Medicine, London, 1989-1993 och blev legitimerad Osteopat i UK 1999. Osteopatiutbildningen bestod av fyra års heltidsstudier. Hon har genomfört en masters i osteopati (MSc) genom Osteopathie Schule Deutschland/ Dresden International University.

Hon är också KBT-terapeut (kognitiv beteendeterapeut) efter att ha genomfört Steg 1 (grundutbldning) i KBT-kognitiv beteendeterapi år 2012. KBT-utbildningen är godkänd av Socialstyrelsen och motsvarar den av ”Svenska föreningen för kognitiva och beteendeinriktade terapier” fastställda normen för grundutbildningen. Jag har även en fil.kand. i biologi.

I England jobbade Caroline på ett hälsocenter i Bethnal Green, London, tillsammans med andra osteopater. Hon samarbetade också med den lokala vårdcentralen där hon erbjöd osteopatiska behandlingar via motsvarigheten till landstinget i Storbritannien. Hon arbetade också som volontär på OCC (osteopathic centre for children) under en tid. År 2004 flyttade Caroline till Sverige från Storbritannien och hennes osteopati- och kbt-mottagning är baserad i centrala Stockholm.

Why treating chronic pain patients can be different

Recent research within neuroscience and psychology has offered new frameworks that may improve our understanding of how Osteopathic treatment works.  One such new framework is central sensitisation (CS), a concept originating from pain research within a laboratory setting, and this paper promotes its role and applications within a musculoskeletal clinical setting.  CS can rule the clinical kingdom in some patients with chronic musculoskeletal pain.

CS is defined as “an amplification of neural signaling within the central nervous system that elicits pain hypersensitivity” and “increased responsiveness of nociceptive neurons in the central nervous system to their normal or sub threshold afferent input” that occurs in chronic pain patients. Not all patients with musculoskeletal pain will go on to develop central sensitisation but a significant proportion do. Research has shown conditions such as low back pain, Achilles tendinopathy, osteoarthritis, tennis elbow and whiplash all involve CS and these are all conditions commonly seen by osteopaths.

CS is thought to act via a change in the way the brain processes sensory information meaning that there is no longer a clear nociceptive pain source (eg torn ligament, prolapsed disc) together with an altered (often increased) response to stimuli such as temperature, touch, stretch.  The patient feels “pain” in the areas activated by these stimuli, but with no peripheral nociception.  Cognitive-emotional factors such as pain catastrophising, stress or depression can increase pain and hyper-responsivity of the central nervous system, but with very little or no actual nociceptive inputs.  This may be familiar presentation to osteopaths.

The review paper discusses research which shows that chronic pain patients with central sensitisation have much higher pain severity and lower quality of life, and that CS influences treatment outcome in low back pain, whiplash, osteoarthritis and tendinopathy.  It is therefore important to identify patients with CS, but how can this be done in osteopathic practice? In the assessment (case history, clinical examination, other investigations) osteopaths aim to find a cause of pain that explains the patients symptoms.  For musculoskeletal pain, CS can be considered when i) pain experience is disproportionate to the assessment findings ii) pain distribution is diffuse and outside segmental area of primary nociception iii) Central Sensitisation Index (Mayer et al 2012) scoring more than 40/100.

Once CS is identified in a patient, the treatment plan needs to be determined. Treatment recommendations focus on three points and are all relevant to osteopathy.  Firstly to not treat only locally.  Manual techniques are still indicated but only provide short-term pain inhibition. However, we can consider how they can potentially influence central processing of pain and be of further benefit in CS.  Secondly some explanation of pain (alongside listening) can help reassure and improve the patient’s pain beliefs and coping strategies. Thirdly, active interventions alongside manual work: graded activity or exercises, graded exposure to pain-eliciting movements.

In conclusion, greater awareness and understanding of the influence of CS in chronic musculoskeletal patients is key to successful treatment and relevant to osteopathic practice.

Nijs, J., Goubert, D., & Ickmans, K. (2016). Recognition and Treatment of Central Sensitization in Chronic Pain Patients: Not Limited to Specialized Care. The Journal of orthopaedic and sports physical therapy, 46(12), 1024–1028. https://doi.org/10.2519/jospt.2016.0612 

Mayer, T. G., Neblett, R., Cohen, H., Howard, K. J., Choi, Y. H., Williams, M. J., Perez, Y., & Gatchel, R. J. (2012). The development and psychometric validation of the central sensitization inventory. Pain practice : the official journal of World Institute of Pain, 12(4), 276–285. https://doi.org/10.1111/j.1533-2500.2011.00493.x

Hazel Mansfield

January 2021

Hazel is an Osteopath of 15 years’ experience with a background in neuropsychology, and a renowned lecturer of osteopaths and other manual therapists at both undergraduate and post-graduate levels. 

Hazel studied Natural Sciences at Cambridge University, specialising in neuropsychology before training as an osteopath at the British College of Osteopathy in London.

She consults in private practice in Stockholm, with a special interest in back pain, stress, and using the best available knowledge to elevate standards of patient care.

Keeping a diary improves your clinical decision making!

This paper presents an interesting and relevant topic for contemporary osteopathic practice, namely that keeping a diary has been shown to improve clinical reasoning skills.  The key take home message is that by keeping a diary osteopaths can deepen their reflective skill set, and thereby gain a deeper engagement with their clinical decision making.

There is a convincing review from other healthcare professions where this form of reflective practice is more common place, and is considered a valuable tool to help with clinical reasoning.  Examples of embedded reflective practice are to be found in nursing, physiotherapy, occupational therapy and medicine.  Within these professions it is considered a valuable tool and practitioners are given help to structure this process.  In essence reflective practice requires practitioners to “actively write and question one’s own actions and thoughts”.  Sharing these thoughts in a peer group or with a supervisor deepens this process.  It has been shown that this helps to focus on what is actually being done during the treatment, not what practitioners think they are doing.  This process enhances healthcare provision.  This is clearly relevant to us as osteopaths as it opens up the possibility of improving our interactions with patients.  This will not only help those we treat but also improve out understanding of our interactions and deepen our learning around the therapeutic encounter.

For those interested in research methodology the authors utilise a qualitative method where they analyse data from the lead researcher’s use of diary keeping, in combination with discussions with peers and supervisors.  They, therefore, present a real life case of an osteopath using this method.

The results section is full of interesting and rich data.  For example, there is a realisation from the main researcher that she has relied on the biomechanical model and tended to exclude psychosocial factors. This emerges from a meeting with her supervisor who suggests she may be over relying on pattern recognition and intuition.  On reflection she realises that she feels untrained to deal with psychological issues.  This leads her to read around the subject and revisit some earlier psychology training material.

This is a very relevant paper for our profession, if we can develop some form of reflection into our practice this will enhance our therapeutic interactions for both parties.  The way to incorporate this process into practice requires the practitioner to write regularly about their experiences and then seek feedback from peers and/or a supervisor.  I can speak from my experience as a psychotherapist where supervision is normal, that the ability to discuss patients in a safe and supportive environment is both challenging and rewarding. It can highlight our blind spots and show where we need to seek further training.  I would strongly advocate some form of supervision for the osteopathic profession.  This paper provides compelling evidence that deepening our clinical reflective capacity improves our clinical decision making, and keeping a diary is an important tool in this process.

McIntyre C, Lathlean J and Esteves J E (2019) Reflective practice enhances osteopathic clinical reasoning, International Journal of Osteopathic Medicine, 33-34; 8-15

Robert Shaw PhD

January 2021

Robert has worked as an osteopath for over 30 years and a psychotherapist for over 25 years. He obtained his PhD in 2000 exploring the concept of embodiment within the therapeutic encounter. He has written many journal articles, a book, and lectured throughout Europe on the subject.

He has a specialised training in dealing with the physical and psychological aspects of post traumatic stress disorder. He moved to Sweden in 2010 and currently has a private practice as an osteopath, integrative psychotherapist, and supervisor, and is the program leader for the Skandinaviska Osteopathögskolan.

He is on the international editorial board for The International Journal of Osteopathic Medicine, and a member of the European School of Osteopathy International faculty. He is an Honorary Research Fellow at University of Technology Sidney (ATS), Australia, which has organised the first International Osteopathy Research Leadership and Capacity Building Program for osteopathy.