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Osteopathy:

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Living with persistent low back pain?

This article forms part of Biliana’s master’s degree dissertation that was originally aimed at the manual therapy community. It has been adapted to address you - the person in persistent pain who is looking for insights.

Please feel free to get in touch with us if this article resonates with you.

You have a long and frustrating history of low back pain (LBP). You have heard that osteopaths specialise in spinal pain, yet their examinations shed little light as to the physical origin of your pain.

You have read the NHS guidelines and probably some research too, research – looking for the next cure or at least – to make sense of your pain. You may already know that management of chronic low back pain (cLBP) sits in the intersecting domains of the biopsychosocial (BPS) framework, including, it is argued, the religious and spiritual. The National Health Service back pain treatment guidelines recommend a combined physical and psychological approach as part of a treatment package for patients with persistent symptoms. So where do you go from here: does your heart sink a little or do you feel equipped to embark on this journey with your osteopath?

PREVALENT — EXPENSIVE
LBP is the single biggest cause of years lived with disability worldwide. In the UK, it is the leading cause of absence from work, costs of care exceed £500 million per year and its prevalence is expected to keep rising.

NON-SPECIFIC — CHRONIC
85% to 90% of patients presenting to a healthcare setting with LBP are given a diagnosis of Non-Specific Low Back Pain (NSLBP). This means that their pain is not due to a recognisable, specific pathology like infection, tumour, osteoporosis, fracture, structural deformity, or an inflammatory disease such as ankylosing spondylitis, or radicular and cauda equina syndrome 8. When symptoms persist beyond the expected healing time of the affected tissues and / or for a period greater than 3 months, their presentation is defi ned as chronic.

PREVALENT — EXPENSIVE — RELEVANT
LBP is the single biggest cause of years lived with disability worldwide. In the UK, it is the leading cause of absence from work, costs of care exceed £500 million per year 3 and its prevalence is expected to keep rising. A pilot study of 342 osteopathic practices in the UK demonstrated that low back pain was the most common presenting symptom (36%), and that 37.7% of all patients presenting had chronic complaints.

A CHALLENGE FOR OSTEOPATHS
Osteopathy has a long legacy of manipulative treatments based on biomechanical principles, and these are given prevalence in educational settings to this day. Autonomous sensory meridian response (ASMR) “cracking” techniques are gaining huge popularity on social media, with views in the millions. This contrasts with high quality evidence concluding that structural methods of treatment and management of persistent low back pain yield temporary symptom relief at best. The BPS model is central to osteopathic philosophy, yet a cross-sectional questionnaire-based survey of 216 UK-registered osteopaths reveals that engagement with psychosocial factors, knowledge of chronic pain and attitudes towards its management need improvement and further training.

THE MIDDLE WAY?
Psychologically informed practice is offered as a combined physical and psychological approach for the management of cNSLBP. It is described as the “middle way” between biomechanically focused physical therapy and cognitive behavioural therapy, originally developed for the treatment of mental illness. A neat definition of PIP is elusive, so describing its intended function within a clinical decision-making framework may be a helpful starting point. The primary goal of PIP is to help gain a better understanding of a patient’s individual response to pain (expectations, beliefs, feelings) to help identify risk factors for chronicity, individualise the intervention(s), improve adherence to treatment methods, and achieve better outcomes at reduced costs. From a clinical standpoint, PIP incorporates a combination of communication, educational, cognitive, and behavioural strategies into musculoskeletal practice. Several moderate quality systematic and narrative reviews examine the evidence from a heterogeneous body of randomised control trials. They conclude that PIP is a promising model of care but is still to overcome a series of methodology and practice implementation challenges. These include the multi-dimensional nature of cNSLBP, heterogeneity of the tested interventions and outcome measures, potentially onerous training demands, as well as clinicians’ own beliefs and attitudes.

A CHALLENGE FOR OSTEOPATHS
Osteopathy has a long legacy of manipulative treatments based on biomechanical principles, and these are given prevalence in educational settings to this day. Autonomous sensory meridian response (ASMR) “cracking” techniques are gaining huge popularity on social media, with views in the millions. This contrasts with high quality evidence concluding that structural methods of treatment and management of persistent low back pain yield temporary symptom relief at best. The BPS model is central to osteopathic philosophy, yet a cross-sectional questionnaire-based survey of 216 UK-registered osteopaths reveals that engagement with psychosocial factors, knowledge of chronic pain and attitudes towards its management need improvement and further training.

You might find this quiz by Prof O’Sullivan and Dr Ng interesting and insightful of some less than perfect communication practices that are still prevalent in the manual therapy world…

It consists of 8 questions and takes about 18 minutes to complete. Have a go and let us know what your experiences have been?

https://lowbackpaincommunication.com/quiz

The next blog will investigate one of the more promising psychologically-informed approaches to the treatment and management of cLBP: Cognitive Functional Therapy.

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