Clinical Reasoning In Manual Therapy

Touch is an important part of human interaction.

Pain is an unpleasant human experience.

Touch conveys meaning that words often cannot.

Pain is often hard, if not impossible to put into words.

It is not surprising that touching people in pain is a common ritual, and it has likely been performed for thousands of years of humanity.

Touching people in pain has now evolved into specialised forms of physical therapy, from massage to manipulation and everything in between. However, what it all boils down to is touch and narrative.

Many therapists, and particularly those who define themselves by what they do (like osteopaths), will be upset to hear that I don’t think manual therapy has to (or can be) very specific to be effective for pain relief.

Manual Therapy is Applied Force

In his excellent book The Science and Practice of Manual Therapy, osteopath and researcher, Dr Eyal Lederman describes the 2 types of force you can apply to a body with your hands, instruments or body:

  1. Tension forces
  2. Compression forces

He elaborates that combinations of these two forces can also be applied, yielding resultant forces such as:

  • Torsional forces
  • Shearing forces
  • Bending forces

When you consider the other variables relating to applied force:

  • Direction
  • Speed (technically velocity)
  • Duration
  • Rhythm/frequency
  • No of cycles

You can then begin to develop different techniques.

Techniques have historically been name in anatomical terms (myofascial release, joint articulation) or by descriptors of what the technique involves or a proposed mechanism (high velocity-low amplitude – HVLA, counterstrain, muscle-energy technique/proprioceptive neuromuscular facilitation).

Clinically, most therapists will say that different techniques (aka different applications of forces) result in different clinical effects and outcomes.

While there is some research to suggest there are different descending modulation pathways that are stimulated with different manual therapy techniques, overall, our current body of knowledge suggests that the effects are non-specific.

The (Non-Specific) Effects of Manual Therapy

Referring back to Lederman’s book, we can describe the effects of manual therapy in 3 main areas:

  1. Tissue effects, which are primarily local
  2. Neurological effects (yes, the nervous system is tissue, but this relates to function of the nervous system)
  3. Psychological effects

You Can’t Change Tissues, Directly

One of the big misnomers surrounding manual therapy is that it directly changes tissues like muscles, ligaments and fascia.

This is not the case – and it doesn’t make biological sense for it to be.

Imagine, if a pair of hands touching you for a few minutes could stretch out your muscles. What would happen to your muscles as you sit down, or sleep?

Manual therapy can possibly stimulate some cellular responses via mechanotransduction.

  • Mechanotransduction is the physiological process where cells sense and respond to mechanical loads. It is independent of the nervous system.
  • Mechanotherapy is the therapeutic application of force/load, used to differentitate between homeostatic mechanotransduction.

A 2012 study, Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage, demonstrated this.

While it was quite a small study, with only 11 participants, it shed light on some cellular effects as a result of massage.

The researchers induced muscle fatigue/damage via exercise (stationary cycling) and then massaged one thigh and used the other as a control.

They found that massage activated the mechanotransduction signaling pathways:

  • Focal adhesion kinase (FAK)
  • Extracellular signal-related kinase 1/2 (ERK1/2)
  • Potentiated mitochondiral biogenesis signaling [nuclear peroxisome proliferator-activated receptor γ coactivator 1α (PGC-1α)
  • Mitgated the rise in nuclear factor κB (NFκB) nuclear accumulation

However, whether at all this is clinically relevant remains to be seen. It is one small study, and most other studies demonstrate a very small effect as well.

What is relevant, is that there is a benefit to tissue repair, particularly in the first 2 weeks after injury from harmonic articulation. This is outlined further in Lederman’s text, but considering that pain often leads to decreased use of tissues, this should be considered as a potential therapeutic option.

So it is fair to say that tissue effects, via mechanotransduction are not relevant to the clinical outcomes resulting from manual therapy.

In part, this is because of the way force is distributed by the body.

The Frictionless Skin-Fascia Interface

Between the skin/subcutaneous fascia exists a frictionless interface. That is, the skin will slide over the fascia below it. Think about this, if this didn’t happen, you could pull your subcutaneous tissues around (this would not be good).

As a result, only force applied perpendicular to bone affects bone – tangential force is dissipated.

This knowledge has implications for manual therapy: can you really shear a fibula or radius? What about a vertebrae?

It’s not possible.

Again, thank goodness.

NeuroModulation?

The most likely effect of manual therapy on pain seems to be facilitating “the drug cabinet in the brain” by descending modulation.

Descending modulation is an important biological process that is protective of us in times of threat, but also helpful in managing pain.

It is known that manual therapy, and even touch can cause the brain to release inhibitory neurotransmitters that modulate pain, most likely at the spinal cord level.

As mentioned above, different types of manual therapy seem to evoke slightly different modulation responses.

Psycho(social) Effects of Touch

Touch is the most important sense we have. Without it, we cannot entirely feel pleasure or pain – we are less than human. – David J. Linden

Psychological effects have some crossover with neurological effects, and tend to evoke:

  • Descending modulation
  • ANS changes
  • Pleasant feelings (positive affect)

People can discern meaning from touch – thus can create therapeutic context with touch.

Think about this, if you caress a loved one, versus firmly grab them around the forearm, does the evoke different thoughts and feelings?

In their paper, The Skin As A Social Organ, the authors argue

However, because the skin is the site of events and processes crucial to the way we think about, feel about, and interact with one another, touch can mediate social perceptions in various ways.

The authors cite 3 mechanisms by which the skin can convey social meaning:

  1. Through affiliative behavior and communication
  2. Via affective processing in skin-brain pathways
  3. As a basis for intersubjective representation

I have never heard this described in any manual therapy course, or through my years of university study, yet it is arguably a bigger factor than mobilising joints or stretching muscles.

The Devil Is In The Dosage

There is scant (read: no) good research on dosage for manual therapy.

Practically, dosage is often constrained by patient/practitioner availability and resources (time, money etc).

Within a session, we can do more manual therapy or less. That much is obvious. However, it is hard to prescribe a dosage for intensity, unlike say, exercise.

That is because, as discussed above, the effects of manual therapy do not rely on mechanical stimulation, but rather contextual facilitation, affective change and possibly (probably) expectation.

So a simple way to gauge the response to manual therapy for dosage reasons is:

In other words, if you can gauge a response (within session changes) and measure the adaptation (between session changes) you can reverse engineer the dosage.

Within Session Changes: What to Look For

The responses we are looking for are often subtle, and if missed, can easily lead to overstimulus.

These are (tanks to Barrett Dorko for a couple of these):

  • Softening: a subjective feeling from either patient or practitioner of the tissues softening
  • Warmth: a noticeable increase in superficial warmth, typically explained as an increase in cutaneous blood flow
  • Movement: this is often spontaneous and effortless (think of a person “adjusting” themselves on the treatment table), but it can also be improved movement based on pre/post clinical assessment.

It is important to realise that within session improvements do not suggest resolution, only that there as been a response to the implied stimulus.

Is It Effective Though?

None of this matters if manual therapy isn’t clinically effective.

Here’s the rub (pun not intended): there is low quality evidence to suggest manual therapy can help certain conditions, while there is high(er) quality evidence that shows a smaller effect.

There is evidence (of varying quality) to suggest manual therapy can also influence the following processes:

  • Affects ANS
  • Affects tissue tone and ROM
  • Affects lymphatic system
  • Affects immune system
  • Affects haemodynamics
  • Descending modulation

Hence I favour a process based approach over a condition based approach to clinical reasoning.

This means that you aim to influence processes that are involved in the patient’s presenting complaint.

Putting It Altogether

In order for manual therapy to have a positive clinical effect, we have to apply the right dosage. In practice, underdosing is preferable to overdosing, as you can always do more, but you cannot take away work that has been performed.

We also know that manual therapy is non-specific, but different techniques potentially effect different descending modulation pathways. With this in mind, using a variety of forces (tension, compression, twisting etc) with a variety of variables (direction, duration, magnitude, frequency etc) will provide a hedge of sorts when an individual’s response and preferences are not fully known or understood. This can be modified over time as the practitioner-patient relationship develops.

Finally, we know that we can’t affect tissues, but we can affect processes, so again, as a hedge of sorts, it is preferable to treat a large proportion of the physical body over a localised approach. The exception to this is harmonic style techniques in the early stages of injury to enhance repair.

Conclusions

Two governing quotes govern my thinking around manual therapy for the treatment of pain:

When pain is the primary complaint, treatment of pain should be primary. – Barrett Dorko, PT

And the second:

Manual therapy is optional, but it can be optimal (for the treatment of pain). – Diane Jacobs, physiotherapist

If we understand the likely processes involved in manual therapy, and we acknowledge what we don’t know, along with what we know with a high degree of certainty is unlikely, then I can see well explained and well executed manual therapy continuing to play a role in therapy for many years to come.

If we continue to “treat anatomy” in relation to pain, then over time, funding from health systems and insurers will dry up, as the link between anatomy and pain is tenuous at best.

Finally, we have to give patients a voice. If patients determine they receive a benefit that is meaningful to them, we cannot discount that, as long as they understand the nature of the benefit (i.e. often transient and part of a bigger picture approach to health and pain management).

Workshop

If the topic of clinical reasoning and evidence informed practice with manual therapy interests you, come along to the 3 and a half day DermoNeuroModulation workshop in Melbourne at the end of March (presented by author and developer of the method, Diane Jacobs, who I’ve referenced throughout this post).

Details via the embedded link below.

Comments From Past Attendees:


Nick Efthimiou Osteopath

This blog post was written by Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

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References

A Process Model in Manual and Physical Therapies http://www.cpdo.net/Lederman_A_Process_model_in_Manual_and_Physical_Therapies.pdf

Mechanotherapy: how physical therapists prescription of exercise promotes tissue repair https://bjsm.bmj.com/content/43/4/247

Mechanotransduction: use the force(s) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4491211/

The frictionless properties at the thoracic skin-fascia interface: implications in spine manipulation https://www.ncbi.nlm.nih.gov/pubmed/12034123

The relationship between the application angle of spinal manipulative therapy (SMT) and resultant accelerations in an in situ porcine model https://www.mskscienceandpractice.com/article/S1356-689X(08)00170-7/pdf

Three-Dimensional Mathematical Model for Deformation of Human Fasciae in Manual Therapy http://jaoa.org/article.aspx?articleid=2093620

Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage https://www.ncbi.nlm.nih.gov/pubmed/22301554

The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775050/

Pain https://www.ncbi.nlm.nih.gov/pubmed/26304172

Mobilization and Manipulation of the Cervical Spine in Patients With Cervicogenic Headache: Any Scientific Evidence? https://www.ncbi.nlm.nih.gov/pubmed/27047446

Manual therapy, exercise therapy or combined treatment in the management of adult neck pain – A systematic review and meta-analysis. https://www.ncbi.nlm.nih.gov/pubmed/28750310

The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5814665/

Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs https://bjsm.bmj.com/content/51/18/1340

Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis https://www.thespinejournalonline.com/article/S1529-9430(18)30016-0/abstract

Exercise, Manual Therapy, and Booster Sessions in Knee Osteoarthritis: Cost-Effectiveness Analysis From a Multicenter Randomized Controlled Trial. https://www.ncbi.nlm.nih.gov/pubmed/29088393

Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review. https://www.ncbi.nlm.nih.gov/pubmed/29686479

Manual lymphatic drainage for lymphedema following breast cancer treatment. https://www.ncbi.nlm.nih.gov/pubmed/25994425

Manual Therapy Influences on the Autonomic Nervous System https://www.otago.ac.nz/physio/research/otago363201.html

Acute electromyographic responses of deep thoracic paraspinal muscles to spinal manual therapy interventions. An experimental, randomized cross-over study. https://www.ncbi.nlm.nih.gov/pubmed/28750955

Changes in biochemical markers following spinal manipulation-a systematic review and meta-analysis https://www-sciencedirect-com.wallaby.vu.edu.au:4433/science/article/pii/S246878121730067X

Assessment of skin blood flow following spinal manual therapy: A systematic review https://www.ncbi.nlm.nih.gov/pubmed/25261088

The Role of Descending Modulation in Manual Therapy and Its Analgesic Implications: A Narrative Review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4695672/

Further Reading

The Science and Practice of Manual Therapy – Eyal Lederman

DermoNeuroModulating – Diane Jacobs

Clinical Neurodynamics – Michael Schacklock

Touch – David J. Linden

Career Advice For Osteopaths

As we approach the end of the 2018 academic year in Australia, a new cohort of student osteopaths are about to graduate and enter the next stage of their journey as an osteopath.

With this in mind I have reached out to a number of osteopaths, from new graduates to experienced practice owners, academics and entrepreneurs, to share with you some career advice in the form of a tweet (280 characters or less, although some couldn’t help themselves, and went a little longer).

The aim of this post is to help start you thinking about what you want from your career, and what you might have to do (or not do) to achieve that. I hope it will also save you some of the frustrations I (and many others) have gone through in the early stages of our careers.

A successful professional life looks different to everyone.

For some, it means making a lot of money. For others, it’s about having time flexibility. Others still want to have a big reputation and sphere of influence. Many want to be anonymous instead.

There is no one way to define success, however there are some common practices between all who have achieved success in their own way:

  • Self awareness
  • Patience
  • Flexibility
  • Discipline
  • Reflection
  • Mentorship

Whether you are a student, a recent graduate or an experienced professional, there is always potential upside in hearing from others what they believe to be important to achieving professional success.

If I have seen further it is by standing on the shoulders of giants. – Isaac Newton

Absorb What Is Useful

When it comes to receiving advice, it’s important to take what is relevant to you on board, and not get too caught up in the rest. I’ve tried to reach out to a variety of practitioners, with different professional skills and experience, to give a broad perspective on osteopathy.

Absorb what is useful. Reject what is useless. Add what is essentially your own. – Bruce Lee

So, without further ado, posted in the order I received them, the advice for new osteopaths:

Giles Gyer

Giles is an osteopath (2012 graduate of College of Osteopaths, London), medical acupuncturist and sports/remedial massage therapist and is the co-found of OMT Training, a teaching organisation for manual and physical therapists. I don’t know Giles personally, but apparently we look similar enough for a colleague to use his image (from Google Images) on a PowerPoint slide when introducing me, so he had to be part of this piece. His advice is:

“YOU are the most important person in the treatment room” the key to longevity within osteopathy is to look after your body and your hands.. Don’t use techniques that compromise your joints especially your thumbs and back.. Be opened minded to other professions, they’ve got some great skills and techniques you can steal!!

Follow Giles on Twitter and OMT Training on Instagram.

Aaron Anderson

Aaron is an Australian trained Osteopath. He completed his studies in Australia – Osteopathy with Distinction (RMIT), Sport Science (University of Ballarat). Aaron treats both adults and children. Aaron operates Movement Squared, both in Melbourne and Hong Kong locations (definitely a long commute), and additionally has been an onsite practitioner in both the corporate and sports performance world. He is currently completing a Masters in High Performance Sport through ACU. His advice is:

I recommended to my Associate try to excel in Anatomy and HVLA. These fields can easily put you in the top 10%. Be out and about in person. That’s when people will enquire directly about making an appointment. Still better than running an awesome social media campaign in my experience.

Find out more about Aaron and his business Movement Squared or follow Aaron on Twitter.

Jena Chang

Jena is an osteopath who graduated from RMIT in 2013. She works in private practice at Box Hill Osteopathy and Complete Health Osteopathy and Pilates. Her advice to new osteopaths is:

RE: job hunting
If they are interviewing you, you have a right to interview them back. Finding the right workplace is essential in your growth and development as your as your emotional well-being! Never settle for less.

Follow Jena on Instagram (side note: I love Jena’s content, it’s so positive) and Facebook.

Bruce Duncan

In over twenty five years as an Osteopath, Bruce has treated people from all walks of life. He has been Osteopath to the Australian Open Tennis Tournament since 2004, and at the Hawthorn Football Club since 2015. A graduate of RMIT, class of 1992, Bruce founded North Carlton Osteopathy in 1998. His advice is:

Interpersonal skills maketh the osteopath. Diagnostic & hands-on skills are a given, but connecting with warmth, understanding & empathy will take you next level. Build trust and take ownership of their management together.

Follow Bruce via North Carlton Osteo on Instagram and Facebook.

Alison Sim

Alison is an osteopath and pain management specialist. She graduated from Victoria University in 2001 and went on to complete her Masters in Pain Management from Sydney University Medical School and Royal North Shore Pain Management Research Institute. Alison works in private practice at Brighton Spinal and Sports Clinic and Pain Matrix in Geelong, treating people with chronic pain, and runs an education company for allied health professionals, Beyond Mechanical Pain.

Stay flexible in your thinking and humble about your role. Listen and learn from your patients. Keep a strong focus on life outside of work. Keep learning and evolving for your whole career.

Follow Alison’s work via Beyond Mechanical Pain on Twitter and Facebook.

Claire Reed

Claire is in her first year of practice as an osteopath, after graduating from RMIT with the class of 2017. Claire primarily works at Coburg Osteopathy & Health Services, and earlier this year organised the #3058Workout, a massive charity exercise day that raised over $11,000 for cancer council. She has had a great start to her career, no doubt with more to come. Her advice is:

Keep reading and asking questions. Your colleagues are your greatest resource and supporters so use them, ask them questions and observe them as often as you can.

Follow Claire on Instagram.

Nathan Kelly

Nathan, The Surfing Osteopath, a graduate of the class of 2013 from Southern Cross University, owns and operates Universal Health & Performance on the Gold Coast. He practices in an evidence informed manner, utilising traditional osteopathic techniques, dry needling and strength and conditioning principles to help people with injury management and rehab as well as performance enhancement. His advice is:

You’ve spent the last 5 years learning everyone else’s version of osteopathy, it’s now time to spend the next few years exploring how you want yours to look. Osteopathy is a framework which you can build from, and that’s the brilliant part of this job; the exterior is yours to create. The heart of osteopathy is inherently punk, it was born out of rebellion and questioning of the status quo. So keep asking questions, keep studying the human condition and keep osteopathy punk.

You can follow Nathan on his popular Instagram page.

Jacqueline Shergold

Jacquieline (Jacqui) graduated with me from Victoria University in the class of 2011, and since graduating has worked in private practice in Ireland, studied a Diploma in Paediatric Osteopathy at the Osteopathic Centre for Children (OCC) in London and now works as part of a multi-disciplinary team at a specialist baby treatment centre. Her advice is:

Listen. Listen to your instincts. Listen to your peers and mentors. Listen to your patients and listen to what their bodies need and want. Listen to podcasts and go to conferences/workshops/lectures. Take time to listen and you’ll be amazed at what you hear.

For more information, check out her practice website or connect with her on LinkedIn.

Jade Scott

Jade is a graduate of Victoria University, in the class of 2001. She is the owner and director of Western Region Health, one of Australia’s largest osteopathic practices. Jade has been involved in clinical education for a number of years and has an extensive graduate mentorship program in place in her practice and was involved in the development of the 5th year student internship program. Recently Jade has been presenting to osteopathic and allied health business owners on employment models in healthcare. Jade still practices and has a particular interest in maternal and paediatric health. Her advice is:

Don’t confuse confidence with conviction

Never underestimate the need to ‘fake it till you make it’

Social recognition is the key to filling your books

A patient’s financial situation should never cloud your ability to deliver their best treatment plan
Always go above and beyond

‘See how you go’ is not an option

‘Find, it fix it, leave it alone’ should be replaced with ‘find it, fix it, address the predisposing factors and maintain health’

Money is a wonderful byproduct of loving what you do

Core values make us the best at what we do (professionalism, integrity, respect, care and innovation)

If you surround yourself with brilliant people, remarkable things happen…

You can find out more about Jade via Western Region Health and follow them on Facebook for the latest updates.

Shane Buntman

Shane is a graduate of the Victoria University program, class of 2004. He currently operates a large practice across two locations in Melbourne’s CBD – Melbourne Osteopathy Sports Injury Centre. Shane has previously worked in the UK, and before osteopathy studied biology and genetics, as well as worked as  remedial massage therapist. Shane is passionate about developing the profession of osteopathy, and writes for Osteopathy Australia in their quarterly magazine on the topic of business in healthcare/osteopathy. Shane’s advice is:

Every time you step into the consulting room think ‘I’m representing the entire profession Osteopathy’.

It’s not about how interesting you can be, it about how interested you can be in others.

You can find out more about Shane via the MOSIC website and follow them on Facebook and Instagram.

Jon Marshall

Jon, owner of Back in Health Osteo is an osteopath and acupuncturist with clinic locations in Melbourne and Singapore, where he is currently based. Jon graduated from the program at RMIT in the class of 2008, and in 2011 he completed his Masters of Acupuncture, having previously studied a diploma prior to osteopathy. He is a master of the Japanese martial art Aikido and he founded the Melbourne Budo Academy in 2010, which teaches Aikido, Brazilian Jiu Jitsu, Shinkendo (Japanese swordsmanship),  Japanese Jujutsu, and Judo. He also teaches dry needling and cupping courses through his education company, Manual Medicine Australia. His advice is:The greatest thing that I would like to impress on you is that your learning NEVER stops.

Keep all your textbooks and don’t burn your notes. You will refer to them and keep learning from them over your entire working life; they have been written by some real giants in the Osteopathic world and we are lucky to be able to stand on their shoulders.

Don’t be overwhelmed, everything you have learnt in the course takes years to sink in, just keep learning and studying.

Be a generalist before a specialist. Be a Manual Medicine Master.

Work on yourself professionally and personally.

Don’t put down similar professions as it is unprofessional and it makes you sound like a knob. Everyone has something to teach us and never stop honing your craft.

Get together with colleagues, attend seminars and maximise your potential and be the very best Osteopath you can be.

Don’t get lazy or complacent, go out and chase your dreams.

Leaving Melbourne, while hard may be the best decision you ever make professionally…..

You have one of the best jobs for work life balance.

Keep healthy, take regular breaks and taste those sweet fruits!

The future is bright!

You can follow Jon’s clinics on Instagram and Facebook.

Tina Maio

Tina is a highly experienced osteopath who graduated from the osteopathy program at Victoria University in 1999, having also completed a Physical Education degree there previously. Tina owns and consults at Coburg Osteopathy and Health Services, where she treats people from all walks of life, but has established a reputation for her work with athletes, from the junior level all the way through to elites. Tina is particularly known for her work with golfers, with her current stable of players on the US PGA Tour, Nationwide Tour, European Tour, One Asia Tour, Japanese Tour and PGA and LPGA. Tina has presented locally and internationally in sports osteopathy and sports medicine. She is on the leadership committee for the Clinical Practice Group in Sports Osteopathy through Osteopathy Australia and is a clinical advisor for EMS Swiss Dolorclast. Her advice is:

Allocate time to professional development that excites you, it will create lightbulb 💡 moments that will fuel your passion for wanting to help others. Be committed to you career, but don’t abandon your personal life. Remember that working with people in pain is exhausting so take steps to look after yourself.

You can follow Tina through the Coburg Osteopathy Instagram and Facebook pages.

Nigel Roff

Nigel graduated from RMIT in the class of 1993. He practiced in Sydney for 6 years before establishing Willsmere Health Osteopaths in Kew, Victoria in 2000.  He practises patient-centred care with an emphasis on current evidence-based practice. He has a special interest in distance running and the treatment of injuries associated with running, and can also provide training advice. Nigel describes himself as having “No specialisations, I just treat people and their nervous systems”, but he also describes himself as a “hack runner”, so he is definitely modest (he recently competed the Chicago marathon, which is fairly far from “hack”). Nigel is an example of a practitioner who has built a successful career in osteopathy without having a high profile, except with his patients, where it counts most. His advice is:

Assume nothing, actively listen to your patients, they will tell you what’s wrong. You may not be able to help but that’s ok. And finally you are not responsible for your patients problems.

You can follow Nigel on Twitter or Facebook.

Anne Cooper

Anne is a former nurse and a 1989 graduate of the International College of Osteopaths, making her the most experienced practitioner on this list. She founded what is now Central Sydney Osteopathy in 1990 and has had a huge influence on the profession over the years. She has been president of Osteopathy Australia, and is now a life member, she is currently president of the NSW Osteopathic Council and has previously sat on the Osteopathy Board of Australia. Anne calls herself a dinosaur, but dinosaurs are extinct, while she is still overseeing a busy practice and seeing patients. Her advice is:

A new business is like any newborn; feed it when it asks to be fortified, nurture it, love it and help it grow strong and robust. That means 100% attention. Meet your patients needs, and very soon they will meet yours.

Osteopathy is medicine, not sports science. The human form, and what ails it, is not a predictable equation. Our job is simply to assist homeostasis. Treat what you find in that one unique patient, not what you’ve been told you should find.

If you think your patients should reflect your own image, then you’ll struggle. Appeal to ALL types. Old, young, fat, normal and thin, non/sporty, sick, well, straight, gay, black coffee and white, mums, overworked, unemployed.

When you graduate you don’t chat about technique at conferences and reunions. You talk business. So get it right from the start. This is a physical job, output exactly matches input, and if you get it right from the start you’ll enjoy a comfortable lifestyle and a deeply satisfying career.

You can follow Anne via the Central Sydney Osteopathy Facebook page.

 

Della Buttigieg

Della is a graduate of the Victoria University program, class of 2003. She is the founder of Melbourne Osteohealth, and a lecturer at Victoria University. She is a caring and passionate osteopath with particular interest in pain and rehabilitation for long term health and function. She firmly believes that the key to preventing many health problems from developing and recurring lies in educating our patients; arming them with an understanding of the their pain and teaching them how to reduce or eliminate it. Recently she has been involved in presenting on both the theory and application of pain science to clinical practice for allied health professionals. Her advice is:

What most patients want is someone who can help them feel good again and while better movement, more sleep and a balanced diet are a good start, humans never feel better than when they are having fun… prescribe fun!

You can follow Della via Melbourne Osteohealth on Instagram and Facebook.

Heath Williams

Heath is the founder of Principle Four Osteopathy, Corporate Work Health Australia and Ergawell. He is a graduate of Victoria University, class of 2003, and currently lectures there along with Southern Cross University, primarily in rehabilitation. Heath previously has worked in the UK and Sweden, and is currently a member of the Osteopathy Australian Clinical Practice Group for Occupational Health and Safety. Heath has a big focus on continuing education, and has undertaken numerous courses, workshops and seminars covering topics as diverse as manual therapy and exercise rehabilitation all the way through to communication. His advice is:

Be curious and open to opportunities! Learn from your own experiences, your clients and your colleagues and say yes to opportunities. Life will never be dull and work will always be fun and engaging.

You can follow Heath on his popular Instagram or Facebook pages.

Josh Lamaro

Josh is a graduate of the Victoria University osteopathy program. He owns Paleo Osteo in Bendigo and Torquay in Victoria, which is an “evolutionary medicine and nutrition clinic”. He has a special interest in the treatment of chronic conditions such as fibromyalgia, chronic fatigue syndrome, and auto-immnune diseases using the modern and traditional principles employed by Osteopaths. Certified in anti-ageing medicine through the Australasian Academy of Anti-Ageing Medicine, Josh uses functional medicine principles to help address his patients’ health in a wholistic manner. His advice is:

There is an alarming trend in osteopathic education at the moment that is tending away from what osteopathy really is.

There is a tendency to look for the “tissue causing the symptoms” and eradicate or palliate the symptoms. The ancient wisdom of the body is that it is always seeking balance, and will find it irrespective of the minds influence on what is “normal.”

A metaphor might be something like a boat sinking due to a hole in the bow of the hull. The passengers on the boat necessarily have to run to the rear of the boat to counterbalance it away from the sinking end. This could be seen as an “abnormal” distribution of human weight on a vessel (analogous to abnormal lab tests, abnormal tissue tonus etc,) but without this shift having occurred, the result would be far more disastrous. It is therefore of little use to usher the passengers back down the front (medicate/palliate/undo local “restriction,”) rather, what must be done is to seek the true reason the body is needing to find balance in this way.

Asking “why?” til one can no longer ask it anymore lands you somewhere in the realm of where to begin.

You can follow Josh on Facebook and Twitter.

Stephen King

Stephen is dual qualified as an osteopath and physiotherapist. He graduated from the Victoria University osteopathy program in the class of 2010, and the University of South Australia physiotherapy program in 2013. He is the director of Movement Assessment Technologies (MAT), which teaches allied health professionals about movement assessment and functional rehabilitation, The Injury Rehab Centre, a practice in Cheltenham, Melbourne which integrates the concepts taught through MAT and the host of the 21st Century Physio podcast, where he interviews industry leaders about the future of physiotherapy and allied health. Prior to working as a clinician he was a personal trainer and strength and conditioning coach, which is where his interest in movement started, and nowadays he spends his time helping professionals get better outcomes for their clients and patients. His advice is:

My top 3 things that I wish I knew as a new grad.

  1. Do not take everything from Uni as fact – a lot of what you learnt is out of date (it’s not 1898).
  2. Osteopathy is more than a 3x3m room. Think outside the box, set goals and work hard.
  3. Be the change you want to see.

You can follow Stephen via MAT on Facebook, Instagram and YouTube and through The Injury Rehab Centre on Facebook and Instagram.

Dr Nic Lucas, PhD

Nic is an osteopath, medical researcher, lecturer turned entrepreneur. Having completed his osteopathic studies at Victoria University in 1999, he went on to further studies at the University of Newcastle in epidemiology and pain medicine, before completing his PhD in diagnostic medicine at The University of Sydney. While at uni, Nic founded the International Journal of Osteopathic Medicine (IJOM) and served as an executive editor for 19 years and sold to Elsevier, the world’s largest medical publisher. He also started the Student Osteopathic Medicine Association (SOMA), helped develop the osteopathic course at The University of Western Sydney, where he went on to lecture for almost 9 years, and sat on numerous osteopathic committees and registration boards. After selling his two osteopathic practices, he has moved into coaching online entrepeneurs with his company X10 Entrepreneur.

Are you an Osteopath, or are you qualified as an Osteopath? Big difference. Don’t lose sight of yourself in a Title. Your identity is greater than your qualification. You can go anywhere, do anything. There’s never been more opportunity. Don’t ask for permission to go be awesome AF.

You can follow Nic on Facebook, Instagram or check out his website.

Summary

You probably started to sense a trend with the advice given.

While a few of the quotes mentioned technique, the majority talked about attitude, and the big picture.

Common themes were personal growth, education, self-care and listening/communication. This might not make sense now, but when you see such diversity in methods, all with similar results, then you have to look deeper at what is being done.

At the end of the day, this is just a milestone in your life journey. Graduating may feel like “everything” right now, but over time, you will grow and it will become “something”.

You have the opportunity to make an impact on people’s lives, which is an amazing privilege.  I wish you every success in your future, both personally and professionally, and hope that this blog helps you in some way.

Finally, start building your network. The internet makes this easier than ever before, and will strengthen your professional life immensely.

Good luck!

Class of 2011 at Victoria University (phone cameras have come a LONG way since then).

 

Nick Efthimiou Osteopath

This blog post was written by Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

You can follow Nick on Facebook, Instagram, Twitter and connect with him on LinkedIn and Snapchat.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 


 

 

How Specific Do Treatments For Pain Need To Be?

Specific; On TargetPain is what drives people to consult a medical professional more than any other symptom.

The vast majority of pain is benign, somatic (musculoskeletal) in nature, though some somatic pain has a visceral component.

Most of the time, complex examinations and treatment rituals are performed, in order to diagnose and treat said pain.

Patients feel like they are getting good value, practitioners feel like they are providing it.

But is it necessary to go through all these examinations, and aim for all these specific hands on, taping and exercise techniques to help people get better?

I’m going to argue, that no, it isn’t.

Can We Be Specific With Assessment?

A typical assessment of someone in pain consists of the following:

  • History
  • Neurological and orthopaedic testing
  • Active movement
  • Passive movement
  • Palpation/provocation

It can also include

  • Functional/task specific assessment
  • Capacity testing: strength, endurance etc

Based on all of this, a clinician then formulates a diagnosis, which dictates a management plan.

However, and this is a massive “however”, it could very well be that we are wasting our time.

Let’s have a look at each of those components, and see how specific they can be.

History

The clinical history is probably the most important part of an initial consultation. Combined with general information about a patient (age, occupation, family status etc) and how they carry themselves, a clinician can hypothesise a working diagnosis prior to any further assessment, which usually serves to confirm or refute the diagnosis.

For certain presentations, the history is quite diagnostic.

For example, neuropathic pain occurs when there is damage to a nerve, causing it to have what’s called an ectopic discharge. Without going into too much depth, when patients complain of burning, lancinating pain, often that will point us towards a diagnosis of neuropathic pain.

On the flip side, a recent study questioned whether commonly held true concept of clicking in the knee being related to meniscal damage. It was shown that equal numbers of people with and without meniscal injuries experience things like clicking and catching. (1)

Neurological and Orthopaedic Testing

The neurological examination consists of things like a cranial nerve examination, reflex testing, sensory testing and motor/strength testing, along with neurodynamic testing.

Unfortunately, neurodynamic testing often yields false positives (so not that specific).

Strength testing, at least the manual version, is very unreliable, and thus not specific.

Isokinetic strength testing is more reliable, however most clinics do not have this equipment. Some clinics have hand-held dynamometers, which increase reliability of strength testing. (2)

Additionally, strength testing only tells us there may or may not be a weakness, not why. Additionally, strength is not related to pain, though it is important for both injury risk and activities of daily living.

Sensory testing is helpful, while reflexes don’t really tell us much except that reflexes are there or not.

Orthopaedic tests, those which clinicians use to rule in/out certain tissue based injuries are notoriously unreliable. Even those which have demonstrated high sensitivity and specificity are subject to error as a result of neurological changes when we are in pain.

Active Movement

Okay, by now you should be sensing where I’m going with this.

Active movement tests the ability to perform that movement. Yes, certain tissues/structures are involved in certain movements, but that doesn’t mean that movement is a specific test.

For example, raising your arm out to the side as high as you can involves multiple muscles acting at the shoulder joint. If it hurts to do so, it implicates all these muscles involved, as well as the tendons, ligaments, joint, nerves etc.

Is it helpful to know? Most of the time.

Is it specific? No.

Passive Movement

See above.

Yes, passive movement takes muscles out of the picture, at least from a contractile point of view. That doesn’t mean that if active movement hurts, and passive doesn’t, that the problem is with a muscle.

Thus, not specific.

Still valuable, but not specific.

Palpation

Most practitioners, especially osteopaths, believe their palpation skills are reliable means of assessment.

They’re wrong. (3)

Palpation is not reliable, and thus definitely not specific.

Still valuable, but not specific.

Can We Be Specific With Treatment?

The short answer: it depends on the treatment.

Let’s look at my common methods of treating pain:

  • Education
  • Manual therapy
  • Graded exposure
  • Movement therapy/exercise rehab

Can any of them be specific?

Education

Education can address specific themes and topics, but the challenge with education, as is the case with any communication, is that what is heard and understood is not always what is intended. We are at mercy of the interpretation of the receiver. Language is more than words. It is influenced heavily by our social circles and our cultural experiences. (4)

But because teaching people about their pain, how to manage it and how to prevent future flare ups is a hugely important part of practice, this means these are simply challenges to be overcome.

I’ve said before, that education is the only thing that stays with a patient after they finish working with me. The caveat to this is, education that is effective. Saying things is not educating. Helping someone understand is educating.

As important as it is, I think it is a stretch to say it has a specific effect on pain. We can’t measure the effect it has, and say what amount of pain reduction was attributable to what amount and type of education.

Manual Therapy



I’m going to upset a lot of my colleagues by saying you can’t be that specific with manual therapy.

But it’s true.

Think about it, all we can truly touch is the skin. Not muscles, not ligaments or tendons, and not bones. The skin.

We can direct force to deeper lying tissues, like those mentioned previously, but this depends on the magnitude and direction of the force, as well as where the target tissues are situated.

Physics dictate that the only force that can be efficiently transmitted to bone has to be perpendicular to bone. Any horizontal or tangential force is dissipated by the frictionless interface of the skin/fascia. (5)

Another strike against the blow of specificity is the way the body is innervated. No one section is supplied by a single neurological level. Hence, because of convergence of multiple levels, we end up with less specificity.

Finally, when it comes to spinal movement, there is a plethora of research showing that you cannot isolate movement to a single vertebral level. Even neck manipulations, which allow the best contacts compared to thoracic and lumbar manipulations, result in movement of adjacent interverterbal joints.

So strike specificity off the list of things manual therapy is.

Graded Exposure

What about graded exposure? Many people conflate graded exposure with exercise rehabilitation. There are similarities, in that they are both (should be) progressive. However, graded exposure borrows from psychological research, and in theory, addresses psychological factors relating to pain and activities just as much as the physical factors. It’s kind of obvious when you think about it: gradually doing the things that hurt, or that you are worried about hurting makes it easier to do them over time.

Worried about bending over to garden all day? Let’s start with kneeling for a short period of time. Then you can gradually (the graded part) do more (the exposure part) until you are bending over gardening all day

There are two arguments about whether graded exposure is specific:

  1. It works for the specific task/scenario, hence it has a specific effect
  2. The same can be achieved in other means, hence it doesn’t

In my experience, the former holds true more so than the latter.

Here’s an example:

A patient of mine who was very active injured himself playing hockey. The injury came about because he wasn’t physically prepared for the demands of hockey, despite being physically fit and active. That and plain old bad luck – he simply moved in a way that loaded his back too much, which was in part due to the circumstances of the game at that moment.

After history and assessment, I was able to narrow it down to a diagnosis of “acute low back pain, without referred pain” (remember, we can’t really be that specific).

Treatment was manual therapy (didn’t really make a big difference), stay active (kind of hurt, but didn’t make things worse), some gym work for posterior chain (was able to train, but didn’t help pain), time (definitely made a difference) and gradually increasing hockey load (really helped).

Does that mean it (graded exposure) has specific effects that cannot be achieved any other way? I really don’t know. Let’s call this a maybe, at best.

Movement Therapy/Exercise Rehab


Like manual therapy, the fact that so many approaches can work holds the answer: if everything works, then nothing works. 

Or less cynically (and this is my position, because we know this works for many pain presentations), if everything works, the effects are non-specific.

Honestly, aside from the specific adaptations of exercise, which can definitely be important to an individual based on their capacity (power, strength, endurance, mobility etc), or lack thereof, when it comes to pain, the most important thing is to do something, do it appropriately (not too much, not too little) and continue to do it (consistency).

This can shatter the hearts (and wallets) of professionals who espouse a specific approach as “the only approach”. Of course it works. But not because of the reasons you say it works.

Do We Even NEED To Be Specific?

So here is the big question, or rather two questions:

  1. How specific do we need in order to be effective?
  2. Can we be that specific?

We could argue that currently, we are not very effective at treating low back pain, for example. Most of the time we can help people manage it, and the condition takes it’s natural history, which for most, is a resolution over a long enough time-frame.

But could we be more effective if we were able to be more specific?

There is still so much unknown about pain, that it is very difficult to answer.

We do know that pain typically has a blend of biological factors, including local tissue factors and central nervous system factors. We also know that pain consists of psycho-emotional-social components, which play a large role in the nature and course of pain.

We can’t measure the exact contribution of each, and nor can we isolate tissue factors – even evidence of tissue damage on imaging or surgery is at best, correlated with pain. Sacreligious? Perhaps, but, if we go “full academic”, you can’t separate the non-tissue factors from the resolution of pain. For years, surgeons thought sub-acromial impingement improved because of surgical decompression (it didn’t) (6). Same with arthroscopic surgery for arthritic knee pain (7).

Clinically, I have seen people with total and partial knee replacements still experiencing pain, more than 12, and in some cases 24 months post surgery. This doesn’t mean there is no effect of the surgery, but we aren’t 100% sure what it is.

Anyway, I digress.

With most non-specific pain presentations, by nature, we can improve people with non-specific interventions.

Neck pain for no apparent reason? Here’s a scientific valid approach:

  1. Rule out serious pathology.
  2. Rule out tissue injury (via history and assessment).
  3. Rule out complications/comorbid factors.
  4. Educate.
  5. Provide coping strategies
  6. Neuromodulate with chosen intervention, if desired (see above).
  7. Improve function (see above).
  8. Let time and physiology do the rest.

We can apply this concept to nearly all non-specific pain and be evidence based.

In fact, you can apply this to many instances of specific pain too.

Let’s Get Critical

Earlier this year a study on managing lateral hip pain (gluteal tendinopathy/trochanteric bursitis) was published in BMJ:  Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial (8)

 After critiquing this study, you could easily come to the conclusion that there was a lot of confirmation bias taking place in how much effect these interventions were having, and how much of that effect was due to the specific nature of the intervention (there was no general exercise arm as a comparison).

The methods of intervention were pretty generic:

  1. Education (basically, avoid compression of the tendons by not sitting and moving in certain ways) and exercise (a standardised hip exercise protocol) was one group
  2. Corticosteroid injection was another
  3. Wait and see was the third

Everyone got really excited on social media when this was published, because “exercise works!”, and “I do exercise with my patients” so there was lots of back patting and confirmation bias all around.

However, in my opinion, the interventions didn’t result in that much improvement over a wait and see approach in the main outcome measure (Visual Analogue Scale or VAS, a numerical pain scale). In fact, average pain intensity (score out of 10) changed from 5 to 3 in the wait and see group, while the intervention groups (education + exercise or corticosteroid injection) improved from 5 to 2 on average (there was only a minor difference between the two groups).

Consider the cost for that 10% improvement over wait and see:

  • The education + exercise was 14 sessions, which, if we take an average of $80 per consult, is $1120.
  • A corticosteroid injection under ultrasound guidance, ranges from between $150 and $300 on average.

So was all that effort of exercise, expense of education and injections worth it? Yes, in the short term, there was a big difference at 8 weeks over wait and see. However, if you told someone they had to spend $1000 over 8 weeks to end up 10% better than doing nothing at a year, how many people would still take that option?

Now let’s look at the other main outcome measure, the Global Rating of Change or GROC. The GROC is a single-item instrument that asks each patient to indicate whether and to what extent they perceive change has occurred, typically relative to the date of the initiation of care. The GROC uses a Likert scale to indicate the direction of change (ie, worsening or improvement) and the extent of change (ie, “tiny” to “very great”).  (9)

However, there is contention that the GROC doesn’t reflect functional changes (9), as it is a subjective assessment, but unlike the VAS it isn’t assessing pain, which is subjective, but the participants perception that something has changed. The problem with this, is the recency illusion and the availability heuristic inherently skew the results.

So when we look at the GROC scores: we see that at 8 weeks there is a big difference between the education + exercise and wait/see group, which makes sense, because the education/exercise program was 8 weeks long. But over time that difference was reduced, which is explained as follows:

Our data showed that a patient’s current FS exerts a strong bias on perception of change, even for short recall periods (fewer than 30 days), and this effect increased as transition time lengthened. (9)

So where does that leave us? Time to draw some conclusions.

Conclusions

That was really a long winded way of saying, no, we don’t need to be specific, because even when we try, we can’t be.

The constituents of good care are listed above. This much is clear, though some will debate the manual therapy aspect, others debate the exercise aspect, the moderates will say these 4 interventions are all good in various degrees.

What is emerging, is that what you do isn’t as important as how you do it, and who you do it with (the therapeutic alliance is a big predictor of outcomes in pain). It is also important to not do the wrong things – i.e. those that are clearly ineffective, but moreso, those that actively do harm.

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 

Tightness Is A Stress Response: Get Regular Treatment To Reduce It

Visceral manipulation.

Most people think tightness is a muscle problem.

In actual fact, tightness is a stress problem.

The key to managing stress is not to eliminate it completely.

Instead, aim to reduce what you can, and better respond to what you can’t.

[Let’s get this out of the way: tightness is not a scientific or physiological term. But we all know what someone means when they say it. In physiology we talk about shortness, stiffness and muscle tone.]

We Are Like An Oil Burner

I have heard world renowned strength coach Charles Poliquin describe us as an oil burner.

Our output is the flame, which can only be as big as the oil reserve allows.

Everything we do, both positive and negative, burns some oil, to keep the flame going.

If you are like most people, you are over stressed, under slept and nutrient deficient.

You have ever increasing work demands. You want to spend as much quality time with your family as possible. You do try and get to the gym or go for a run, but some weeks you simply can’t make it.

That’s a lot of burning, and not much refilling.

Add all this together, and your brain puts you in fight or flight mode.

Now if someone was about to hit you, would you be tense or relaxed?

Well to your brain, stress is stress. Whether it is a fight, a work deadline or your kid getting sick.

Tightness Protects Us Against Stress In The Short Term

You can see that an increased muscle tone is the result of stress, but can you see the benefit?

A muscle, or joint that is tight is protective against stress, in the short term.

That increased stiffness helps to resistance against external disturbance.

But this protective behaviour comes at a cost: it impairs function.

Tight tissues use more energy, don’t drain properly and can’t contract efficiently. (1)

We aren’t designed for sustained bouts of stress. So when this stress isn’t alleviated, the effects become noticeable.

Be Proactive, Not Reactive

Most people think of going to see an osteopath when they are in pain.

This is like deciding to eat healthy after you’ve had a heart attack. It’s better than nothing, but optimal would have been to eat well all along.

Now, I’m not saying that getting regular treatments will prevent pain and injury.

I’m not even saying that eating well prevents heart attacks.

These are complex events, with lots of factors, seen and unseen that contribute.

That doesn’t mean do nothing.

You can learn to tune into your body, and learn to understand your response to stress.

I don’t recommend thinking about your health from a reactive point of view.

You can learn to get in tune with your body and take the measures to manage stress, in all its forms.

When it comes to getting a treatment, exercise and most things health, being proactive is almost always superior to being reactive.

Use A Systematic Approach To Assess and Measure Changes

A treatment should make you better. That is obvious.

But how do we know?

Anyone can identify areas of tightness and then rub a little and call it a treatment.

To me, a good osteopathic treatment is about working out why.

A systematic approach to assessment takes away the guesswork.

You can then apply the interventions where it is most needed.

This enhances efficiency, giving you the biggest response in the shortest time.

It also allows you to reassess, to measure change.

After all, “what gets measured, gets managed”. More on that next.

Oh, And It Doesn’t Need To Hurt

Remember when I said tightness is a stress response?

That means that you don’t always need deep tissue work that is painful to relieve it.

There are many gentle techniques that do just as a good a job, without the pain.

After all, does it make sense to relieve stress with more stress in the form of an intensive treatment?

There is definitely a time and a place for deep work, but don’t think that because something doesn’t hurt it is ineffective.

How Do You Know How Often?

I have never been a fan of routine “maintenance” treatments.

First, an osteopath doesn’t maintain you.

Second, how often you need treatment should be based on your physiology, not the calendar.

So what you need is a way to keep score. A way to interpret your physiology.

The Old School Way: Wellness Monitoring

Wellness monitoring is an effective way to keep track of your physical and mental state.

Used by sporting teams as a way to monitor their athletes, it is a great way for non-athletes to keep on top of their stress levels.

Wellness monitoring records how you feel and what you did on a day to day basis, given you a score.

This score then indicates when you are over stressed/under recovered.

You can start to correlate this to how tight you feel.

I have linked to a good example of wellness monitoring in the references.

The New School Way: HRV Apps

I’ve talked about Heart Rate Variability (HRV) before, but it’s worth mentioning again.

HRV is a measure of your physiological state.

Lower HRV indicates higher stress levels.

The leading app on the market, HRV4Training allows you to use your phone’s camera to record your HRV. This is much more convenient than using a chest strap every morning. Unfortunately, until now, it has only been available on iPhone. The good news is, in the next week it will launch on the Google Play store.

I will be purchasing it.

By tracking HRV, you can not only see your physiological state, but the effects of your lifestyle.

You can then use this info, correlated to your muscle tone to decide how often to get a treatment.

And of course, you can then use the info to see the effects of treatment.

Or, You can go by feel

At the end of the day, only you know how you feel. If you are feeling tight and stiff, then it’s a good time to get a treatment.

Do you need to be in pain?

No.

We are aiming to be proactive, remember?

This means understanding your body, and intervening before the onset of pain or injury.

The old cliche rings true: “An ounce of prevention is worth a pound of cure”.

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 


 

 

References

(1) Will add reference tomorrow, the book is at work

(2)Why Do Muscles Feel Tight

(3) Wellness Monitoring

Osteopathy For Carpal Tunnel Syndrome

Image credit: By DoPhotoShop - http://dophotoshop.com/carpal-tunnel-exercises.php, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=14614865

Image credit: By DoPhotoShop – http://dophotoshop.com/carpal-tunnel-exercises.php, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=14614865

Carpal tunnel syndrome is a common presentation, but is often poorly managed. Osteopathy can provide a conservative option to treat carpal tunnel syndrome.

Carpal tunnel syndrome is a fairly common condition that affects women slightly more than men, with numbers ranging from 1-7% of the population affected. (1)

It is described as “a painful disorder of the hand caused by pressure on nerves that run through the wrist. Symptoms include numbness, pins and needles, and pain (particularly at night).” (2)

It usually presents with the following symptoms (3):

  • paresthesia, dull, aching pain, or discomfort in the hand associated with weakness or clumsiness;
  • fluctuating level of symptoms with exacerbation at night (nocturnal numbness), worsened by strenuous hand use or activities with maintained posture (driving);
  • and partial relief of symptoms by changing hand posture or shaking the hand.

Diagnosis or description?

Generally speaking, any condition that has the word “syndrome” in its name is not a diagnosis, but rather a collection of clinical findings.

In the case of carpal tunnel syndrome, it is considered a clinical diagnosis, but, whilst the symptoms can be similar from person to person, the clinical findings (and thus underlying causes) can be quite different, based on a variety of different factors.

Some of these factors include:

  • Individual anatomical differences (wrist space, nerve length, a cervical rib etc)
  • Lifestyle and occupational activities (assembly line workers tend to have a higher incidence of carpal tunnel syndrome than other occupations – NINDS)
  • Pregnancy – pregnant women have a higher incidence
  • Health status – diabetes, hypothyroidism and obesity are known risk factors (Frontiers)

To diagnose carpal tunnel syndrome a clinical examination is sufficient, though in more severe cases, nerve conduction tests are recommended.

When you consider that any combination of factors can be present, an individualised approach to management becomes critical.

General Recommendations

The general medical recommendations (1, 4, 5) to treat carpal tunnel are (in order):

  • Rest. Rest is important, but it is often futile if there are other issues involved, because as soon as you stop resting, symptoms flare up again.
  • Splinting, particularly at night. Splinting can be useful, but again, it isn’t because of a “lack of splinting” that you develop the condition in the first place. This means, that without addressing the other factors, splinting is just another form of rest, and symptoms will likely return once splinting has stopped.
  • Physiotherapy. Hand, wrist and arm exercises can be useful in helping reduce symptoms and address causative factors. Exercises targeted at mobilising the nervous tissue, can be particularly helpful here. Whilst different professions, osteopaths can do most of what physiotherapists can do and vice versa, and what matters most is that the professional in question is up to date in their knowledge and provides an individualised treatment approach.
  • Diuretics to reduce fluid. Diuretics can provide a short term reduction in fluid, but again, we need to work out why the fluid was accumulating in the first place. If, for example, there is lymphatic congestion, the diuretics will only have a short term effect, often with the risk of side effects. Another common cause of congestion is hypothyroidism, which needs to be medicated properly, so identifying the cause of the congestion is as important as reducing the fluid with diuretics.
  • Cortisone. Cortisone can reduce inflammation locally, with the potential risk of nerve injury resulting in worse pain. The benefits do not outweigh the risks, in my opinion, considering the alternatives available. If you do decide to have a cortisone injection, it’s best to have it performed by a surgeon who performs it often, as their skills will be higher, reducing the risk of adverse effects.
  • Surgery. Surgery is indicated in severe cases, but is not always successful (like any treatment). It has the risk of nerve and/or artery damage, with the benefit of increasing the space under the transverse carpal ligament, which is often a cause of symptoms. The success rate of surgery for carpal tunnel is generally higher at 12 months than conservative approaches, when considering nerve conduction studies, but due to the risks involved, the recommendation is to initially treat conservatively, and only explore surgery if there is not the desired improvement.

(My) Osteopathic Approach

To understand my osteopathic approach to treating carpal tunnel syndrome (and any condition really), you have to have a grasp of complex systems and emergent properties.

Put as simply as possible:

This means that something like pain, or symptoms arising from the nervous system are not predictable based on statistical or experiential averages, and any linear causality we deduce, is false logic.

So, when it comes to treatment, we have to have an understanding of normal physiology, then use our clinical skills to find the “abnormal” or “dysfunctional” or “disturbances to normal”.

We can then apply an intervention that results in a change (remember, this change is unpredictable), monitor the change (see if the abnormal has become normal) and then reevaluate the approach.

In essence, it is a trial and error approach, but an educated one.

Measure Twice, Don’t Cut

It’s important to measure the effects of treatments somehow, but, this can be hard, because clinical findings vary for the same condition, and the same clinical findings will not always result in symptoms, even in the same patient.

Because of this difficulty in measuring clinical findings and symptoms, I try to use objective outcome measures. These are simple, validated (by research) questionnaires, like the Boston Carpal Tunnel Syndrome Questionnaire, which provide a measure of the disability associated with a certain condition; and they can be very helpful to use at the beginning, mid-point and end of treatment process to gauge efficacy.

As mentioned earlier, nerve conduction tests are valuable in certain cases, but are invasive and costly from an economic point of view, so they are not always practical.

Treat The Whole, Not The Cause

As I described in Osteopathy For Low Back Pain, there are general, or systemic effects from osteopathic treatment, as well as local.

When treating a person with carpal tunnel syndrome, as opposed to treating carpal tunnel syndrome as a condition, these general effects can be important in improving overall sense of wellbeing as well as positively affecting the body’s physiological functioning.

Sense of wellbeing is often overlooked in outcomes based medicine, but, with outcomes being equal, the process that produces a more pleasant/less unpleasant experience for the patient is superior.

nerves_of_the_left_upper_extremityIn addition to the general aspects of an osteopathic manual treatment, with carpal tunnel syndrome, a focus on the structures related to the median nerve starting from it’s origin in the brachial plexus as it arises from the C5-T1 nerve roots, all the way to it’s end point in the hand.

It is surprising how many people I see who have consulted with their GP and perhaps a rehabilitation professional (occupational therapist, physiotherapist, hand therapist) who have only had interventions directed at the wrist and hand.

Simple anatomy suggests that this will not be adequate.

Given the nature of nerves, symptoms will appear distal to (below) any site of adverse tension/compression. Considering the hand is the site of carpal tunnel syndrome symptoms, my preference is to work up from the hand and wrist towards the neck and thorax.

Common areas of dysfunction include:

  • Transverse carpal ligament (this is what surgeons cut)
  • Carpal (wrist) bones
  • Radius and ulna (forearm bones and their joints)
  • Interosseus membrane of forearm (connection between radius and ulna)
  • Elbow flexor muscles and associated connective tissues
  • Pectoralis minor
  • Upper ribs (especially the 1st rib) and clavicle
  • Scalenes (and other neck muscles)
  • Cervical spine (neck) and thoracic spine and rib cage

Unless all these areas are considered and any dysfunction addressed, I wouldn’t consider the examination process thorough enough.

Neurodynamics must be considered

One of the issues with traditional approach to carpal tunnel syndrome, is that the median nerve itself is not considered as a primary cause of the symptoms, but rather a secondary “victim” to other changes.

Neurodynamics considers 3 aspects (Shacklock):

  1. The mechanical interface of the nerve and body tissue (joint, ligament, muscle etc)
  2. The neural tissue itself
  3. The innervated tissues

Abnormal changes at any of these aspects can alter neurodynamics (the function of nerves), leading to symptoms.

Techniques Are Secondary

Lot’s of people want to know what technique will work best, whether it is a manual technique delivered by an osteopath, or an exercise to self manage. The technique doesn’t matter as much as the reasoning behind the technique and how the technique is executed.

So if someone reasons that muscular tension in the neck muscles is affecting the median nerve, a range of techniques to reduce said tension will be helpful. These can be active or passive and are guided by patient and practitioner experience and preference, as well as a risk to benefit analysis (when known).

This technique needs to be delivered or performed in a mindful manner, with attention being paid to the experience of the technique, as well as the response, by all parties involved (patient and practitioner).

By engaging patients in the process, the treatment automatically becomes more “active”, which we know produces superior results to passive treatments in the long term (BMP).

Conclusions: Putting It Altogether

 

Carpal tunnel syndrome has two components – the symptoms experienced (pain, numbness and tingling etc) and the reduced nerve conduction, which is not always perceptible.

Osteopaths have a role to play in reducing the symptoms (6), and research performed on other manual therapies supports this (7).

However, it must be considered that there is no set formula for a condition like carpal tunnel syndrome, and that each person will have their own “physical story” explaining their condition, and it is this story that a practitioner must somehow read, understand and interact with.

So when you are seeking treatment for carpal tunnel syndrome, you want to find a practitioner who considers everything, not just what is happening at the wrist, not just what is happening “in your body”, but everything.

It sounds cliche, but that is what a truly holistic approach entails.

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

References

(1) Primary Care Management of Carpal Tunnel Syndrome

(2) Better Health Channel – Carpal Tunnel Syndrome

(3) Carpal Tunnel Syndrome – Primary Care and Occupational Factors

(4) Conservative Interventions for Carpal Tunnel Syndrome

(5) Is surgical intervention more effective than non-surgical treatment for carpal tunnel syndrome: a systematic review

(6) Effectiveness of Osteopathic Manipulative Treatment for Carpal Tunnel Syndrome: A Pilot Project

(7) A Pilot Study Comparing Two Manual Therapy Interventions for Carpal Tunnel Syndrome

(8) Median Nerve Image