Monthly Archives: May 2018

Can an Osteopath Help with Persistent Pain? (Saracutu et al, 2018)

What is Persistent Pain?

Chronic pain has a more descriptive, less pessimistic name. Persistent pain is the term used for pain that has been present for 3-6 months, or longer than the expected healing time. It’s a complicated process that researchers understand better now than ever before. This is because mainstream medicine is beginning to apply the BioPsychoSocial (BPS) model. This is the idea that pain and illness are not purely biological, but are also affected by the patient’s psychological and social factors. In other words: pain is not all about what we can see on a scan, but about how we think about and interpret the pain.

Saracutu et al (2018) list “catastrophizing and fear-avoidance” as the most clearly related pyschosocial factors in persistent pain. Catastrophising is defined as “a set of exaggerated and maladaptive cognitive and emotional responses during actual or anticipated painful stimulation”. Fear avoidance is when we excessively avoid doing things for the fear of worsening the pain. Education has been proven to reduce fear avoidance, and osteopaths are in the ideal position to provide this education. Interestingly, the psychosocial factors can be better predictors of how the patient will progress than the biological ones.

How Does Persistent Pain Happen?

Lorimer Moseley’s “Tame the Beast” video is a great introduction to persistent pain.

There is a lot of psychological involvement in this over-protective type of pain. Saracutu et al report that:

There is a high rate of comorbidity in the occurrence of pain and mental health. The average percentage of patients living with persistent pain who also display symptoms of anxiety and depression is reported to be between 50% and 75%

What can Osteopathy do for Persistent Pain?

Osteopaths inherently follow the BPS model. As well as applying a holistic approach to the biomechanical causes of persistent pain, we have the time to speak to patients and address psychosocial issues. Although we are not counsellors, we are equipped to manage a range of psychosocial factors in persistent pain. We are also able to refer on to someone more appropriate when something is beyond our scope of treatment. Fear avoidance and catastrophising can be managed with education, and exercises to improve strength and mobility (and highlight what is already there). Objective progress throughout the course of treatment is very powerful against psychosocial barriers.

A diagram to show how fear avoidance exacerbates ostearthritis

Osteoarthritis is a good example for a condition very clearly exacerbated by fear avoidance. It is often poorly understood by patients, who allow the pain to dictate how they behave. This is natural, but it is the opposite of what needs to be done to improve arthritis.

In a nutshell, osteoarthritis responds well to movement through the full range of a joint. When a hip joint becomes osteoarthritic, the patient is likely to keep it flexed. They may not even notice that they’re doing this, but often this change in use is led by ideas such as “I should rest it” and “I don’t want to cause any more damage”. Ironically, it is exactly this behaviour that causes the joint health to worsen at a faster rate, typically leading to compensation elsewhere in the body. This can lead to osteoarthritis in other joints.

Education alongside manual therapy can be the key to improving movement, and therefore the health of the joint.

The results indicated that common outcomes of osteopathy were: a reduction in pain, increased flexibility, and improvements in posture and in the ability to complete daily tasks.

Does Osteopathy Work For Persistent Pain?

  • After six weeks of osteopathic treatment, mindfulness, and ACT, OsteoMap patients with persistent pain showed a significant improvement in psychological flexibility, but also in levels of pain, mood, and coping.
  • Licciardone et al’s meta-analysis showed that osteopathic manipulative treatment significantly reduces back pain, compared to placebo. Results remained for at least three months.
  • The Medical Research Council conducted a randomised controlled trial that concluded that spinal manipulation and exercise was more beneficial than either of the treatments alone, and when compared with ‘’best care’’ for persistent pain. This approach was also shown to be cost-effective in GP practices.
  • Williams et al reported that an osteopathy primary care clinic improved short-term pain-related outcomes and long-term psychological outcomes for neck or back pain. 

In addition to these points, osteopathy was shown to have the added benefit of a smaller dropout rate than other interventions in Chown et al’s study. These other interventions included group exercise and physiotherapy. Reasons given for remaining in the study included “preference for hands-on treatment, a more flexible appointment schedule or past experience with private practice”.

Saracutu, M., Rance, J., Davies, H., Edwards, D. (2018). The effects of osteopathic treatment on psychosocial factors in people with persistent pain: A systematic review. International Journal of Osteopathic Medicine, 27, pp.23-33.