Tag Archives: research

Does Osteopathy Help with Arthritis?

What is Osteoarthritis?

Diagram to show osteoarthritis in the hipOsteoarthritis is the most common form of arthritis, that people sometimes just call “arthritis”. For simplicity’s sake we will only cover osteoarthritis (or OA for short) in this post. Often people just accept it as a by-product of getting older, but this isn’t really the case. Previously the tagline that’s gone with osteoarthritis is “wear and tear”, but more recently a new phrase has come into the foreground: “flare, tear, and repair”. This phrase emphasises that the condition isn’t a clear progressive one, but that it can be exacerbated and improved.

OA affects cartilaginous joints. The simple explanation is that the cartilage gets irritated and breaks down. One factor in this is that cartilaginous joints like to be moved throughout their whole range. This means that the whole surface of the joint will have some compression and some decompression, which is necessary to refresh the fluid in the joint and to essentially provide nutrition to the joint surface of cartilage. The mechanism of osteoarthritis is understood to be a breaking down of cartilage and less-than-perfect repair, with some bony growth coming in to replace cartilage. (UW Orthopaedics and Sports Medicine)

Does Osteopathy Work for Osteoarthritis?

Key findings from French et al’s 2017 paper included:

  • Manual therapy may reduce pain for knee osteoarthritis in the short term
  • Manual therapy may improve physical function for patients with knee osteoarthritis in the short term
  • Improvements in pain and function following manual therapy may last up to six months for hip osteoarthritis

Ottawa’s clinical practice guidelines for OA, published in 2005, found that:

  • Patients with arthritis tend to report a reduction of pain after exercise
  • Manual therapy was significantly more effective than therapeutic exercise for patient global assessment, pain, stiffness, functional status, and range of movement after 5 weeks [of treatment]
  • The Ottawa Panel has found evidence to recommend and support the use of therapeutic exercise (on their own or combined with manual therapy), especially strengthening exercises and general physical activity, for patients with OA, particularly for the management of pain and improvement of functional status.

What does treatment entail?

A good treatment plan for osteoarthritis will target the secondary effects as well as the joint surfaces. Prevention of further irritation is also important.

Cartilage and Muscle

We’ve established that cartilage likes to be used. Osteoarthritis can be a vicious cycle in that as a joint becomes arthritic and painful, you might avoid using it through its full range. This makes it worse! Often we find that a patient with osteoarthritis expects the pain, so tenses their muscles around the joint as they approach the painful movement. This can bring the irritated joint surfaces closer together (particularly in the case of the knee cap), causing more pain and irritation. Lenhart et al provide good evidence of this for the joint behind the kneecap. Your osteopath can help you break the cycle by gently working through the joint’s full range for you. This improves the availability of nutrition and waste removal in the joint, and helps to let your brain realise that the movement doesn’t have to be painful.

Swelling

Cartilage doesn’t have a good blood supply, so it relies on diffusion of nutrients and waste products to maintain a healthy state. Diffusion is easiest when there is a high concentration gradient: for example when the fluid is high in nutrients and the cartilage is lacking. So replenishment of this fluid will directly benefit the cartilage.

Swelling is a sign of inflammation. It’s more obvious in joints that sit close to the skin, like knee joints; but is less likely to affect the fingers. If you have an arthritic knee that is prone to swelling, then the joint will be surrounded by a fluid high in waste products. This means there’s less of a concentration gradient, so less waste can be removed from the joint. There are a few ways we can target excessive swelling:

  1.  Manual drainage techniques: light pressure over the swollen area, towards larger vessels can give immediate results. By moving the more skin-deep fluid away from the area, the deeper swelling can begin to settle down too. This is not a cure, but it is a good starting point. (Vairo et al, 2009)
  2. Passive movement: an important part of treating osteoarthritis is getting the joint moving again. As above, this has the two-fold effect of refreshing the fluid around the cartilage and telling the brain that the movement doesn’t have to hurt.
  3. Active movement: when the joint is more comfortable, you’ll find that you can move the joint further through its full range. This has the benefit of compressing and decompressing more of the cartilage, with the bonus that the pumping action of muscles will further aid drainage.

Posture

A diagram to show postural changes due to hip arthritisAfter everything above about moving, it’s important to keep moving well to prevent a flare up. Continuing to use the joints through their full range will help to keep progression of the arthritis to a minimum. Not only will this benefit the joint in question, but it means that less compensation is required from other joints.

Someone with hip arthritis is likely to bend forward a bit to ease the pain. With this change in posture, the leg no longer needs to extend all the way back anymore when while walking. It’s not unusually for an OA hip to barely reach neutral. The joint is not taken through its whole range, so some areas of cartilage are not pumped to benefit from the joint fluid.

The cycle begins: the OA gets more progressive, the patient bend forwards more, and maybe takes shorter steps because it’s more comfortable. The local muscles respond to this, and the muscles on the front of the hip tighten, or shorten, because they are never stretched. Other areas start to adapt: the hunched posture of the lower back  caused by the hip pain has to be corrected further up the spine, leading to achiness in the neck from craning the neck to look forward. (Truszczyńska 2017)

Summary

Osteoarthritis is a very common condition, but can be helped by bringing movement back to the joint. This can be achieved with a treatment plan from your osteopath involving hands on treatment and exercise. Reduction of pain and improvement of function have been proven to result from manual therapy. Improving function in the affected joint is important for reducing similar problems elsewhere as a direct result of compensation for the arthritic joint.

References

Brosseau, L., Wells, G., Tugwell, P., Egan, M., Dubouloz, C., Casimiro, L., Robinson, V., Pelland, L., McGowan, J., Judd, M., et al (2005) Ottawa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises and Manual Therapy in the Management of OsteoarthritisPhysical Therapy. 85 (9), pp. 907–971.

French, H., Brennan, A., White, B. and Cusack, T. (2011). Manual therapy for osteoarthritis of the hip or knee – A systematic reviewManual Therapy, 16(2), pp.109-117.

Lenhart, R., Smith, C., Vignos, M., Kaiser, J., Heiderscheit, B., Thelen, D. (2015).
Influence of Step Rate and Quadriceps Load Distribution on Patellofemoral Cartilage Contact Pressures during Running
. Journal of Biomechanics, 48(11), pp.2871–2878.

Pinto D, e. (2017). Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee. 2: economic evaluation alongside a ran… – PubMed – NCBI . [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23811491 [Accessed 10 Nov. 2017].

Truszczyńska A, e. (2017). Characteristics of selected parameters of body posture in patients with hip osteoarthritis. – PubMed – NCBI . [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25058110 [Accessed 13 Nov. 2017].

UW Orthopaedics and Sports Medicine, Seattle. (2012). Joints. [online] Available at: http://www.orthop.washington.edu/?q=patient-care/articles/arthritis/joints.html [Accessed 12 Nov. 2017].

Vairo, G., Miller, S., Rier, N. and Uckley, W. (2009). Systematic Review of Efficacy for Manual Lymphatic Drainage Techniques in Sports Medicine and Rehabilitation: An Evidence-Based Practice ApproachJournal of Manual & Manipulative Therapy, 17(3), pp.80E-89E.

Lower back and pelvic pain during and after pregnancy (Franke et al, 2017)

PregnancyRoughly 50% of pregnant women suffer from lower back pain or posterior pelvic pain; this increases towards the end of the pregnancy and through the first year after giving birth. The most widely accepted explanation for this is that these areas provide the most compensation for the increase in weight in the abdomen.

This research study is a systematic review, meaning it incorporates a large number of existing studies to draw the most accurate conclusions. This includes unpublished theses, and studies not written in the English language.

Does osteopathy work for lower back and pelvic pain associated with pregnancy?

Osteopathy provides significant reduction of pain, and improvement in function, for lower back and pelvic pain associated with pregnancy.

The key findings were:

  • Osteopathic Manual Therapy (OMT) was significantly more effective than usual care alone, or no treatment.
  • There were no serious side effects of OMT. Tiredness after treatment was a minor side effect.

Techniques that fell under the umbrella of OMT included structural, visceral, and cranial techniques. Specifically, structural techniques were listed as soft tissue manipulation, stretching, joint mobilisation, muscle energy techniques, and spinal manipulation. It is important to note that these techniques were used along with the philosophies of osteopathy. They were not just applied locally to the lower back and pelvis, but holistically, wherever needed to improve the body as a whole.

The study recognised that there was a limited amount of high quality evidence, but that the papers analysed were still significant with regards to OMT. Evidence was low to moderate for the benefit of exercise for pain and function. There was also low quality evidence to support craniosacral therapy, use of a lumbopelvic belt, and acupuncture. Due to the low quality of the evidence, it was difficult to compare to osteopathic treatment. The authors suggested that further research on the topic should involve more long-term follow-up for better quality evidence.

In the discussion, the point is raised that although there is clear benefit of osteopathic treatment, the exact reasons why are unclear. The authors draw the hypothesis that, as manual techniques have repeatedly been shown to reduce pain sensitivity, that these mechanisms allow for better neuromuscular function and control. This leads to the patient beginning to feel better, improving pain beliefs, and and allowing for further pain reduction and benefits to function.

Franke, H., Franke, J., Belz, S. and Fryer, G. (2017). Osteopathic manipulative treatment for low back and pelvic girdle pain during and after pregnancy: A systematic review and meta-analysis. Journal of Bodywork and Movement Therapies, 21(4), pp.752-762.

Cervicogenic Headaches (Biondi, 2005)

The Cervicogenic Headache International Study Group Diagnostic Criteria

The Cervicogenic Headache International Study Group Diagnostic Criteria

A cervicogenic headache is one that is caused by structures in the neck, such as muscles, joints, nerves, and blood vessels. It is estimated that up to 2.5% of the general population in the USA are experiencing a cervicogenic headache at any one time. Women are four times as likely to experience this than men.

By definition, neck movement or sustained awkward positioning will aggravate or bring on the headache. It is common to also find restriction in neck movement, and a change in neck posture. Pressure over the joints of the neck, or into the muscular trigger points around the neck and shoulder are also common aggravating factors.

Biondi’s paper is a review of a selection of previously published research, covering diagnostic criteria, guidelines, and the pathophysiology of cervicogenic headaches. Despite the research being funded by pharmaceutical companies, it reiterates the benefit of manual therapy for the treatment of cervicogenic headaches.

Does osteopathy work for cervicogenic headaches?

The paper regards physical and manual therapies to be important parts of the treatment program.

A controlled trial testing the effectiveness of therapeutic exercise and manipulative treatment for cases of cervicogenic headache found that efficacy was not substantially affected by age, gender, or headache chronicity in patients with moderate to severe pain intensity. This finding suggests that all patients with cervicogenic headache could benefit from manual modes of therapy and physical conditioning.

Categories of recommended treatment include

  • Pharmacologic
  • Non-pharmacologic
  • Interventional
  • Surgical

Osteopathic treatment comes under “non-pharmacologic”, along with physical therapy, use of a TENS machine, relaxation therapy, and psychotherapy.

A combination of both exercise and manipulation had better results than either modality alone. Both significantly reduced the frequency and intensity of cervicogenic headaches with long lasting results. It was also found that long term benefits are most substantial in patients who continute to participate in exercise programs.

Recommended techniques include craniosacral therapy, strain-counter strain, and muscle energy techniques. HVLA thrusts (or “clicking”) may suit some individuals, but can cause an increase in pain, particularly if the treatment is strong. The paper suggests that gentle techniques such as stretching should be used initially, leading up to strengthening. It also notes that other modalities that give temporary relief can aid the progress made through physical therapy.

Early diagnosis and management by way of a comprehensive, multidisciplinary pain treatment program can significantly decrease the protracted course of costly treatment and disability that is often associated with this challenging pain disorder.

Biondi, D. (2005). Cervicogenic Headache: A Review of Diagnostic and Treatment Strategies. The Journal of the American Osteopathic Association, [online] 105(4_suppl), pp.16S-22S. Available at: http://jaoa.org/article.aspx?articleid=2093083 [Accessed 12 Oct. 2017].

Shoulder Conditions (Hawk et al, 2017)

Hierarchy of Evidence diagram

Hierarchy of Evidence © National Library of Medicine

This study is a Systematic Review, which ranks very highly in the hierarchy of evidence (pictured). It investigated a number of conditions and their responses to various treatment modalities.

It was published in the International Journal of Manipulative and Physiological Therapeutics in June 2017. Funding was provided by The Council on Chiropractic Guidelines and Practice Parameters.

A full reference for the article is embedded at the end of this post.

Does osteopathy work for shoulder conditions?

Manual therapy is the hands-on treatment you expect to receive from your osteopath in the treatment room. This encompasses mobilisation and manipulation, which was sometimes differentiated between in the studies below.

Manual therapy was shown to be beneficial for non-calcific rotator cuff associated conditions, adhesive capsulitis, and shoulder impingement syndrome; less so for non-specific shoulder pain.

Your osteopath may employ other treatment modalities, such as electrotherapy. Shockwave therapy was proven to be effective for the treatment of rotator cuff calcific tendinitis. LLLT was effective to variable degrees for managing adhesive capsulitis.

It is important to remember that Osteopathy is a complementary therapy, not an alternative to medicine. We understand the limits of manual therapy, and there are patients who will benefit more from surgical intervention. However, we all see patients who have been told they need surgery, but would rather try a less invasive method first.

More detailed information of all findings is summarised below.

Non-calcific Rotator Cuff-Associated Conditions

  • Three separate studies found that manual therapy was effective- two of these also found that manual therapy in addition to exercise was effective. A fourth study suggested that a combination of acupuncture and dietary advice was also effective.
  • Extracorporeal Shock Wave Therapy was found to be ineffective for non-calcific rotator cuff tendinitis.
  • There was insufficient evidence to conclude the level of effectiveness for TENS, or taping.
  • Exercise therapy was found to be less effective than surgery in the mid- to long term.

Rotator Cuff Calcific Tendinitis

  • High energy Extracorporeal Shock Wave Therapy was proven to be safe and effective in five reviews. A fourth study found improvements in function, pain levels, and reduction in calcifications with continued improvement over the following 6 months.
  • Good outcomes were also found with ultrasound-guided needling, and arthroscopy.
  • The study also noted that although there were some adverse effects, these only affected the minority and resolved within a few days.
  • Manual and physical therapies were not investigated.

Adhesive Capsulitis (Frozen Shoulder)

  • Two studies found mobilisation to be effective in reducing pain. The first also suggested spinal mobilisation as a beneficial technique, and the other found that exercise and mobilisation are most effective in the “frozen” and “thawing” stages. A third review found that manual therapy with or without exercise therapy did have some positive evidence, but that more research would be required to draw a strong conclusion.
  • Low Level Laser Therapy (LLLT) gave very good results for pain relief, as shown in one study, but not for improving range of movement. A second study suggested that LLLT gave short term pain relief, and that steroid injections gave short to mid term benefits. In a third paper, LLLT showed improvement in pain levels for up to 4 weeks, and improvement in function for up to 4 months longer than combined placebo and exercise. Other electrotherapy modalities showed no benefit compared to placebos.
  • Arthrographic distension was shown to be moderately effective in the short term.
  • Glucocorticoid injections were indicated to be more effective than manual therapy and exercise in the short term.

Non-specific Shoulder Pain

  • Suprascapular Nerve Blocks had similar results to intra-articular injection of the glenohumeral joints: these results were better pain relief and function than with placebo injections with physical therapy.
  • A high quality systematic review found that thoracic manual therapy had an immediate effect in improving pain and function, and these benefits lasted for up to a year. The study also concluded that thoracic manual therapy helped to speed up recovery.
  • Another high quality study found only minor benefits in multimodal physical therapy when compared to usual care performed by GPs, or no treatment
  • Two more systematic reviews concluded that evidence is limited for mobilisation and/or manipulations with soft tissue release and exercise.
  • Neither ultrasound nor interferential current therapy were found to be effective.
  • A final systematic review reported that massage therapy gave significant immediate to short term effects. It also concluded that massage therapy was as effective as other therapies for improving shoulder function. However, pain was no better than when compared to other active therapies.

Shoulder Impingement Syndrome (SIS)

  • A systematic review concluded that there is moderate evidence that conservative treatment is as effective as surgery for the reduction of pain from shoulder impingement syndrome
  • Another paper found that taping and shockwave therapy are ineffective for SIS.
  • A study of acceptable quality found little difference between multimodal care and placebo, but reported better improvement with multimodal care compared to corticosteroid injections at some stages of SIS.
  • Isokinetic training had too little evidence for its effectiveness to be commented upon.

 

Hawk, C., Minkalis, A., Khorsan, R., Daniels, C., Homack, D., Gliedt, J., Hartman, J. and Bhalerao, S. (2017). Systematic Review of Nondrug, Nonsurgical Treatment of Shoulder Conditions. Journal of Manipulative and Physiological Therapeutics, 40(5), pp.293-319.