Osteopathy

In 2008, I originally posted this article shamelessly plagiarising an essay by Samuel Homola entitled ‘What a Rational Chiropractor Can Do for You’.

In view of the differences between osteopaths and chiropractors in America I felt that it seemed appropriate for me to anglicise Homala’s piece.

I can take absolutely no credit for what follows but have re-posted it on this site primarily because the text continues to sum up my own feelings about osteopathy, perfectly.

I added a small amount of text and removed some non-osteopathic references. Furthermore, I contacted Samuel Homola and asked his permission to reproduce his essay and invited him to comment which, as you will see after the article, he did.

‘What an osteopath can do for you…’

Spinal manipulation can relieve some types of back and neck pain and other conditions related to tightness and loss of mobility, such as tension headache or aching in muscles and joints. It is also considered that massage may be as effective as cervical manipulation in relieving tension headaches. However, physical therapy techniques may be as effective as spinal manipulation in long-term relief of back pain. Osteopaths can offer all of these modalities, when appropriate, and thus provide patients with a choice. They may also offer basic advice about nutrition, weight loss, exercise, ergonomics, relaxation techniques, body mechanics, home care (such as use of hot or cold packs), massage, and other self-help measures that might help relieve or prevent aches and pains.

Science-based osteopaths make appropriate judgments about the nature of their patients’ problems, determine whether these problems lie within their scope, and make appropriate referrals for problems that do not. Osteopaths who use manipulation and physical therapy appropriately are also willing to coordinate with your doctor so you can therefore benefit from the best that both have to offer.

Making a hypothesis

While some types of back pain can benefit from spinal manipulation, not every patient who sees an osteopath needs it. Proper investigation and examination should precede treatment of any type. This is why, if you consult an osteopath, it is crucial to choose one who can make an appropriate hypothesis, uses spinal manipulation only when indicated, does not order unnecessary x-rays, and refers to an appropriate physician when needed.

Back-pain sufferers who have been diagnosed with musculoskeletal pain and have reservations about spinal manipulation should ask their doctor whether a referral for physical therapy is appropriate for their condition. A study published in 1998 in The New England Journal of Medicine found that the long-term effectiveness of spinal manipulation was no better than the McKenzie method of physical therapy (an exercise program) [1].

Manipulation vs. Mobilisation

Manipulation and mobilisation are used primarily in the treatment of conditions related to mechanical-type problems in joints and muscles.

Manipulation is a hands-on procedure used to restore normal movement by loosening joints and stretching tight muscles. In some cases, manipulation will restore normal movement by ‘unlocking’ a joint. A popping sound often occurs when a spinal joint is stretched a little beyond its normal range of motion.

Mobilisation simply stretches soft tissues by moving joints through a full range of movement. Mobilisation can increase the range of motion of the arms, legs, and shoulders, but manipulation may be more effective in relieving pain and restoring normal movement in the spinal joints.
Any portion of the spine that is tight, stiff, or painful on movement might benefit from appropriate manipulation. Different methods are used in different portions of the spine, since joint structure and the direction of movement in the neck and upper back differ from those of the lower back. For example, neck manipulation and upper-back manipulation might be done while the patient lies on their back whilst lower-back manipulation might be done while the patient lies on one side. Dozens of manipulative techniques can be used to meet the special needs of patients who must be positioned one way or another.

Neck Manipulation

Manipulation may improve the mobility of a cervical spine that has been stiffened by osteoarthritis or by scar tissue from an old injury. Disc degeneration caused by wear and tear or by injury is a common cause of loss of range of motion in the cervical spine and can often benefit from manipulation. Neck manipulation or mobilisation may improve range of motion and provide relief for neck pain and muscle-tension headache. But remember that benefit must be weighed against risk. Neck manipulation should not be used unless symptoms indicate a specific need for it. It should be done gently with care to avoid excessive rotation that could damage the patient’s vertebral artery. Neck manipulation should not be done immediately after an injury that causes acute neck pain. When the acute pain subsides, usually after a few days, manipulation may be useful to relieve restriction and restore normal joint mobility. Once the patient is symptom-free, it should be discontinued.
Patients who have pain caused by acute inflammation, as in rheumatoid arthritis or spondylitis, will rarely benefit from neck manipulation. Damage to upper cervical connective tissues in rheumatoid arthritis can also be a contraindication. When in doubt about whether you should undergo neck manipulation, check with your doctor and osteopath. A competent osteopath should not object to your seeing a specialist for a second opinion, in fact, they might actively encourage it.

Tension headaches, often called muscle-contraction or cervicogenic headaches, may benefit from manipulation that loosens joints and stretches tight neck muscles. Some anecdotal case reports suggest that migraine headache can be relieved with cervical manipulation. However, true migraine is unlikely to be relieved by neck manipulation.

Any kind of persistent headache should be brought to the attention of your family doctor whom may refer you to a neurologist. And so should any headache accompanied by fever, vomiting, weakness, a change in speech or vision, or any other unexplained symptoms. Severe headaches may require medical attention for pain relief.

Before submitting to cervical manipulation for the treatment of headache, it is essential to determine whether the problem might be caused by other factors and this is why it is important you’re your osteopath and doctor are aware of your symptoms. Fortunately, most headaches are of the simple tension or muscle-contraction variety. So there is a good chance that simple mobilisation or stretching of neck will relieve them.

A study published in 1998 in the Journal of the American Medical Association found that cervical manipulation might be no more effective than massage in the treatment of episodic or recurring tension headache [2]. Thus people with frequent tension headaches might want to first try mobilisation rather than cervical manipulation.

Thorax and Low Back

Pain in the upper and lower portions of the spine can often be treated successfully with manipulation and physical therapy. Low back pain is more common, is usually more serious, and deserves more attention. Herniated discs are rarely a problem in the upper back or thoracic spine, for example, while a herniated disc in the lower back or lumbar spine can pinch spinal nerves and cause weakness and loss of sensation in the legs or encroach upon the spinal canal to impair bladder or bowel function (this is referred to as cauda equina syndrome). This is why the Agency for Health Care Policy and Research (AHCPR) guidelines for treating low back pain caution against manipulating the lumbar spine when there is leg pain caused by nerve-root involvement [3].

Except when the thoracic vertebrae have been softened by disease or by aging, appropriate thoracic spine manipulation is rarely harmful and often can relieve backache related to fatigue, postural strain, arthritis, myofacitis, or other problems involving muscles and joints.

Other Joints and Muscles

Uncomplicated mechanical-type problems of the muscles or joints of the shoulder, elbow, wrist, knee, ankle, and foot can often be helped by an osteopath who uses physical therapy. Most osteopaths learn manipulative techniques for treatment of extremity joints, but these joints often benefit as much from mobilization as from manipulation.

Severe or prolonged problems with extremity joints should always be brought to the attention of a doctor. As with back pain, diagnosis is essential. When a condition under osteopathic care has not improved after three to six weeks, a specialist should be consulted for a second opinion. On the other hand, there are many situations where home care can be effective once the diagnosis has been made and acute symptoms have subsided. An osteopath will be able to advise when cost-saving self-care can be substituted for clinical, outpatient treatment. It is rarely necessary to continue any form of osteopathic treatment month after month.

References

1. Cherkin DC and others. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. New England Journal of Medicine 339:1021-1029, 1998.
2. Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache: A randomized controlled trial. JAMA 280:1576-1579, 1998.
3. Bigos S and others. Acute Low Back Problems in Adults. Rockville, MD: Agency for Health Care Policy and Research, 1994. AHCPR publication 95-0642.

Samuel Homola on July 15, 2008 at 1:26 pm said:

Jonathan,

I have no problem with your use of my article in equating musculoskeletal osteopathy with rational chiropractic.
I do not know anything about chiropractic in the UK. But since you are an osteopath, I do not see anything in your “plagiarized” version of the article that I would object to. Good luck.

Samuel Homola, D.C.

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