Mechanisms of action in the improvement of somatic pain and functional limitations after osteopathic treatment
Improvement of somatic pain-min

Mechanisms of action in the improvement of somatic pain and functional limitations after osteopathic treatment

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Osteopathic manipulative therapy (OMT) is the umbrella term for all osteopathic techniques. These include myofascial release, craniosacral treatment, high-velocity low-amplitude manipulations (HVLA) as well as minimal-lever manipulations, balanced ligamentous tension (BLT), muscle-energy techniques, biodynamics, strain/counterstrain, visceral manipulation, etc. (Cerritelli et al. 2011).

This wide range of manual techniques allows an individual choice of the most appropriate technique to optimise function and relieve pain.

According to a national pilot project with standardised data collection in England, patients most often come to the osteopathic practice with pain in the lumbar spine (LS), followed by cervical spine symptoms, pelvic and lumbar pain as well as head and facial pain, shoulder problems and pain in the thoracic spine. They often bring so-called comorbidities (additional, further illnesses) with them, such as high blood pressure, asthma or arthritis (Fawkes et al. 2014). 

Unlike classical orthodox medicine, however, osteopathy concentrates on promoting general health and always seeks health in the organism rather than disease. In addition to the manual therapy, the therapeutic conversation and the detailed anamnesis, which also asks about biopsychosocial aspects, are central to osteopathic treatment. In this way, osteopaths support their patients in topics such as establishing and maintaining a healthy lifestyle with sufficient exercise and a healthy diet (Fryer 2017).

People with chronic pain and functional limitations also often suffer from anxiety and depression, which have a negative impact on social, leisure and working life. These effects can hardly be explained by the biomedical framework, which is why the biopsychosocial model for chronic pain was developed. It encompasses physical, psychological, educational and social/work-related influences and attempts to include all facets of the disorder. Multidisciplinary interventions derived from this model are then implemented by a team of professionals from the different health care sectors. Already in 2015, a high-quality meta-analysis by the Cochrane Collaboration concluded that multidisciplinary biopsychosocial rehabilitation interventions are more effective than standard care in reducing pain and dysfunction in people with chronic low back pain. 

 

How do acute pain differ from chronic pain?

Acute pain is defined as pain of short duration that is triggered by noxious (tissue-damaging) stimuli. These include exogenous stimuli (such as intense heat) and endogenous disturbances (e.g. inflammation), both of which are capable of activating the nociceptors and triggering the typical experience of nociceptive pain (Kröner-Herwig 2011). However, pain is not a purely physical experience, but a conscious perception that is modulated by the brain and the psyche. Fear or the feeling of threat trigger an increased perception of pain in the brain (Moseley et Flor 2012). 

 

One speaks of chronic pain when the pain lasts longer than 6 months and no direct cause (such as tissue damage) can be identified as a trigger (Kröner-Herwig 2011). This can occur when the noxious stimulus is so intense or persistent that it leads to sensitisation of the central nervous system (CNS). The 2nd neuron of the nociceptive pain pathway is located in the spinal cord, which then leads to higher centres in the brain where the 3rd neuron is located. With long-lasting pain, neuroplastic changes occur in these neurons, which lead to hyperexcitability and increased synaptic efficacy. This process is also called central sensitisation. This leads to exaggerated pain reactions to normally non-painful stimuli, although the original tissue damage caused by noxious substances has long since healed. Chronic pain thus originates in the CNS (Esmaili et al. 2016). In addition to the sensitisation process, peripheral noxious agents also play a role in the experience of chronic pain.

Restructuring also takes place in the brain itself when pain becomes chronic: Activity in pain-related brain regions such as the insula, anterior cingulate gyrus and thalamus decreases, and emotion-based brain circuits involving the medial prefrontal cortex, amygdala and basal ganglia become stronger (Hashmi et al. 2013). This can lead to disturbances in propioception (perception of the body in space) and motor control (Moseley et Flor 2012). In addition, psychosocial factors also play an important role in the transition from acute to chronic pain (Shaw et al. 2016).

 

How does osteopathy look at chronic pain?

Research in recent years has shown that the central nervous system and the psyche have an influence on chronic pain, while evidence for tissue-related, postural or biomechanical causes is lacking. 

Osteopathy developed at a time when the biomedical paradigm was still predominant, which we still notice today in the use of the term "osteopathic lesion". More information about the origin of osteopathy can be found here: XXX (insert link from article on "osteopathic lesion").

Many osteopathic schools strictly follow the traditional concepts of Still, Littlejohn & Co, while more modern institutions are comprehensively questioning and developing the old concepts in the light of current scientific knowledge and also looking at osteopathy from an evidence-based perspective.

Old school osteopaths view manipulative techniques as correcting altered biomechanics and restricted movement and explain a person's pain in pathological and biomechanical terms rather than neurological or psychosocial terms. However, if the practitioner is aware that pain and restricted movement are associated with a combination of biological and psychosocial causes in varying degrees of dominance in most people, they can design a treatment plan that takes into account the physical and psychosocial components. Furthermore, osteopaths should recognise that chronic pain may also be the product of the long process of central sensitisation of the CNS and no longer have a tissue or nociceptive origin. 

 

Which mechanisms are responsible for the improvement of somatic pain and functional limitations after osteopathic treatment?

 

Osteopathic treatment can influence a variety of biological and psychosocial factors to help patients with acute or chronic somatic pain and movement restrictions. The effect of osteopathic treatment can be described in three dimensions (Lederman 2005):

 

  1. Tissue mechanisms
    • Promotion of tissue healing, movement and drainage of tissue fluid
  2. Neurological dimension
    • Stimulation of ascending afferent tissue receptors to facilitate sensorimotor integration, interoception, proprioception and motor control
  3. Psychological dimension
    • Promote reassurance, education, psychological approaches to pain management, improved confidence and empowerment

 

All three dimensions are closely linked and a treatment always influences all the areas addressed by bringing about changes in cognition and the psychological state. By modulating the perception of pain, this can lead to desensitisation in the body. Osteopaths can have a strong positive influence by carefully choosing their language to reassure, empower and provide a positive context for people who come to their practice.

 

First small-scale osteopathic studies prove the effect of osteopathic treatment of low back and neck pain (Franke et al. 2014, 2015). However, these results still need confirmation by many large RCT studies and meta-analyses to achieve scientific significance. 

The analgesic effect and reduction of pressure pain sensitivity of other manual techniques, such as spinal manipulations, joint treatments, mobilisation and massage, are well documented. There are even studies that prove that touch alone can reduce pain. It is believed that the so-called C-fibres, which respond optimally to gentle touch, are responsible for this and play an important role in the effectiveness of manual therapies. The mechanisms responsible for improving chronic pain are likely to be a combination of short-term tissue mechanisms and longer-term neurological mechanisms that allow the CNS to desensitise the stimuli, as well as psychological mechanisms (Fryer 2017).

literature

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Franke H, Franke JD, Fryer G. Osteopathic manipulative treatment for chronic nonspecific neck pain: A systematic review and meta-analysis. Int J Osteopath Med. 2015;18(4):255-267

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Hashmi JA, Baliki MN, Huang L, et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain. 2013;136(9):2751-2768

Kröner-Herwig B. Pain as a Biopsychosocial Phenomenon - an Introduction BT - Pain Psychotherapy: Fundamentals - Diagnosis - Disease Patterns - Treatment. In: Kröner-Herwig B, Frettlöh J, Klinger R, et al., eds. Springer Berlin Heidelberg; 2011:3-14.

Lederman E. The Science & Practice of Manual Therapy. Elsevier Health Sciences; 2005

Moseley GL, Flor H. Targeting cortical representations in the treatment of chronic pain: a review. Neurorehabil Neural Repair. 2012;26(6):646-652

Shaw WS, Hartvigsen J, Woiszwillo MJ, et al. Psychological distress in acute low back pain: a review of measurement scales and levels of distress reported in the first 2 months after pain onset. Arch Phys Med Rehabil. 2016;97(9):1573-1587

 

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