research and treatment bulletin

International Journal of Osteopathic Medicine (2014) xxx, xxxexxx

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Research and treatment bulletin

Specific and nonspecific effects of spinalmanipulation on pain reduction

Rafael Zegarra-Parodi. Private practice, Paris,France

Underlying mechanisms that have been pro-posed to understand spinal manipulative therapy(SMT) induced analgesia are suggesting a concom-itant activation of at least two different neuro-physiological mechanisms: (1) a segmentalinteraction of nociceptive and mechanoreceptivepathways at the spinal cord level and (2) a supra-segmental stimulation of the dorsal peri-aqueductal grey matter in the midbrain and itsdescending pathways, which excite and producenon-opioid analgesia by specifically suppressingthe mechanical nociceptive stimuli and produce ageneral pattern of sympathoexcitation.1�3 Someauthors investigating physiological effects associ-ated with SMT have described an apparent simi-larity between placebo and treatment conditionson physiological outcome measurements suggest-ing that clinical outcomes result from bothintervention-specific and placebo mechanisms.4

Placebo is associated with robust analgesiaenhanced by expectation for pain relief. A team ofphysical therapists have recently investigated theefficacy of SMT for changes in pain sensitivityoccurring beyond placebo in order to determinewhether lessening of pain is specific to SMT or theexpectation of receiving SMT.5 According to theseauthors, clarifying the mechanisms of SMT couldassist in identifying key features of individuals withLBP likely to respond to those interventions,allowing more efficacious clinical application.

110 participants with low back pain (LBP) wereincluded in thismechanistic trial andwere randomlyallocated to four different groups: SMT (n ¼ 28),placebo SMT (n ¼ 27), enhanced placebo SMT(n¼ 27) and no treatment (n¼ 28). The SMTused in

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this study, described as a “Chicago roll lumbarmanipulation” in the osteopathic profession, wasapplied twice on each side. For the placebo SMTgroup, a thrust of similar force to the studied SMTwas applied but participant’s lumbar spine wasmaintained in a neutral position with the pelvisremaining in contact with the table to prevent mo-tion. The enhanced placebo group received thesame placebo but participants were told “themanual therapy technique youwill receive has beenshown to significantly reduce LBP in some people”.Participants received their assigned interventionssix times over two weeks. Outcome measurementswere psychological questionnaires (the Fear Avoid-ance Belief Questionnaire, the Tampa Scale ofKinesiophobia and the Pain Catastrophizing Scale),pain sensitivity (mechanical and thermal painsensitivity, suprathreshold heat response and aftersensation) and participant satisfaction.

Authors did not observe group-dependent dif-ferences for changes in pain intensity anddisability at two weeks. Immediate attenuation ofsuprathreshold heat response was greatestfollowing SMT (P < .05). Significantly more partic-ipants receiving the enhanced placebo SMT indi-cated “probably to definitely yes” in response tothe question “would you have the same interven-tion you received in this study again for LBP?”(P < .05). Authors attributed SMT-specific attenu-ation of suprathreshold heat response to an effectbeyond the expectation of receiving an SMT.5

One key point of this study is the proposal of anew placebo control SMT that may help future in-vestigators to distinguish the nonspecific effects ofSMT.5 This important issue was raised by theosteopathic profession when designing controlprocedures in clinical trials to evaluate osteo-pathic manipulative treatment.6,7 Another inter-esting point that was highlighted in this study isparticipants’ satisfaction that was significantly

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greater when investigators added a simple andpositive quote prior to the application of the sameplacebo control SMT.5 Clinicians’ effectivenessdepends not only on their specific skills, but alsoon the amount of nonspecific effects they are ableto generate.8 Research on nonspecific effects ofseveral manual procedures may then help clini-cians to optimize their use during a patientencounter. This sounds promising because partici-pants’ satisfaction was improved after only fourenhanced placebo SMT applied six times over a twoweek period.5

References

1. Bialosky JE, Bishop MD, Price DD, Robinson MEand George SZ. The mechanisms of manualtherapy in the treatment of musculoskeletalpain: A comprehensive model. Man Ther 200914: 531e8.

2. Pickar JG. Neurophysiological effects of spinalmanipulation. Spine J 2002 2: 357e71.

3. Van Buskirk R. Nociceptive reflexes and thesomatic dysfunction: a model. J Am OsteopathAssoc 1990 90: 792.

4. Moulson A and Watson T. A preliminary inves-tigation into the relationship between cervicalsnags and sympathetic nervous system activityin the upper limbs of an asymptomatic popu-lation. Man Ther 2006 11: 214e24.

5. Bialosky JE, George SZ, Horn ME, Price DD,Staud R and Robinson ME. Spinal ManipulativeTherapyeSpecific Changes in Pain Sensitivity inIndividuals With Low Back Pain (NCT01168999).J Pain 2014 15: 136e48.

6. Licciardone JC and Russo DP. Blinding Pro-tocols, Treatment Credibility, and Expectancy:Methodologic Issues in Clinical Trials of Osteo-pathic Manipulative Treatment. J Am Osteo-path Assoc 2006 106: 457e63.

7. Fulda KG, Slicho T and Stoll ST. Patient ex-pectations for placebo treatments commonlyused in osteopathic manipulative treatment(OMT) clinical trials: a pilot study. OsteopathMed Prim Care 2007 1: 3.

8. Walach H. Non-specific effects, placebo ef-fects, healing effectsdAll doctors are healers.Eur J Integr Med 2008 1, Supplement 1: 33.

The enduring impact of what clinicianssay to people with low back pain

Dr Oliver Thomson, The British School of Osteop-athy, London, UK


A growing body of research confirms that psy-chosocial factors are central in the developmentand maintenance of low back pain and disability.For example, patients’ illness perceptions, self-efficacy beliefs and catastrophising of theirsymptoms have been identified as psychologicalobstacles to recovery of low back pain.1,2 Manualtherapy practitioners are also laden with their ownpersonal beliefs and conceptions towards manyaspects of their clinical practice3,4 including atti-tudes towards common clinical conditions such aslow back pain.5,6

This qualitative study by Darlow and colleagues7

aimed to understand why patients have particularbeliefs about low back pain and the impact of thesebeliefs. A secondary aim was to explore how pa-tients’ beliefs may relate to their practitioners’beliefs in regards to low back pain. Interview datawas collected from a total of 23 participants withlowback pain (12with acute and 11with chronic lowback pain). It is worth noting that several partici-pants with chronic low back pain had consultedwithmany different professionals for their problem,including osteopaths, Chinese medical practi-tioners, orthopedic surgeons, and spiritual healers.

The findings from this study form an explanatorymodel of how low back pain patients’ beliefs andperceptions develop. Although participants’ un-derlying beliefs about low back pain were influ-enced by a range of sources (such as the internet,family and friends), healthcare professionals werethe strongest influence on participants’ beliefs andtheir understanding of their pain and disability.Specifically, the authors suggest that the way inwhich practitioners communicated their expectedprognosis and described the cause and meaning ofsymptoms, influenced patients’ beliefs and un-derstanding of their low back pain, in some casesfor many years. Statements from practitionerswere interpreted by some patients that theyneeded to protect their back, and avoid move-ment. Such comments may introduce or reinforcepatients’ negative perceptions that their spine wasvulnerable, may encourage patients to adoptmaladaptive beliefs and behaviours. The findingsalso suggest that practitioners could positively in-fluence patients’ beliefs by emphasising theimportance of movement and activity andproviding reassurance. It is thought that cognitivereassurance strategies, which centre on educationand empowerment have the potential to positivelychange patients’ beliefs and perceptions and willin turn improve adherence and self-management.8

The findings from this study indicate that mes-sages and at times single, off-hand, statementsfrom practitioners can heavily influence how


Research and treatment bulletin 3

patients think about their back pain, and have alasting impact. Importantly for osteopathy, thisstudy indicates that emphasising pathoanatomicexplanations may directly contribute to avoidancebeliefs and maladaptive behaviours. Phrases suchas ‘joint restrictions’, ‘segmental dysfunction’,and ‘pelvic torsion’ form part of the osteopathicclinical ‘jargon’ and such notions are thought to becentral to effective osteopathic diagnosis, treat-ment and management.9,10 This research shouldencourage practitioners to critically reflect on thelanguage used with patients and be aware thattransferring their own personal and professionalbeliefs of low back pain may have a lasting andpossibly detrimental impact on patients’ recovery.

References

1 Foster NE, Thomas E, Bishop A, Dunn KM andMain CJ. Distinctiveness of psychological ob-stacles to recovery in low back pain patients inprimary care. Pain 2010 148: 398e406.

2 Grotle M, Foster NE, Dunn KM and Croft P. Areprognostic indicators for poor outcomedifferentfor acute and chronic lowback pain consulters inprimary care? Pain 2010 151: 790e7.

3 Thomson OP, Petty NJ and Moore AP. A quali-tative grounded theory study of the concep-tions of clinical practice in osteopathy e Acontinuum from technical rationality to pro-fessional artistry. Man Ther 2014 19: 37e43.

4 Thomson OP, Petty NJ and Moore AP. Osteo-paths’ professional views, identities and con-ceptions- A qualitative grounded theory study.Int J Osteopath Med (In Press) http://dx.doi.org/10.1016/j.ijosm.2013.12.002.

5 Pincus T, Foster NE, Vogel S, Santos R, Breen Aand Underwood M. Attitudes to back painamongst musculoskeletal practitioners: Acomparison of professional groups and practicesettings using the ABS-mp. Man Ther 2007 12:167e75.

6 Pincus T, Vogel S, Breen A, Foster N and Under-wood M. Persistent back pain-why do physicaltherapy clinicians continue treatment? A mixedmethods study of chiropractors, osteopaths andphysiotherapists. Eur J Pain 2006 10: 67e76.

7 Darlow B, Dowell A, Baxter GD, Mathieson F,Perry M and Dean S. The Enduring Impact ofWhat Clinicians Say to People With Low BackPain. Ann Fam Med 2013 11: 527e34.

8 Pincus T, Holt N, Vogel S, Underwood M, SavageR, Walsh DA et al. Cognitive and affective reas-surance and patient outcomes in primary care: Asystematic review. Pain 2013 154: 2407e16.


9 DiGiovanna EL, Schiowitz S. An osteopathicapproach to diagnosis and treatment: 2nd ed.Edition. Philadelphia: Lippincott-Raven; 1997.

10 Greenman PE. Principles of manual medicine:3rd ed. Edition. Philadelphia, Pa.; London:Lippincott Williams & Wilkins; 2003.

What matters to patients during outpa-tient rehabilitation withphysiotherapists?

Chris Macfarlane, Victoria University, Melbourne,Australia

This paper by Del Bano-Aledo and colleaguesconsiders patient perceptions of the ther-apistepatient interaction. Although this reflectionis on physiotherapy in an outpatient facility, thesereflections also relate to osteopathy as a manualtherapy family member. Patient perceptions areimportant as they provide data that captures whatmatters to patients when they evaluate theirhealthcare.1 Furthermore, this article informs the‘evidence in practice’ debate, as the authorsrightly note that patient-centred approaches arethe trend for health service delivery today. Suchdata, like perceptions, can inform the qualitycycle that guides a patient-centred approach. Thearticle is also a qualitative piece utilising Groun-ded Theory methodology and these articles areunder-represented in osteopathic literature.2

Del Bano-Aledo et al. identify a modifiedGrounded Theory as their method although they donot specifically describe any modifications. Theydetail the setting, participants and recruitmenthaving purposively sampled 95 eligible participantsby age, gender, and clinical condition. The finalgroup of 57 patients were organised into focusgroups (six to seven participants). The focus groupsexplored the perceptions of the post-acuteoutpatient rehabilitation physiotherapy sessions(for fractures, joint replacements, orthopaedicsurgery) the participants had received at threesimilar interdisciplinary outpatient rehabilitationcentres located in Spain.

Clarity and transparency have an important rolein providing support for the authors’ claims to anytheory generated from their analysis. The analyticprocess became somewhat clouded, however, forthe following reasons: the authors note in the ab-stract that predetermined questions were used butpresent a thematic guide - (Table 1) in the report;the authors do not indicate if emerging themeswerefollowed up, refined or further defined by subse-quent focus groups and; the authors note that




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predetermined categories were used in the analysisbut do not describe them, leaving one to assumethey arose from the literature review. Addingmember checking to the focus groupswould provideadditional support for the rigour of such a project.Theseare key points andwould help to replicate anddevelop a similar project in the future.

Despite these limitations the three themes thatemerged appear plausible and relevant to prac-tice. The outcomes were unsurprising and werepotentially relevant to a wide variety of industriesthat serve the public. Perhaps the process had‘cleaned’ the data too thoroughly and diluted orremoved potential themes that might have pro-vided a richer description of the patient-therapistinteractions in the rehabilitation centres. Never-theless most osteopaths and other manual orphysical therapists would agree that the resultingthree themes representing these patients’ expe-riences and perceptions of (1) interpersonal man-ners; (2) providing information and education; and(3) technical expertise are relevant, in fact key tocontemporary health practice.

References

1. Del Bano-Aledo ME, Medina-Mirapeix F, Escolar-Reina P, Montilla-Herrador J and Collins SM.Relevant patient perceptions and experiencesfor evaluating quality of interaction withphysiotherapists during outpatient rehabilita-tion: a qualitative study. Physiotherapy 2014100: 73e9.

2. Thomson OP, Petty NJ and Scholes J. Groundingosteopathic research e Introducing groundedtheory. Int J Osteopath Med 2013. (In Press:http://dx.doi.org/10.1016/j.ijosm.2013.07.010).

Visceral osteopathy and irritable bowelsyndrome

Emma Chippendale, The British School of Osteop-athy, London, UK

Irritable bowel syndrome (IBS) is defined as anassociation between abdominal pain and/orabdominal distention and bowel dysfunction for aspecified time, as classified by theRome III criteria.1

There aremanynon-drug treatments involved in themanagement of IBS including relaxation, hypnosis,acupuncture, yoga and cognitive behaviouralpsychotherapy. One previous study has looked atthe efficacy of osteopathy for IBS and showedimprovement in symptoms compared with standardtherapy but the study design did not control for a


placebo effect which is known to be strong amongthese patients.2

This study, conducted by the French team ofAttali and colleagues, attempted to assess visceralosteopathy versus a standardised placebo manipu-lation and to evaluate its effect on symptoms,colonic transit time and rectal sensitivity in re-fractory IBS patients.3 The study was a prospective,single centre, randomised, placebo controlled crossover trial where patients without organic diseasewere randomly assigned to a group having placebotreatment for six sessions followed by visceralosteopathic treatment for six sessions or to visceralosteopathy followed by placebo. The osteopathictreatment was carried out by the same clinician forall study subjects and involved global osteopathicvisceral techniques with local and specific vibrationtechniques to affect the organs. Placebo sessionsconsisted of a more superficial abdominal massagewithout organ manipulation. The patients wereassessed by standardised questionnaires and visualanalogue scales to record their symptoms and painlevels as well as clinical and physiological evalua-tion for colonic transit time and rectal sensitivity.

A total of 31 patients entered the study, only oneof whom had experienced osteopathy before whichconfirmed their ignorance of whether they werebeing subjected to osteopathic or sham treatmentalthough patients later reported being able to tellthe difference between the two treatments. Ingroup A, placebo treatment improved abdominaldistention and abdominal pain and then osteopathyfurther decreased diarrhoea, abdominal distentionand abdominal pain. In group B, osteopathy firstimproved all symptoms; constipation, diarrhoea,abdominal distention and abdominal pain. Theplacebo manipulation thereafter was not associ-ated with any change of symptoms. After theintervention, all symptoms scores had reduced incomparison to the initial evaluation. The decreasein abdominal pain was found to be significant in 7 of9 abdominal segments. A global analysis showedthat osteopathy decreased self-reported diar-rhoea, abdominal distention and abdominal pain,while VAS evaluated constipation did not changesignificantly. Rectal sensitivity was improved byosteopathy and unaltered by placebo manipulationand neither treatment altered colonic transit time.

The study concludes that visceral osteopathy iseffective for abdominal distention and abdominalpain, two cardinal symptoms of IBS. There weresignificant limitations in this study, notably thesample size and the presence of placebo, espe-cially where patients can tell the difference be-tween the two treatments and where the resultshave a subjective element.





References

1. Longstreth GF, Thompson WG, Chey WD,Houghton LA, Mearin F and Spiller RC. Func-tional Bowel Disorders. Gastroenterology 2006130: 1480e91.

2. Hundscheid HW, Pepels MJ, Engels LG andLoffeld RJ. Treatment of irritable bowel syn-drome with osteopathy: results of a random-ized controlled pilot study. J GastroenterolHepatol 2007 22: 1394e8.

3. Attali TV, Bouchoucha M and Benamouzig R.Treatment of refractory irritable bowel syn-drome with visceral osteopathy: Short-termand long-term results of a randomized trial. JDig Dis 2013 14: 654e61.

Short-Term effects of manual therapyon fibromyalgia syndrome

Brett Vaughan, College of Health & Biomedicine,Victoria University, Melbourne, Australia

The prevalence of fibromyalgia (FM) in thegeneral population is anywhere between 1.4%1 and4.7%2 depending upon the methodology employed.Previous work provides some support for the use ofmanual therapy in the management of FM.3,4 Cas-tro-Sanchez et al.5 investigated the short-termeffects of a specific manual therapy protocol ona range of outcome measures relevant to FM pa-tients. The authors employed a randomised,controlled trial methodology where participants,who had previously been diagnosed with FM ac-cording to the American College of RheumatologyCriteria, were allocated to either a control ormanual therapy intervention. The outcomesmeasured were pressure pain threshold, McGillPain Questionnaire (MPQ), Fibromyalgia ImpactQuestionnaire (FIQ), Pittsburgh Quality of SleepIndex and the Centre for Epidemiologic StudiesDepressive Symptoms Scale (CES-D). Outcomemeasurements were taken at baseline and afterthe five week intervention period.

Ninety participants were allocated to one of thetwo groups, with 45 participants in each group.Participants in the manual therapy group receivedone 45-minute treatment session per week for fiveweeks. The treatment session consisted of sub-occipital release, pectoral release, diaphragmrelease, lumbosacral decompression, psoas releaseand a prone thoracic spine HVLA. The interventionwas provided by a single physiotherapist. Partici-pants in the intervention group experienced lesspain, a decrease in the number of tender points,


and improvements in MPQ, FIQ, Pittsburgh, CES-Dscores when compared to the control group, andcompared to baseline measurements.

There are however, a number of issues with thestudy. The authors reported that the patients wereblinded to their group allocation. This is difficult toachieve with a control group receiving no inter-vention, and the lack of a placebo intervention.Allocation blinding is difficult to achieve in manualtherapy intervention studies but a placebo inter-vention would have strengthened the conclusions ofthe study. The generalisabilty of the results is alsolimited by the fact that only one practitioner pro-vided the intervention. The authors also failed toreport whether there were any adverse effectsfrom the interventions, something that is now ex-pected in any intervention study. From a trialmethodology standpoint, there is no indication thatthe study was registered as an RCTwith the ISRCTN.

This study presents a simple protocol that couldeasily beemployed indaily osteopathic practicewithFM patients. Practitioners are encouraged to applythe protocol described in the present study, andpotentially publish them as a case study or series inthe International Journal of Osteopathic Medicine.

References

1. Bannwarth B, Blotman F, Roue-Le Lay K, Cau-bere J-P, Andre E, Taıeb C. Fibromyalgia syn-drome in the general population of France: aprevalence study. Joint Bone Spine 2009 76:184e7.

2. Branco JC, Bannwarth B, Failde I, Abello Car-bonell J, Blotman F, Spaeth M et al. Prevalenceof fibromyalgia: a survey in five Europeancountries. Semin Arthritis Rheum 2010 39:448e53.

3. Gamber RG, Shores JH, Russo DP, Jimenez C,Rubin BR. Osteopathic manipulative treatmentin conjunction with medication relieves painassociated with fibromyalgia syndrome: resultsof a randomized clinical pilot project. J AmOsteopath Assoc 2002 102: 321e5.

4. Schneider M, Vernon H, Ko G, Lawson G, PereraJ. Chiropractic management of fibromyalgiasyndrome: a systematic review of the literature.J Manipulative Physiol Ther 2009 32: 25e40.

5. Castro-Sanchez AM, Aguilar-Ferrandiz ME, Mat-aran-Penarrocha GA, del Mar Sanchez-Joya M,Arroyo-Morales M, Fernandez-de-las-Penas C.Short-Term Effects of a Manual Therapy Proto-col on Pain, Physical Function, Quality of Sleep,Depressive symptoms and Pressure Sensitivity inWomen and Men with Fibromyalgia Syndrome:


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A Randomized Controlled Trial. Clin J Pain2013. (In Press) http://dx.doi.org/10.1097/AJP.0000000000000008.

Physiotherapy students experiences ofbullying during clinical placements

Simeon London, The British School of Osteopathy,London, UK

This recent study set out to consider the expe-riences of final year physiotherapy students in theUK who experienced workplace bullying on a clin-ical internship.1 The authors defined workplacebullying and the extent to which bullying inhealthcare is a problem nationally and interna-tionally, citing evidence suggesting that those withthe least experience (e.g. students) may be atgreatest risk. Importantly, the impact bullying canhave on the organisation in which it occurs and onthe individual were bought into focus. Althoughsome studies have been undertaken acrossdifferent health care settings, the authors high-lighted a dearth of research relating to bullying inphysiotherapy education.

A qualitative approach was employed, using asemi-structured interview to explore eight stu-dents’ experiences of bullying during clinicalplacement. Interview transcripts were analysedusing thematic analysis which allowed for theproduction of a thematic map. Coding and cate-gorisation of the data was undertaken to identifyinitial themes and sub themes and subsequentquantitative content analysis was used to detailthe frequencies of each sub-theme identified.

Four main themes were identified from theeight interviews: A) External and situational in-fluences of bullying - key factors identified herewere perceived pressures of the placement wherethe bullying occurred, lack of perceived supportfrom the educator, a meta-perception that theeducator had a lack of confidence in the student’sability. B) Students’ reaction to the experience ofbullying - internalisation of negative cognitions(e.g. not admitting to bullying, self-doubt, ques-tioning their own ability and future in the profes-sion). C) Inability to reveal the experience - aperception that they did not believe their experi-ences were significant enough to be reported,placement was for a limited time and thereforebullying could be tolerated, a lack of preparednessfor dealing with such situations. Ignoring bullyingwas the best way to deal with it so as to avoidpotential negative influences on their educationalcareer. D) Overcoming problems - implementing


institutional procedures for dealing with bullying,education to increase awareness of bullying,provision of an accessible support system (e.g.mediation).

The authors identified that student experiencesmirrored previous research findings highlightingthe personal nature of bullying. Interestingly,some students reported that the educators wereoften felt to be inapproachable which mirrors oneof the key characteristics of good clinical educa-tors identified elsewhere.2�4 A broad range ofother factors that can contribute to bullying is alsodiscussed, establishing that situational circum-stances and organisational behaviour can signifi-cantly contribute to such experiences.

Perhaps unsurprisingly existing literature iden-tifies that under-reporting of bullying is common-place. This study identified that many of the bullieswere responsible for assigning clinicalmarks, therebyinfluencing student’s willingness to identify bullies.

Sensible and practical suggestions as to how toovercome bullying are made, including policydevelopment and awareness, as well as training forsupervisors and education in how to deal withbullying for students, and the involvement of pro-fessional bodies in collaboration with institutionsand training sites to protect placement learningand professional engagement. The authors notethat nursing has made significant headway inaddressing bullying in the workplace. It would seemlogical that such initiatives could be applied withinother clinical education programmes such as phys-iotherapy and osteopathy.

Something that is not explicitly discussed is thefact that many physiotherapy student placementsin the UK are within the NHS where servicescontinually face budgetary and resource limita-tions. Given the potential pressures and demandson the workforce it might be thought unsurprisingthat individuals, departments and institutions caninfluence and contribute to student’s experiencesof bullying, and that it is relatively commonplace.Further research in this area could help to eval-uate the possible costs of such socioeconomicfactors and their significance.

References

1. Whiteside D, Stubbs B and Soundy A. Physio-therapy students’ experiences of bullying onclinical internships: a qualitative study. Phys-iotherapy 2014 100: 41e6.

2. Cross V. Perceptions of the Ideal ClinicalEducator in Physiotherapy Education. Physio-therapy 1995 81: 506e13.


http://dx.doi.org/10.1097/AJP.0000000000000008

http://dx.doi.org/10.1097/AJP.0000000000000008


3. Bennett R. Clinical Education: Perceived abili-ties/qualities of clinical educators and teamsupervision of students. Physiotherapy 200389: 432e40.


4. Davys, A. M. (2007). Active participation in su-pervision; a supervisors guide. In D. Wepa (Ed.),Clinical Supervision in Aotearoa/New Zealand(pp. 26e42). Auckland: Pearson Education.

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