Welcome

I do hope this blog will be a useful resource for students, colleagues and those with an interest in osteopathy and manual medicine. I will update the blog from time to time with additional resources and observations which are either noteworthy or curious in themselves or contribute to the promotion of health, the scope of practice and the osteopath’s role in the wider healthcare context.
You will also find information relating to student workshops and CPD courses, based on small groups with PBL and practical content.
Kind regards
Laurence Kirk



Top Blogs

Feb 27 / admin

Vascular Claudication

still to come

http://www.manualtherapyjournal.com/article/S1356-689X%2808%2900136-7/abstract

Feb 27 / admin

Complex Regional Pain Syndrome

coming soon

The International Association for the Study of Pain(IASP)recommended some time ago that the old terms of ‘causalgia’ and ‘reflex sympathetic dystrophy'(RSD) be replaced with ‘complex regional pain syndrome'(CRPS). Type 1 CRPS is associated with trauma and equivalent to the old RSD whilst type 2 occurs in he absence of trauma and is similar to the old description of ‘causalgia’

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WFG-4XBR4S2-1&_user=10&_coverDate=01%2F31%2F2010&_rdoc=1&_fmt=high&_orig=gateway&_origin=gateway&_sort=d&_docanchor=&view=c&_searchStrId=1657674047&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=1850e772279c3981e7d08685a508e0f5&searchtype=a

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WFG-4XBR4S2-1&_user=10&_coverDate=01%2F31%2F2010&_rdoc=1&_fmt=high&_orig=gateway&_origin=gateway&_sort=d&_docanchor=&view=c&_searchStrId=1657674047&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=1850e772279c3981e7d08685a508e0f5&searchtype=a

Jan 31 / admin

Back to the Future

There has been an assumption, which appears to have some face value, that disability from low back pain (LBP) may be greater as a result of inactivity.  A recent review has suggested that there is however only a weak link with acute LBP, but a demonstrable and significant correlation for chronic LBP1

It may also seem self evident that a lifetime of relative inactivity could predispose to a greater risk of LBP.  Waddell famously described LBP as a late 20th century epidemic and a healthcare enigma2, and it shows no sign of letting up in the 21st century.

Given our increasingly sedentary lifestyles, a number of researchers have tried to investigate a potential direct ink between weakness in the lumbar paraspinal muscles and increased risk of LBP. A large scale Finnish study has recently demonstrated that in subjects with a mean age of just 21 years, lumbar paraspinal muscle weakness  does not correlate with an increased predisposition to LBP3. Although the conclusion was that atrophy or infiltration of  lumbar paraspinal muscles did not predict an increased risk of LBP, it will be interesting to look at the same subjects in 15 years time.

So, it would still seem prudent for all of us  to continue to recommend structured activity and  specific exercise for individuals  with LBP when appropriate.

Jan 31 / admin

Deep Vein Thrombosis in Practice

Deep vein thrombosis(DVT) can present in clinical practice as apparent musculoskeletal pain. A thorough case history is vital and new predictive rules can aid in the recognition of DVT.

Patients with deep vein thrombosis(DVT) of the lower limb may present in osteopathic practice with symptoms which may feel, to them, rather like a muscle tear or even nerve pain.

The clinical features accompanying a DVT can often be  somewhat variable. Since the 1990’s, Well’s criteria1 have been used in an attempt to quantify those variables which make  a diagnosis of DVT more likely. A recent research study has compared a new primary care rule with Well’s existing criteria and suggested that the new rule may be more reliable in clinical practice, in deciding whether  ultrasonography and treatment is indicated. 2

Physical testing procedures  such as Homan’s test for DVT appear to be out of favour as they are thought to be potentially risky as well as unreliable and non-specific 3 Nevertheless, it is important to remember that if in doubt, err on the side of caution before applying vigorous deep inhibition to a painful calf.

Wells Rule and the Primary Care Rule Scoring

to Rule Out Deep Vein Thrombosis (DVT)

Variables Wells Rule Primary Care Rule
Male sex 1
Oral contraceptive use 1
Presence of active malignancy (in last 6 mo) 1 1
Immobilisation paresis/plaster lower ex. 1
Major surgery (last 3 mo) 1 1
Absence of leg trauma 1
Localised tenderness of deep venous system 1
Dilated collateral veins (not varicose) 1 1
Swelling, whole leg 1
Calf swelling ≥3 cm 1 2
Pitting oedema confined to the symptomatic leg 1
Previously documented DVT 1
Alternative diagnosis at least as likely as DVT -2
Positive D-dimer result 6
Cutoff scores for considering DVT as absent ≤1 ≤3
  1. Wells et al: Lancet 1997; 350: 1795-1798.
  2. van der Velde et al; Comparing the Diagnostic Performance of 2 Clinical Decision Rules to Rule Out Deep Vein Thrombosis in Primary Care Patients; Ann Fam Med 9: 31
  3. Joshua AM, Celermajer DS, Stockler MR.Beauty is in the eye of the examiner: reaching agreement about physical signs and their value. Intern Med J. 2005 Mar;35(3):178-87.
Dec 31 / admin

Kindness Revisited

Kindness’ as a taught objective  does not feature prominently, if at all, in the curricula or course outlines of many osteopathic or medical institutions.

This may seem anomalous, since as far as the recipient is concerned, kindness is one of the most notable qualities of an effective practitioner1. We may be guilty of over emphasising the ‘cold’ scientific and quantitative elements of practitioner-ship at the expense of the ‘warm’ or more qualitative elements of human interaction.

In some quarters there even appears to be a perception that ‘kindness’ is somehow a weak, non-scientific and archaic quality far removed, in clinical  education, from the cold acquisition of specific academic and clinical skills. But, as practitioners, we are aware that kindness is a powerful factor and acts to not only enhance the therapeutic relationship, but also benefits the ‘giver’. Indeed, Buddhist teaching has long advocated the merit of  ‘metta’ a loving kindness and compassion. In addition, Professor Paul Gilbert has recently published ‘The Compassionate Mind‘ which, from a western psychotherapeutic approach, reinforces the very same notion that kindness and compassion do seem to confer benefits on both the giver and the receiver.

Clichéd  as it may be, many of us feel that we have a genuine vocation to help others and have long recognised that there is much more to  clinical effectiveness than the  mantra of evidence based practice alone would imply. To paraphrase John Launer: “I’m not a clever osteopath, but I am a kind one.”2

Wishing you all a very Happy and Healthy New Year

  1. W G Pickering: Kindness, prescribed and natural, in medicine. J Med Ethics 1997;23:116-118
  2. John Launer: On kindness. Postgrad Med J 2008;84:671-672.
Nov 30 / admin

To Crack or not to Crack?

Cavitation

‘Manipulation’ in the context of osteopathy or chiropractic refers to the technique of applying a quick force with little depth to a joint to influence function. Practitioners often feel that the technique is more successful when accompanied by the typical ‘crack’ .

This seems to be supported by a small preliminary study which identified greater joint gaping following HVT with cavitation when compared to HVT without1

A further recent study2  seems to also be convergent with many practitioner’s experience of using the technique. The study indicated that muscle spindles adjacent to the site of dysfunction were ‘down regulated’ following an HVT with audible cavitation. The implications are that the effect of HVT could be mediated at a local level, in addition to previous research which has postulated a dual somatosensory central effect.

  1. Cramer D et al;Assessing joint vibration during spinal manipulation; The FASEB journal.
  2. Clark et al. BMC Musculoskeletal Disorders 2011, 12:170
Nov 30 / admin

More Effects of Manual Treatment

In Progress
Diego T Field; Moderate Pressure Massage Elicits a Parasympathetic Nervous System Response
2009, Vol. 119, No. 5 , Pages 630-638

    Twenty healthy adults were randomly assigned to a moderate pressure or a light pressure massage therapy group, and EKGs were recorded during a 3-min baseline, during the 15-min massage period and during a 3-min postmassage period. EKG data were then used to derive the high frequency (HF), low frequency (LF) components of heart rate variability and the low to high frequency ratio (LF/HF) as noninvasive markers of autonomic nervous system activity. The participants who received the moderate pressure massage exhibited a parasympathetic nervous system response characterized by an increase in HF, suggesting increased vagal efferent activity and a decrease in the LF/HF ratio, suggesting a shift from sympathetic to parasympathetic activity that peaked during the first half of the massage period. On the other hand, those who received the light pressure massage exhibited a sympathetic nervous system response characterized by decreased HF and increased LF/HF.

    Moderate Pressure is Essential for Massage Therapy Effects
    May 2010, Vol. 120, No. 5 , Pages 381-385

    Moderate pressure appears to be necessary for massage therapy effects. Studies comparing moderate and light pressure massage are reviewed and they suggest that growth and development are enhanced in infants and stress is reduced in adults, but only by moderate pressure massage. The stimulation of pressure receptors leads to increased vagal activity which, in turn, seems to mediate the diverse benefits noted for massage therapy.

    Oct 29 / admin

    More on Manipulation

    As practitioners we are often asked how osteopathic treatment works, and in previous posts I have explored some of the theories and possible mechanisms. To add further to the possibilities it is worth looking at the phenomenon of arthrogenic muscle inhibition (AMI),  a persisting  reflex reaction of the musculature around a joint, usually ocurring after trauma to that joint 1. The initial reflex response may be potentially advantageous in preventing motion which could further damage an already injured joint, in a similar way to the swelling associated with the inflammatory response. Just like initial inflammation, and for the majority of individuals,  AMI does not persist. When AMI remains however, often for unknown reasons, it is likely to cause weakness and loss of function.

    AMI has been previously investigated and shown to occur in peripheral joints, particularly the ankle and knee, but to date there has been  little research conducted to investigate its occurence elsewhere.  There has been some previous research indicating that both ice treatment and electrical stimulation can switch the aberrant AMI off 2.  A recent osteopathic research pilot study has looked at muscle imbalance in low back pain, and it is suggested that one mechanism which may be responsible for the assymmetry visible on muscle functional MRI scans is AMI following irritation to the lumbar apophyseal joints 3(see image from Clark et, A=control, B=pre-treatment, C=post treatment, deactivated psoas is darker on the left and lighter post-treatment). Osteopathic manipulative treatment (OMT) may have the effect of restoring normal muscle activity by possibly switching off or ‘resetting’ the neural mechanism underlying the AMI responsible for persistent loss of muscle activation.

    1. Palmieri R et al; Arthrogenic response to a simulated ankle joint effusion; Br J Sports Med 2004;38:26-30
    2. Hopkins J et al; Cryotherapy and Transcutaneous Electric Neuromuscular Stimulation Decrease Arthrogenic Muscle Inhibition of the Vastus Medialis After Knee Joint Effusion, Journal of Athletic Training 2001;37(1):25–31
    3. Clark B et al; Muscle functional magnetic resonance imaging and acute low back pain: a pilot study to characterize lumbar muscle activity asymmetries and examine the effects of osteopathic manipulative treatment; Osteopath Med Prim Care. 2009; 3: 7
    Oct 10 / admin

    Anti-ageing Elixir?

    A report in the latest edition of cell metabolism has been widely reported in the media as potentially constituting the ‘elixir of life’1
    The research study evaluated the response of ‘middle aged mice’ to supplementation with liquid branched chain amino acids(BCAA’s). The BCCA’s used were leucine, isoleucine and valine. The mice benefited considerably in terms of longevity, muscle power and endurance. The middle aged mice apparently showed the sort of resistance to cellular damage normally only found in young mice.

    It appears that the BCCA’s were able to supercharge the ageing mice’s antioxidant resistance to nitric oxide and return their cellular metabolism to a more efficient and typically younger condition. The mice also had enhanced longevity as a result.
    There are obvious implications if the results are transferable to human populations. Indeed, some previous human studies appear to endorse the use of BCAA post exercise as an ergogenic aid to limit muscle damage2 . As a result of the media attention, at this very moment, ageing sports people(author included) will be considering attempting to relive the glory of their youth by taking the supplemental AA’s.
    Of clinical interest, a previous human study 3supports the idea of BCCA supplementation in enhancing muscle function, and notes that it may be of particular benefit in the treatment of fibromyalgia, in line with the ‘muscle energy’ theory of causation.

    Fibromyalgia has been a contentious and somewhat elusive condition to clinically quantify and evaluate, but there are felt to be some indications of an inherent defect in muscle metabolism, with cytokine imbalance being one factor4. In a previous post the author highlighted a potential beneficial  effect of manual treatment on cytokine levels,  posing the question as to whether  fibromyalgia  sufferers may derive even greater benefit from manual treatment and BCCA supplementation combined- perhaps a new research study is indicated?

    1. D’Antona G, et al; Branched-chain amino acid supplementation promotes survival and supports cardiac and skeletal muscle mitochondrial biogenesis in middle-aged mice.(2010) Cell Metab. 12 (4), 362-72.
    2. Shimomura Y, et al: Exercise promotes BCAA catabolism: Effects of BCCA supplementation on skeletal muscle during exercise J Nutr. 2004 Jun;134(6 Suppl):1583S-1587S.
    3. van West D, Maes M; Neuroendocrine and immune aspects of fibromyalgia.(2001) BioDrugs. 15 (8), 521-31.
    4. Hernandez ME, et al; Proinflammatory cytokine levels in fibromyalgia patients are independent of BMI; BMC Res Notes. 2010 Jun 3;3(1):156.
    Sep 29 / admin

    Manipulation and inflammation

    A recent, rather interesting,  small scale study has attempted to identify any further potential biochemical effects of manual treatment (referred to as OMT in the study)

    This small scale laboratory study used rats to identify pro-inflammatory and anti-inflammatory markers pre and post treatment. A reactive arthritis was induced to increase pro-inflammatory concentrations, then treatments in the form of modified muscle energy technique and stretch were applied. Blood samples were taken prior to inducing arthritic change and  analysed at intervals post treatment.

    It appeared that the treatment caused a rise in levels of certain cytokines. The authors, one of whom is well known American osteopath Jane Carriero,  conclude that further in vivo research with human subjects may give further insight into the effects and mechanisms of action of osteopathic treatment.

    Free Access to journal

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