Osteopathy Blog

Shoulder Pain Manual Therapy and Prescriptive Exercise by Osteopaths

Shoulder Pain

Shoulder pain is one of the most common musculoskeletal disorders. The lifetime prevalence is estimated to be in the range of 6.7–66.7%. Shoulder pain and stiffness may reduce the performance efficiency of a person in family life or social life as well as reduce productive activities (Yeun, 2017).

Osteopathic Approach to Shoulder Pain



Causes of Shoulder Pain

Referred pain from the neck (Radiculopathy)
Frozen shoulder / Adhesive encapsulitis
Rotator Cuff Injury
Subacromial Impingement
Subacromial Bursitis
Shoulder Dislocation
Glenohumeral Joint Capsular strain
Acromio-Clavicular Joint Capsular Strain
Shoulder Ligament Sprain

Quadrangular space syndrome

Massage for Shoulder Pain

there are various massage techiques that can be applied to the shoulder this includes t effleurage, petrissage, and friction.

Effleurage is rubbing the skin lightly from the distal site to the proximal site using the extremities. It reduces edema and promotes muscle relaxation by facilitating the flow of the lymph nodes (Yeun, 2017).

Petrissage is performed for the purpose of increasing the movability of the muscle, by twisting the area between the muscle and the skin after holding the soft
tissue (Yeun, 2017).

Friction is pressing the skin soft tissue deeply using a thumb, by putting it on the bone or on the fascia of the muscle (Yeun, 2017).

These techniques smoothen scar tissue and loosens the deep adhesion in the tendons, ligaments, joint capsules, Soft-tissue massage stimulates the trigger points, which are hyperirritable spots in skeletal muscle and are characterized by pain appearing at muscle contraction. The typical trigger points around the shoulder include the rotator cuff, latissimus dorsi, teres major, deltoids, and pectoral muscles (Yeun, 2017).

Massage therapy is frequently used as a method of improving the shoulder ROM, but there have not been many studies that comprehensively investigated its effect on the shoulder Range of Motion (Yeun, 2017).

Effectiveness of Massage for Shoulder Pain

Massage is an effective treatment for reducing shoulder pain in the short term (Yeun, 2017) and massage therapy for improving the shoulder Range of Motion, especially flexion and abduction movements (Yeun, 2017).

Thoracic Spine (Mid Back) Manipulation

Thoracic manipulation can accelerate recovery, in terms of pain reduction and reduced disability in Non Specific Shoulder Pain population. Pain relief and accelerated recovery can be achieved without directly treating the glenohumeral joint, which may be preferential in treating patients with a highly irritable
presentation (Peek, 2015).

What Techniques are most suitable for Shoulder Pain?

The Osteopath will make different choices about what techiques to apply as each patient is different and treatment is tailored to the individual. Also the osteopath must help each patient arrive at a management decision consistent with her or his values and preferences in mind

Cam Osteopathy

To book an appointment go to booking

Reference List

Peek AL, Miller C, Heneghan NR (2015). Thoracic manual therapy in the management of non-specific shoulder pain: a systematic review. J Man Manip Ther.  Sep;23(4):176-87

Yeun YR (2017). Effectiveness of massage therapy for shoulder pain: a systematic review and meta-analysis. J Phys Ther Sci. May; 29(5):936-940.

Yeun YR (2017). Effectiveness of massage therapy on the range of motion of the shoulder: a systematic review and meta-analysis. J Phys Ther Sci.  Feb;29(2):365-369

Thoracic Outlet Syndrome Manual Therapy by Osteopaths

What is Thoracic Outlet Syndrome?

Thoracic outlet syndrome (TOS) is a condition in which there is compression of the nerves, arteries, or veins in the passageway from the lower neck to the armpit. There are three main types: neurogenic, venous, and arterial. The neurogenic type is the most common and presents with pain, weakness, and occasionally loss of muscle at the base of the thumb. The venous type results in swelling, pain, and possibly a bluish coloration of the arm. The arterial type results in pain, coldness, and paleness of the arm.

Types of Thoracic Outlet Syndrome

There are three main types of TOS, named according to the cause of the symptoms; however, these three classifications have been coming into disfavour because TOS can involve all three types of compression to various degrees. The compression can occur in three anatomical structures (arteries, veins and nerves), it can be isolated, or, more commonly, two or three of the structures are compressed to greater or lesser degrees. In addition, the compressive forces can be of different magnitude in each affected structure. Therefore, symptoms can be variable.

• Neurogenic TOS includes disorders produced by compression of components of the brachial plexus nerves. The neurogenic form of TOS accounts for 95% of all cases of TOS.
• Arterial TOS is due to compression of the subclavian artery. This is less than one percent of cases.
• Venous TOS is due to compression of the subclavian vein. This makes up about 4% of cases.

Signs and Symptoms

Signs and symptoms of Thoracic Outlet Syndrome vary with every patient according to the location of the neurovascular tension and/or compression injury within the thoracic outlet. Symptoms of TOS can range from mild pain and sensory changes to limb- and/or life-threatening complications. Patients can present with multiple unilateral or bilateral signs and symptoms associated with involvement of both neurogenic and vascular components. The quality, location and timing of symptoms all present valuable information to the clinician (Hooper et al. 2010).
Arterial TOS, while infrequent, can produce a series of profound symptoms. Patients suffering from this condition can present with pain, numbness in a nonradicular distribution, coolness to touch and pale discoloration, all of which worsen with cold ambient temperatures (Hooper et al. 2010).
Venous TOS results in excruciating deep pain the chest, shoulder and entire upper extremity, accompanied by a feeling of heaviness that occurs especially after activity. The patient will present with cyanotic discoloration and distended collateral veins, potentially accompanied by edematous increases in the volume of the extremity (Hooper et al. 2010).
Symptoms associated with neurogenic TOS include pain, paresthesia, numbness, and/or weakness (Hooper et al. 2010).

Conditions with similar symptoms

Other conditions that can produce similar symptoms include rotator cuff tear, cervical disc disorders, fibromyalgia, multiple sclerosis, and complex regional pain syndrome

What could have caused Thoracic Outlet Syndrome

There are many causes of Thoracic Outlet Syndrome. The most frequent cause is trauma, either sudden (as in a clavicle fracture caused by a car accident), or repetitive (as in a legal secretary who works with his/her hands, wrists, and arms at a fast paced desk station with non-ergonomic posture for many years). TOS is also found in certain occupations involving lots of lifting of the arms and repetitive use of the wrists and arms.

One cause of arterial compression is trauma, and a recent case involving fracture of the clavicle has been reported.
The two groups of people most likely to develop TOS are those suffering from neck injuries due to traffic accidents and those who use computers in non-ergonomic postures for extended periods of time. TOS is frequently a repetitive stress injury (RSI) caused by certain types of work environments.

Other groups which may develop TOS are athletes who frequently raise their arms above the head (such as swimmers, volleyball players, dancers, badminton players, baseball pitchers, and weightlifters), rock climbers, electricians who work long hours with their hands above their heads, and some musicians.

Neurovascular impingement sites seen in Thoracic Outlet Syndrome

According to Hooper et al. (2010) Neurovascular impingement sites include:

1. Presence of a cervical rib (uncommon)
2. Abnormal Clavicle (collar bone) can create compression through exostosis, tumor, callus or fracture of the first rib, subsequently irritating the brachial plexus
3. Soft tissue abnormalities may create compression or tension loading of the neurovascular structures found within the thoracic outlet container. Scalene muscle variations include hypertrophy of the anterior scalene muscle, passage of the brachial plexus through the substance of the anterior scalene muscle, and a broad, excessively anterior middle scalene muscle insertion on the first rib the container, resulting in an increased potential for neurovascular load

Treatment of Thoracic Outlet Syndrome

Treatment can either involve a conservative non-surgical approach or surgical. The non-surgical approach can involve manual therapy and exercise to treat various neurovascular impingements that occur in thoracic outlet syndrome.

Treatment of the Costoclavicular space

Restoring mobility to the first rib can increase the costoclavicular space and reduce the imposed load on the neurovascular structures in the thoracic outlet container. Investigators have reported decreased TOS symptoms by restoring the mobility of the first rib through manual therapeutic procedures. Other authors have recommended mobilizations or manipulative treatment to the first rib costotransverse and costovertebral joints in order to restore first rib mobility and open the costoclavicular gate (Hooper et al. 2010).

It is possible that these mobilization techniques may reproduce the patient’s symptoms, particularly upper extremity paresthesias. Selected authors discourage the use of first rib mobilization in these patients for this reason. However, if the symptoms are the result of a ‘release phenomenon’, patients should be encouraged to continue with the measures, as the symptoms may be occurring due to a normalization of nerve function associated with unloading of the brachial plexus (Hooper et al. 2010).

Overuse of the scalenes and other accessory respiratory muscles may result in an elevation of the first rib and rib cage, reducing the costoclavicular space. Encouraging diaphragmatic breathing helps reduce the activity of these muscles, increasing the costoclavicular space. Vigorous aerobic activities may increase scalene activity and elevation of the first rib, so careful use of aerobic activities may help reduce symptoms, especially early in the rehabilitation process (Hooper et al. 2010).

Mobilization of the sternoclavicular and acromioclavicular joints is necessary to restore normal end-range arthrokinematics of the clavicle during elevation activities. Additionally, end-range limitations of glenohumeral motion can lead to compromise of the costoclavicular space. These limits can be addressed with mobilizations in the elevated arm position. The humerus can be glided in an anterior, posterior and inferior direction, respecting the orientation of the glenoid (Hooper et al. 2010).

Treatment of the Posterior Scalene Triangle

The posterior scalene triangle can be widened by (1) mobilizing the first rib in the direction of expiration and (2) stretching the scalene muscles. First rib mobilizations are performed as previously described. Once mobility of the first rib has been restored, increased activity of the scalene muscles may be addressed. Patients with hypertrophy or spasm of the scalenes will benefit from diaphragmatic breathing and a reduced reliance on the accessory respiratory muscles. These muscles can be stretched through a caudal mobilization of the first rib with the head rotated towards and laterally flexed away from the side being treated. The first rib self-mobilization technique may be modified to emphasize a stretch of the scalenes (Hooper et al. 2010).

Treatment of Thoraco-Coraco-Pectoral Space

Narrowing of the thoraco-coraco-pectoral space can result from shortening of the pectoralis minor or pectoralis major muscles. The pectoralis minor is stretched in a supine position with the patient’s shoulder over the edge of the table. The patient is brought into 70 degrees of glenohumeral flexion with internal rotation and slight adduction. The clinician’s contralateral hand is placed over the coracoid process, and the shoulder is stretched in a cranial and dorsal direction. The pectoralis major can be stretched with a corner stretch with the shoulders abducted 90 degrees and 125 degrees to stretch the clavicular and sternal heads, respectively. Care must be taken that this position does not increase the patient’s symptoms (Hooper et al. 2010).

Patients, with TOS resulting from narrowing of the thoraco-coraco-pectoral space, often present with a forward head posture and rounded, sagging shoulders. Proper posture should be emphasized throughout the treatment program with these patients. Encouraging a relative retraction of the shoulders increases the thoraco-coraco-pectoral space (Hooper et al. 2010).

A strip of hypoallergenic tape applied across the scapulae while in a comfortably retracted posture provides an effective tactile cue for the patient when the shoulders begin to fall into a protracted position. Another factor that may cause a sagging shoulder posture is heavy breasts in females. Pressure on the neurovascular tissues may be decreased by wearing a good support bra with wide, crossed posterior straps. Reduction mammoplasty has been recommended for extreme cases (Hooper et al. 2010).

Compromised sensorimotor control of the posterior parascapular muscles, particularly the rhomboids, serratus anterior, and lower and middle trapezius, can alter the position of the scapula at rest and during arm elevation activities, ultimately leading to thoracic outlet narrowing (Hooper et al. 2010).

Sensorimotor control exercises for these muscles are begun once relative pain control has been achieved. Novak recommends beginning these exercises in a gravity-assisted position in order to ensure proper recruitment of the lower scapular stabilizers and reduce the influence of the upper scapular elevators (Hooper et al. 2010).

All exercises should focus on muscular endurance rather than strength.7 Because limited upward rotation, posterior tilting and retraction of the scapula during elevation activities may decrease the costoclavicular space, these exercises may be beneficial for patients with symptoms due to narrowing of that passage as well (Hooper et al. 2010).

When a loss of neural mobility is present, neural mobilizations are incorporated in order to improve gliding of the neural tissue in relation to its surroundings and minimize tension and adhesion formation. These techniques are especially important in cases of a double crush phenomenon (Hooper et al. 2010).

Specific neural mobilization techniques can be modified to emphasize the brachial plexus proximally in the costoclavicular or thoraco-coraco-pectoral space while the clinician performs an inferior mobilization of the first rib. Additionally, the median and ulnar nerves more distally can be emphasized. Neural mobilizations should be performed in a pain-free manner; therefore, any increases in symptoms with these exercises are best addressed by either decreasing the number of repetitions or altering the technique used (Hooper et al. 2010).

For a home mobilization program, patients are instructed to initially perform up to 20 repetitions and gradually increase up to 100 repetitions as tolerated. This program may be repeated one to two times daily (Hooper et al. 2010).

Treatment at Cam Osteopathy

The Osteopaths at Cam Osteopathy are very competent to treating the neurological thoracic outlet syndrome. So for more information on thoracic Outlet Syndrome or to book an appointment with an Osteopath.

Reference List

Hooper TL, Denton J, McGalliard MK, Brismée JM, Sizer PS Jr (2010). Thoracic outlet syndrome: a controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis. J Man Manip Ther. Jun; 18(2):74-83

Hooper TL, Denton J, McGalliard MK, Brismée JM, Sizer PS Jr (2010). Thoracic outlet syndrome: a controversial clinical condition. Part 2: non-surgical and surgical management. J Man Manip Ther. Sep; 18(3):132-8.

Low Back Pain Osteopathy and Prescriptive Exercise by Osteopaths

Osteopathic Treatment of Low Back Pain

Low back pain (LBP) is the most common musculoskeletal condition affecting the adult population, with a prevalence of up to Chronic low back pain (CLBP) is a chronic pain syndrome in the lower back region, lasting for at least 12 weeks.

Looking for the Pain Generator

Low back pain symptoms can derive from many potential anatomic sources, such as nerve roots, muscle, fascial structures, bones, joints, intervertebral discs (IVDs), and organs within the abdominal cavity. Moreover, symptoms can also spawn from aberrant
neurological pain processing causing neuropathic Low back pain. The diagnostic evaluation of patients with low back pain can be very challenging and requires complex clinical decision-making. Nevertheless, the identification of the source of the pain is of fundamental importance in determining the therapeutic approach.

Furthermore, during the clinical evaluation, a clinician has to consider that low back pain can also be influenced by psychological factors, such as stress, depression, and/or anxiety. History should also include substance use exposure, detailed health history, work, habits, and psychosocial factors. Clinical information is the leading element that drives the initial impression, while magnetic resonance imaging (MRI) should be considered only in the presence of clinical elements that are not definitely clear or in the presence of neurological deficits or other medical conditions.

Type of spinal pain according to pain generator

In spite of the hard work done by the International Association for the Study of Pain, there remains a degree of confusion in the medical
community regarding the definitions of back pain, referred pain, radicular pain, and radiculopathy. Nevertheless, a precise diagnostic assessment is necessary to indicate the right treatment.

Radicular pain

Radicular pain is pain evoked by ectopic discharges emanating from an inflamed or lesioned dorsal root or its ganglion; generally, the pain radiates from the back and buttock into the leg in a dermatomal distribution. Disc herniation is the most common cause, and inflammation of the affected nerve rather than its compression is the most common pathophysiological process. Radicular pain is pain irradiated along the nerve root without neurological impairment. Even though it is nociceptive pain, it is distinguished from usual nociception because in radicular pain the axons are not stimulated along their course or in their peripheral terminals but from the perinevrium.

Radicular pain differs from radiculopathy in several aspects. Radiculopathy impairs conduction down a spinal nerve or its roots. The impairment of sensory fibers causes numbness (dermatomally distributed); however, blockade of motor fibers causes weakness (myotomal). Sensory or motor block may result in diminished reflexes. Although radiculopathy and radicular pain often accompany one another, radiculopathy has been observed in the absence of pain, and radicular pain may happen in the absence of radiculopathy. It is important to underline that, contrary to popular belief, it is not possible to make a distinction among the patterns of L4, L5, and S1 radicular pain. In fact, only when radiculopathy is seen together with radicular pain can segments been estimated. In such cases, the dermatomal distribution of numbness indicates the segment of origin rather than the distribution of pain. Lumbar disc herniation with radiculopathy can be diagnosed during clinical examination using manual muscle testing, supine straight leg raise, Lasègue sign, and crossed Lasègue sign.

Facet joint syndrome

The lumbar zygapophyseal joints are the posterior articular process of the lumbar column. They are formed from the inferior process of upper vertebra and the superior articular process of lower vertebra. They are supplied by the medial branches of the dorsal rami (MBN). These joints have a large amount of free and encapsulated nerve endings54 that activate nociceptive afferents and that are also modulated by sympathetic efferent fibers. Lumbar zygapophyseal or “facet” joint pain has been estimated to account for up to 30% of chronic low back pain cases, with nociception originating in the synovial membrane, hyaline cartilage, bone, or fibrous capsule of the facet joint.

Diagnosis of facet joint syndrome is often difficult and requires a careful clinical assessment and an accurate analysis of radiological exams. Patients usually complain of low back pain with or without somatic referral to the legs terminating above the knee, often radiating to the thigh or to the groin. There is no radicular pattern. Back pain tends to be off-center and the pain intensity is worse than the leg pain; pain increases with hyperextension, rotation, lateral bending, and walking uphill. It is exacerbated when waking up from bed or trying to stand after prolonged sitting. Finally, patients often complain of back stiffness, which is typically more evident in the morning. Jackson was able to correlate seven features with facet pain: older age, previous episodes of low back pain, normal gait, maximal pain with lumbar extension but a failure to aggravate pain with the Valsalva maneuver, and a lack of leg pain or muscle spasm.

Sacroiliac joint pain

Sacroiliac joints (SIJs) are dedicated to providing stable but flexible support for the upper body. SIJs are involved in sacral movement, which additionally directly influences the discs and almost certainly the higher lumbar joints.  The SIJ is well recognized as a source of pain in many patients who present with CLBP. It is thought that pain could be generated by ligamentous or capsular tension, extraneous compression or shear forces, hypermobility orhypomobility, altered joint mechanics, and myofascial or kinetic chain dysfunction causing inflammation.

Intra-articular sources of SIJ pain include osteoarthritis; extraarticular sources include enthesis/ligamentous sprain and primary enthesopathy. In addition, ligamentous, tendinous, or fascial attachment and other cumulative soft tissue injuries that may occur posterior to the dorsal aspect of the SIJ may be a source of discomfort. SIJ pain is often underdiagnosed. It has to be considered in every situation in which the patient complains of postural LBP that worsens in a sitting position and with postural changes. Furthermore, it is possible that SIJ pain is often strictly related to facet joint syndromes as both are related to postural problems.

Finally, it is important to consider that SIJ pain could also be a sign of rheumatic disease. MRI findings of articular effusion and inflammation (especially if bilateral) can alert the clinician to consider this condition.

Lumbar spinal stenosis

Lumbar spinal stenosis (LSS) can be congenital or acquired (or both). It could be determined by inflammatory/scar tissue after spine surgery or, even in absence of previous surgery, by disc herniation, thickening of the ligaments, or hypertrophy of the articular processes. The majority of cases of LSS are degenerative, related to changes in the spine with aging. LSS is determined by a progressive narrowing of the central spinal canal and the lateral recesses and consequent compression of neurovascular structures.

Degenerative LSS is the most common indication for spinal surgery in people older than 65 years of age. The most frequent symptoms of lumbar stenosis are midline back pain, radiculopathy with neurologic claudication, motor weakness, paresthesia, and impairment of sensory nerves. Symptoms may have a different distribution depending on the type of LSS. If the LSS is central, there maybe involvement of the area between the facet joints, and pain may be bilateral in a non-dermatomal distribution. With lateral recess stenosis, symptoms are usually found dermatomally because specific nerves are compressed, resembling unilateral radiculopathy.

Trunk flexion, sitting, stooping, or lying can all ease the discomfort, while prolonged standing or lumbar extension can aggravate the pain. Sitting or lying down become less effective in alleviating pain as the condition progresses, and rest pain or a neurogenic bladder can develop in severe cases. Neurogenic claudication pain is the classical symptom of LSS, caused by venous congestion and hypertension around nerve roots. Pain is exacerbated by standing erect and by downhill ambulation but alleviated with lying supine more than prone, sitting, squatting, and lumbar flexion.

Discogenic pain

Disc degeneration (DD) has been estimated as the source of Chronic LBP in 39% of cases. Its symptoms are aspecific, axial, and without radicular radiation and they occur in the absence of spinal deformity or instability. Discogenic pain is often a diagnosis of exclusion among other types of Chronic LBP. Pathologically, it is characterized by the degradation, within the disc, of the NP matrix with accompanying radial and/or concentric fissures in the AF.

UK Clinical Guidelines

The National Institute of Clinical Excellence (NICE) (2016) Recommends manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) for managing low back pain with or without sciatica, but only as part of a treatment package including exercise, with or without psychological therapy. Please see the diagram below in Low back pain and sciatica: summary of NICE guidance (2017) from the British Medical Journal.

Cam Osteopathy

For more information on osteopathic treatment of Low back pain or to book an appointment with an Osteopath at Cam Osteopathy, then click on the Home Page or book an appointment

Reference List

Allegri M, Montella S, Salici F, Valente A, Marchesini M, Compagnone C, Baciarello M, Manferdini ME, Fanelli G (2016). Mechanisms of low back pain: a guide for diagnosis and therapy. Version 2. F1000Res. Jun 28

National Institute of Clinical Excellence (NICE) (2016). Low back pain and sciatica in over 16s: assessment and management. NICE: London. November 2016.

Low back pain and sciatica: summary of NICE guidance (2017). British Medical Journal 356: i6748

Guide to Fibromyalgia Multi-Disciplinary Management and Massage by Osteopaths

What is Fibromyalgia?

Fibromyalgia, also called fibromyalgia syndrome (FMS), is a long-term condition that causes widespread pain all over the body.

Why do People with Fibromyalgia have widespread pain?

The Central Nervous System and Central Sensitization

Abnormalities in the central nervous system are associated with the intense widespread enhancement of pain in fibromyalgia. Where there is imbalance in the neuropeptides that regulate pain sensitivity in the central nervous system. In particular it has been found that  there is sustained 2- to 3-fold elevation of Cerebrospinal fluid substance P and other neuropeptides that facilitate pain in patients with fibromyalgia, as well as diminished metabolites of Cerebrospinal fluid serotonin, norepinephrine, and dopamine, which act to inhibit pain perception (Hawkins, 2013).

Pain is the sine qua non of fibromyalgia, and patients with this disorder experience widespread allodynia (perception of pain caused by a stimulus that should not normally cause pain) and hyperalgesia (exaggerated sense of pain in response to a noxious stimulus) (Hawkins, 2013).

Musculoskeletal Soft Tissues

The connective tissue overlying the musculoskeletal soft tissues known as fascia can be dysfunction in Fibromyalgia. The  fascial dysfunction in fibromyalgia leads to widespread pain and central sensitization (Liptan et al. 2010).


Sign and Symptoms of Fibromyalgia



Differentiating Between Fibromyalgia and Myofascial Pain Syndrome

In accordance with guidelines of the American College of Rheumatology (ACR), the Fibromyalgia Syndrome is diagnosed on the basis of two basic criteria. The first is a generalized pain stated during the anamnesis (that is: occuring on the left and right side, below and above waist, and concerning at least one part of spine and chest). The second criterion is a pressure achiness of at least 11 out of 18 tender points (TP) of precisely determined location (Chochowska et al. 2015).

Myofascial Pain Syndrome is defined as as sensory, motor and autonomic complaints, caused by the occurrence of trigger points (TrP). Presence of TrP makes up minimal criteria provided by Simons and collaborators – TrP have to occur in order to enable recognizing MFPS. The other predicates are: palpable tense muscle strand (so called “tense ribbon”) in the area of which a presence of at least one painful nodule (papule) is stated. Subsequently in the area of aforesaid nodule there is a hypersensitive point which – if being pressed, scratched by needle, or when only the tissues surrounding it are stretched – cause pain disproportionate to the intensity of stimulus and frequently radiating. Such pain is recognized by the patient as the one experienced before. This sensitive point is defined as a trigger point (Chochowska et al. 2015).

Fibromyalgia Massage

Fibromyalgia massage may improve pain, anxiety, depression, and sleep disturbance by complex interplay of both physical and mental modes of action (Li et al. 2014).

Myofascial Release

Myofascial release can be used to treat fascial restrictions that occur with fibromyalgia, where the aim of treatment focuses primarily on muscle relaxation.  The involves direct mechanical stimulation of connective tissue can potentially reverse connective tissue fibrosis in fibromyalgia. Myofascial fibrotic changes can theoretically be treated by breaking up excessive collagen adhesions through soft-tissue and myofascial release techniques. If there is excess tension in the fascial system in fibromyalgia due to chronic sympathetic nervous dominance, manual therapy may also help reduce that tension (Liptan et al. 2010).

What Style of Massage Works Best for Fibromyalgia?

There is moderate evidence that myofascial release has positive effects on multiple fibromyalgia symptoms, especially pain, anxiety and depression, for which the effect sizes are clinically relevant. Effects on pain and depression were observed in the medium and short terms, respectively. When comparing connective tissue massage or shiatsu with educational approaches, limited evidence supports the application of these styles of massage. Manual lymphatic drainage might be superior to connective tissue massage in terms of stiffness and depression. Swedish massage may not be beneficial for fibromyalgia. Overall, most styles of massage therapy consistently improved the HRQoL of fibromyalgia patients (Yuan et al. 2015).

All of these styles of massage can be performed by the Osteopaths at Cam Osteopathy Ltd.

How Does Massage Effect Fibromyalgia

Effect of Massage on the Peripheral Microcirculation and Musculoskeletal Soft Tissues

When massage therapy is delivered to soft and connective tissues, local biochemical changes would be stimulated. This helps to improve muscle flexibility, and modulate local blood and lymph circulation. As a result, local nociceptive and inflammatory mediators may be reabsorbed (Li et al. 2014).

Massage treatment helps improve the microcirculation of the muscles and fascia causing better fluid exchange bringing more nutrients to the soft tissues and prevents the accumulation of inflammation. This is because the connective tissue (fascia) encasing the muscles in fibromyalgia develops entrapment patterns can appear when a body segment stops receiving appropriate stimuli, establishing a pathological process with deficient circulation and limitation in nutrient supply to the fundamental substance of connective tissue, with its consequent densification. Because dense tissue is hypomobile, this situation leads to movement limitations (Castro-Sánchez et al. 2011). Massage treatment can also help break down the dense connective tissue.

Effect of Massage on the Central Nervous System

Some studies found that massage therapy improved pain by modulating serotonin levels in patients with FM. The local effects may change neural activity at the spinal cord segmental level, which is responsible for both mood and pain perception. Some studies maintained that massage therapy resulted in the reduction in the H-reflex. A large reduction in the H-reflex would seem to be desirable, because spinal hyperexcitability is associated with a variety of chronic pain syndromes (Li et al. 2014).

How Often Might I Need Fibromyalgia Massage?

Everyone’s requirements are different and treatment is tailored to your needs. Though it has been suggested that fibromyalgia massage needs to be painless and performed once or twice a week, with intensity increasing gradually according to symptoms (Kalichman, 2010).

Evidence Base for Fibromyalgia Massage?

A systematic review found the positive evidence that massage therapy with duration 5 weeks had beneficial immediate effects on improving pain, anxiety, and depression in patients with FM. Massage therapy should be one of the viable complementary and alternative treatments for FM. However, given fewer eligible RCTs in subgroup meta-analyses and no evidence in follow-up effects, large-scale RCTs with long follow-up are warrant to confirm the current findings of massage therapy for FM (Li et al. 2014).

Where as a long term, 20-week massage-myofascial release program significantly improved the pain, anxiety, quality of sleep, and quality of life in FMS patients. The treatment reduced the sensitivity to pain at sensitive points, mainly at the lower cervicals, gluteal muscles, and right greater trochanter (Castro-Sánchez et al. 2011).

Multi-Disciplinary Management of Fibromyalgia

Ultimately managing this condition is going to involve multiple treatments and therapies, so this will involve psychologists to do cognitive behavioral therapy, exercise and medication prescribed by a GP or rheumatology specialist doctor.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (to address maladaptive thoughts) and stress-reduction techniques have been shown to be effective in some patients. Recognizing and addressing behavioral issues of catastrophizing behavior and learned helplessness can aid in focusing treatment on self-management technique (Hawkins, 2013).


Aerobic exercise and muscle strength training can reverse deconditioning and improve sleep, pain, and function in patients with fibromyalgia. Patients who choose activities they like (eg, walking, pool exercise, group activities) and who start at low levels of exercise are more likely to be successful in managing their fibromyalgia in the long term. Exercise intensity should be increased very slowly to avoid injury and flares of pain, which may cause the patient to abandon the activity. Patients with good coping skills are most likely to adhere to an exercise program (Hawkins, 2013).


Antidepressants appear to exert their effects by modulating serotonin and norepinephrine pathways. Tricyclic antidepressants (TCAs) such as amitriptyline, desipramine, and nortriptyline have been shown in short-term studies to improve pain, sleep, fatigue, and overall sense of well-being. However, they are associated with more adverse effects when used at higher doses.Tricyclic antidepressants are often prescribed initially for patients with fibromyalgia who do not have depression (Hawkins, 2013).

Antiepileptic Drugs

Pregabalin, which is approved by the US Food and Drug Administration for the management of fibromyalgia, and gabapentin appear to inhibit the release of pain pathway neurotransmitters, including substance P and glutamate.They have been demonstrated to improve pain, sleep, fatigue, and overall quality of life in patients with fibromyalgia (Hawkins, 2013).

Combined Treatment Safety

One pilot study showed that combined Osteopathic Manual Manipulative treatment and gabapentin are safe and clinically efficacious treatment of pain and other constitutional and somatic symptoms associated with fibromyalgia (Marske et al. 2018).

Massage Treatment at Cam Osteopathy

To book an appointment go to booking

Reference List

Castro-Sánchez AM, Matarán-Peñarrocha GA, Granero-Molina J, Aguilera-Manrique G, Quesada-Rubio JM, Moreno-Lorenzo C (2011). Benefits of massage-myofascial release therapy on pain, anxiety, quality of sleep, depression, and quality of life in patients with fibromyalgia. Evid Based Complement Alternat Med. 561753.

Chochowska M, Szostak L , Marcinkowski JT , Jutrzenka-Jesion J (2015). Differential diagnosis between fibromyalgia syndrome and myofascial pain syndrome. Journal of Pre-Clinical and Clinical Research, Vol 9, No 1, 82-86.

Hawkins RA (2013). Fibromyalgia: a clinical updateJ Am Osteopath Assoc. Sep;113(9):680-9.

Kalichman L (2010). Massage therapy for fibromyalgia symptoms. Rheumatol Int. Jul;30(9):1151-7

Li YH, Wang FY, Feng CQ, Yang XF, Sun YH (2014). Massage therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials. PloS One. Feb 20; 9(2):e89304

Liptan GL (2010). Fascia: A missing link in our understanding of the pathology of fibromyalgia. Journal of Bodywork and Movement Therapies, Volume 14, Issue 1, January, Pages 3-12

Marske C, Bernard N, Palacios A, Wheeler C, Preiss B, Brown M, Bhattacharya S, Klapstein G (2018). Fibromyalgia with Gabapentin and Osteopathic Manipulative Medicine: A Pilot Study. J Altern Complement Med. Jan 3

Yuan SL, Matsutani LA, Marques AP (2015). Effectiveness of different styles of massage therapy in fibromyalgia: a systematic review and meta-analysis. Man Ther. Apr; 20(2):257-64.

Guide to Pregnancy Related Low Back Pain and Pelvic Girdle Pain Manual Therapy by Osteopaths

How does pregnancy dispose you to Low Back Pain and Pelvic Girdle Pain

Numerous changes in body posture and musculoskeletal disorders occur during pregnancy – most commonly involving bodily statics in the pelvic and spinal areas – due to horizontal positioning of the sacrum and increased lordosis in the lumbar area (Majchrzycki et al. 2015).


Pregnancy contributes to irritation of ligaments between the spinous processes (interspinous and supraspinous ligaments) (Majchrzycki et al. 2015).

Lumbar Intervertebral Discs

Pregnancy causes overload of intervertebral discs at the level of L4/L5 and L5/ S1 is observed, as well as vertebrae rotation and muscle contracture causing tension of the ligaments (Majchrzycki et al. 2015).

Pelvis, Lumbar Facet Joints and Surrounding Muscles

Other causes include loss of stabilization in the spinal muscles in the lumbar area, increased load on facet joints, and loosening of ligaments in the sacroiliac joint and pubic symphysis (Majchrzycki et al. 2015).

How does the body adapt to these changes during pregnancy?

Summary of the Changes

All these processes result in an excessive pelvic mobility, and lead to severe pain in the lumbosacral spine during pregnancy. Approximately 50% of pregnant women complain of pelvic and spinal pain in the lumbosacral area, with 25% reporting prevalent pain also postpartum (Majchrzycki et al. 2015).

In the group of women with chronic spinal pain, around 10% report the pain to have appeared during the pregnancy, most commonly between the fourth and the eighth month (Majchrzycki et al. 2015).

Pain Levels

Most women consider the discomfort caused by the back pain to be an integral element of pregnancy, and fail to seek medical help. Only about 50% of the women, usually those with high pain intensity measured with the visual analogue scale (VAS), consult a doctor. Out of that group, approximately 70% are treated, in most cases with the use of different methods of therapy (Majchrzycki et al. 2015).

Pregnancy related Pelvic Girdle Pain

Pelvic Girdle Pain (PGP) is typically experienced in the vicinity of the sacroiliac joints. The underlying etiology of pregnancy related low  back pain and pelvic girdle pain is not fully understood. Current theories suggest that the symptoms may be related to changes in posture during pregnancy (increased lumbar lordosis), and increases in weight and instability of the pelvic girdle due to hormonal changes. It is estimated that more than two-thirds of pregnant women experience LBP, whereas, 20% suffer from PGP (Hall et al. 2016).

Pregnancy related Low Back Pain

Low back pain (LBP) is encountered in an estimated 70% of pregnant patients but challenges persist in identifying safe, effective treatment options. For example, most pain medications are not recommended during pregnancy, leaving few options for pain control (Hensel et al. 2015).

Osteopathic manipulative treatment (OMT) is a body-based treatment that offers a conservative, non-invasive option for relieving pregnancy-related LBP while increasing back-related function. Osteopathic manipulative treatment is defined as “the therapeutic application of manually guided forces by an osteopathic physician to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction” (Hensel et al. 2015).

Pregnancy brings dramatic musculoskeletal changes that alter normal biomechanics, accompanied by ligamentous strain, increased muscle tension, and decreased range of motion, causing pain. OMT treats somatic dysfunctions with a variety of techniques, thereby increasing range of motion, improving tissue texture, and decreasing pain (Hensel et al. 2015).

The Royal College of Obstetricians and Gynaecologists Recommends Osteopathy for pregnancy related Pelvic Girdle Pain

Manual therapy (hands-on treatment) to the muscles and joints by a osteopath, who specialises in pelvic girdle pain in pregnancy. They will give you hands-on treatment to gently mobilise or move the joints to get them back into position, and help them move normally again. This should not be painful (RCOG, 2015).

Osteopathic Treatment during pregnancy

Osteopathic manipulative treatment is a form of therapy based on the use of relevant manual techniques to reduce tension in the myofascial structures, joints and ligaments. It is one of therapies treating lumbosacral spine pain in pregnant women and it occupies a special place among manual procedures. OMT can be used in severe lumbosacral spine pain (Majchrzycki et al. 2015).

Is Osteopathic Treatment Effective During Pregnancy?

Manual procedures are effective and significantly reduce back pain in pregnancy. Also manual therapy is effective in the prevention and treatment of back and pelvic pain in pregnant women. Manual procedures are a popular technique in pain management in the USA, where this treatment is offered primarily to pregnant women (Majchrzycki et al. 2015).

What Trimester Does Back Pain Usually Appear?

Back pain ailments usually appear in the third trimester of pregnancy as a result of thoracic kyphosis, lumbar lordosis and pelvic tilt. It is suggested that in case of lumbosacral pain in pregnant women, muscle energy techniques can be used to relax the joints. All of the above mentioned techniques are safe to be applied in pregnant women at any stage of pregnancy (Majchrzycki et al. 2015).


The Pregnancy Research in Osteopathic Manipulation Optimizing Treatment Effects (PROMOTE) study was designed to evaluate the efficacy of a nine-week regiment of OMT to reduce LBP during the third trimester  (Hensel et al. 2015).

The primary objective was to evaluate the influence of OMT on self-reported pain and back-related functioning (Hensel et al. 2015).

A secondary objective was to corroborate an earlier study that found a relationship between receiving OMT during the third trimester and a decrease in meconium-stained amniotic fluid. We chose to examine this relationship based on a supposition that reducing maternal stress caused by pain may reduce meconium-staining, a potential objective measure of fetal stress (Hensel et al. 2015).

Results of the PROMOTE Study

The treatment goals for LBP in pregnancy differ from other conditions in that it may not be reasonable to expect to eliminate pain and disability, but instead to slow the progression related to advancing pregnancy. In PROMOTE, both OMT and Placebo Ultrasound treatment (PUT) demonstrated significant mitigating effects on pain and functional disability compared to Obstetric Care only (UCO) (Hensel et al. 2015).

Therefore, the inclusion of body-based therapies such as OMT that provide touch, time and interaction may offer patients and providers a safe, effective adjunctive option to improve comfort and reduce the impact of pain commonly associated with third trimester pregnancy (Hensel et al. 2015).

Results of Application of osteopathic manipulative technique in the treatment of back pain during pregnancy Study (2015)

Manual therapy procedures appear to be effective and safe for pelvic and spinal pain management in the lumbosacral area in pregnant women and women in reproductive age. OMT use for back pain in pregnancy can eliminate or signifcantly reduce the need for pharmaceutical drugs which, especially when used in the first and second trimester, can result in adverse fetal effects (Majchrzycki et al. 2015).

When is the most appropriate time to combine Osteopathic Manipulative Treatment with Obstetric Care?

A study by Licciardone et al. (2010) demonstrated the feasibility of providing OMT as a complement to conventional obstetrical care during the third trimester of pregnancy.

The Safety of Osteopathic Manipulative Treatment

Osteopathic manipulative treatment (OMT) during the third trimester of pregnancy as applied in the PROMOTE study is safe with regard to labour and delivery outcomes. Though, the increased duration in labour in the OMT group needs further study (Hensel et al. 2016).

Impact of Massage during Labour

Lower back massage can significantly reduce labour pain and increase the satisfaction with birth. Health professionals, who work in the delivery unit, can use massage intervention for decreasing pain, shortening delivery time and increasing satisfaction with birth experience (Unalmis Erdogan et al. 2017).

What the Osteopath should be aware of?

In the application of osteopathic techniques, osteopath will evaluate your level of pain as a factor for whether treatment is safe during pregnancy. As it has been shown that mothers who experience high levels of pain during pregnancy may be at increased risk of complications during labour. Whether the relationship has a physiological, mechanical or psychological cause, raising awareness of how pain at this time may affect women‘s birth experiences (Brown and Johnston, 2013).

Current Evidence Base of Osteopathic Treatment for Pregnancy related Low Back Pain and Pelvic Girdle Pain

There is currently limited evidence to support the use of manual therapies including massage and osteopathic manipulative treatment as an option for managing low back pain and Pelvic girdle pain during pregnancy. Current research is associated with a risk of publication and methodological biases, and lack of robust control comparisons. Further high-quality research is needed to determine causal effects, the influence of the therapist (Hall et al. 2016).

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Reference List

Brown A, Johnston R (2013). Maternal experience of musculoskeletal pain during pregnancy and birth outcomes: significance of lower back and pelvic pain. Midwifery. Dec;29(12):1346-51.

Hall H, Cramer H, Sundberg T, Ward L, Adams J, Moore C, Sibbritt D, Lauche R (2016). The effectiveness of complementary manual therapies for pregnancy-related back and pelvic pain: A systematic review with meta-analysis. Medicine (Baltimore). Sep; 95(38):e4723.

Hensel KL, Buchanan S, Brown SK, Rodriguez M, Cruser dA (2015). Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects: the PROMOTE study. Am J Obstet Gynecol. Jan; 212(1):108.e1-9.

Hensel KL, Roane BM, Chaphekar AV, Smith-Barbaro P (2016). PROMOTE Study: Safety of Osteopathic Manipulative Treatment During the Third Trimester by Labor and Delivery Outcomes. J Am Osteopath Assoc. Nov 1; 116 (11):698-703.

Licciardone JC, Buchanan S, Hensel KL, King HH, Fulda KG, Stoll ST (2010).  Osteopathic manipulative treatment of back pain and related symptoms during pregnancy: a randomized controlled trial. Am J Obstet Gynecol. Jan;202(1):43.e1-8.

Majchrzycki M, Wolski H, Seremak-Mrozikiewicz A, Lipiec J, Marszałek S, Mrozikiewicz PM, Klejewski A, Lisiński P (2015). Application of osteopathic manipulative technique in the treatment of back pain during pregnancy. Ginekol Pol. Mar; 86(3):224-8.

Royal College of Obstetricians and Gynecologists (RCOG) (2015). Pelvic girdle pain and pregnancy.

Unalmis Erdogan S, Yanikkerem E, Goker A  (2017). Effects of low back massage on perceived birth pain and satisfaction. Complement Ther Clin Pract. Aug;28:169-175

Guide to Temporomandibular Joint Disorder Manual Therapy by Osteopaths

What is a Temporomandibular Joint Disorder?

Temporomandibular joint disorder is a problem affecting the ‘chewing’ muscles and the joints between the lower jaw and the base of the skull. It is sometimes referred to as a “myofascial pain disorder”. It’s been estimated that up to 30% of adults will experience a temporomandibular joint (TMJ) disorder at some point in their lives.

The condition itself isn’t usually serious, and the symptoms it can cause – including pain, jaw joint clicking or popping, and difficulties eating – usually only last a few months before getting better. However, these symptoms can significantly lower quality of life, and specialist treatment might be required if they’re severe.

What are the symptoms?

Temporomandibular Joint Disorder can cause:
• clicking, popping or grating noises as you chew or move your mouth
• muscle pain around the jaw
• pain in front of the ear that may spread to the cheek, ear and temple
• difficulty opening the mouth – the jaw may feel tight, as if it is stuck, making eating difficult
• headache or migraine
• earache or a “buzzing” or blocked sensation in the ear
• pain in other areas of the body – such as neckache or backache
These symptoms may lead to related symptoms, such as disturbed sleep.

Possible causes of Temporomandibular Joint Disorder

• clenching your jaw or grinding your teeth during sleep (bruxism) – which overworks the jaw muscles and puts pressure on the joint (often caused by stress)
• wear and tear of the inside of the jaw joint – usually caused by osteoarthritis
• injury to the jaw joint – for example, after a blow to the face or surgery
• stress – some people may inherit increased sensitivity to pain or stress
• uneven bite – for example, when new fillings, dental crowns or dentures are fitted
• specific diseases – temporomandibular joint disorder may be associated with specific diseases such as rheumatoid arthritis, gout or fibromyalgia

The Dental Approach to a Temporomandibular Joint Disorder

Dentists may use occlusal splints to manage a temporomandibular joint disorder. These are known as nightguards, bruxism appliances, or orthotics.
Various kinds of splints are available and can be classified into 2 groups—anterior repositioning splints and autorepositional splints. Physiologic basis of the pain relief provided by splints is not well understood. Factors such as alteration of occlusal relationships, redistribution of occlusal forces of bite, and alteration of structural relationship and forces in the temporomandibular joint (TMJ) seem to play some role.

Also, Auto-repositional splints, also known as muscle splints, are used most frequently. Some sort of pain relief is seen in as many as 70-90% of patients using splints. In acute cases the splint may be worn 24 hours a day for several months and as the condition permits, worn at night only.

Manual Therapy for Temporomanibular Joint Disorder

Manual therapy has also been shown to be more cost effective and less prone to side effects than dental treatment (Martins et al. 2007).

Purpose of Temporomandibular Joint Manipulation

Temporomandibular manipulation is based on the premise that the curvilinear motion of the mandibular condyle can be interrupted should the articular disc be held anteriorly along the articular eminence through adhesions, myospasm or disc deformity. Since the TMJ is also capable of lateral glide, deviations and deflections also need to be addressed. Conditions are usually described as either acute or chronic and in terms of their functional capacity (open or closed lock, restricted range of motion) and tissue involvement (myogenous, arthrogenous, combined) (Kalamir et al. 2007).

Combined Osteopathic Manipulative Treatment and Osteopathy in the Cranial Field for Temporomandibular Joint Disorder

A pilot study demonstrated the reduction of pain, the improvement of temporomandibular joint dysfunction and the positive impact on quality of life after osteopathic manipulative treatment and osteopathy in the cranial field (Gesslbauer et al. 2016). However it is important to bear in mind that osteopathy in the cranial field has not been proven to effective for many musculoskeletal conditions.

Massage Around The Tempormandibular Joint

Massage of the lateral pterygoid muscle according to Cyriax’s principles is a simple and efficient method that can be recommended for patients presenting with temporomandibular joint dysfunction syndrome (Barriere et al. 2009)

Effectiveness of Manipulative Techniques for Temporomandibular Joint Disorder

Musculoskeletal manipulations approaches are effective for the treatment of temporomandibular joint disorders. In short term, there is a larger effect for musculoskeletal manual approached manipulations compared to other conservative treatments for temporomandibular joint disorder (Martins et al. 2016).

Additionally, there is a fair level of evidence for the Manual and Manipulative treatment (MMT) of the temporomandibular joint disorder in the short term (≤3-6 months) using: MMT to the jaw joint, cervical spine, myofascial structures and/or combined with exercise, multimodal therapy and/or interdisciplinary care (Brantingham et al. 2013).

Effectiveness of Neck Joint Mobilization and Muscle Stretching for Temporomanibular Joint Disorder

The cervical spine therapy approach using neck joint mobilization, muscle stretching, and stretching stabilization seems to cause significant improvement in pain-free maximum mouth opening, self-reported pain, and mandibular functionality in subjects with myofascial pain or mixed Temporomandibular Joint Disorders (Calixtre et al. 2016).

Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Joint Disorder

Exercises and Manual Therapy are safe and simple interventions that could potentially be beneficial for patients with Temporomandibular Joint Disorders. Active and passive exercise for the jaw, postural exercises, and neck exercises appear to have favorable effects for patients with Temporomandibular Joint Disorders. Manual therapy alone or in combination with exercises shows promising effects. Exercises did not show clear superiority over other conservative treatments for Temporomandibular Joint Disorders (Armijo-Olivo et al. 2016).

Which Techniques work best to treat a Temporomandibular Joint Disorder?

The most effective techniques to improve clinical outcomes (pain and range of movement of the TMJ) include combined articular (e.g. mandibular distraction mobilization, mandibular translation mobilization, mandibular accessory movements, cervical mobilization, cranio-cervical thrust) and extraarticular (e.g. myofascial release in jaw elevator muscle, general myofascial release, muscle energy, balance membrane tension, cranial-sacral therapy, tender-trigger point, muscle stretching, soft tissue cervical and TMJ mobilization) techniques (Martin et al. 2016).

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Reference List

Armijo-Olivo S, Pitance L, Singh V, Neto F, Thie N, Michelotti A (2016). Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis. . Jan; 96(1): 9–25

Barriere P, Zink S, Riehm S, Kahn JL, Veillon F, Wilk A (2009). [Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome]. Rev Stomatol Chir Maxillofac. Apr; 110(2):77-80.

Brantingham JW, Cassa TK, Bonnefin D, Pribicevic M, Robb A, Pollard H, Tong V, Korporaal C (2013). Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: a systematic review. J Manipulative Physiol Ther. Mar-Apr; 36 (3):143-201.

Calixtre LB, Grüninger BL, Haik MN, Alburquerque-Sendín F, Oliveira AB (2016). Effects of cervical mobilization and exercise on pain, movement and function in subjects with temporomandibular disorders: a single group pre-post test. J Appl Oral Sci. May-Jun;24(3):188-97

Gesslbauer C, Vavti N, Keilani M, Mickel M, Crevenna R (2016). Effectiveness of osteopathic manipulative treatment versus osteopathy in the cranial field in temporomandibular disorders – a pilot study. Disabil Rehabil. Dec 28:1-6.

Kalamir A, Pollard H, Vitiello AL, Bonello R (2007). Manual therapy for temporomandibular disorders: A review of the literature. Journal of Bodywork and Movement Therapies. 11, 84–90

Martins WR, Blasczyk JC, Aparecida Furlan de Oliveira M, Lagôa Gonçalves KF, Bonini-Rocha AC, Dugailly PM, de Oliveira RJ (2016). Efficacy of musculoskeletal manual approach in the treatment of temporomandibular joint disorder: A systematic review with meta-analysis. Man Ther. Feb; 21:10-7.

Guide to Migraine Treatment with Osteopathy by Osteopaths

What are Migraines?

The International Headache Society describe migraine as a Idiopathic, recurring headache disorder manifesting in attacks lasting 4-72 hours. Typical characteristics of this headache are unilateral/one sided pain location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity, and association with nausea, photo- and phonophobia.

Many people also have symptoms such as nausea, vomiting and increased sensitivity to light or sound.
Migraines affect around one in every five women and around one in every 15 men. They usually begin in early adulthood.
There are several types of migraine, including:
•  with aura – where there are specific warning signs just before the migraine begins, such as seeing flashing lights
• without aura – the most common type, where the migraines occurs without the specific warning signs
• aura without headache, also known as silent migraines – where an aura or other migraine symptoms are experienced, but a headache doesn’t develop
Some people have migraines frequently, up to several times a week or occasionally. It’s possible for years to pass between migraine attacks.

Stages and Symptoms of Migraine


The Osteopathic Treatment of Migraines

With migraines the pain originates around the pericranial, neck and/or shoulder muscles may be referred to the head and experienced as a headache. In their comprehensive text, they described referred pain patterns emanating from different myofascial trigger points (MTrPs) in the head and neck muscles which might potentially contribute to certain head and neck symptoms found in migraine sufferers. MTrPs have been defined as highly localized and hyperirritable points situated in a palpable taut band of skeletal muscle fibers. When compressed or stretched, MTrPs may elicit local and/or referred pain or local twitch response (Tali et al. 2014).

Combination Headache

Migraine and tension-type headache often coexist in the same patient. Previously the diagnosis “combination headache” has been used, but it has never been defined.

Effect of Massage/ Manual Therapy on Migraines

A study by Noudeh et al. (2012) found that cervical spinal manipulation and upper thoracic spine massage could significantly reduce the headache pain intensity in acute migraine attacks. As the prevalence of MTrPs in neck muscles are associated with migraines (Tali et al. 2014). Therefore massage treatment would be the preferred option by the osteopath to treat any mechanical/ musculoskeletela aspects of the migraine

Comparing the effects of Manual Therapy and Medication

In a systematic review by Chaibi et al. (2011), they concluded that massage therapy, physiotherapy, relaxation and spinal manipulative therapy might be equally efficient as propranolol and topiramate in the prophylactic management of migraine because some migraineurs do not tolerate medication because of AEs or co-morbid disorders,cervical spine manipulative therapy might be considered in situations where other therapeutic options are ineffective or poorly tolerated.

Though a manual therapy approach would only be suitable if the migraine is caused by musculoskeletal presentation.

Effect of Cervical Spine Manipulation on Migraines

Chaibi et al. (2016) claims  some suffers of migraine may not be able to tolerate the side effects of medication, then cervical spine manipulation may be considered where other therapeutic options are ineffective or poorly tolerated. However the effect of cervical spine manipulation was no better than the sham or the placebo. Therefore the osteopath is less likely to perform cervical spine manipulation for migraine, as may be not be an effective intervention.

Osteopathic Manipulative Treatment (OMT)

OMT has a positive effect on pain reduction and quality of life improvement in patients with migraines without aura (Adragna et al. 2015).

How many many appointments will I need to reduce pain and improve my mood associated with migraines?

Osteopathic treatment is tailor the individual, so it based on what that person needs. However it has been shown that  patients with high-frequency migraine and comorbid mood disorders showed significant improvement after four 45-minute osteopathic manipulative treatment (OMT) sessions (D’Ippolito et al. 2017).

Though further investigation into the effects of OMTh on pain and mood disorders in patients with high-frequency migraine is needed (D’Ippolito et al. 2017).

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Reference List

Adragna V, Bertino AS, Carano M, Soru A, Taranto G, Desideri R (2015). O052. Migraine without aura and osteopathic medicine, a non-pharmacological approach to pain and quality of life: open pilot study. Headache Pain. Dec;16(Suppl 1):A180

Chaibi A, Tuchin PJ, Russell MB (2011). Manual therapies for migraine: a systematic review. J Headache Pain. Apr; 12(2):127-33.

Chaibi A, Benth JŠ, Tuchin PJ, Russell MB (2016). Chiropractic spinal manipulative therapy for migraine: a three-armed, single-blinded, placebo, randomized controlled trial. Eur J Neurol. Oct 2.

D’Ippolito M, Tramontano M, Buzzi MG (2017). Effects of Osteopathic Manipulative Therapy on Pain and Mood Disorders in Patients With High-Frequency MigraineJ Am Osteopath Assoc. 2017 Jun 1;117(6):365-369.

Noudeh YJ, Vatankhah N, Baradaran HR (2012). Reduction of current migraine headache pain following neck massage and spinal manipulation. Int J Ther Massage Bodywork. 5(1):5-13.

Tali D, Menahem I, Vered E, Kalichman L (2014) Upper cervical mobility, posture and myofascial trigger points in subjects with episodic migraine: Case-control study. J Bodyw Mov Ther. Oct;18 (4):569-75.

Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 33(9) 629–808

Guide to Cervicogenic Headache Osteopathy and Prescriptive Exercise by Osteopaths

What is a Cervicogenic Headache?

A cervicogenic headache is a headache that comes from a problem with neck. The pain is referred from one of these structures in the neck and can spread from the back of the head to the forehead and even to the area around the eyes. Women are four times more likely from these headaches than men.

What are the symptoms of a Cervicogenic Headache?

Cervicogenic Headaches are usually on one side of the head but can occur on both sides. The pain tends to be dull, not throbbing and can become moderate to severe in intensity. The pain is usually caused by awkward or sustained neck positions and can usually be reproduced by applying pressure to the back of the head or neck.

Along with head and/or neck pain, symptoms may include:
  • Stiff neck.
  • Nausea and/or vomiting.
  • Dizziness.
  • Blurred vision.
  • Sensitivity to light or sound.
  • Pain in one or both arms.
  • Mobility difficulties.

Cervicogenic Headache Pain Distribution

cervicogenic headache

What Causes a Cervicogenic Headache?

People suffering with Cervicogenic headaches tend have a forward neck posture with high muscular tone and fatigue in superficial muscles to
keep unstable head from gravity, which easily induces postural disorder and pain. Consequently in an effort to keep upright postur (Yang and Kang, 2017).

Exercise For Cervicogenic Headache

The application of craniocervical flexion exercise and suboccipitalis relaxation in cervicogenic headache patient is effective in decreasing fatigue of cervical muscles, tone of SCM, and headache intensity and craniocervical flexion that can directly influence postural sustainment is considered to be more effective in reduction of SCM fatigue and headache intensit (Yang and Kang, 2017).

Manual Therapies for Cervicogenic Headaches

Cervicogenic headache treatment should be targeted where the peripheral input is mainly dominant, can benefit from a multimodal manual therapy management including upper cervical spine joint mobilization and/or manipulation, thoracic spine manipulation, and deep cervical flexors endurance exercises. Clinicians should remember that the aim of these techniques is the restoration of the function by limiting the chance of sustained central nervous system facilitation for preventing the development of central sensitization (Fernández-de-Las-Peñas et Courtney, 2014).

Effects of Spinal Manipulation on Cervicogenic Headaches

A study by Dunning et al. (2016) demonstrated that patients with cervicogenic headaches who received cervical and thoracic manipulation (to the neck and mid back) experienced significantly greater reductions in headache intensity, disability, headache frequency, headache duration, and medication intake as compared to the group that received mobilization and exercise; furthermore, the effects were maintained at 3 months follow-up.

Effects of Spinal Mobilization on Cervicogenic Headaches

Patients can experience dizziness associated with cervicogenic headaches. Manual therapy is effective for reducing cervicogenic dizziness, a disabling and persistent problem, in the short term. A study by Reid et al. (2015) found that applying sustained natural apophyseal glides (SNAGs) and passive joint mobilisations (PJMs) for cervicogenic dizziness have long-term beneficial effects in the treatment of chronic cervicogenic dizziness.

Combining Manual Therapy with Physiotherapy for Cervicogenic Headache

In a systemic review by Chaibi et Russell (2012), they concluded that physiotherapy and spinal manipulative therapy might be an effective treatment in the management of cervicogenic headaches.

Evidence base for Manual Therapy as an intervention for Cervicogenic Headache

Clar et al. (2014) summarises that there was moderate (positive) evidence for mobilisation techniques in cervicogenic headache (change from inconclusive (unclear) evidence in the UK evidence report). But inconclusive (non-favourable) evidence for friction based massage and trigger points in cervicogenic headache. Whereas, a systematic review by Garcia et al. (2016) suggested that mobilization or manipulation of the cervical spine may be beneficial for individuals who suffer from cervicogenic headaches.

One systematic review suggests that Osteopathic Manual Therapy can reduce future pain episodes and related disability in adults with headache (Cerritelli et al. 2017).

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Reference List

Cerritelli F, Lacorte E, Ruffini N, Vanacore N (2017). Osteopathy for primary headache patients: a systematic review. J Pain Res  Mar 14;10:601-611

Chaibi A, Russell MB (2012). Manual therapies for cervicogenic headache: a systematic review. J Headache Pain. Jul; 13(5):351-9.

Clar C, Tsertsvadze A, Court R, Hundt GL, Clarke A, Sutcliffe P (2014). Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Chiropr Man Therap. Mar 28; 22(1):12.

Dunning JR, Butts R, Mourad F, Young I, Fernandez-de-Las Peñas C, Hagins M, Stanislawski T, Donley J, Buck D, Hooks TR, Cleland JA (2016). Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: multi-center randomized clinical trial. BMC Musculoskelet Disord. Feb 6; 17:64.

Fernández-de-Las-Peñas C, Courtney CA (2014). Clinical reasoning for manual therapy management of tension type and cervicogenic headache. J Man Manip Ther. Feb;22(1):44-50.

Garcia JD, Arnold S, Tetley K, Voight K, Frank RA (2016). Mobilization and Manipulation of the Cervical Spine in Patients with Cervicogenic Headache: Any Scientific Evidence? Front Neurol. Mar 21; 7:40.

Mesa-Jiménez JA, Lozano-López C, Angulo-Díaz-Parreño S, Rodríguez-Fernández ÁL, De-la-Hoz-Aizpurua JL, Fernández-de-Las-Peñas C (2015). Multimodal manual therapy vs. pharmacological care for management of tension type headache: A meta-analysis of randomized trials. Cephalalgia. Dec; 35 (14):1323-32.

Reid SA, Callister R, Snodgrass SJ, Katekar MG, Rivett DA (2015) Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomised trial. Man Ther. Feb; 20(1):148-56.

Yang DJ, Kang DH (2017). Comparison of muscular fatigue and tone of neck according to craniocervical flexion exercise and suboccipital relaxation in cervicogenic headache patients. J Phys Ther Sci. May;29(5):869-873

Guide to Tension Type Headache Osteopathy and Prescriptive Exercise by Osteopaths

What is a Tension Type Headache?

A tension type headache is the most common type of headache and the one we think of as a normal, everyday headache. It may feel like a constant ache that affects both sides of the head. You may also feel the neck muscles tighten and a feeling of pressure behind the eyes. A tension headache normally won’t be severe enough to prevent you doing everyday activities. It usually lasts for 30 minutes to several hours, but can last for several days.

Who gets Tension Type headaches?

Most people are likely to have experienced a tension headache at some point. They can develop at any age, but are more common in teenagers and adults. Women tend to suffer from them more commonly than men. It’s estimated that about half the adults in the UK experience tension-type headaches once or twice a month, and about 1 in 3 get them up to 15 times a month. About 2 or 3 in every 100 adults experience tension-type headaches more than 15 times a month for at least three months in a row. This is known as having chronic tension-type headaches.

What causes tension headaches?

The exact cause of tension-type headaches isn’t clear, but certain things have been known to trigger them, including:
• stress and anxiety
• squinting
• poor posture
• tiredness
• dehydration
• missing meals
• lack of physical activity
• bright sunlight
• noise
• certain smells

Frequency of Tension Type Headache

There is relationship between headache frequency and the emotional burden of condition was indirectly mediated by depression and sleep quality, but not anxiety, in individuals with Chronic Tension Type Headache. Sleep quality mediates th erelationship between pain interference and the frequency of headaches (Palacios-Ceña et al. 2017).

Tension Type Headache and Posture

Look at the diagram below which shows mechanisms of how tension type headaches develop as a result of poor posture.
tension type headache

Osteopathy and Manual Therapy as treatment for Tension Type Headache

Osteopathy and manual therapy for tension type headache is an uninvasive and conservative treatment option with very few side effects. The techniques used by the Osteopaths at Cam Osteopathy Ltd. could involve massage, muscle inhibition, myofascial release, pin and stretch, neck and mid back mobilization.

Osteopathic Treatment of Myofascial Trigger Points occurring with Tension Type Headache

The approach include treating the inactivation of active trigger points in the upper trapezius, sternocleidomastoids, temporalis, sub occipitals, extra-ocular superior oblique or extraocular lateral rectus muscles. Additionally cervical mobilization/manipulation and exercises targeted to the neck flexor or extensor synergy may be appropriate (Fernández-de-Las-Peñas et Courtney, 2014).

Treatment of the myofascial triggers points with massage can reduce the severity of pain associated with Tension Type Headache. As single and multiple massage applications increase Pain Pressure Threshold (PPT) at Muscular Trigger Points (MTrPs). The pain threshold of MTrPs have a great capacity to increase; even after multiple massage treatments additional gain in PPT was observed (Moraska et al. 2017).

Quality of Life following treatment for Tension Type Headache

Manual therapy techniques have some influence on different aspects of quality of life in people with TTH. Considering the overall quality of life, the sub-occipital inhibitory treatment was the most effective. When considering individual dimensions of quality of life, the combined treatment showed the greatest change. Separately, the application of the sub-occipital inhibitory and manipulative treatment provided similar results (Espí-López et al. 2016).

Effects of Manual therapy on Tension Type Headache

Manual therapies were associated with moderate effectiveness at short term, but similar effectiveness at longer follow-up for reducing headache frequency, intensity and duration in tension type headache than pharmacological medical drug care (Mesa-Jiménez et al. 2015).

Comparing the effect of Manual Therapy with Medication for Tension Type Headache Management

In a systemic review by Chaibi et Russell (2014), they concluded that manual therapy has an efficacy in the management of Chronic Tension Type Headache that equals prophylactic medication with tricyclic antidepressant.

Evidence Base for Manual Therapy as an invention for Tension Type Headache

One systematic review suggests that Osteopathic Manual Therapy can reduce future pain episodes and related disability in adults with headache (Cerritelli et al. 2017). Whereas Clar et al. (2014) summarises that there was Inconclusive, (but favourable) evidence for manual therapy (osteopathic care, spinal mobilisation) in treating tension-type headache and Inconclusive (unclear) evidence for spinal manipulation in treating tension-type headache.

Hence, why the Osteopaths at Cam Osteopathy Ltd. tend to avoid using spinal manipulation techniques as a treatment option for tension type headaches.

Prescriptive Exercise for Tension Type Headache

Cervical traction and Mckenzie exercise induce stretching around muscles at the base of the skull (known as the occiput).

Cervical traction,  and McKenzie exercise applied to either low frequency and high frequency episodic tension-type headache patients where some muscles showed significant changes (Choi and Choi, 2016).

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Reference List

Cerritelli FLacorte ERuffini NVanacore N (2017)Osteopathy for primary headache patients: a systematic review. J Pain Res  Mar 14;10:601-611

Chaibi A, Russell MB (2014). Manual therapies for primary chronic headaches: a systematic review of randomized controlled trials. J Headache Pain. Oct 2; 15:67.

Choi SY, Choi JH (2016). The effects of cervical traction, cranial rhythmic impulse, and Mckenzie exercise on headacheand cervical muscle stiffness in episodic tension-type headache patients. J Phys Ther Sci. Mar;28(3):837-43

Clar C, Tsertsvadze A, Court R, Hundt GL, Clarke A, Sutcliffe P (2014). Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Chiropr Man Therap. Mar 28; 22(1):12.

Espí-López GV1, Rodríguez-Blanco C, Oliva-Pascual-Vaca A, Molina-Martínez F, Falla D (2016). Do manual therapy techniques have a positive effect on quality of life in people with tension-type headache? A randomized controlled trial. Eur J Phys Rehabil Med. Aug; 52(4):447-56. Epub 2016 Feb 29.

Fernández-de-Las-Peñas C, Courtney CA (2014). Clinical reasoning for manual therapy management of tension type and cervicogenic headache. J Man Manip Ther. Feb;22(1):44-50.

Mesa-Jiménez JA, Lozano-López C, Angulo-Díaz-Parreño S, Rodríguez-Fernández ÁL, De-la-Hoz-Aizpurua JL, Fernández-de-Las-Peñas C (2015). Multimodal manual therapy vs. pharmacological care for management of tension type headache: A meta-analysis of randomized trials. Cephalalgia. Dec; 35 (14):1323-32.

Moraska AF, Schmiege SJ, Mann JD, Butryn N, Krutsch JP (2017).  Responsiveness of Myofascial Trigger Points to Single and Multiple Trigger Point Release Massages: A Randomized, Placebo Controlled Trial. Am J Phys Med Rehabil.  Feb 28

Palacios-Ceña M, Fernández-Muñoz JJ, Castaldo M, Wang K, Guerrero-Peral Á, Arendt-Nielsen L, Fernández-de-Las-Peñas C (2017). The association of headache frequency with pain interference and the burden of disease is mediated by depression and sleep quality, but not anxiety, in chronic tension type headacheHeadache Pain. Dec;18(1):19