Osteopathy Blog


Lateral Epicondylitis Osteopathy and Prescriptive Exercise by Osteopaths

Lateral Epicondylitis (Tennis Elbow)

Massage for Lateral Epicondylitis (Tennis Elbow)

Deep friction massage is an effective treatment for lateral epicondylitis and can be used in patients who have failed other nonoperative treatments, including cortisone injection (Yi et al. 2017).

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Reference List

Yi R, Bratchenko WW, Tan V (2017). Deep Friction Massage Versus Steroid Injection in the Treatment of Lateral Epicondylitis. Hand (N Y). Feb 1:1558944717692088


Osteoarthritis Osteopathy and Prescriptive Exercise by Osteopaths

What is Osteoarthritis?

Osteoarthritis (OA) is a type of joint disease that results from breakdown of joint cartilage and underlying bone.[5] The most common symptoms are joint pain and stiffness. Initially, symptoms may occur only following exercise, but over time may become constant. Additionally, symptoms may include joint swelling, decreased range of motion, and when the back is affected weakness or numbness of the arms and legs.The most commonly involved joints are those near the ends of the fingers, at the base of the thumb, neck, lower back, knee, and hips. Joints on one side of the body are often more affected than those on the other. Futhermore the symptoms come on over years. It can affect work and normal daily activities. Unlike other types of arthritis, only the joints are typically affected. Osteoarthritis osteopathy maybe beneficial.

Osteoarthritis osteopathy

Osteoarthritis Exercise and Osteoarthritis Osteopathy

We recommend and support the use of TE (on their own or combined with manual therapy), especially strengthening exercises and general physical activity, for patients with OA, particularly for the management of pain and improvement of functional status (Brosseau et al. 2005).

Also, Exercise therapy is effective for reducing pain and improving function in patients with knee OA, some evidence that exercise therapy is effective for hip OA, and early indications that manual therapy may be efficacious for hip and knee OA (Abbott et al. 2009).

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Reference List

Abbott JH, Robertson MC, McKenzie JE, Baxter GD, Theis JC, Campbell AJ and the MOA Trial team (2009). Study protocol Open Access Exercise therapy, manual therapy, or both, for osteoarthritis of the hip or knee: a factorial randomised controlled trial protocol. Trials, 10:11

Brosseau L, Wells GA,  Tugwell P,  Egan M, Dubouloz CJ, Casimiro L, Robinson VA, Pelland L, McGowan J, Judd M, Milne S, Bell M, Finestone HM, Légaré F, Caron C,  Lineker S,  Haines-Wangda A, Russell-Doreleyers,  Hall M, Lamb GAM (2005). Ottawa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises and Manual Therapy in the Management of Osteoarthritis. Physical Therapy . Volume 85 . Number 9 . September


Knee Osteoarthritis Osteopathy and Prescriptive Exercise by Osteopaths

Knee Osteoarthritis

Knee Osteoarthritis is a disease that affects your knee joints. The surfaces within your joints become damaged so the joint doesn’t move as smoothly as it should. The condition is sometimes called arthrosis, osteoarthrosis, degenerative joint disease or wear and tear. (AR, n.d)

Knee Osteoarthritis

What are the Symptoms of Knee Osteoarthritis

The symptoms of osteoarthritis can include:
• pain
• stiff ness
• a grating or grinding sensation when
the joint moves (crepitus)
• swelling (either hard or soft).
Sometimes the knee may either lock or give way when you put weight on it. (AR, n.d.)

Who gets Knee Osteoarthritis?

Almost anyone can get osteoarthritis,
but it’s most likely if:
• you’re in your late 40s or older
• you’re overweight
• you’re a woman
• your parents, brothers or sisters
have had osteoarthritis
• you’ve previously had a severe
knee injury
• your joints have been damaged by another disease, for example rheumatoid rheumatoid arthritis arthritis or gout (AR, n.d.)

The National Institute of Clinical Excellence Reccomendations

NICE (2014) advises people with osteoarthritis to exercise as a core treatment, irrespective of age, comorbidity, pain severity or disability. Exercise should include:

  • local muscle strengthening and
  • general aerobic fitness.It has not been specified whether exercise should be provided by the NHS or whether the healthcare professional should provide advice and encouragement to the person to obtain and carry out the intervention themselves. Exercise has been found to be beneficial but the clinician needs to make a judgement in each case on how to effectively ensure participation. This will depend upon the person’s individual needs, circumstances and self-motivation, and the availability of local facilities.
  • Manipulation and stretching should be considered as an adjunct to core treatments, particularly for osteoarthritis of the hip. 

Manual Therapy for Knee Osteoarthritis

Manual therapy provided significant, clinically important and sustained improvements in symptoms for patients with OA of hips or knees (Abbott et al. 2013).

Short term effect of Manual Therayp for Knee Osteoarthritis

Manual therapy improves pain and physical function, in the short and long-term, compared with exercise for those with hip OA, and massage therapy providesshort-term benefit in pain and function over no treatment for those with knee OA (French et al. 2011).

Long Term Effect of Manual Therapy for Knee Osteoarthritis

After 3-months an 8-session multi-modal treatment of exercise, OA education, manual-therapy and taping that was targeted to the PFJ and tailored to individual patients resulted in superior outcomes for patient-perceived change and pain compared to OA-education alone in people with predominant PFJ OA (Crossley et al. 2015).

Safety of Manual Therapy for Knee Osteoarthritis

Manual therapy might be effective and safe for improving pain, stiffness, and physical function in KOA patients and could be treated as complementary and alternative options (Xu et al. 2017).

Hip Mobilisation for Knee Osteoarthritis

Patients experienced increases in ROM, decreased pain, and fewer subjects had painful test findings immediately following a single session of hip mobilizations (Currier et al. 2007).

Combining Manual Therapy With Exercise for Knee Osteoarthritis

Manual Therapy appears to be moderately effective for improved function, specifically as an adjunct to another treatment and versus comparators of no treatment or other treatments (Salamh et al. 2016).

Exercise therapy plus manual mobilisation showed a moderate effect size on pain (0.69) compared to the small effect sizes for strength training (0.38) or exercise therapy alone (0.34). Supervised exercise treatment in physiotherapy and manual therapy should in our opinion include at least an active exercise program involving strength training, aerobic activity exercises, and active range of motion exercises. To achieve better pain relief in patients with knee osteoarthritis, physiotherapists or manual therapists might consider adding manual mobilisation to optimise supervised active exercise programs (Jansen et al. 2011).

Knee Osteoarthritis Exercise

Among people with knee osteoarthritis, land-based therapeutic exercise provides short-term benefit that is sustained for at least 2-6 months after cessation of formal treatment (Fransen et al. 2015).

Non-Elastic Tapping for Knee Osteoarthritis

Therapeutic taping seemed to be superior to control taping in pain control for knee osteoarthritis. Non-elastic taping, but not elastic taping, provides benefits in pain reduction and functional performance (Ouyang et al. 2017).

How Many Maintenance Appointments will I need for Knee Osteoarthritis?

Distributing 12 sessions of exercise therapy over a year in the form of booster sessions was more effective than providing 12 consecutive exercise therapy sessions. Providing manual therapy in addition to exercise therapy improved treatment effectiveness compared to providing 12 consecutive exercise therapy sessions alone (Abbott  et al. 2015).

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Reference List

Arthritis Research (AR) UK (n.d.). Osteoarthritis of the Knee

Abbott JH, Chapple CM, Fitzgerald GK, Fritz JM, Childs JD, Harcombe H, Stout K. (2015)The Incremental Effects of Manual Therapy or Booster Sessions in Addition to Exercise Therapy for Knee Osteoarthritis: A Randomized Clinical Trial. J Orthop Sports Phys Ther. Dec;45(12):975-83

Abbott JH, MC Robertson m MC, Chapple, Pinto CD (2013). Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness Osteoarthritis and Cartilage 21 525e534

Crossley KM, Vicenzino B, Lentzos J, Schache AG, Pandy MG, Ozturk H, Hinman RS (2015). Exercise, education, manual-therapy and taping compared to education for patellofemoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. Sep;23(9):1457-64

Currier LL, Froehlich PJ, Carow SD, McAndrew RK, Cliborne AV, Boyles RE, Mansfield LT, Wainner RS (2007). Development of a Clinical Prediction Rule to Identify Patients With Knee Pain and Clinical Evidence of Knee Osteoarthritis Who Demonstrate a Favorable Short-Term Response to Hip Mobilization. Physical Therapy, Volume 87, Issue 9, 1 September, Pages 1106–1119

Fransen M, McConnell S, Harmer AR ,Van der Esch M, Simic M, Bennell KL. (2015). Exercise for osteoarthritis of the knee: a Cochrane systematic reviewBr J Sports Med. Dec;49(24):1554-7

French HP, Brennan A, B White, T Cusack (2011). Manual therapy for osteoarthritis of the hip or knee–a systematic review. Manual therapy

Jansen MJ, Viechtbauer W, Lenssen AF, Hendriks EJM (2011).  Strength training alone, exercise therapy alone, and exercise therapy with passive manual mobilisation each reduce pain and disability in people with knee osteoarthritis: a systematic review Journal of Physiotherapy Vol. 57 

National Institute of Clinical Excellence (NICE) (2014). Osteoarthritis: care and management

Salamh P, Cook C, Reiman MP, Sheets C (2016) Treatment effectiveness and fidelity of manual therapy to the knee: A systematic review and meta-analysis. Musculoskeletal Care. Nov 18.

Ouyang JH, Chang KH, Hsu WY, Cho YT, Liou TH, Lin YN (2017). Non-elastic taping, but not elastic taping, provides benefits for patients with knee osteoarthritis: systemic review and meta-analysis. J Orthop Sports Phys Ther.  Jun;45(6):453-61

Xu Q, Chen B, Wang Y, Wang X, Han D, Ding D, Zheng Y, Cao Y, Zhan H, Zhou Y (2017). The Effectiveness of Manual Therapy for Relieving Pain, Stiffness, and Dysfunction in Knee Osteoarthritis: A Systematic Review and Meta-Analysis. Pain Physician. May;20(4):229-243.



Coccydynia (Coccyx / Tail bone pain) Osteopathy and Conservative Treatment Advice by Osteopaths


Coccydynia, or coccygodynia, is pain in the region of the coccyx (Lirette et al. 2014).


The Coccydynia

The coccyx is the terminal segment of the spine. The word coccyx is derived from the Greek word for the beak of a cuckoo bird because of the similarity in appearance when the latter is viewed from the side. The coccyx is a triangular bone that consists of 3 to 5 fused segments, the largest of which articulates with the lowest sacral segment (Lirette et a. 2014).

The Function of the Coccyx

The coccyx has several important functions. Along with being the insertion site for multiple muscles, ligaments, and tendons, it also serves as one leg of the tripod—along with the ischial tuberosities—that provides weight-bearing support to a person in the seated position. Leaning back while in a seated position leads to increased pressure on the coccyx. The coccyx also provides positional support to the anus (Lirette et al. 2014).

What can predispose you to Coccydynia?

There are factors associated with increased risk according to Lirette et al (2014):

-Women are 5 times more likely to develop coccydynia than men.

-Adolescents and adults are more likely to present with coccydynia than children.

– Rapid weight loss can also be a risk factor because of the loss of mechanical cushioning when seated

Mechanism of Injury that can occur with Coccydynia

The mechanism of injury can either be external or internal trauma. External trauma usually occurs due to a backwards fall, leading to a bruised, dislocated, or broken coccyx. The location of the coccyx makes it particularly susceptible to internal injury during childbirth, especially during a difficult or instrumented delivery. Minor trauma can also occur from repetitive or prolonged sitting on hard, narrow, or uncomfortable surfaces (Lirette et al. 2014).

Non-Traumatic Coccydynia

Nontraumatic presentations can result from a number of causes, including degenerative joint or disc disease, hypermobility or hypomobility of the sacrococcygeal joint, infectious etiology, and variants of coccygeal morphology (Lirette et al. 2014).

Conservative Coccydynia Treatment

Conservative treatment is successful in 90% of cases, and many cases resolve without medical treatment. Relatively simple measures are sufficient in most cases. Modified wedge-shaped cushions (coccygeal cushions) canrelieve the pressure on the coccyx while the patient is seated and are available over the counter. Circular cushions (donut cushions) have been suggested for the treatment of coccydynia but they can place pressure on the coccyx by isolating the coccyx and ischial tuberosities and are more useful for treating rectal pain (Lirette et al. 2014).

Manual Therapy for Coccydynia

For the few cases that do not respond to these conservative treatments, more aggressive treatments may be indicated. Pelvic floor rehabilitation can be
helpful for coccydynia that is associated with pelvic floor muscle spasms. Manual manipulation and massage can be both diagnostic and therapeutic. Intrarectal manipulation can identify and potentially correct a dislocated sacrococcygeal joint. Manual manipulation and massage can help relieve associated
muscle spasms or ligament pain (Lirette et al. 2014).

Cam Osteopathy

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Reference List

Lirette LS, Chaiban G, Tolba R, Eissa H (2014). Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain. Ochsner J. Spring;14(1):84-7


Mechanical Neck Pain Manual Therapy and Prescriptive Exercise by Osteopaths

Mechanical Neck Pain

Mechanical Neck Pain is the general term that refers to any type of pain caused by placing abnormal stress and strain on muscles of the vertebral column. Typically, mechanical pain results from bad habits, such as poor posture, poorly-designed seating, and incorrect bending and lifting motions.


neck pain

What Manual Therapy Techniques do Osteopaths use to Treat Mechanical Neck Pain?

Osteopaths use spinal manipulation, spinal mobilisation / mobilization, spinal distraction, massage, myofascial, muscle energy techniques and strain /counterstrain techniques to treat mechanical neck pain.

Spinal Manipulation

There are different variations of manipulative techniques that can applied to neck and mid back to treat mechanical neck pain. Where a single cervical manipulation is capable of producing both immediate and short-term benefits for mechanical neck pain (Gorrell et al. 2016).

Also not all manipulative techniques have the same effect as the spinal manipulative tecnhiques have dfferent biomechanical characteristics that may be responsible for varying clinical effects (Gorrell et al. 2016).

So essentially the reduction in neck pain is dependent how the technique was applied, the biomechanics of the patients neck and which technique was applied.


Manual cervical distraction (MCD) is a traction-based therapy performed with a manual contact over the cervical region (neck) producing repeating cycles while the person lies on their back. The traction force of the technique reduces neck pain intensity and neck-related disability (Gudavalli et al. 2015).


Regular massage over a 4 week period can significantly reduce (chronic) neck pain and dysfunction (Cook et al. 2015).

Myofascial Release

Myofascial release is a technique used to the connective tissues over the musculature, usually by pinching the skin and moving the tissue in a rolling motion. The technique has been shown to reduce neck pain disability in the short and long terms (De Meulemeester et al. 2017).

Which Manual Therapy Techniques are the Most Effective for Mechanical Neck Pain?

When you compare the effectiveness of manual therapy techniques applied as a treatment for mechanical neck pain.  It has been shown that the effect of manual therapy including spinal manipulation, mobilization, stretching and massage for patients seeking care for neck  pain in clinic is similar regardless if spinal manipulation or stretching is left out as a treatment option (Paanalahti et al. 2016).

So the osteopath will decide what is the most appropriate technique to apply on a case by case basis and no technique is superior to the other.

Are There Any Adverse Events following Manual Therapy?

Most reports of neck pain started after a manipulation and/or mobilisation, of which 53.4% lasted less than 24 hours, 38.1% more than 24 h but more than 3 months where 13.7% still experienced neck pain to date. Though mild to moderate adverse effects occur follwoing manual therapy are commonly reported and usually resolve within 24 hours (Thoomes-de Graaf et al. 2017).

Consequently, the benefits of reducing the severity of neck pain often outweigh the risks of treatment.  Furthermore, the Osteopath should be careful in their choice and application of manual therapy techniques for treating mechanical neck pain.

How Long Will It Take To Reduce The Severity of Mechanical Neck Pain Following Manual Therapy and Prescribed Exercise?

It can take anywhere between 48-96 hours. As one study showed that Improvements in neck disability and pain do not differ, for at least a 96-hour period, between patients performing general exercises and those performing an Augmented Exercise Programme following Manual Therapy (Petersen et al. 2015). Furthermore exercise  does have some preventive properties by reducing neck pain intensity and improved sensitivity (Murray et al. 2017).

Manual Therapy Treatment at Cam Osteopathy

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Reference List

Cook AJ, Wellman RD, Cherkin DC, Kahn JR, Sherman KJ. (2015). Randomized clinical trial assessing whether additional massage treatments for chronic neck painimprove 12- and 26-week outcomes. Spine J. Oct 1;15(10):2206-15

De Meulemeester KE, Castelein B, Coppieters I, Barbe T, Cools A, Cagnie B (2017). Comparing Trigger Point Dry Needling and Manual Pressure Technique for the Management of Myofascial Neck/Shoulder Pain: A Randomized Clinical Trial. Manipulative Physiol Ther. Jan;40(1):11-20

Gorrell LM, Beath K, Engel RM  (2016). Manual and Instrument Applied Cervical Manipulation for Mechanical Neck Pain: A Randomized Controlled Trial. Manipulative Physiol Ther. Jun;39(5):319-29.

Gudavalli MR, Salsbury SA, Vining RD, Long CR, Corber L, Patwardhan AG, Goertz CM (2015). Development of an attention-touch control for manual cervical distraction: a pilot randomized clinical trial for patients with neck painTrials. 2015 Jun 5;16:259

Murray M, Lange B, Nørnberg BR, Søgaard K, Sjøgaard G (2017). Self-administered physical exercise training as treatment of neck and shoulder pain among military helicopter pilots and crew: a randomized controlled trial. BMC Musculoskelet Disord. Apr 7;18(1):147

Paanalahti K, Holm LW, Nordin M, Höijer J, Lyander J, Asker M, Skillgate E (2016). Three combinations of manual therapy techniques within naprapathy in the treatment of neckand/or back pain: a randomized controlled trial. BMC Musculoskelet Disord. Apr 23;17:176.

Petersen SB, Cook C, Donaldson M, Hassen A, Ellis A, Learman K (2015). The effect of manual therapy with augmentative exercises for neck pain: a randomised clinical trial. J Man Manip Ther. Dec;23(5):264-75

Thoomes-de Graaf M, Thoomes E, Carlesso L, Kerry R, Rushton A (2017). Adverse effects as a consequence of being the subject of orthopaedic manual therapy training, a worldwide retrospective survey. Musculoskelet Sci Pract. Jun;29:20-27


HIV Associated Musculoskeletal Pain Treated with Massage by Osteopaths

What Musculoskeletal and Rheumatological Conditions Occur in HIV Patients?

The high prevalence of musculoskeletal involvement  of HIV cases occurs in the advanced stages. Though stage 2 patients predominantly suffer from arthralgia, spondyloarthropathy, and rheumatoid arthritis. Whereas patients with stage 3 disease had suffer predominantly from body ache and mechanical low back pain, but patients with stage 4 disease had suffered predominantly from septic arthritis, osteomyelitis, and pyomyositis (Kole et al. 2013).

However, musculoskeletal disorders are not always related to the HIV infection, these may be either the direct effect of the virus, opportunistic infections, noninfectious HIV complications (malignancy, drug toxicities), or unrelated rheumatologic disorders whose course have been altered (Kole et al. 2013).

How Might Musculoskeletal Pain Manifest In HIV Patients?

Myalgia (muscle pain) was the commonest symptom present and arthralgia(joint pain) involving knee, shoulder, and elbow are frequent complaints. The most distressing musculoskeletal disorders were mechanical low back pain and painful articular syndromes (Kole et al. 2013).

How Might Massage Help HIV Patients?

Musculoskeletal involvement in human immunodeficiency virus infected patients are important disease manifestations, responsible for increased morbidity and also decreased quality of life (Kole et al. 2013).
The effects of massage on HIV / AIDS musculoskeletal soft tissues include pain relief, decreased levelof depression, improved immune function, improved blood floand blood composition, reduced edema, and increased mobility of connective tissue, muscle and the nervous system . Massage is therefore potentially effective in improving the quality of life in patients suffering from chronic disorders (Hillier et al. 2010).
Furthermore, an increase in immune function following massage where the proposed mechanisms for this effect occurs via alterations in bio-chemistry, such as reduced levels of cortisol and increased levelof serotonin and dopamine. Though what mediates these biochemical effects is not known but presumed to occur through stress reduction (Hillier et al. 2010).

Effectiveness of Massage for HIV Musculoskeletal Pain

In a Cochrane review by Hillier et al. (2010),  they found that individuadomains of quality of life, there were findings in favour of massage therapy in combination with other modalities,such as meditation and stress reduction, being superior to massage therapy alone oto the other modalities alone.

The Suitability of Massage for Musculoskeletal Pain in HIV Patients?

Osteopaths have had success at managing  musculoskeletal complaints in HIV patients at the Blanchard Clinic (affiliated with the British School of Osteopathy, London). There is even research to suggest massage treatment might be effective for managing the musculoskeletal pain associated with HIV.
Though bear in mind, the osteopath will decide whether massage isa suitable and safe treatment option for managing musculoskeletal pain associated with HIV by completing an appropriate case history and examination or decide to refer you to the most appropriate medical practitioner.

The Challenge of Managing HIV Patients in Musculoskeletal Practice

The major challenges for the osteopath includes not only recognizing HIV infection associated rheumatic disorders but also distinguishing them from classic rheumatic diseases like rheumatoid arthritis, SLE, spondyloarthropathy, and vasculitis. So an aggressive multidisciplinary approach to early detection and timely intervention of these disorders, sometimes in consultation with a rheumatologist are all essential for effective management and to improve the quality of life (Kole et al. 2013). The other consideration is infection control during treatment.

HIV Infection Control During Treatment

As a blood-borne pathogen HIV is controllable in healthcare environments using the same guidelines and universal precautions which prevent all blood-borne infections including infectious hepatitis. The routine practice of osteopathy involves non-invasive manual contact only, therefore precautions are minimal. On the occasions that digital work within body cavities does take place (i.e. intraoral, peranal) the practitioners hand should be suitably gloved (Blanchard, 2009).

Massage Treatment at Cam Osteopathy

For more information or to book an appointment with an osteopath, click on the Home Page or book an appointment

Reference List

Blanchard PD (2009).  Masterclass: HIV-infection and osteopathy. International Journal of Osteopathic Medicine 12: 115–120
Hillier SLLouw QMorris LUwimana JStatham S (2010). Massage Therapy for People with HIV/AIDS.  Cochrane Database Syst Rev. Jan 20;(1):CD007502
Kole AK, Roy R, Kole DC (2013)Musculoskeletal and rheumatological disorders in HIV infection: Experience in a tertiary referral center. Indian J Sex Transm Dis. 2013 Jul;34(2):107-12.

Manipulation: Should Osteopaths Perform it on The Intervertebral Discs?

What is Spinal Manipulation?

The definition of spinal manipulation is quite broad and does have many descriptive elements as shown a paper by Evans and Lucas (2010) which provides a reappraisal of what spinal manipulation is.

 A force is applied to the recipient

Manipulation involves a force being applied to the recipient. Most commonly, this force is externally generated and is usually applied to the recipient by physical contact at the skin surface. The force may include reaction forces from furniture,such as a plinth or chair and, in some circumstances, gravitational force may be utilised (Evans and Lucas, 2010).

The line of action of this force is perpendicular to the articular surface of the affected joint

Importantly the force has always been applied along a line of action perpendicular to the articular surfaces of the affected joint. Moreover, the motion produced by this force was joint surface separation, without any obvious ‘gliding’ motion. As synovial joint surfaces are designed to glide smoothly over one
another, the motion produced during this type of MCP joint manipulation is hence distinguished from that produced during typical ‘physiological’ motion. A complexity of this feature is that most synovial joints are curved rather than planar, and are not always congruent (Evans and Lucas, 2010).

Whereas the line of action of the applied force may be perpendicular to one point along the articular surface, this will not be the case with the
entire articular surface. Hence, the applied force may be more accurately described as acting perpendicular to a plane that is tangential to a point of contact between the articular surfaces of the joint (Evans and Lucas, 2010).

This joint motion always includes articular surface separation

The applied force induces motion between the articular surfaces of the affected joint, and when measured, articular surface separation (gapping) has always been observed (Evans and Lucas, 2010).

Cavitation occurs within the affected joint

Associated with joint surface separation is the elicitation of a high frequency vibration that manifests as an audible ‘click’ or ‘crack’ sound. .The most likely and widely accepted explanation for this audible sound during joint manipulation is a process known as cavitation, occurring within the synovial fluid of the affected joint. Cavitation is an engineering term used to describe the formation and activity of bubbles (or cavities) within fluid, which are formed when tension is applied to the fluid as a result of a local reduction in pressure (Evans and Lucas, 2010).

The UK Osteopath’s attitude towards Manipulation of Intervertebral Discs

You will find that Osteopaths in the UK have  quite varied opinions either in favour or against manipulation of the Intervertebral Joints. Though as a student Osteopath in the Osteopathic Colleges of the United Kingdom, it is kind of frowned upon to manipulate the intervertebral joints, Particularly when they are a final year osteopathic student are sitting their final clinical competency exam to register with the General Osteopathic Council. If the student has case during the exam where there is an opportunity to manipulate, the examiner would ask, “so would you manipulate a disc injury /Disc herniation?” The answer expected of the student should be “No!”

However with the research emerging at the moment, it makes it quite hard to justify whether this sort of treatment is appropriate for disc injuries /disc herniations.

In Favour of Manipulation of Intervertebral Discs

Reduction of radicular pain

The majority of patients in this study had either extruded or sequestered disc herniations. Patients with sequestered herniations treated with Spinal Manipulative Treatment to the level of herniation reported significantly higher levels of leg pain reduction at 1 month and a higher proportion reported improvement at all data collection time points compared to patients with extruded disc herniations but this did not reach statistical significance. Further investigation is needed to determine mechanisms for this finding. This also calls into question the seriousness of disc sequestration in determining appropriate treatment (Ehrler et al. 2016).

Clinical Improvement with no serious adverse events

A large percentage of acute and importantly chronic lumbar disc herniation patients treated with high-velocity, low-amplitude side posture SMT reported clinically relevant “improvement” with no serious adverse events (Leemann et al. 2014).

Against Manipulation of Intervertebral Discs

Surgical Treatment maybe required when Manipulation of Intervertebral Joints causes Dics

Patients with Lumbar Disc Hernation, who underwent surgical treatment due to exacerbation of presentation caused by SMT. Five risk factors have been identified regarding the treatment of LDH by SMT. The present data attempt to offer guidance to chiropractors for the appropriate management of patients. Chiropractors should assess patients with back pain before performing SMT and practice the manipulation particularly carefully if any of the risk factors exists. To the best of our knowledge, this is the first study to address the risk factors of SMT in the treatment of LDH (Huang et al. 2015).

Potential Paralysis

We presented an extremely rare case of cervical intervertebral disc hernation causing progressive quadriparesis after excessive spinal manipulation therapy (Yang et al. 2016).


Osteopaths should think careful about whether is it safe and appropriate to manipulate the intervertebral joints. As their are arguements in favour of manipulation as treatment to reduce the symptomology associated with a discal injury /disc hernations. But their arguements against performing manipulative techniques on the intervertebral joints from a safety aspect and possible associated adverse events that can occur. In which it is completely understandable for the osteopathic colleges in the UK to teach osteopathic students not to manipulate the intervertebral joints of the spine in the teaching clinics.

Cam Osteopathy

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Reference List

Ehrler M, Peterson C, Leemann S, Schmid C, Anklin B, Humphreys BK.  Symptomatic (2016). MRI Confirmed, Lumbar Disc Herniations: A Comparison of Outcomes Depending on the Type and Anatomical Axial Location of the Hernia in Patients Treated With High-Velocity, Low-Amplitude Spinal ManipulationManipulative Physiol Ther. Mar-Apr;39(3):192-9

Evans DW, Lucas N (2010).  What is ‘manipulation‘? A reappraisal. Man Ther. Jun;15(3):286-91

Huang SL, Liu YX, Yuan GL, Zhang J, Yan HW (2015). Characteristics of lumbar disc herniation with exacerbation of presentation due to spinal manipulative therapy. Medicine (Baltimore). Mar;94(12):e661.

Leemann S, Peterson CK, Schmid C, Anklin B, Humphreys BK (2014). Outcomes of acute and chronic patients with magnetic resonance imaging-confirmed symptomatic lumbar disc herniations receiving high-velocity, low-amplitude, spinal manipulativetherapy: a prospective observational cohort study with one-year follow-up. Manipulative Physiol Ther.  Mar-Apr;37(3):155-63.

Yang HS, Oh YM, Eun JP (2016). Cervical Intradural Disc Herniation Causing Progressive Quadriparesis After Spinal ManipulationTherapy: A Case Report and Literature Review. Medicine (Baltimore).  Feb;95(6):e2797.


Cerebral Palsy: An Osteopathic Approach to Muscle Spascity

Cerebral Palsy

What Causes Cerebral Palsy?

Cerebral palsy (CP) is caused by an injury to an infants brain that interrupts normal development. People with CP have reduced muscle strength and aerobic fitness, which may impact their ability to perform activities such as standing, walking, running and to participate in everyday life. Exercise is defined as a planned, structured and repetitive activity that aims to improve fitness. Aerobic exercise aims to improve aerobic fitness, while strength training aims to improve muscle strength. Health professionals often prescribe exercise to people with CP, primarily to improve function, but there has been no comprehensive evaluation of the evidence for th e effe ctiveness of these interventions in people with CP (Ryan et al, 2017).

Types of Cerebral Palsy

Exercise Prescription

aerobic exercise

resistance training

Mixed training

Passive muscle stretching

6 weeks of combined passive muscle stretching and whole body vibration could decrease the spasticity and increase the muscle strength and balance of children and adolescents with CP. Whole body vibration could be an alternative additional treatment to passive muscle stretching for both clinical and home therapy programs for children and adolescents with CP (Tupimai et al. 2016).

Effect of Massage Treatment on Microcirculation and musculoskeletal soft tissues

Massage is one of the oldest and most widely used treatments in complementary and alternative medicine, with more than 75 forms of it practised today.
Deepfriction massage (DFM), which was introduced by James Cyriax for treating tendon disorders, involves application of forces perpendicular to the fibres as to separate each fibre and align the newly formed collagen. It helps to promote analgesia, local hyperaemia, and reduce adherence of scar tissue to muscles, tendons and ligaments. Moreover, it helps to break subcutaneous adhesion and prevent fibrosis, leading to improved sensory feedback and decreased pain  (Rasool et al. 2017).

Massage has been used to improve blood and lymphatic circulation, enhance inelastic and elastic properties of muscles and connective tissue, alleviate muscle pain and promote relaxation. 9 It has been reported that mechanical properties and stretch reflex of spastic muscle differ from normal muscles. Stretch reflex is responsible for regulation of muscle stiffness and exaggerated response as this is responsible for hypertonia (Rasool et al. 2017).

Consequently, treatment is directed towards reducing stretch reflex which has been demonstrated by O’Dwyer et al. in young people with CP through the use of visual feedback.Deep cross-friction massage is used to stretch spasticmuscles and bring the sacromere length to an optimal level. Physical contact in this technique aids in decreasing the pain and benefiting the patient through psychological effects and by acting on the gate control theory.  M Hernandez Reif et al. found that children receiving massage therapy showed fewer cerebral palsy symptoms, including overall less rigid muscle tone reduced spasticity, and improvement in gross and fine motor functioning  (Rasool et al. 2017).

Effectiveness of Deep Friction Massage on Spascity associated with Cerebral Palsy

Deep Friction Massage was found to be a better and efficacious treatment option for management of spasticity in children with cerebral palsy than the traditional physical therapy alone. However, its role in improving function could not be established but it is speculated that reducing the spasticity
may help benefit in functional level and performance (Rasool et al. 2017).

Massage Treatment At Cam Osteopathy

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Reference List

Rasool F, Memon AR, Kiyani MM, Sajjad AG (2017). The effect of deep cross friction massage on spasticity of children with cerebral palsy: A double-blind randomised controlled trial. J Pak Med Assoc. Jan;67(1):87-91.

Ryan JM, Cassidy EE, Noorduyn SG, O’Connell NE (2017). Exercise interventions for cerebral palsyCochrane Database Syst Rev. Jun 11;6:CD011660

Tupimai T, Peungsuwan P, Prasertnoo J, Yamauchi J (2016). Effect of combining passive muscle stretching and whole body vibration on spasticity and physical performance of children and adolescents with cerebral palsyJ Phys Ther Sci. Jan;28(1):7-13.


Pelvic Joint Dysfunction Diagnosis + Treatment: An Osteopathic Approach

The posterior pelvic joint (s) are also known as the sacroiliac joints.

The Sacroiliac Joint ( Posterior Pelvic Joint) and Low Back Pain

The Sacroiliac Joint has been identified as the source of low back and buttock pain for approximately 15% to 30% of the population. Pain resulting from mechanical disorders, including innominate (ilium) positional and movement abnormalities appears to be the most commonly reported causes for non-specific LBP of SIJ origin.  As it has been shown that movement of innominate bones of pelvis can indicate relationships between innominate kinematic anomalies and LBP of SIJ origin., This indicates that SIJ (pelvic joint) pain reproduction is closely linked in people with clinically diagnosed LBP (Adhia et al. 2016).

How do Osteopaths Diagnose a Sacroiliac Joint Dysfunction (Posterior Pelvic Joint)

Gillet Test

The Gillet test assesses SIJ mobility with sensitivity 8% and specificity 93% . To perform this test, the subjects stands while the examiner sits behind the patient and palpates each of the patient’s PSIS, one at a time, with one thumb on the inferior aspect of the PSIS while simultaneously palpating the sacrum with the other thumb staying parallel to the first thumb. The subject is then instructed to stand on one leg while pulling the opposite leg up toward the chest with hip and knee flexion. The test is then repeated on the other side and compared bilaterally. The test is negative when either PSIS moves posterior inferiorly in relation to the sacrum. If the PSIS on the ipsilateral side of the knee flexion does not move or moves posterior-inferiorly only minimally or even paradoxically moves superiorly, it indicates a positive test (Soleimanifar et al. 2017).

Standing in Flexion Test (SIFT)

The standing flexion test assesses SIJ (pelvic joint) mobility with sensitivity 17% and specificity 79% . To perform this test, the subject stands while the examiner sits behind the patient and palpates both of the patient’s posterior superior iliac spines on their inferior margins. The examiner maintains his/her eyes level with the palpating thumbs while the subject bends forward slowly as if to touch his/ her toes as far as comfortable while keeping both legs straight (knees extended). The examiner assesses the symmetry of movement of both PSIS landmarks. The test is negative if both PSIS landmarks appear to move equally and symmetrically; the test is positive on the side in which the PSIS moves superiorly more than the other side. A positive result in a standing flexion test indicates limited movement of the ilium on the sacrum, and therefore limited SIJ (pelvic joint) motion on the side of the superior PSIS (Soleimanifar et al. 2017).

The Sitting in Flexion Test

The sitting flexion test assesses SIJ mobility with sensitivity 9% and specificity 93% (Levangie, 1999). The procedure is similar to standing flexion test except that it is performed with the patient sitting on a level surface. A positive result in this test indicates limited movement of the sacrum on the ilium, and limited SIJ (Pelvic Joint) motion on the side of the superior PSIS (Soleimanifar et al. 2017).

How Osteopaths Treat a Sacroiliac Joint Dysfunction

Osteopaths can manual therapy interventions such as joint manipulation, joint mobilisation and soft tissues techniques as treatment for a sacroiliac joint dysfunction.

SIJ ( Posterior Pelvic Joint) manipulation

The patient was supine and the therapist stood contralateral to the side which was to be manipulated (e.g. right) (Fig. 2). The patient was passively moved into side bending toward the side to be manipulated. The patient interlocked the fingers behind his or her head. The therapist passively rotated the patient, and then delivered a quick thrust to the Anterior Superior Iliac Spine (ASIS) in a posterior and inferior direction (Cleland et al. 2006).

Lumbar rotational manipulation

The patient lay on a treatment table in lateral recumbent position with the more painful side uppermost (e.g. right) (Fig. 3). The therapist stood opposite the patient. The therapist then flexed the top leg until the lumbar spine was flexed and placed the patient’s foot in the popliteal fossa of the lower leg. Next, the therapist grasped the patient’s lower shoulder and arm, and introduced left trunk side bending and right rotation, until motion was felt at the desired segment of the lumbar spine. The patient’s arms were positioned around the therapist’s right arm. The set up was maintained while the patient was rolled toward the therapist. Finally, the therapist’s left arm was used to apply a high-velocity low-amplitude thrust of the pelvis in an anterior direction (Cleland et al. 2006).


It is concluded that both treatment techniques, e.g. SIJ (Pelvic Joint) manipulation and lumbar & SIJ manipulation, significantly improve pain and functional disability in patients diagnosed with SIJ syndrome (Kamil and Esmaeil, 2012).

Cam Osteopathy

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Reference List

Adhia DB, Milosavljevic S, Tumilty S, Bussey MD (2016). Innominate movement patterns, rotation trends and range of motion in individuals with low back pain of sacroiliac joint origin.  Manual Therapy, Volume 21, February, Pages 100-108

Cleland, J.A., Fritz, J.M., et al., (2006). Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: study protocol of a randomized clinical trial [NCT00257998]. BMC Musculoskelet. Disord. 7, 11

Kamali F, Esmaeil Shokri E (2012). COMPARATIVE STUDY The effect of two manipulative therapy techniques and their outcome in patients with sacroiliac joint syndrome. Journal of Bodywork & Movement Therapies 16, 29e35.

Soleimanifar M, Karimi N, Arab AM (2017). Association between composites of selected motion palpation and pain provocation tests for sacroiliac joint disorders. Journal of Bodywork and Movement Therapies, Volume 21, Issue 2, April, Pages 240-245


Adhesive Encapsulitis (Frozen Shoulder) Manual Therapy by Osteopaths

Adhesive encapsulitis (Frozen Shoulder)

The frozen shoulder is a multifactorial disease characterized by inflammatory adhesion and stiffness of the glenohumeral capsule, pain in the shoulder, and limitation of movements in all directions (especially abduction, external rotation, and posterior extension). The age of onset falls between 30 and 70 years, with an average of fifty. More females are affected than males, with the left shoulder more often involved than the right (Cui et al. 2017).

The prevalence of frozen shoulder is about 2%–5%. Risk factors include diabetes, thyroid diseases, stroke, and autoimmune diseases. The prevalence of frozen shoulder in patients with diabetes is as high as 10%–20% and in patients with paralysis 16%–84% (Cui et al. 2017).

frozen shoulder adhesive encapsulitis

Imaging of Frozen Shoulder

Imaging studies of frozen shoulder (s) revealed reduced joint volume and a thickened and shortened glenohumeral capsule. Magnetic resonance imaging showed a significant thickening of the coracohumeral ligament and the rotator cuff interval as well as obliteration of the fat triangle between the coracoid process and the coracohumeral ligament (Cui et al. 2017).

frozen shoulder adhesive encapsulitis

Effectiveness of Osteopathic Treatment for Frozen Shoulder

Manual Mobilization with Exercise for Frozen Shoulder

Both manual mobilization therapy along with general exercises and exercises alone brought improvements in outcome measure scales for pain, glenohumeral ranges and shoulder pain and disability index but none of intervention is significantly effective over one another in 5 weeks of treatment (Ali and Khan, 2015).

There is a wide variety of manual therapy techniques that can be applied to treat frozen shoulder.

Angular Joint Mobilization for Frozen Shoulder

A case report suggests that Angular Joint Mobilization , which is rotational joint mobilization with joint axis shift, may be an effective intervention for improving shoulder pain, ROM, and disability in individuals with adhesive capsulitis (Kim and Lee , 2017).

Mobilization with Distension For Frozen Shoulder

Also hydraulic distension plus manual therapy decreased shoulder pain and improved shoulder function. Specifically, pain, satisfaction, and range of motion showed quick improvement from 6 weeks to 12 weeks after treatment. The treatment results of this study can be used for frozen shoulders (Kwak and Kim, 2016).

Mobilization with Distension combined with Steriod Injections for Frozen Shoulder

Whereas another study suggested that the most effective treatment for subacute Adhesive encapsulitis is a combination of intensive mobilization and steroid injection with capsular distension, and helped to control inflammation, extend joint space, and recover ROM. Therefore, intensive mobilization should be conducted by a skilled physical therapist after steroid injection with capsular distension to optimize the treatment effect for patients with Adhesive Encapsulitis (Park et al. 2014).

Spencer Technique for Frozen shoulder

Osteopaths use hydraulic distention when applying an articulatory technique to the shoulder known as the Spencer Technique  to help relieve restriction and pain at the shoulder. Although variations exist, normally 7 steps are included. Indications for the Spencer technique include adhesive capsulitis.

The following is a common sequence (of the 7 stages of the technique:


spencer technique frozen shoulder

Spencer Technique

A pilot study suggested that the Spencer technique is an effective treatment modality for improving the functional ability of the shoulder in the elderly (Knebl et al. 2002).

Niel Asher Technique

The Niel-Asher technique (NAT) involves a deliberate, specific algorithm of manipulations to the muscular and ligamentous apparatus of the glenohumeral
joint based around a five-step treatment protocol. Treatment sessions last between 25 and 40 (average of 30) minutes in duration; the technique was performed on all patients in sequential order on each visit. Within the five steps of the NAT protocol there are two main types of techniques employed which have been slightly modified; deep stroking massage (step one) and compression of trigger points (steps two, four and five) (Niel-Asher et al. 2014).

The notion of a “one-technique-fits-all” technique may initially seem an anathema to the “treat the individual” model that osteopathy currently promotes.
Whilst the idea may be challenging to some, the results of NAT are fast, effective and reproducible (Niel-Asher et al. 2014).

Compression technique

This technique involves locating the tender point that when compressed triggers a specific referred pain pattern (preferably reproducing the patient’s symptoms)and applying a direct pressure to this point:

1. Identify the tender/trigger point you wish to work on
2. Place the patient in a comfortable position,where the tissue which contains the tender/trigger point can undergo full excursion if required;
3. Apply gentle, gradually increasing pressure to the tender point until you feel resistance;
4. This should be experienced by the patient as therapeutic discomfort but in this technique it may sometimes border on pain;
5. Apply sustained pressure until you feel the tender point yield and soften. This can take from seconds to several minutes;
6. This can be repeated, gradually increasing the pressure on the tender/trigger point until it has fully yielded.
7. To achieve a better result, you can try to change the direction of pressure during these repetitions.

(Niel-Asher et al. 2014).

Deep stroking massage technique

This approach follows a technique advocated by Travell and Simons involves a deep slow stroking technique over a tender/trigger point rather than a compression as described above

1. Place the patient in a comfortable position, where the affected/host muscle can undergo full excursion;
2. Lubricate the skin if required (the lead author uses simple BLUE NIVEA);
3. Identify and locate the tender/trigger point or taut band;
4. Perform slow stroking massage using your thumb/applicator just beneath the taut band, and reinforce with your other hand if required;
5. This should be experienced by the patient as therapeutic discomfort but in this technique it may sometimes border on pain;
6. Sustained pressure is applied until the tender/ trigger point softens, followed by continued stroking in the same direction towards the attachment of the taut band;

(Niel-Asher et al. 2014).

Manual Therapy for Frozen Shoulder in Diabetics

Manual therapy approaches may be safely applied in diabetic patients with frozen shoulder (Düzgün et al. 2012).

Cochrane Review of Manual Therapy and exercise for Frozen Shoulder

The best available data show that a combination of manual therapy and exercise may not be as effective as glucocorticoid injection in the short-term. It is unclear whether a combination of manual therapy, exercise and electrotherapy is an effective adjunct to glucocorticoid injection or oral NSAID. Following arthrographic joint distension with glucocorticoid and saline, manual therapy and exercise may confer effects similar to those of sham ultrasound in terms of overall pain, function and quality of life, but may provide greater patient-reported treatment success and active range of motion (Page et al. 2014)

Treatment at Cam Osteopathy

For more information or to make an appointment with an osteopath at Cam Osteopathy, go to the home page or click on book an appointment

Reference List

Ali SA, Khan M (2015). Comparison for efficacy of general exercises with and without mobilization therapy for the management of adhesive capsulitis of shoulder – An interventional study. Pak J Med Sci.  Nov-Dec;31(6):1372-6

Cui J, Lu W, He Y, Jiang L, Li K, Zhu W, Wang D (2017). Molecular biology of frozen shoulder-induced limitation of shoulder joint movements. J Res Med Sci. May 30;22:61

Düzgün I, Baltaci G, Atay OA (2012). Manual therapy is an effective treatment for frozen shoulder in diabetics: an observational study.  23(2):94-9.

Kim Y, Lee G (2017). Immediate Effects of Angular Joint Mobilization (a New Concept of Joint Mobilization) on Pain, Range of Motion, and Disability in a Patient with Shoulder Adhesive Capsulitis: A Case Report. Am J Case Rep. Feb 10;18:148-156.

Knebl JA, Shores JH, Gamber RG, Gray WT, Herron KM (2002). Improving functional ability in the elderly via the Spencer technique, an osteopathic manipulative treatment: a randomized, controlled trialJ Am Osteopath Assoc. Jul;102(7):387-96.

Kwak KI,  Kim EK (2016).  The clinical effect of hydraulic distension plus manual therapy on patients with frozen shoulderJ Phys Ther Sci. Aug;28(8):2393-6.

Niel-Asher S, Hibberd S, Bentley S, Reynolds J (2014).  RESEARCH REPORT Adhesive capsulitis: Prospective observational multi-center study on the Niel-Asher technique (NAT) International Journal of Osteopathic Medicine. 17, 232e242

Page MJ, Green S, Kramer S, Johnston RV, McBain B, Chau M, Buchbinder R (2014). Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. Aug 26;(8)
Park SW, Lee HS, Kim JH (2014). The effectiveness of intensive mobilization techniques combined with capsular distension for adhesive capsulitis of the shoulder. J Phys Ther Sci. Nov;26(11):1767-70.