Person-centered versus body-centered approaches in osteopathic care for chronic pain conditions

We read with great interest the recently published study by Coste et al. ¹ The authors reported no benefit of osteopathic treatment in a sample of patients with fibromyalgia (FM) and, therefore, concluded that its use was not recommended. ¹ We argue that their findings were expected given their lack of rationale for evaluating the benefits of a single therapeutic approach in the care of individuals with this chronic pain syndrome.

In this multicenter randomized controlled trial, the osteopathic (‘real’) intervention consisted of a strict protocol of manual techniques routinely applied for each patient. ¹ No justification was provided regarding their choice of the specific techniques used in the study. In addition to this concern about the selected techniques, the actual study protocol raises other concerns about the lack of rationale for applying this kind of manual approach for a chronic pain condition like FM and about the authors’ reductionist and biomechanical-based understanding of what constitutes osteopathy and osteopathic treatment.

FM is a functional bodily distress syndrome ² with variable symptoms, psychophysiological responses to stress, patterns of coping, and responses to treatment. ³ In line with previous evidence, ⁴ a survey study conducted in France (which included several authors from the Coste et al. ¹ study) showed that patients with FM commonly had lifelong histories of chronic pain throughout their body and experienced a wide range of comorbidities. ⁵ Moreover, the severity of FM was more often related to psychosocial factors than to physical symptoms. ⁵ Given this complexity and variability, recent clinical guidelines for chronic pain conditions recommend therapeutic approaches based on a person-centered assessment.^6–8 For patients with FM, treatment strategies should be framed within a multidisciplinary approach and mainly promote physical activity, such as aerobic fitness or strengthening exercises.^3,9,10 Therefore, activating and centrally acting therapies that engage the patient appear to be more effective than passive ones that primarily act on the peripheral physiology. ¹¹ In this scenario and according to the available evidence, it can be easily anticipated that no single, isolated passive intervention will significantly improve the outcomes of these patients.

Although the legal definition of osteopathy in France stresses the body-centered model of practice, it also acknowledges the need for individualized diagnosis and treatment based on an individualized clinical examination. ¹² Perhaps, results would be different just by applying a more pragmatic attitude to treatment. For example, relying only on a manual approach, Albers et al. ¹³ showed positive effects from individualized osteopathic interventions when treating patients with FM. These findings were also supported by a recent systematic review. ¹⁴ In contrast, the manual techniques in the study by Coste et al. ¹ targeted articular and/or myofascial structures under the assumption that “patients with FM are usually normally mobile or even hypermobile”. Despite the variability in defined signs and symptoms, the literature on FM does not mention hypermobility as a clinical feature.^4,15–18 Therefore, the assumption on which Coste et al. ¹ based their intervention should be considered, at least, speculative, and likely compromises the validity of their results. Moreover, for patients experiencing hypermobility, the recommended treatment also involves a multidisciplinary approach and physical activity. ¹⁹

So is there a place for osteopathic manual intervention in the treatment of patients with FM? Yes, we believe there is, but not as an isolated and exclusively body-centered intervention. There is compelling evidence about the biological mechanisms and effect of manual therapy.^20,21 However, the impact of manual therapies is mainly short term and more effective in acute presentations than in chronic pain conditions, limiting their value in those cases. ²² Nonetheless, the very nature of manual therapies (touch-based), ²³ the therapeutic relationship (patient–practitioner) that commonly defines these interventions, and the associated contextual factors^24,25 provide a good environment to treat functional somatic disorders associated with FM. As such, a good understanding of the processes involved in the development and maintenance of chronic widespread pain is paramount to provide more benefit than harm. ²⁶

As a manual intervention, osteopathic treatment uses a hands-on approach to interact with patient physiology; however, beyond the desired analgesic modulation, affective responses and somatoperceptual reorganization are also key elements of human touch. ²³ Despite its central role in osteopathy, hands-on care is not the only therapeutic intervention that osteopaths can use to improve their patients’ health. For chronic pain conditions like FM, other strategies such as pain education, cognitive reassurance, exercise, and health advice in conjunction with psychologically informed interventions should be taken into account. A recent systematic review provided encouraging evidence of the effects of osteopathic treatment on psychosocial factors in people with persistent pain. ²⁷ Moreover, preliminary evidence from the OsteoMAP study ²⁸ showed that a psychologically informed osteopathic intervention worked for patients with chronic pain.

Ultimately, we would argue that the osteopathic care of individuals with persistent physical symptoms, such as those with FM, should only be considered from a multimodal person-centered perspective. Further, a person-centered and biopsychosocially informed approach to osteopathic care can positively modulate nociplastic changes in central pain pathways and address psychosocial factors typically present in patients with persistent physical symptoms. After repeated calls to move away from biomechanical-postural models of osteopathic care,^29–34 it is also time for a change in how osteopathic research is designed and conducted to avoid wasting time and resources in the pursuit of predictable results.