An investigation into the benefits of postural re-education in osteopathic treatment of low back pain

Background: Osteopathy has been shown to be effective in the treatment of patient suffering from non-specific low back pain (NSLBP) either alone or in association with an exercise program. Osteopathy and postural re-education claim to approach the patient from a global perspective, nevertheless, there is no research in the literature comparing osteopathy and postural re-education.

Objectives: This pilot study was undertaken to establish the feasibility for further clinical trials into the clinical benefits of adding a programme of postural re-education, the Mézières Method, to osteopathic treatment of NSLBP.

Methods: A pilot randomised controlled trial recruited 20 patients complaining of NSLBP from the British School of Osteopathy’s clinic. The patients were randomly assigned to two experimental groups: osteopathy plus Mézières Method treatment and osteopathy plus a standard home exercise program. The intervention lasted eight weeks and the outcome measurements were represented by the Visual Analogue Scale (VAS), Euro Quality of Life (EuroQoL) and Oswestry Disability Index (ODI). Data were collected twice, at baseline and at the end of the intervention by a qualified physiotherapist.

Results: There was significant improvement in VAS (p=0.000178), ODI (p=0.000089) and EuroQoL global health state (p=0.001) in both groups after the intervention. However, patients following the osteopathy plus Mézières Method treatment demonstrated greater significant improvement, with VAS (p=0.043), ODI (p=0.035) and EuroQoL global health state (p=0.002).

Key words: low back pain, spinal manipulation, postural re-education, osteopathy, Mézières Method, posture, muscular chain.

INTRODUCTION

The social and economic impact of low back pain (LBP) is felt throughout the world (Dagenais et al. 2007). NICE guidelines (2009) use the term non-specific low back pain (NSLBP) to describe persistent or recurrent lower back pain that lasts for more than 6 weeks but for less than 12 months. NSLBP is tension, soreness and/or stiffness in the lower back region for which it is not possible to identify a specific cause of the pain (NICE guidelines, 2009). In the UK osteopaths diagnose and treat patients with a range of musculoskeletal disorders, with LBP being the most common (GOsC, 2013). Research showing possible benefits of osteopathy on LBP has been undertaken by Hadler et al. (1987) and Andersson et al. (1999). Andersson et al. (1999) demonstrated that osteopathic care was comparable to standard care in terms of low back pain reduction, diminishing the consumption of medications and therefore costs.

Licciardone et al. (2005) investigated whether osteopathic manipulation could be considered complementary to conventional care for LBP. Their meta-analysis of six randomised controlled trials (RCT) concluded that there was a reduction of pain particularly in patients treated with osteopathy than with standard active treatment. However, a weakness of this study was the high variability of an individual trial in terms of methods used: setting, subject characteristics, type of osteopathic manipulation, pain measurements and control group treatment, even if stratification was used to limit these. Posadszki and Ernst (2011) offered a critique to Licciardone’s work, highlighting the scarce number of RCTs analysed and setting up a larger review of 16 RCTs. This research identified five studies suggesting that osteopathy decreased pain in musculoskeletal issues and eleven studies suggesting that osteopathy enhanced results without giving statistically significant changes in comparison with standard care. Although still unclear was the role of osteopathic care, in 2010 the American Osteopathic Association recommended the use of manipulative treatment in the new guidelines for the treatment of LBP, considering it of primary relevance on the management of this condition. Despite these positive conclusions there are still many unknowns about the role of osteopathy along other healthcare disciplines. It is therefore important for osteopaths to continue investigating new methodologies of practice supported by research (Osteopathic Practice Standards, 2012).

Although there is evidence proving that osteopathy alone and with exercise is effective in LBP care (UK BEAM trial team, 2004), a lack of comparisons between osteopathy and a postural re-education program is evident.

Osteopathy claims to approach the patient and its assessment in a global way (Parsons, Marcer, 2006) as do methods of postural re-education that have as a central tenet the importance of breathing in postural control: Pilates in the early 20^th century (Friedman, Eisen, 1980), Alexander technique (Kosminsky, Hurt, 1999), Mézières Method (Mezieres, 1954), Souchard Method (Souchard, 2005).

Specifically, the Mézières Method of postural re-education was founded upon observations made on the musculoskeletal system, when attempting to escape pain and adapt to a condition of discomfort. Coelho (2008) describes the method as an innovative way to approach the body and the concept of posture. The Mézières Method (Mézières, 1954) is designed to work on the muscular chains and their lengthening throughout the whole body. Its benefits have been studied in different conditions. Barrientos (2009) examined its utility in a functional somatic syndrome such as fibromyalgia, while comparing Mézières Method treatment and standard exercises. In this study a reduction of pain symptoms and improvement on muscular functionality was evident after 12 weeks of treatment in both groups. The study showed positive but still not statistically significant trends associated with the postural re-education treatment.

Teodori et al. (2011) showed positive trends associated with the method too, demonstrating improvement in respiratory muscle strength, chest expansibility, thoracic and abdominal mobility, pain and flexibility in the treatment of musculoskeletal disorders of a postural nature. Although there is some evidence showing the applicability of the Mézières Method in musculoskeletal care, the majority of the published articles are poor in quality of research methodology and mainly based upon subjective observations of experts. To date, the effectiveness of the Mézières Method has not been tested with a RCT.

The critical review of the literature suggests that osteopathy has evidence of effectiveness in terms of pain reduction (Andersson et al. 1999, Licciardone et al. 2005) and although it has been compared and combined with standard exercises, it has never been compared with a postural re-education method. This study aimed therefore to establish the feasibility for further full scale studies into the beneficial clinical effects of adding Mézières Method in the treatment of patient suffering from LBP and receiving osteopathy as primary care.

Moreover, as described in its method design section, it has indirectly tested the role of patient self-management in LBP, analysing an element already identified as relevant in the treatment of this condition by Triano et al. (1995). They compared in a randomised trial the effects of manipulative/osteopathic treatment versus educational programme (booklet about back diseases) in patients with chronic low back pain. The outcomes being measured by self-reported pain level and activity tolerance of patients after one month of follow up. Although results appeared to be more significant for patients manually treated, an improvement in self-beliefs and consciousness of the pathology was achieved for patients following the educational programme. Results being confirmed by Goldby et al (2006). They realised a randomised trial following the same line of Triano’s study (1995) but improved method’s reliability in terms of measures of outcome. In fact they considered a larger number of variables, such as intensity of pain, disability, handicap, radiations and quality of life and expanded the follow up timeframe to a period of two years. Results showed that although overtime standard or manual treatment were more effective than the educational programme, improvement on patient’s self-care and consciousness was achieved in terms of lifestyle and preventive behaviours. The conclusions possibly drawn from the analysis of the aforementioned researches are that if carefully selected and presented to patients, advices and home exercises can add positive clinical outcomes.

Little data have been collected to compare the Mézières Method to other physical therapies, whereas in literature there is no evidence of comparison between the former and osteopathy. A quantitative investigation on the possible effects of postural re-education on patients following osteopathy as primary lower back pain care is therefore required. Although the few studies accomplished on the Mézières Method haven’t shown a statistical significancy of data, some positive trends have emerged (Barrientos, 2009. Teodori et al, 2011). Some predictions can therefore be drawn and a more consistent improvement of the symptoms may be expected in the patients allocated in the study group.

METHODS

A pilot RCT was carried out at the British School of Osteopathy’s (BSO) clinic. The project was reviewed by and received ethics clearance through the BSO Research Ethics Committee. The pilot research design was selected as an appropriate method for the initial analysis of possible emerging trends (Lancaster et al. 2004), to test the feasibility of the research topic and methods in a busy osteopathic clinic, where performing a non-osteopathic therapeutic treatment on a large sample would be practically and logistically difficult. Furthermore the RCT design represents the most appropriate way to investigate a clinical effectiveness type research question (Hicks, 2004).

Twenty patients, suffering from NSLBP were recruited from the BSO clinic, randomised via an Excel statistical function and assigned to either the intervention or the control group (ten patients each) to start an eight-week program.

The intervention group (group 1) received, in addition to the osteopathic treatment, four sessions of Mézières Method of postural re-education carried out by the researcher and four carried out independently by the patients at home, after being given a clear and detailed exercise hand-out. The control group (group 2) received the osteopathic treatment and a different weekly exercise program of specific mobility and stretching exercises commonly suggested by practitioners to patients with NSLBP. These were represented by the cat-camel mobility exercise, aiming to train the alternation of anterior and posterior pelvis tilt and by a sitting stretching posture of the posterior muscular chain. Providing an active control treatment helped in blinding the participants of the control group. The osteopathic treatment was based on the principles taught at the BSO and carried out in the clinic by the third and fourth year osteopathy students supervised by their clinical tutors. This included osteopathic manipulative treatment, soft tissue, articulation techniques and myofascial release. All participants were offered the same range of osteopathic techniques, applied specifically on the patient’s case.

The participants in the study group were evaluated on a clinical standing and gait examination first. The researcher assessed the possibility of postural imbalances arriving at a diagnosis of the state of the articular and myofascial chains. The techniques addressed during the treatment were chosen on the specific case following the Mézières principles. The full range of techniques used included diaphragmatic breathing, global stretching postures and manual, myofascial and articular mobilisation techniques applied with the patient lying on an appropriate mattress. Active contraction of specific muscular groups was taught by the physiotherapist and repeated throughout the session.

Participants were represented by BSO patients wishing to participate after reading posters displayed in the clinic waiting area or being addressed by tutors or students as suitable to participate. Their proposal to take part in the study was totally voluntary and no justification was asked if they decided to abandon the study, regardless of the current phase of the study. Patients were asked to drop a piece of paper with their contact details inside a collection box in the reception area, enabling the researcher to contact them to arrange the date of the pre-intervention rating scales administration. On this occasion a screening questionnaire and a consent form were asked to be signed by the willing participant. The inclusion criteria to meet for the participants are described in table 2:

Table 2: Inclusion and exclusion criteria.

Data were collected twice, at baseline and at the end of the intervention. The outcome measurements were represented by:

1. Level of pain, assessed by the Visual Analogue Scale.

The Visual Analogue Scale (VAS) has been chosen because considered reliable and valid (Price et al, 1983; Bijur et al, 2001). Furthermore it represents a constant instrument of measurement during the daily practice at the BSO clinic.

2. Disability, by the Oswestry Disability Index (Fairbank et al. 2000, Vianin 2008)

Vianin (2008) performed a literature review to test the validity and reliability of the Oswestry Disability Index (ODI) in patients with chronic low back pain (CLBP) and stated that the ODI shows good construct validity; internal consistency is rated as acceptable; test-retest reliability and responsiveness have been shown to be high and burden of administration is low. Moreover it is easy to administer and score, resulting particularly suitable for clinical practice.

3. Quality of life, by the EuroQOL Scale (Soer et al 2012).

The EuroQOL has recently been validated in a diverse patient population in 6 countries, including 8 patient groups with chronic conditions (cardiovascular disease, respiratory disease, depression, diabetes, liver disease, personality disorders, arthritis, stroke) and a students cohort (Euroqol, 2013). Soer (2012) stated as a result of a perspective study comparing this scale with the Roland Morris Disability Questionnaire, the Pain Disability Index and a NRS of quality of life (numeric rating scale) that EuroQOL has a high level of reliability and responsiveness in the assessment of the quality of life of patients with CLBP.

The pre and post-intervention data collection was undertaken by fellow senior BSO students who were blinded at the intervention stage.

The study data have been analysed by inferential statistics methods, Shapiro-Wilks test was used to test for normality of data distribution throughout the sample.

Data from VAS, ODI and EuroQoL were tested intra-group, comparing pre-test and post-test data, and inter-groups to assess the difference post-intervention.

Depending on the normality of the distribution parametric related samples t test or non-parametric Wilcoxon Signed Rank test were used to compare the measurements of data pre/post intervention and to assess the possibility of change in the rating scales score during the 8 weeks of intervention.

Mann Whitney test was used to test the comparison of score change in VAS, ODI and EuroQoL between groups post-intervention, assessing the hypothesis of greater changes in the group receiving both types of treatment during the 8 weeks, compared with the group receiving osteopathy and home exercise program.

The scores from ODI and EuroQOL were summed to obtain a Total score which represented a quasi-interval scale. Therefore suitable for parametric analysis (Feinstein, 1996).

RESULTS

The mean value for age of participants was found to be 44.45 year old with a total of 8 females and 12 males participating to the study. The age mean for the intervention group was 41.5 year old with 3 females and 7 males participating, whereas the age mean for the control group was 47.4 year old with 5 females and 5 males participating.

On pre and post intervention data (VAS, ODI, EuroQoL) a Shapiro-Wilk test was performed on a total of eight variables. The data were found to conform to parametric assumptions for VAS, ODI and EuroQoL VAS, pre and post intervention. A significant difference from normal distribution was found, pre and post intervention, for EuroQoL descriptive system variables, therefore suitable for non-parametric analysis.

A paired Sample T test was performed on the three variables suitable for parametric analysis, pre and post-intervention.

A significant difference (for Paired Sample T test p=<0.01) between data pre and post-intervention was found for each of the three variables for both groups of intervention. A p<0.001 was found for VAS, p=0.000178 (patient’s subjective perception of the pain) and ODI, p=0.000089, whereas p=0.001 was found for EuroQoL VAS (patients subjective perception of their global health state).

A Wilcoxon Signed Rank Test was performed on the variables suitable for non-parametric analysis.

A significant difference between data pre and post-intervention (for Wilcoxon Signed Rank test p<0.05) was found for three out of five descriptive systems of the EuroQoL rating scale for both groups of intervention.

The “mobility” corresponding value was p=0.025, the “usual activities” corresponding value p=0.001 and the “pain/discomfort” corresponding value p=0.002.

A Mann Whitney U test was performed to assess the score change between groups post-intervention.

A significant difference in score change between groups post-intervention was found (for Mann-Whitney U test p<0.05) for three of the eight variables assessed, with study group having a greater change than control group. A significant p=0.043 was found for VAS (patients subjective perception of the pain), p=0.035 for ODI and p=0.002 for EuroQoL VAS (patients subjective perception of their global health state).

DISCUSSION

The aim of the study was to determine the feasibility for further clinical trials into the clinical benefits of adding the Mézières Method in the treatment of patient suffering from LBP and receiving osteopathy. This study suggests that there are significant differences for both groups pre-post intervention, with larger improvement seen in patients receiving additional Mézières Method concerning subjective pain level (VAS), subjective quality of life level (EuroQoL VAS) and lower back pain related disability (ODI). No major methodology issues were identified in this pilot study design.

The reduced level of pain shown (p=0.043) supports Barrientos (2009) as he suggested a reduction in pain level and improvement on muscular functionality after 12 weeks of Mézières Method treatment, although his findings were not statistically significant. However, in the study by Barrientos the subjects were suffering from fibromyalgia, so not representative of the whole population of people with postural disorders.

The reduction of pain supports also Teodori et al. (2011), who showed improvement in pain level with further benefits on respiratory muscle strength, chest expansibility, thoracic and abdominal mobility and flexibility with the Mézières treatment of musculoskeletal disorders of a postural nature.

This study has also shown a significant improvement in subjective general health state (EuroQoL VAS p=0.002) and disability linked with the lower back pain (ODI p=0.035) as being larger for the intervention group (group 1) than the control group (group 2). However, as a significant improvement of the aforementioned variables has been shown for both intervention groups, these findings support Triano (1995) and Goldby et al. (2006), who suggested an improvement in self-beliefs and consciousness of the pathology for patients following osteopathy and a home exercise program, showing improvement in pain and quality of life.

Although group 1 had a significantly greater improvement than group 2, this study shows that both groups improved in pain, quality of life and disability after the eight week treatment. This supports Licciardone (2005), who suggested that osteopathy is helpful in reducing the level of lower back pain, and Andersson (1999), whose study showed that osteopathic care was comparable to standard care in terms of low back pain reduction. In fact, in both cases osteopathy was found a valid therapy for lower back pain, with or without standard exercises. However, in Licciardone’s study (2005) too a high variability in terms of subjects characteristics and osteopathic manipulation was evident, therefore the sample didn’t appear enough representative of the population.

The results of this study have shown a significant improvement of patients following the Mézières Method treatment. Critically, It could also be explained by the addition of a second “hands on” treatment for group 1 compared to the additional exercise handout for group 2. However, the aim of the study was to test the validity of the Mézières Method as a potential adjuvant to osteopathy, therefore resulting helpful in highlighting positive trends associated with the addition of the postural re-education method.

Methodological limitations of this study are found in the potential unreliability of patients while performing the assigned home exercises. Ensuring a one to one treatment for each patient of both groups would have increased the reliability of the results and ensured a full undertaking of the exercises. Furthermore a larger sample of subjects would have been indicated to achieve a more precise understanding of the findings and a better representation of the population.

CONCLUSION

The addition of Mézières Method in the treatment of patients suffering from low back pain and receiving osteopathy has a beneficial effect in reducing patients’ level of pain and disability. Furthermore the findings from this study suggest that the addition of the postural re-education treatment improves the patients’ subjective level of global health state, having a beneficial effect on their quality of life.

This pilot study demonstrated the study methodology to be feasible and the positive trends shown can be considered a first basis on which to undertake a further larger research project.

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