Evolution of subjective health complaints (SHC) following osteopathic treatment of patients with neck or back pain.


Public health leaders all over the world struggle with limited budgets and expanding health-care costs. In Western countries, allopathic care costs are rising exponentially, while in developing countries, access is limited.  Large cities have well equipped university or private hospitals but the rural areas or poor neighborhoods are providing care with basic health units that are limited in terms of services they can provide. WHO says that in developing countries, where more than one-third of the population lacks access to essential medicines, the provision of safe and effective traditional or complementary and alternative medicine (TM/CAM) therapies could become a critical tool to increase access to healthcare.  Ideally, countries would blend traditional and conventional ways of providing care in ways that make the most of the best features of each system and allow each to compensate for weaknesses in the other.

Osteopathy is growing everywhere. It is the fastest growing health profession in Australia and the USA.  It is well established in Europe and Canada. Osteopathy has grown from the base, mostly because of practitioners wanting more effective modalities and patients enthusiastically embracing them. Most osteopathic practice in Western countries is in private practice, although the situation in the USA is harder to evaluate as osteopathic physicians mostly work as allopathic physicians with little place in the current health-care system for manual practice.

The Osteopathic International Alliance (OIA) published a report “Osteopathy and Osteopathic Medicine, A Global View of Practice, Patients, Education and the Contribution to Healthcare Delivery” that reviews published research, including meta-analysis, showing positive results of osteopathy for a variety of diagnosis, most commonly for musculoskeletal disorders (back and neck pain, headaches), but also for functional internal medicine disorders (breathing disorders, pregnancy issues, otitis media, menstrual problems, digestive disorders, disorders of childhood). Unfortunately, most studies are small and do not give a global view of the reach and potential impact of osteopathic treatment. The present study looks to add necessary data to demonstrate the potential benefit of osteopathic care.

Osteopathy looks to restore health by normalizing alignment and mobility to the structure, therefore normalizing weight-bearing on joints but also improving fluid circulation and nerve conduction. All systems being interrelated, the improvement in one system improves the others. Homeostasis, better named homeodynamics, is a normal functioning of the body and every cell is programmed to maintain it. When there is disease, the osteopath looks to the causes of functional dysfunction and releases the mechanical barriers to proper function. That is how patients treated by osteopathy show benefits outside of the system they consulted for. These effects could be called positive side-effects. For example, coming for low back pain and seeing improvement in digestion or sleep. It is clinically experienced, though not yet studied, that osteopathy is a very good preventative medicine, thanks to its possible and wanted effect on circulation and on freeing the ability to maintain homeodynamics, in the same way that tuning your car’s motor with a regular check-up insures better long-term functioning.

The study:

This observational study was performed by the first two osteopaths of Pakistan, Haider Ali and Usmara Zafar, of Lahore, Pakistan. They were trained thanks to the support of the foundation Osteopathy Without Borders. The study measured the changes in subjective health complaints and medication intake before and after 5 weekly osteopathic treatments in patients coming for neck or back pain.

We used a validated health score questionnaire, the Subjective Health Complaints  (SHC) by Eriksen, Ihlebaek and Ursin (Annex 1). The SHC was chosen for accurately describing the health of a person, both physical and mental. Its inventory was found to be a systematic, easy and reliable way to score subjective health complaints and follow the well-being, or lack thereof, in individuals or specific groups of individuals.  Severity of each complaint is rated on a 4-point scale (0 is no issue, 3 is severe pain or dysfunction).  The SHC includes 29 questions, covering pain, flu, neurological, gastro-intestinal and respiratory-allergy issues. Using our clinical experience, we chose to add 3 questions in order to collect data about all body systems, specifically 2 questions for uro-genital issues and 1 question for ENT symptoms. (Appendix 1). To satisfy research protocols, we statistically analyzed the results for the original 29 questions and performed the same analysis for the updated 32 questions questionnaires.  Subscores by systems, as proposed in the initial validating study, were analyzed (flu, pain, pseudo-neurology, gastro-intestinal, respiratory/allergy, with the addition of uro-genital).  The change in the number of medication doses per week was analyzed to provide another perspective on the evolution of health before and after treatment.

The study was conducted at Fatima Memorial Hospital (FMH), Sadman, Lahore, Pakistan. Patients were recruited with the help of Dr. Misbah ul Arfeen, medical director of the Naimshuk health center, between October 2014 and September 2015.  All patients were residents of this low socio-economic neighborhood.

Inclusion criteria were patients of both genders, older than 5, suffering from musculo-skeletal pain and with no significant improvement after 3 months of Standard Care (SC).  Standard care was provided by the community health center and consisted mostly in medication prescription. All patients were used as their own controls as they had been seen by a physician and given SC unsuccessfully prior to being enrolled in the present study.

To avoid confusion as to the causes of changes in SHC scores, exclusion criteria were surgery in the last three months, using steroids, receiving manual or physical therapy in the last two months, and patients unable to communicate well.

There were no adverse effects reported.


50 patients were included in the study, 33 women, 17 men, with an average age of 42 years.

Chart 1: SHC score results.

The best results, with a p-value <0.0001 were found for all symptoms of pain and headaches, anxiety, sleep problems, tiredness and dizziness.  The improvements were also statistically significant (p value<0.05) for the symptoms of extra-heartbeats, stomach discomfort, heartburn, constipation, breathing difficulties and ENT. All other symptoms improved, although since fewer patients complained of those, they couldn’t reach statistical significance. Only the symptom of heat flushes increased, because one patient reported it as a new symptom at the 2nd evaluation.


Chart 3: Evolution of total SHC score

Total Subjective Health Complaints (SHC) score showed significant improvement after 5 osteopathic sessions. Analysis was made twice, one for the original validated 29-questions questionnaire and another one for the 29 + 3 questions. P value was <0.0001 in both instances with a mean difference of 9.74 for the 29-question questionnaire (from 17.00 to 7.26).  It went from an average of 17.78 points to 7.52 points for the 32-question questionnaire. A decrease of 10.26 points, p value <0.0001. The range of SHC score at the initial evaluation was 3 to 41 points. It was 1 to 29 points at the 2nd evaluation.


Chart 4: Subscores results.


This table shows that all 50 patients complained of pain and after treatment only one patient had no pain at all (49 had some level of pain, ranging from 1 to 3). Nonetheless there is significant difference (p value<0.05) in pre- and post- score indicating the severity of pain had decreased significantly in response to the osteopathic treatment. There is a decrease in post scores for all groups however it reaches significant levels for those subscores that had enough patients with those particular symptoms, that is: pain, pseudo-neurology, gastro and allergy (p value<0.05). Flu and urogenital with 4 and 7 patients respectively, didn’t reach statistical significance.

Other variables:

ANOVA analysis were made to see if gender or age affected the quantity of response to the treatment. Results were negative for all variables for general SHC score and each subscore, meaning that the osteopathic treatments helped all population groups equally. Osteopathic treatment was found to be as effective for the complex cases who complained of more than 10 symptoms as for those cases who complain of fewer symptoms. Also, it was found that the duration of symptoms, that ranged from less than 6 months to more than 5 years, didn’t affect the response to the osteopathic treatment. This analysis was done by splitting the symptoms according to duration of <6months, 6-12 months, 1-5 years and more than 5 years.

Chart 5: Medication intake.

Medication intake was calculated on a weekly basis, with a dose of medication taken once a day given a value of 7, twice a day 14, etc…  The change in type of medication, for instance going from Voltaren to Tylenol, was not taken into account. We asked about all medications, not only those to alleviate pain, but didn’t include nutritional supplements. Average intake of medication went from 25.35 doses per week to 9.38, with a p value <0.0001.



While osteopathy cares to relieve symptoms, its focus is on restoring the body’s ability to self-heal. Because of the basic concept that all of the body systems are interrelated, changes in one system affect the others, positively or negatively.  Osteopathy looks to find the causes of functional dysfunctions, releasing mechanical strains in the tissues that interfere with proper alignment and mobility. Releasing tissue tightness, while relieving pain, also allows normalization of fluid circulation and nerve conduction, which allow proper organ function. An often quoted saying of the founder Andrew Taylor Still, MD, is: “To find health should be the object of the doctor. Anyone can find disease”.  The primary goal of an osteopathic treatment is to restore the body’s ability to maintain health.

This study brings data to the claim that osteopaths make that when treating a patient for one condition, other conditions or symptoms will also improve. We found improvement in all items measured by our questionnaire (except for one patient with a new symptom of heat flushes) whether concerning pain or functional internal medicine issues.  These results, while preliminary, warrant further research into the validity of adding osteopathy to an integrative medical model.  The results of this study are consistent with the number of studies that have measured outcomes of osteopathic treatments for specific diagnosis.  These outcomes are very interesting in themselves, but putting all of those results together is when osteopathy becomes remarkable.

This study calls for more research building on this interesting data, with proper RCTs, adding a third questionnaire and evaluating the cost-savings benefit of providing osteopathic treatments. This would require a coordinated effort between different medical departments and a long-term evaluation but could possibly inform the evolution of a healthy health-care system.

Appendix 1



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