Please note that the information is a guide and if you have worries please consult a physician.
Do not use this information as a means of self diagnosis and professional advice should be sought prior to endeavours of self-treatment.
A physician will conduct a thorough interview and correlate subjective findings with objective findings to recognize presenting conditions that may require medical follow-up.
What should I expect?
On your first visit with an osteopath, and before examination begins, the osteopath will discuss and record your medical history in detail.During examination and treatment from an osteopath or physiotherapist you will normally be asked to remove some of your outer clothing. Please wear underwear, shorts or sports bra that you feel comfortable in. The osteopath will then apply a highly developed sense of touch to identify points of weakness or excessive strain throughout the body. This will allow a full diagnosis of the problem and will enable the osteopath to tailor a treatment plan to your needs.
Your osteopath should make you feel at ease and tell you what is happening throughout your consultation. You should ask questions if you have any concerns. Osteopathy can help most people, and our osteopaths work closely hand in hand with the other therapists in the clinic to always achieve the optimal results If further medical treatment is needed the osteopath may contact your doctor, with your permission.
The Patient History
A carefully taken medical history is the most single important element in the evaluation of a patient who has musculoskeletal pain of unknown origin or cause. Symptoms are likely to appear sometime before striking physical signs of disease are evident. An accurate and sufficiently detailed history provides historical clues that can be significant in determining when a patient should be referred for a medical follow-up.
Pain patterns/pain types
The therapist should try and establish pain associated with each anatomical part and differentiated as systemic from musculoskeltal whenever possible. The characteristics of the pain, the onset, description, duration, daily pattern, aggravating and relieving factors and associated signs and symptoms should be established in the history taking.
Associated signs and symptoms
After reviewing the patient history and identifying pain types or patterns the therapist should ask about the presence of additional signs and symptoms.
It is important to note that signs and symptoms of systemic origin are often unidentified either because the patient does not volunteer the information or the therapist does not ask.
The therapist in the time given will normally as part of their physical therapy assessment conduct a review of systems by asking general questions about fevers, excessive weight gain or loss and appetite loss. Depending on the gathered information they may follow up with questions relating to specific organs. For example if you go to see your therapist because you fell and injured your wrist and seek treatment for the injury they unlikely to persue questions about your bladder control, however if you fell for a unexplained reason and have been experiencing falls/faints their questioning would want to establish the cause of the falls prior to treating the injury.
Back pain
A specific diagnosis of back pain is commonly impossible or unavailable. Back pain is a symptom not a diagnosis. It may arise in the spine from mechanical, inflammatory, metabolic, or neoplastic disorders, or it can be referred from abdominal or pelvic disease.
The therapist must be aware that many different diseases can appear as back pain, they take into account the quality of pain, the patients age and the presence of systemic complaints or associated signs and symptoms. They are looking for clues which indicate the need to refer the patient for further medical follow up. A physical therapist will not ordinarily claim to treat systemic complaints although they may be able to assist in alleviating musculoskeletal symptoms. If a systemic cause is suspected the physical therapist should advise on relevant referral for medical follow up. This advise is sometimes as simple as asking the patient to see their medical physician and for them to tell the physician their symptoms, in some instances the physical therapist may ask to write to the patients medical physician listing their findings.
A physical therapist will rarely give a systemic disorder diagnosis even though they may have an idea.
What is the clicking noise?
Joint manipulation is characteristically associated with the production of an audible clicking sound. When a manipulation is performed, the applied force separates the joint surfaces of a fully encapsulated synovial joint. This stretches the joint capsule, which in turn creates a reduction in pressure within the joint cavity. In this low pressure environment, some of the gases that are dissolved in the synovial fluid leave the solution creating a bubble which rapidly collapses upon itself, resulting in a 'clicking' sound.
The presentation of stiffness and reduced movement is second only to pain.
Stiffness and reduced range of movement are often caused by two processes, which are adaptation associated with trauma and poor repair or non-traumatic long-term adaptation.
Adaptation associated with trauma and poor repair
The background mechanical environment is the main influencing factor regarding adaptation of tissue during the regeneration and remodelling phase. Adaptation is fairly fast due to the rapid turnover of tissues in the early stages of repair after trauma.
If normal mechanical stimulation is deprived poor quality repair occurs during the repair stages. This results in a variety of tissue maladaptations such as shortening, stiffening and adhesions.
Connective tissue may form abnormal cross-links and may have abnormally shaped collagen fibres resulting in shortening of the tissue.
In muscle the reduction of sarcomeres in series, shortening of the tendon or excessive proliferation of connective tissue results in shortening.
Non-traumatic long-term adaptation
The shortening and stiffening of different soft tissues is dependant on a number of factors. Patterns of behaviour such as postural sets, the sports one does, ageing and central nervous system damage can all contribute to non-traumatic long-term adaptation.
Serial sarcomeres tend to decrease in instances of continual repetitive use of muscle in reduced ranges of movement. Behaviour such as sitting in front of a computer, sporting activities, high heels are all examples of how non-traumatic long term adaptation may occur.
There are three underlying mechanisms that lead to loss of extensibility and movement.
Tissue shortening due to reduced sarcomeres
Increased stiffness due to increased proliferation of connective tissues
Adhesion due to cross links
The therapist treats the dysfunctional adaptation by introducing stimuli to create an environment promoting further adaptive changes to occur.
Mechanism in tissue elongation
There are two principle mechanisms associated with tissue elongation mechanical elongation and adaptive elongation.
Mechanical elongation provides the short-term signals to which the tissues adapt in the long term.
Mechanical elongation
Short and long-term elongation brought on by stretching can be accounted for by the material properties found in connective tissues and muscle. One such property is viscoelasticity which dictates the different variables affecting stretching such as the rate, repetition and force.
Viscoelasticity is the mechanical behaviour of soft tissues related to the overall property of connective tissue and muscle. Elasticity is the spring-like element within tissue and the viscous properties are the dampening and lubricating elements.
When stretch is applied to a viscoelastic structure such as muscles of ligaments they display a characteristic physical response and can be plotted as a stress strain.
The Stress strain curve
Step One
The toe region
The toe region is the initial elongation that occurs. It is the straightening and flattening of the wavy configuration of tissues. In this region there is no true elongation as the tissue will return to its original state. The toe region is dependant on the waviness of the collagen pattern. For example in tendons the collagen lies in almost parallel patterns and the toe region is very short whereas ligaments have some wavy structure and hence a longer toe region.
In manual therapy the toe region is often referred to as a 'slack' area.
Step two
The elastic region
The elastic region follows the toe region, it has spring-like properties and true elongation occurs in this region. Elasticity is determined by the ratio of elastin and collagen.
Step Three
The plastic region
Progressive failure and microscopic tearing of collagen fibres occurs as stretching reaches the end of the elastic region. This region of the stress strain curve is called the plastic region. In this region the mechanical changes in tissue are irreversible. The tissue will not return to original state once the load has been removed. Following plastic changes the return of the tissues to normal length and tensile strength is through inflammation and repair.
The end of the elastic region and the beginning of the plastic region can be said to be when a more rigid barrier accompanied by stretching pain has been reached.
Creep deformation
During the elastic region sustained load at a constant length will result in slow elongation of tissue. Elongation is a transient biomechanical phenomenon called creep deformation. The tissues do not immediately return to its original pre-stretched length. Creep changes tend to occur during slow rather the high velocity stretching.
Code for stretching
Clues for the mechanical signals needed for tissue elongation can be derived from the viscoelastic properties of the musculoskeletal tissues. For effective stretching the manual therapy techniques should contain the following elements of adequate tensional forces, adequate duration and repetition.
Tensional forces should be within the late elastic region to early plastic region of tissues.
Duration should be performed slowly and maintained to allow for viscoelastic changes to take place.
Repetitive stretching is more likely to activate the long-term adaptive elongation process.