Spine Conversations 2: What Really Happens at an Osteopath

Spine Conversations · Episode 2 · About 9 minutes

In Spine Conversations, Mr Ahmed-Ramadan Sadek talks through common treatments for back and neck pain. In this episode he talks with Alison about what osteopaths do, how the profession is regulated, what happens at a first visit, what NICE says, the evidence for manipulation, the risks, and the questions to ask.

Also on YouTube → · Spotify → · Apple Podcasts →

Read the full chiropractic and osteopathy guide

Transcript

Ahmed: For long-standing low back pain, spinal manipulation does about as well as other recommended treatments. Not better. And NICE says to consider it only alongside exercise, never on its own. So what can an osteopath offer you?

Ahmed: Hello, I’m Ahmed Sadek, a neurosurgeon, and welcome to Spine Conversations from Spinemathema. Last time, Sam took us through physiotherapy. Today it’s osteopathy, with Alison. Alison, welcome.

Alison: Thanks, Ahmed.

Ahmed: Start with the basics. What does an osteopath do?

Alison: We assess and treat problems with muscles and joints, mostly with our hands. That means massage and stretching. Mobilisation, which is slow, repeated movement of a joint. And manipulation, a quick, small thrust to a joint, sometimes with a click. We also advise on posture, lifestyle and exercise.

Ahmed: The NHS lists osteopathy among complementary therapies, which it says aren’t tested in the same way as standard medicines. Fair?

Alison: I won’t argue with that. But the same page says osteopaths must be registered by law, and other complementary therapists don’t have to be. It’s illegal to call yourself an osteopath unless you’re on the General Osteopathic Council’s register. It’s free and online, so check before you book.

Ahmed: And the training?

Alison: You need a recognised qualification to register. Undergraduate courses on the council’s list run from three to four years full time, and up to six years part time.

Ahmed: Talk me through a first visit.

Alison: It’s usually about forty five minutes to an hour. I’ll ask about your problem, your general health, any other care you’re having and any medicines you take. I’ll watch you move, and examine your joints and muscles with my hands. You should get privacy to undress, and you can bring someone with you. I’m also checking for signs of something serious that I can’t treat. Then I’ll explain what I think is going on, what treatment can realistically achieve, and the benefits and risks. And I’ll ask your permission before I start.

Ahmed: Who pays?

Alison: Usually you. Most osteopaths work privately, and most patients refer themselves. The council quotes an average of around sixty five pounds for a first appointment and fifty five after that. Teaching clinics charge less. Some treatment is available on the NHS, so ask your GP.

Ahmed: What can it help with? The council’s page lists back, neck and shoulder pain, sciatica and sports injuries. But also some digestion and circulatory problems. I’d push back on those.

Alison: That’s fair. The page says commonly treated, and that isn’t the same as shown to work in good trials. The evidence we’re about to discuss is about back and neck pain, so that’s what I’ll speak to today.

Ahmed: Let’s start with NICE, the National Institute for Health and Care Excellence.

Alison: Its guideline on low back pain and sciatica says what Sam told you. Consider manual therapy, meaning manipulation, mobilisation or massage, but only as part of a package that includes exercise.

Ahmed: Some people will hear that as hands-on treatment doesn’t work.

Alison: It doesn’t say that. It says not on its own. If a course of treatment has no plan to get you moving, it falls short of the guideline.

Ahmed: So what do the numbers show?

Alison: A review in the British Medical Journal pooled forty seven trials, with over nine thousand people with long-standing low back pain. Against other recommended treatments, the difference in short-term pain was about three points on a scale of nought to a hundred. The range ran from nearly eight points better to about one and a half points worse. So similar, with a small extra gain in function. Against treatments that aren’t recommended, it did slightly better.

Ahmed: Those are trials of a technique. What about osteopathy itself?

Alison: It’s thinner, and it’s mixed. An osteopath gave the treatment in only five of those studies. For neck pain, a twenty twenty two review found a large benefit against no treatment or sham, but the evidence was very low quality. A twenty twenty four review of neck and low back pain found no clear difference from sham. And in a trial of ninety people with long-standing neck pain, adding osteopathic treatment to neck exercises gave no extra benefit at three or six months.

Ahmed: So we can’t say how much of the benefit comes from the technique itself.

Alison: Not with confidence. Although uncertain doesn’t mean no effect.

Ahmed: It doesn’t mean proven either.

Alison: No. I’ll give you that.

Ahmed: If the results are similar, why not go straight to exercise?

Alison: For many people, that’s a perfectly reasonable choice, and exercise has to be in the plan anyway. Manipulation is an option, not a superior one. Some people want hands-on treatment as part of their package, and NICE allows for that. What I wouldn’t defend is hands-on treatment alone.

Ahmed: And the risks?

Alison: Reactions are common but usually minor. Soreness, stiffness or a headache that settles within a day or two. One review put minor or moderate short-lived reactions at about twenty two in a hundred people in trials, and forty one in a hundred in cohort studies. The serious concern is a small tear in the lining of a neck artery, which can lead to a stroke. The American Heart Association found that most population studies show a link with neck manipulation in younger patients. That isn’t proof that manipulation causes it, because a tear can cause neck pain before the stroke, so some people may already have one when they arrive. The risk is probably low, and you should be told about it first. You can say no, and ask for mobilisation and exercise instead.

Ahmed: We’ll go further into that with Joe, in the next conversation. Who should avoid this altogether?

Alison: The NHS says it may not be safe if you take blood-thinning medicines, have a higher risk of bleeding or stroke, have very weak or seriously damaged bones or joints, or have a condition affecting your nerves.

Ahmed: I’d add progressive weakness or numbness in the legs, and suspected nerve compression from a slipped disc or spinal stenosis. They need a proper medical assessment first. And if you’ve had recent spinal surgery, check with your surgical team first. So how should osteopaths and surgeons work together?

Alison: Mostly by me knowing when it isn’t for me. If I find signs of something serious, I should advise you to see your GP or go to hospital, with a letter explaining what I think the problem is. With your permission, I can also send your GP a report.

Ahmed: And a clear letter helps whoever reads it next. What was found, what’s been tried, and whether there’s any weakness or numbness. What should people ask you?

Alison: Are you registered? What do you think is wrong? How many sessions do you expect, and how will we know it’s working? Where’s the exercise in this plan? And be cautious about large prepaid packages.

Ahmed: The NHS says see a GP if back pain hasn’t improved after a few weeks, if it’s stopping your day-to-day activities, or if it’s worse at night. The same goes for neck pain that hasn’t gone after a few weeks. For severe pain that starts suddenly or gets worse quickly, ask for an urgent GP appointment or contact NHS one one one. And if symptoms keep coming back, ask a GP. Don’t just talk to a therapist.

Alison: I’d say the same.

Ahmed: Now the warning signs. Go to A and E or call nine nine nine straight away if you have back pain with pain, tingling, weakness or numbness in both legs, loss of feeling around your genitals or anus, or changes in your bladder or bowels. Those can be signs of cauda equina syndrome. The same applies to new or worsening weakness in your legs, and to sudden severe neck pain or headache with dizziness, double vision, slurred speech, difficulty swallowing, or weakness or numbness of your face or limbs. If you think it could be a stroke, call nine nine nine, even if the symptoms stop. Don’t drive yourself.

Alison: And an osteopath should want to know about any of those straight away too.

Ahmed: Thank you, Alison. This is general information and not a substitute for advice about your own situation, so please speak to your GP or specialist. The full written guide, with references, is on spinemathema dot com. And please subscribe to the Spinemathema YouTube channel. Thanks for listening.

References

1. NHS. Herbal medicines and complementary therapies. Page reviewed 1 May 2026. Link
2. General Osteopathic Council. Protecting the title ‘osteopath’. Link
3. General Osteopathic Council. What is osteopathy? Link
4. General Osteopathic Council. What to expect at your appointment. Link
5. General Osteopathic Council. Training. Link
6. General Osteopathic Council. Accredited training courses. Link
7. National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management (NG59). Last updated 29 July 2026. Link
8. Rubinstein SM, de Zoete A, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ. 2019;364:l689. PMID 30867144. Link
9. Dal Farra F, Buffone F, Risio RG, Tarantino AG, Vismara L, Bergna A. Effectiveness of osteopathic interventions in patients with non-specific neck pain: A systematic review and meta-analysis. Complement Ther Clin Pract. 2022;49:101655. PMID 35986986. Link
10. Ceballos-Laita L, Jiménez-Del-Barrio S, Carrasco-Uribarren A, Medrano-de-la-Fuente R, Robles-Pérez R, Ernst E. Is Osteopathic Manipulative Treatment Clinically Superior to Sham or Placebo for Patients with Neck or Low-Back Pain? A Systematic Review with Meta-Analysis. Diseases. 2024;12(11):287. PMID 39589961. Link
11. Groisman S, da Silva LS, Sanches TRR, Rocha CSDS, Malysz T, Jotz GP. Assessment of Long-term Effects of Adding Osteopathic Manipulative Treatment to Neck Exercises for Individuals With Non-specific Chronic Neck Pain: A Randomized Trial. J Chiropr Med. 2023;22(4):265-74. PMID 38205221. Link
12. Carnes D, Mars TS, Mullinger B, Froud R, Underwood M. Adverse events and manual therapy: a systematic review. Man Ther. 2010;15(4):355-63. PMID 20097115. Link
13. Biller J, Sacco RL, Albuquerque FC, Demaerschalk BM, Fayad P, Long PH, et al. Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(10):3155-74. PMID 25104849. Link
14. NHS. Back pain. Link
15. NHS. Neck pain and stiff neck. Page reviewed 27 April 2023. Link
16. NHS. Symptoms of a stroke. Page reviewed 12 September 2024. Link

This conversation is general information and is not a substitute for advice about your own situation. Please speak to your GP or specialist.

Last checked: October 2026