Spine-centred integrated osteopathic management for multi-site degenerative musculoskeletal pain after conventional and traditional healing failure in a low-resource setting: a concept-driven case report

1 Introduction

Chronic multi-site musculoskeletal pain represents one of the leading causes of disability globally, with the convergence of osteoarthritis and cervical spondylosis in aging individuals creating a cumulative functional burden that demands integrated therapeutic approaches (1, 2). When such polyarticular conditions coexist, isolated, site-specific interventions often fail to address the biomechanical and neurophysiological interdependence between spinal and peripheral joint dysfunctions, leading to incomplete relief and progressive functional deterioration (3, 4).

Globally, chronic musculoskeletal pain affects an estimated 1.71 billion individuals, with low- and middle-income countries bearing a disproportionate share of this burden due to limited access to specialized rehabilitation services (2). In sub-Saharan Africa, degenerative conditions such as knee osteoarthritis and cervical spondylosis are associated with severe functional consequences—including loss of occupational capacity, social isolation, and progressive kinesiophobia—that remain largely undocumented in the rehabilitation literature (5, 6).

In sub-Saharan Africa, chronic musculoskeletal pain management faces systemic challenges. Specialized manual therapy and osteopathic medicine remain critically scarce, with most countries lacking trained practitioners, structured training programs, and institutional recognition of osteopathic care (5, 6). Patients with complex degenerative conditions often navigate a fragmented therapeutic landscape encompassing conventional physiotherapy of variable quality, pharmacological management limited to basic analgesics, and traditional healing practices including massage, herbal remedies, and therapeutic scarification (7–9). When multiple treatment modalities fail sequentially, patients may develop a state of therapeutic exhaustion characterized by progressive demoralization, functional withdrawal, and diminished therapeutic expectations—a phenomenon that has received insufficient attention in the rehabilitation literature.

Therapeutic scarification, involving deliberate skin incision for perceived pain relief, remains widely practiced in rural Central and West African communities (10, 11). While providing cultural reassurance, these practices carry risks of infection, tissue damage, and critically, the reinforcement of therapeutic exhaustion when expected outcomes fail to materialize (12). The coexistence of conventional treatment failure and traditional healing failure in the same patient creates a unique clinical challenge that has not been previously described in the literature.

The French school of medical osteopathy, particularly the Sorbonne–Maigne method, provides a systematic, anatomically grounded framework for the assessment and treatment of musculoskeletal pain of vertebral origin (13, 14). Professor Robert Maigne's concepts of Painful Minor Intervertebral Dysfunction (PMID) and the segmental cellulo-teno-periosteo-myalgic syndrome offer a coherent diagnostic model particularly suited to multi-site pain presentations, where vertebral dysfunction may generate referred symptoms across multiple body regions through identifiable metameric pathways (15, 16). The rule of painlessness and opposite motion provides a safe, precise manipulation methodology applicable even in complex degenerative contexts (14).

We have previously described several phenomena relevant to healthcare-seeking behaviors in resource-limited settings: the “unique practitioner syndrome,” describing disproportionate patient concentration around a rare specialized practitioner (17); the “therapeutic scarcity dynamics,” documenting how limited specialized care availability generates concentrated migratory patterns (18); the “centralisation informelle du soin,” describing spontaneous care pathway organization around a single practitioner independently of institutional frameworks (17); and the concept of “rehabilitation as a full-fledged medication” with dose-dependent effects (19–22). The Cogni-Famille protocol has demonstrated that training family members as co-therapists can substantially multiply therapeutic contact time compared to conventional institutional models (21).

We present the case of a 56-year-old male farmer from Edéa, Cameroon, with chronic polyarticular degenerative pain who had exhausted multiple conventional and traditional treatment modalities—including two rheumatology consultations, over 70 physiotherapy sessions, and repeated therapeutic scarification—before undertaking a 280 km therapeutic migration to access osteopathic care at the Regional Hospital of Bafoussam. This case demonstrates the effectiveness of integrated Sorbonne–Maigne osteopathic medicine, introduces four novel theoretical concepts, and provides empirical evidence for the previously described phenomena of therapeutic scarcity and the unique practitioner syndrome. The aim of this case report is therefore to document the clinical application and outcomes of a spine-centred integrated osteopathic approach in this context, to introduce four theoretical concepts emerging from this case, and to provide empirical evidence for previously described phenomena of therapeutic scarcity and the unique practitioner syndrome in resource-limited healthcare systems.

2 Case presentation

2.1 Administrative data and ethical considerations

A 56-year-old male patient from Edéa, Littoral Region of Cameroon, was evaluated at the Physical Medicine and Osteopathy Unit of the Regional Hospital of Bafoussam in October 2025 for chronic polyarticular pain and severe functional impairment persisting for over 24 months despite multiple prior treatments. He was married with four children, all residing with him in Edéa. A subsistence farmer by occupation, he managed a small family plot and was the primary economic provider for his household. His educational level was primary school. He had no formal health insurance coverage, and all healthcare costs—including consultations, transport, and radiological examinations—were covered out-of-pocket. The cumulative cost of prior treatments, combined with transport expenditures for the biweekly therapeutic migration to Bafoussam, represented a substantial financial burden relative to his income level.

Written informed consent was obtained for the anonymized publication of clinical data, radiographic images, and photographs. This retrospective clinical evaluation was conducted under the Institutional Certification N°43/DRSO/HRB/55/2023 issued by the Regional Hospital of Bafoussam, which authorizes retrospective clinical evaluations based exclusively on anonymized data obtained from routine patient care under the direct coordination of the responsible department chief, in accordance with the Declaration of Helsinki and international ethical standards (22). This report follows CARE guidelines (23).

2.2 Socioeconomic context and therapeutic migration

The patient was a subsistence farmer with limited financial resources. Edéa, located approximately 280 km from Bafoussam in the Littoral Region, provides standard healthcare services but lacks specialized musculoskeletal or osteopathic care. The patient's therapeutic migration was initiated through informal community referral: a cousin residing in Bafoussam had personally experienced successful osteopathic treatment at the Regional Hospital and recommended the service. This word-of-mouth referral pathway is consistent with the previously described “centralisation informelle du soin” (17).

The patient traveled to Bafoussam every Sunday evening, stayed with his cousin from Monday to Wednesday, attended treatment sessions on Monday and Wednesday at the Physical Medicine and Osteopathy Unit, and returned to Edéa on Wednesday evening. This biweekly pattern was maintained for 6 weeks (12 sessions total), representing a cumulative therapeutic migration of approximately 3,360 km.

2.3 Prior treatment history

Over the preceding 24 months, the patient had undergone the following treatments without satisfactory improvement:

Rheumatology consultations: Two separate consultations with rheumatologists in Yaoundé and Douala, respectively. Both confirmed the diagnosis of bilateral gonarthrosis and cervical spondylosis. Management consisted of oral analgesics, non-steroidal anti-inflammatory drugs, and referral for conventional physiotherapy. Initial radiographs performed in 2025 were lost by the patient.

Conventional physiotherapy: Over 70 sessions of conventional physiotherapy at local facilities in the Littoral Region. The patient reported no meaningful improvement; on the contrary, he described a modest but progressive increase in pain intensity over the treatment period. This iatrogenic-like exacerbation contributed significantly to his therapeutic discouragement.

Traditional healing practices: Multiple courses of traditional massage and therapeutic scarification. Scarifications were performed on the bilateral thighs and knee regions, the thoracolumbar back, and the shoulders (Figures 1, 2), based on cultural beliefs that these incisions could release trapped pain and facilitate healing. Despite repeated treatments, pain persisted and function continued to deteriorate.

Pharmacological management: Chronic use of oral paracetamol and non-steroidal anti-inflammatory drugs providing only transient symptom relief lasting hours.

This cumulative trajectory—two specialist consultations, 70+ physiotherapy sessions, multiple traditional healing courses, and chronic pharmacological management, all without adequate relief—illustrates what we propose to term Therapeutic Exhaustion Syndrome (TES): a state of accumulated therapeutic failure characterized by sequential engagement with multiple treatment modalities resulting in psychological demoralization, functional withdrawal, financial depletion, and diminished therapeutic expectations. The patient himself described his condition as “untreatable” and stated he had “given up hope”.

While the term Therapeutic Exhaustion Syndrome has not been previously defined as such in the literature, it builds upon several established constructs. The concept shares theoretical ground with learned helplessness models describing the progressive loss of agency following repeated exposure to uncontrollable negative outcomes (3, 4)—here, therapeutic failures. It also relates to fragmented care trajectories documented in traditional medicine use in sub-Saharan Africa (7, 8), and to the cultural and institutional barriers to rehabilitation described in Central African contexts (5, 6). TES, however, extends these constructs by capturing the cumulative and multi-systemic nature of sequential therapeutic failure spanning conventional medicine, physiotherapy, pharmacotherapy, and traditional healing—a trajectory specific to low-resource, pluralistic healthcare contexts that has not been previously conceptualized as a unified clinical entity.

2.4 Patient testimony

Patient: “I tried everything—the rheumatologists in Yaoundé and Douala, the physiotherapy sessions for months and months, the scarifications on my knees, my back, my shoulders. Nothing worked. The physiotherapy even made my pain worse. I was walking like a robot. I could not farm, I could not sit properly, I could not turn my head. I had given up. When my cousin in Bafoussam told me about the osteopathic doctor at the hospital, I thought it was my last chance. I came even though it was far and expensive, because I had nothing left to lose”.

This testimony encapsulates several dimensions beyond pain and functional limitation. The patient's reference to the economic cost of his therapeutic journey (“it was far and expensive”) reflects the financial depletion inherent to Therapeutic Exhaustion Syndrome in resource-limited settings. His agricultural activities, which constituted both his livelihood and his primary social role, had become entirely impossible, with consequent loss of income and dependence on family support for daily tasks. The phrase “I had given up” indicates not only functional withdrawal but also a profound erosion of therapeutic self-efficacy, consistent with fear-avoidance and learned helplessness mechanisms previously described in chronic musculoskeletal pain populations (33, 34).

2.5 Clinical examination

At initial presentation, the patient exhibited a markedly rigid, slow gait pattern with reduced stride length, absent arm swing, minimal trunk rotation, and visible guarding of all major joints. The overall impression was of a “robotic” movement pattern reflecting global multi-site pain avoidance and motor deconditioning.

Cervical spine: Severe restriction of all ranges of motion. Active rotation: 25° bilaterally (normal: 70–90°). Lateral flexion: 15° bilaterally (normal: 45°). Flexion-extension arc reduced to approximately 50% of normal. Segmental examination revealed active painful minor intervertebral dysfunctions (PMIDs) at C4–C5, C5–C6, and C6–C7, with positive skin rolling test (cellulalgia) in the C5–C6 dermatome and myalgic bands in the bilateral upper trapezius and levator scapulae, consistent with Maigne's segmental cellulo-teno-periosteo-myalgic syndrome (15).

Bilateral knees: Left knee: active flexion 85° (normal: 140°), extension deficit 10°. Right knee: active flexion 95°, extension deficit 5°. Bilateral crepitus on passive mobilization. Medial joint line tenderness bilaterally. Quadriceps amyotrophy with thigh circumference deficit of 2 cm bilaterally.

Bilateral shoulders: Active elevation: right 110°, left 100° (normal: 180°). Painful external rotation bilaterally. Positive Neer and Hawkins impingement signs bilaterally.

Thoracolumbar junction: Segmental stiffness at T11–T12 and T12–L1. Positive skin rolling test over the iliac crests bilaterally. Myalgic bands in the paraspinal musculature. Findings consistent with thoracolumbar junction syndrome (Maigne's syndrome) (16).

Radiological examination confirmed lumbar rectitude, vertebral fusion at L3–L4 with compensatory overloading of adjacent segments, and discopathy at L5–S1 (Figure 1). The L3–L4 fusion creates a biomechanical chain effect, transferring excessive stress superiorly toward the thoracolumbar junction and inferiorly toward L5–S1, consistent with the multi-level segmental dysfunction identified on Maigne's examination.

Cutaneous findings: Multiple linear and punctiform scarification scars on the bilateral thighs, the thoracolumbar region, and the deltoid regions of both shoulders (Figures 2, 3).

Global pain: Visual Analog Scale (VAS): 8/10 at rest, 9–10/10 during activity, involving the cervical spine, bilateral shoulders, thoracolumbar back, and bilateral knees simultaneously.

Functional assessment: Walking perimeter: approximately 200 meters with obligatory rest. Oswestry Disability Index (ODI): 62% (severe disability) (24). Unable to perform agricultural tasks, climb stairs independently, or sit for more than 20 min. Sleep disrupted by nocturnal pain.

Walking perimeter was assessed through direct clinical observation using a standardized timed walking protocol along a measured hospital corridor, without instrumented analysis. Distance was recorded by the treating clinician using a calibrated measuring tape and stopwatch, consistent with real-world assessment practices in low-resource clinical environments.

2.6 Radiological findings

Previous radiographic examinations performed in 2025 following rheumatology consultations had been lost by the patient. Control imaging was therefore requested and obtained on January 9, 2026, at the Hospital Regional Annexe d'Edéa, during the ongoing treatment period. Three radiographic examinations were performed.

3 Intervention: integrated Sorbonne–Maigne osteopathic protocol

A comprehensive osteopathic treatment protocol was implemented over 6 weeks (12 sessions, biweekly on Mondays and Wednesdays), based on the French school of medical osteopathy as taught at Sorbonne Université and developed by Professor Robert Maigne (13–16). Each session lasted 60–75 min and was supplemented by a structured family-mediated home rehabilitation program performed daily between sessions.

3.1 Systematic segmental examination

Each session began with Maigne's standardized four-step segmental assessment: (1) forced segmental rotation via spinous process pressure; (2) slow, deep posterior-anterior vertebral pressure; (3) facet joint palpation at 1–2 fingerbreadths lateral to the spinous process; and (4) interspinous ligament assessment (13, 14). The cellulo-teno-periosteo-myalgic syndrome was evaluated through systematic skin rolling (pince-roulé), myalgic band palpation, and periosteal pressure point examination in each metamere corresponding to identified PMIDs (15).

3.2 Cervical spine treatment

Cervical treatment strictly followed Maigne's rule of painlessness and opposite motion: manipulation was performed exclusively in the pain-free direction, opposite to the restricted and painful movement (14). Techniques included rhythmic oscillatory mobilization in rotation and lateroflexion targeting C4–C5, C5–C6, and C6–C7 with the patient supine (13); cervical HVLA manipulation in the pain-free direction at segments demonstrating fixation, after thorough pre-manipulative screening and informed consent (27); suboccipital inhibition and upper trapezius release; progressive stretching of the upper trapezius, levator scapulae, and sternocleidomastoid; and myofascial release of identified myalgic bands with deep transverse friction at tender periosteal insertion points (15).

3.3 Thoracolumbar junction treatment

The thoracolumbar junction syndrome at T11–T12 and T12–L1 was treated through lateral decubitus rotational mobilization and, when indicated, HVLA manipulation following Maigne's principles (16), combined with skin rolling treatment of the associated cellulalgia in the dorsal ramus territory and over the iliac crests (28).

3.4 Bilateral knee treatment

Knee management combined osteopathic articular techniques with progressive functional rehabilitation: rhythmic traction-mobilization of the femorotibial joint; mediolateral gapping mobilization of the medial compartment; patellar mobilization in all planes to restore femoropatellar glide; deep transverse friction of the medial collateral ligament insertions; myofascial release of the quadriceps, hamstrings, iliotibial band, and gastrocnemius; trigger point deactivation in the vastus medialis and popliteus; and progressive strengthening from isometric quadriceps sets to closed kinetic chain exercises (mini-squats, step-ups) with proprioceptive training (13, 29).

3.5 Shoulder treatment

Bilateral shoulder impingement was addressed through glenohumeral mobilization (inferior and posterior glides), subacromial decompression maneuvers, rotator cuff stretching and progressive strengthening, and scapulothoracic mobilization, integrating the principle of regional interdependence between the cervicothoracic spine and the shoulder complex (30).

3.6 Family-Mediated home rehabilitation

Adapting the Cogni-Famille model (21) to the osteopathic context, the patient's cousin and his wife—both residing in Bafoussam—were trained as co-therapists during supervised in-session demonstrations and practised the programme under direct guidance before the patient returned to Edéa. On the days the patient was in Bafoussam (Monday to Wednesday), the cousin supervised the daily home programme. On his return to Edéa from Wednesday evening to Sunday, the patient's wife, who had attended two training sessions at the hospital, supervised the home exercises. This dual-supervisor model ensured uninterrupted daily therapeutic continuity throughout the six-week programme. Regarding treatment adherence, the written exercise booklet provided to the patient served as a daily reference tool. The patient reported no major difficulty in performing the prescribed exercises, attributing his motivation to the visible clinical improvement observed from the first sessions. The rapid functional gains—particularly the reduction in pain intensity and the progressive restoration of walking capacity—appear to have been a primary driver of adherence, consistent with self-efficacy reinforcement models (41).

The daily home program (45–60 min) included cervical self-mobilization exercises, knee flexion-extension exercises with progressive resistance, quadriceps and hamstring stretching, an incremental walking program with distance targets, and shoulder pendulum and wall-climbing exercises. Self-treatment techniques (self-applied cervical traction, thoracolumbar self-mobilization, patellar self-mobilization) were demonstrated, practiced under supervision, and documented in a written exercise booklet provided to the patient. This approach achieved a total therapeutic dose of approximately 8–10 h per week (2 hospital sessions + 5–7 home sessions), consistent with established dose-response principles in rehabilitation (19, 20, 31).

4 Outcomes

Outcomes were assessed at three time points: baseline (Week 0, Session 1), mid-treatment (Week 3, Session 6), and end of treatment (Week 6, Session 12). Table 1 presents the comprehensive clinical outcome summary. Clinically meaningful improvement was spontaneously reported by the patient after the first two sessions, with marked reduction in cervical stiffness and decreased pain intensity noted at the third visit.

Table 1. Comprehensive clinical outcome summary at baseline (week 0), mid-treatment (week 3, session 6), and end of treatment (week 6, session 12). VAS: Visual Analog Scale (0–10); ODI: Oswestry Disability Index (0%–100%). All parameters demonstrated clinically meaningful improvement, with the most rapid gains occurring during the first three weeks (Sessions 1–6), consistent with the proposed concept of an Osteopathic Dose-Response Threshold. The ODI improvement of 40 percentage points substantially exceeds the established minimal clinically important difference (MCID) of 10–12 percentage points (32).

The gait pattern evolved from a rigid, robotic pattern with absent arm swing at baseline to a near-normal, fluid gait with restored arm swing, appropriate stride length, and symmetric weight-bearing by Week 6. Walking perimeter increased ten-fold (200 m to 2 km). The patient returned to full agricultural activities and described his experience as “a second life”. A 12-week telephone follow-up confirmed sustained improvement, continued adherence to the home exercise program, and full return to farming.

5 Discussion

5.1 Novel theoretical concepts

This case provides the empirical foundation for four novel concepts that address underexplored dimensions of musculoskeletal care in resource-limited settings (Table 2).

Table 2. Four novel concepts introduced in this case report with definitions and scientific justification. Each concept addresses a specific gap in the current literature on musculoskeletal care in low-resource settings and is grounded in both clinical observation and established theoretical frameworks.

To facilitate the conceptual understanding and clinical translatability of these four interconnected constructs, we propose an integrative framework synthesizing the trajectory from fragmented care and therapeutic exhaustion toward functional recovery in low-resource settings. This model emphasizes the dynamic interaction between structural healthcare inequities, neurosegmental dysfunction, behavioural adaptation, and therapeutic dose amplification. The progressive transition from therapeutic exhaustion to functional restoration is illustrated in Figure 4, which provides a unified representation of the clinical, geographical, and biopsychosocial mechanisms underlying this process.

5.2 The Sorbonne–Maigne method in the African context

This case represents, to our knowledge, one of the first documented applications of the Sorbonne–Maigne method of medical osteopathy for polyarticular degenerative disease in sub-Saharan Africa supported by quantitative functional outcome data. The systematic segmental examination provided a unifying diagnostic framework that connected the patient's multiple pain complaints to identifiable vertebral dysfunctions, transforming an apparently complex and diffuse clinical presentation into a structured and clinically actionable model (13–16).

The identification of thoracolumbar junction syndrome (Maigne's syndrome) contributing to referred back pain, combined with cervical painful minor intervertebral dysfunctions (PMIDs) generating associated shoulder and upper limb symptoms through the segmental cellulo-teno-periosteo-myalgic syndrome, enabled a targeted and coherent intervention strategy. Rather than focusing exclusively on individual symptomatic regions, this approach emphasized the biomechanical and neurosegmental interdependence between the spine and peripheral joints. In this context, previous rehabilitation strategies may have been limited by a predominantly site-specific or locally oriented framework that did not fully integrate vertebral contributions to multi-site pain. Such fragmentation may partly explain the persistence of symptoms and highlights the need for integrative assessment models in complex degenerative conditions (38).

The low-technology nature of the Sorbonne–Maigne method makes it inherently adaptable to resource-limited environments, as it requires minimal equipment and relies primarily on clinical expertise, anatomical precision, and neurophysiological reasoning. This aligns with the previously described “Low-Tech, High-Sense” principle (39), suggesting that context-adapted clinical reasoning can optimize functional outcomes even in settings with limited technological resources. These findings support the broader integration of structured manual medicine training within rehabilitation and medical education frameworks in sub-Saharan Africa.

The discovery of a vertebral fusion at L3–L4 on the lumbar radiograph (Figure 1) provided a critical biomechanical explanation for the patient's multi-level pain pattern. By eliminating segmental mobility at L3–L4, this fusion creates a compensatory hypermobility syndrome at adjacent levels—both at L5–S1 (confirmed discopathy) and at the thoracolumbar junction (clinically confirmed Maigne's syndrome). This finding validates the Maigne method's emphasis on systematic segmental examination of the entire spinal column, as a site-specific approach focused solely on the symptomatic knees or cervical spine would have missed this fundamental biomechanical driver.

5.3 Therapeutic exhaustion and the failure of conventional approaches

The patient's 24-month trajectory of sequential engagement with multiple therapeutic modalities—including specialist rheumatology, conventional physiotherapy, pharmacotherapy, and traditional healing—provides a compelling illustration of Therapeutic Exhaustion Syndrome. The reported worsening of pain during this period should not be interpreted as a direct failure of physiotherapy as a discipline, but rather as a potential consequence of fragmented or non-integrated therapeutic approaches in complex multi-site degenerative conditions. In such contexts, insufficient biomechanical and neurosegmental integration may lead to suboptimal outcomes and, in some cases, symptom persistence or aggravation (33, 34). This case therefore highlights the importance of individualized clinical reasoning and comprehensive segmental assessment prior to initiating rehabilitation strategies, as emphasized in the Maigne framework.

The rapid clinical improvement observed following the introduction of a structured, integrative osteopathic and family-mediated rehabilitation program—with meaningful changes evident after only two sessions—suggests that the patient's condition was not inherently refractory. Instead, it may reflect a mismatch between the patient's clinical profile and the therapeutic strategies previously applied. This observation carries important implications: therapeutic exhaustion should not be equated with treatment resistance. Rather, it may represent a reversible state when an appropriate, context-adapted and coherent therapeutic framework is implemented (40, 41).

Beyond biomechanical and segmental factors, the patient's trajectory can also be interpreted within a contemporary biopsychosocial framework. Prolonged exposure to persistent pain, repeated therapeutic failures, and functional decline may have contributed to fear-avoidance behaviours, movement inhibition, and progressive deconditioning. These mechanisms are well described in chronic musculoskeletal disorders and are associated with central sensitization, reduced self-efficacy, and maladaptive motor strategies. The initial “robotic” gait pattern observed in this patient is consistent with protective motor behaviour frequently reported in chronic pain populations.

The rapid functional gains observed following the implementation of an integrative and family-mediated rehabilitation strategy may therefore reflect not only mechanical correction but also restoration of confidence in movement, increased therapeutic alliance, and reinforcement of active coping strategies. The involvement of family members likely enhanced adherence, reduced kinesiophobia, and increased the effective therapeutic dose, thereby promoting neuroplastic and behavioural recovery. These findings support the integration of biopsychosocial and culturally adapted rehabilitation models in low-resource settings, where contextual factors play a major role in long-term outcomes.

The fragmentation of care observed in this patient's trajectory—involving at least four distinct therapeutic systems (specialist medicine, physiotherapy, pharmacotherapy, and traditional healing) without inter-system communication—deserves specific attention. Such fragmentation, well documented in sub-Saharan African healthcare contexts (7, 8), is not merely a logistical failure but a structural consequence of the absence of coordinated multidisciplinary pathways for complex musculoskeletal conditions. At the Regional Hospital of Bafoussam, the Physical Medicine and Osteopathy Unit operates within a hospital structure that includes rheumatology, internal medicine, and general surgery, yet formal multidisciplinary case review for chronic pain conditions remains exceptional rather than routine. This case therefore serves as a concrete argument for the development of structured multidisciplinary collaboration frameworks in regional hospitals across Central Africa, integrating osteopathic and manual medicine alongside conventional specialist care, so that patients with complex polyarticular conditions do not require 24 months of sequential failure before accessing an integrative diagnostic framework (5, 6, 44).

5.4 Multi-Site scarification as pain cartography

The scarification scars documented in Figures 1, 2 represent a particularly striking finding. The patient had undergone therapeutic scarification on the thighs and knees, the thoracolumbar back, and both shoulders—creating what we describe as a “pain cartography” where the topography of his polyarticular suffering was inscribed onto his body through cultural healing practices (10–12). This multi-site scarification pattern, mapping pain distribution across four anatomical regions, has not been previously documented in the osteopathic or rehabilitation literature.

The anatomical correspondence between scarification sites and clinically identified pain territories is noteworthy: the thoracolumbar scarifications (Figure 1) overlie the exact territory of the thoracolumbar junction syndrome, while the thigh scarifications (Figure 2) correspond to the referred pain territory of the knee osteoarthritis. This correspondence suggests that traditional healers, through empirical observation, may identify the same pain territories that structured osteopathic examination documents, albeit through different conceptual frameworks (42, 43).

5.5 Therapeutic migration and healthcare equity

The 280 km biweekly therapeutic migration provides powerful quantitative documentation of the previously described unique practitioner syndrome (17) and therapeutic scarcity dynamics (18). The radiographs performed at the Hospital Regional Annexe d'Edéa (Figures 5–7) and brought to Bafoussam for clinical correlation provide objective radiological evidence of this geographical trajectory.

That a patient must travel 280 km biweekly for 6 weeks to access basic osteopathic care highlights the critical gap in musculoskeletal specialist distribution across Cameroon and, by extension, across much of sub-Saharan Africa (5, 6, 44). This case therefore constitutes a call to action for the integration of medical osteopathy training into existing medical and physiotherapy curricula across the continent, as previously advocated (45, 46).

The therapeutic migration observed in this case is not an isolated phenomenon. In routine clinical practice at the Regional Hospital of Bafoussam, patients frequently travel from major urban centers such as Douala, Yaoundé, and even distant regions (Ngaoundere 1,000 km+) to access specialized osteopathic and integrative rehabilitation care. This pattern reflects persistent disparities in the geographical distribution of musculoskeletal expertise and supports the concept of informal centralization of care around rare practitioners. Similar dynamics have been previously described in our work on therapeutic centralization and the “unique practitioner syndrome,” where competence scarcity generates spontaneous referral networks independent of formal institutional pathways. These findings highlight the need to strengthen regional rehabilitation capacity and develop structured referral systems to reduce unnecessary therapeutic migration and improve equitable access to care. A detailed anthropo-clinical analysis of this phenomenon has been previously published (at Elsevier, peer review journal) and provides further contextual understanding of these dynamics (When the osteopath attracts more than the hospital: Reflections on the informal centralization of musculoskeletal care around a rare practitioner in Cameroon https://doi.org/10.1016/j.kine.2025.08.004).

5.6 Family-Mediated osteopathic rehabilitation

The successful adaptation of the Cogni-Famille protocol (21) from neurorehabilitation to the osteopathic context confirms the transposability of family-centered rehabilitation models across different clinical domains. The trained cousin and wife served as effective co-therapists, ensuring daily therapeutic continuity that amplified the biweekly professional sessions and contributed to the sustained improvement observed at 12-week follow-up (47).

5.7 Limitations

This report presents several limitations that should be considered when interpreting the findings. First, this is a single-case design without a control group, which limits generalizability and prevents causal inference. The observed clinical improvement may partly reflect the natural history of degenerative musculoskeletal conditions, regression to the mean, placebo or contextual effects, and the influence of therapeutic alliance. In addition, the integrative and family-mediated nature of the intervention makes it difficult to isolate the specific contribution of each therapeutic component.

Second, advanced imaging techniques such as magnetic resonance imaging or computed tomography were not available due to resource constraints. Consequently, the diagnosis relied primarily on clinical reasoning and segmental examination, which, although consistent with the Sorbonne–Maigne framework, may introduce diagnostic uncertainty. Similarly, previous radiographic data from 2025 were unavailable, preventing longitudinal structural comparison.

Third, functional outcomes were assessed using clinical and patient-reported measures without instrumented gait analysis, kinematic evaluation, or isokinetic testing. While this reflects real-world practice in low-resource environments, it limits the objectivity and precision of biomechanical assessment. Moreover, although the Oswestry Disability Index is internationally validated, its specific cultural and contextual validation in rural sub-Saharan populations remains limited.

Finally, longer-term follow-up beyond the reported period was not available, and sustainability of the observed improvements cannot be fully established. Future prospective and controlled studies, including pragmatic trials and cost-effectiveness analyses, are needed to evaluate the reproducibility, scalability, and economic feasibility of integrated spine-centred osteopathic and family-mediated rehabilitation protocols for polyarticular degenerative conditions in African contexts (48–50).

6 What this study adds

• Introduces four interrelated conceptual frameworks—Therapeutic Exhaustion Syndrome, Therapeutic Migration Trajectory, Multi-Site Convergent Osteopathic Approach, and Osteopathic Dose–Response Threshold—providing a structured model to interpret complex musculoskeletal care pathways in low-resource settings.
• Provides one of the first documented applications of the Sorbonne–Maigne spine-centred osteopathic method for polyarticular degenerative disease in sub-Saharan Africa, supported by quantitative functional outcomes (Oswestry Disability Index 62% to 22%; Visual Analog Scale 8 to 2/10).
• Highlights multi-site therapeutic scarification as a potential clinical and cultural marker of prolonged therapeutic trajectories and health-seeking behaviour, offering a novel perspective on the sociocultural mapping of chronic pain.
• Quantifies therapeutic migration (280 km single journey; 3,360 km cumulative exposure) as an objective indicator of healthcare inequity and specialist scarcity, supporting emerging evidence on geographical barriers to rehabilitation access.
• Illustrates the limitations of fragmented or non-integrated rehabilitation strategies in complex multi-site degenerative conditions, emphasizing the importance of segmental and integrative clinical reasoning in musculoskeletal care.
• Demonstrates the feasibility and effectiveness of transposing the Cogni-Famille model from neurorehabilitation to structured, family-mediated osteopathic home rehabilitation in chronic musculoskeletal disorders.
• Provides preliminary evidence that dose amplification through family-mediated rehabilitation may enhance adherence, self-efficacy, and neuroplastic adaptation in chronic degenerative pain management.
• Supports the development of scalable, low-technology, high-clinical-reasoning musculoskeletal care models aligned with global rehabilitation priorities and the World Health Organization Rehabilitation 2030 agenda.

7 Conclusion

This case illustrates that a spine-centred, integrative approach based on the Sorbonne–Maigne framework, combined with structured family-mediated rehabilitation, can lead to clinically meaningful recovery in complex multi-site degenerative musculoskeletal conditions within low-resource environments. Despite 24 months of fragmented care across conventional, pharmacological, and traditional systems, the patient achieved rapid and sustained functional improvement after the implementation of a coherent, segmentally guided and context-adapted therapeutic strategy. These findings suggest that therapeutic exhaustion may reflect a reversible mismatch between patient needs and available care rather than true treatment resistance—a distinction with profound implications for clinical decision-making in resource-limited settings.

The four concepts introduced in this report provide a structured framework to better understand the interplay between clinical complexity, healthcare fragmentation, and contextual constraints in sub-Saharan Africa. The documented therapeutic migration over 280 km highlights persistent inequities in access to specialized musculoskeletal care and underscores the urgency of integrating spine-centred diagnostic skills and manual musculoskeletal medicine into medical and rehabilitation training at regional and community levels. Future prospective and controlled studies are needed to evaluate the effectiveness, scalability, and cost-effectiveness of integrated spine-focused rehabilitation models, in alignment with global rehabilitation priorities and the World Health Organization Rehabilitation 2030 agenda.

Methodological note

This case report was designed to ensure maximum transparency, clinical reproducibility, and contextual relevance. The intervention followed a structured and standardized clinical reasoning framework based on the Sorbonne–Maigne method, combined with a clearly defined family-mediated rehabilitation protocol. All clinical outcomes were measured using internationally recognized and clinically validated tools, including the Visual Analog Scale, the Oswestry Disability Index, and the Kellgren–Lawrence radiographic classification, allowing comparability with existing musculoskeletal research.

Although this is a single-case design, particular attention was given to the ecological validity of the intervention. The therapeutic strategy reflects real-world conditions in low-resource environments, where advanced imaging, technological assessment tools, and multidisciplinary rehabilitation teams are often unavailable. The approach therefore prioritizes clinical reasoning, segmental diagnosis, and therapeutic dose optimization, which are key determinants of functional recovery in such contexts.

Furthermore, the detailed documentation of the patient's therapeutic trajectory—including prior treatment failure across conventional and traditional systems, therapeutic scarification practices, and geographical displacement over 280 km—provides a unique opportunity to explore the interaction between clinical, biomechanical, sociocultural, and health system factors. This contextualized perspective aligns with the World Health Organization Rehabilitation 2030 framework and with contemporary calls for implementation-oriented, context-sensitive rehabilitation research in low-resource settings.

Future studies should aim to replicate these findings in larger cohorts and pragmatic controlled trials, integrating cost-effectiveness analysis and long-term follow-up to evaluate scalability and sustainability. Such research may contribute to bridging global disparities in access to specialized musculoskeletal care, particularly spine-centred integrative approaches that remain critically scarce across sub-Saharan Africa.

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Footnotes

Edited by: Maruti Gudavalli, Keiser University, United States

Reviewed by: Angela Maria Hoyos Quintero, University of the Valley, Colombia

Josiane Mbarga, High School of Health Vaud (HESAV), Switzerland