Complexity-informed osteopathic care for chronic low back pain in a 60-year-old woman: a case report

1 Introduction

Chronic primary low back pain (CPLBP) is characterized as persistent or recurrent pain lasting more than three months that cannot be reliably attributed to a structural lesion, spinal deformity, or specific underlying disease process (1). Within international classification systems, CPLBP is coded as M54.5 in the International classification of diseases, 10th revision (ICD-10) and as MG30.02 under “Chronic primary musculoskeletal pain” in the ICD-11 (2). Globally, it is among the most prevalent health conditions and the leading cause of disability across all ages and sexes, with a mean point prevalence estimated at 11.9%, affecting approximately 619 million people in 2020 (3, 4). Prevalence rises with age, peaks in older adults, and is consistently higher among women, and up to two-thirds of patients report persistent or fluctuating symptoms beyond one year, often with substantial functional limitations and reduced participation (3). Despite this burden, most clinical guidelines are derived from studies in younger and middle-aged adults (1). The 2023 World Health Organization guideline for non-surgical management of CPLBP highlights the urgent need for age-sensitive, multidisciplinary care, particularly for adults over 60, to address functional impairment, reduce disability, and guide personalized management (1). A biopsychosocial approach provides the most valid framework for understanding and managing CPLBP, recognizing pain as a complex interaction of physiological, psychological, and social factors, and effective management integrates physical, psychological, and educational interventions (5). Combined physical and psychological programs can improve pain, function, and disability in adults with CPLBP lasting longer than 12 weeks, although cost-effectiveness data remain variable (5, 6). Within this landscape, the WHO (2023) guidelines stress understanding CPLBP as a multifaceted experience shaped by personal and social factors, adopting a biopsychosocial perspective that accounts for cultural beliefs, patient expectations, and socioeconomic factors, and prioritizing empathic, non-stigmatizing communication focused on functional goals rather than impairment (1, 7). In women in their 60s, the transition toward chronic pain is often driven by systemic biological changes and psychosocial stressors, emphasizing the need for interventions that go beyond traditional biomechanical approaches (8). Non-pharmacological interventions, including structured exercise, cognitive behavioural therapy, mindfulness-based interventions, and manual therapies, have demonstrated benefits in reducing pain, disability, and kinesiophobia in CPLBP (9–11). Managing chronic low back pain also requires clinical decision-making approaches capable of addressing complexity and supporting individualized, context-sensitive care, such as the Cynefin Framework (CF) and its application within healthcare practice (12), as well as in person-centred osteopathic practice (13). Osteopathic care (OC) shows particular promise in improving pain, function, and quality of life, although evidence in older adults remains limited (14, 15). Integrating osteopathy into broader care may also help reduce reliance on pharmacological treatments, which carry higher risks in elderly populations, while addressing both physiological and psychosocial contributors to chronic pain (15). To better manage clinical complexity and chronic conditions, particularly in older populations, the literature recommends the CF as a sense-making and decision-making tool that distinguishes between simple, complicated, complex, and chaotic domains (12). In chronic conditions, the CF emphasises an intuitive, holistic approach, especially in complex cases where cause-and-effect relationships emerge unpredictably, and it advocates flexible, context-sensitive strategies for patients with multimorbidity and social complexity, such as those addressed by OC (12). While the relevance of the CF in contemporary OC has been discussed-particularly in contextualizing biopsychosocial-spiritual and person-centred models within evidence-informed practice- its clinical application remains underexplored (13). This case report describes osteopathic care, interpreted through complexity-based reasoning, for a 60-year-old woman with CPLBP, contributing to the discussion of age-sensitive, personalized management of chronic low back pain. The CARE guidelines and checklist were used to guide the presentation of this case report (16, 17).

2 Report of case

2.1 Patient information

The patient is a 60-year-old Italian woman, a retired hairdresser, with a 10-year history of chronic low back pain. She was diagnosed with hypertrophy of the facet joints at L4–L5 and L5-S1 (ICD-10 code M47.8) and a disc bulge at L5-S1 (ICD-10 code M51.27), accompanied by lumbosacral pain radiating to the coccyx (ICD-10-CM code M54.5). This pain is persistent and has been accompanied by stiffness, tenderness, and limitations in movement, particularly in her shoulders, as well as recurrent cervicogenic headaches. The nature of the pain is reported in Table 1, summarizing the SOCRATES pain assessment (18).

Table 1. SOCRATES pain assessment.

The patient's medical history is notable for a sacral trauma that occurred approximately 10 years ago, which coincided with the onset of her pain. She also has a history of several major surgeries, including cholecystectomy, appendectomy, cesarean section, and reductive mastoplasty, and of a left clavicle fracture and a right elbow trauma. Her medical history was notable for type 2 diabetes mellitus, managed with metformin (500 mg twice daily), and essential hypertension, treated with an angiotensin II receptor blocker (valsartan, 80 mg daily) and antiplatelet therapy (aspirin, 100 mg daily). Her maintenance regimen also included ibuprofen (400 mg as needed for pain), sertraline (50 mg daily for pre-existing depression), and atorvastatin (10 mg daily). She uses a continuous positive airway pressure (CPAP) device for sleep disturbances and had been physically inactive for the eight months preceding presentation due to worsening symptoms. Her history of depression, which developed alongside her diabetes in 1994, was exacerbated by a medication regimen that led to hormonal imbalances. Radiological examinations showed facet joint hypertrophy from L4 to S1 and a disc bulge at L5-S1. These degenerative findings are highly prevalent in asymptomatic individuals of this age group and were therefore not interpreted as necessarily causative of the patient's pain. On the basis of the persistent course, the disproportion between symptom severity and the degenerative imaging findings, the non-radicular distribution, and the co-occurring affective burden (depressive symptoms and sleep disturbance), the clinical picture was interpreted as showing features suggestive of nociplastic pain with a co-occurring affective component.

This represents a clinical impression rather than a formal criteria-based classification, as the IASP grading criteria for nociplastic pain were not systematically applied at assessment (19).

The following account of prior care is based on the patient's retrospective self-report; contemporaneous clinical records and standardized outcome scores from that period were not available. Her prior management had been directed by an orthopedic specialist, who indicated two options: physiotherapy and glucocorticoid injections. The prescribed physiotherapy comprised structured exercise (i.e., motor control and core strengthening, both individual and group-based structured exercise programmes), and manual treatment described by the patient as “massage with traction”, modalities that correspond to non-pharmacological options recommended in the WHO 2023 guideline for CPLBP (1). However, the patient reported that she began only the structured-exercise component and discontinued it because she perceived no benefit, without undertaking the remaining prescribed modalities. During a subsequent acute flare-up, the orthopedic specialist prescribed a course of glucocorticoid injections and gave alarming advice that led the patient to cease working and avoid physical activity, including light exercise. The patient followed the activity-avoidance advice but declined the injections, citing concerns about adverse effects and drug–drug interactions with her existing medications. This patient-led decision is consistent with the WHO 2023 guideline (1), which advises against the routine use of glucocorticoids for CPLBP, particularly in older populations, given the very low certainty of evidence and the likelihood that long-term harms outweigh limited short-term benefits. However, the cautionary advice contributed to an emotionally significant period of kinesiophobia that negatively affected her daily life, social participation, and well-being.

In this report, previous treatment was considered to have failed on the basis of clinically interpretable, patient-referenced criteria: the absence of any sustained improvement reported by the patient during the structured exercise she undertook, a progressive functional decline culminating in 8 months of physical inactivity, and her decision to discontinue physiotherapy. The patient subsequently sought OC through word of mouth rather than through medical referral. Although initially skeptical about manual therapy because of her previous experiences, she agreed to pursue osteopathic manipulative treatment (OMT) with a holistic, person-centred approach.

2.2 Clinical findings

To provide a comprehensive baseline assessment and to evaluate competing pain sources and red-flag features before the osteopathic structural examination (OSE), a structured conventional physical and neurological examination was performed at the first encounter, following standard recommendations for the clinical and neurological assessment of low back pain (1, 20). These findings were documented in the clinical notes during routine care in the concise form used in private practice; they are reported here in expanded form. The ranges of motion reported below are clinical estimates rather than instrumented measurements.

2.2.1 Red flags and safety screening

Perineal sensation was intact with normal bowel and bladder control, and there were no systemic red flags (no unexplained weight loss, night pain, fever, or history of malignancy), reducing the likelihood of systemic or emergent pathology, including cauda equina syndrome.

2.2.2 Gait and functional mobility

Gait was independent and symmetrical without antalgic limp, with mild hesitancy during heel-strike and trunk rotation, which appeared related to movement-related fear (kinesiophobia).

2.2.3 Lumbar range of motion

On clinical estimation, flexion was restricted to approximately 50% of the expected range, with posterior tightness and movement apprehension; extension was moderately restricted (approximately 60% of expected), with mild low-back discomfort at the terminal range; lateral flexion was symmetrically and mildly restricted bilaterally (approximately 70% of expected), without focal side-to-side asymmetry.

2.2.4 Neurological examination

Motor strength was preserved (5/5 on the Medical Research Council scale) across myotomes L2–S1 bilaterally (L2 hip flexion, L3 knee extension, L4 ankle dorsiflexion, L5 great-toe extension, S1 plantarflexion). Light touch and pinprick sensation were symmetrically intact across the L2–S1 dermatomes, with no radicular deficit detected. Deep-tendon reflexes were normal and symmetrical (2 + patellar, L3/L4; 2+ Achilles, S1), with a normal flexor plantar response (Babinski negative bilaterally).

2.2.5 Orthopaedic and provocation testing

The straight-leg-raise test, including the Lasègue sign, was negative bilaterally. A validated sacroiliac provocation cluster (Laslett: distraction, thigh thrust, compression, sacral thrust, and Gaenslen tests) was performed; only the thigh thrust (also termed posterior shear) test was positive, and with fewer than three positive tests the sacroiliac joint was not indicated as a specific source of pain (20, 21). Direction-specific lumbar movement-control (LMC) testing reproduced pain and associated tension during extension, flexion, and rotation/lateral flexion control, consistent with impaired LMC; poor LMC is associated with excessive tissue loading that may contribute to the development and persistence of LBP (22). The Thomas test was positive bilaterally, more pronounced on the right, consistent with reduced hip-flexor length that may contribute to altered lumbopelvic dynamics; the FABER (Patrick) test was negative bilaterally (20, 23).

On this basis the presentation was classified, as a working diagnosis of exclusion, as chronic (primary) low back pain; because a focused coccygeal assessment was not performed, a specific coccygeal source cannot be excluded: a radicular contribution was not supported by the preserved myotomal strength, intact dermatomal sensation, normal reflexes, and negative straight-leg-raise/Lasègue; sacroiliac pain was not indicated by the Laslett cluster; the negative FABER test did not suggest hip pathology, although a negative FABER alone does not exclude it; and systemic or emergent pathology was not suggested by the red-flag and sphincteric screening (20). The coccygeal radiation reported by the patient was interpreted as referred pain on clinical grounds; a focused post-traumatic coccygeal assessment (coccygeal tenderness, pain on sitting or sit-to-stand transition, coccygeal mobility, or dedicated imaging) was not performed, so a specific coccygeal source was not formally assessed and cannot be excluded (see Limitations). This reasoning is consistent with the definition of CPLBP as pain not reliably attributable to a specific structural source (1).

The physical examination was subsequently corroborated by the OSE to identify somatic dysfunction (SD) associated with generalized or regional patterns of the body framework (see Section 2.4.3). The patient's report that “all daily activities” aggravated her pain, with no relieving factors, reflects her subjective account; on objective assessment, symptoms were reproduced specifically by the movement-control testing described above and by movement loading during the functional neuromyofascial activity (FNA), an osteopathic screening of fundamental movements (e.g., rolling–unrolling, hinge–squat, step–walking–lunge, upside-down “V”, and reclining back-bending), personalized to be performed in a manner natural to the patient—for example, the hinge-squat was elicited by asking her to retrieve an object from the floor by squatting and rising, followed by a reclining back-bending to place the retrieved object high and behind her (24).

2.3 Timeline

In 2015, the patient developed lumbosacral pain, which was initially intermittent and mild. In 2018, following an orthopedic consultation, she was advised to cease occupational and sports activities. In August 2024, the pain exacerbated, resulting in notable functional limitations. OC was initiated on 4 March 2025. The clinical timeline comprised five encounters over a total observation period of approximately 10.6 months: Encounter 1 on 4 March 2025 (baseline); Encounter 2 on 11 March 2025 (7 days post-baseline); Encounter 3 on 16 April 2025 (36 days after Encounter 2, ≈5 weeks); Encounter 4 on 28 May 2025 (42 days after Encounter 3, ≈6 weeks); and Encounter 5 on 20 January 2026 (237 days after Encounter 4, ≈7.8 months).

The scheduling of visits followed a person-centred clinical rationale for OC, with OMT and the patient active-participatory osteopathic approach (PAOA) tailored to the patient's evolving condition. The initial 7-day interval was intended to evaluate early response to OMT and to reinforce reassurance and graded exposure during a phase of marked kinesiophobia. The subsequent intervals (≈5 and ≈6 weeks) allowed for tailored OMT addressing the SD identified at each OSE, together with the consolidation of the in-session, osteopath-assisted work and of self-management strategies. Autonomous home practice—independent FNA self-screening (self-assessment) and FNA-snacks (independently performed fascia-oriented exercises)—was introduced only after the fourth encounter, once the patient reached a functional motor ability score of 11 and was considered able to perform and self-assess them safely at home. The final, longer interval (≈7.8 months) reflected the sustained clinical stability achieved (a maintained VAS of 2/10), obviating the need for closely spaced visits. Although Encounters 4 and 5 were originally intended solely as long-term follow-ups, OMT was delivered with preventive intent upon detecting residual SD relevant to her functional profile during reassessment. Throughout the study period, the patient received no additional non-pharmacological interventions apart from the OC described (OMT integrated with PAOA) and the prescribed home fascia-oriented exercises (FNA self-screening and FNA-snacks, from the fourth encounter; see Section 2.4.4), and her baseline pharmacological regimen remained unchanged. The overall timeline of main events related to OC is illustrated in Figure 1.

2.4 Diagnostic assessment and intervention: clinical reasoning, osteopathic structural examination, and osteopathic manipulative treatment

2.4.1 Sense-making decision-making and clinical reasoning

Contemporary osteopathy embraces a phenomenological approach that focuses on the patient's lived experience throughout the healing process. To navigate complex patient narratives, the CF has been proposed as a sense-making tool derived from complexity science, applied by osteopaths to address internal contradictions and unexplained bodily representations and to foster a shared understanding between practitioner and patient (13, 25–27). The CF integrates psychological and existential factors with biomedical knowledge, supporting collaborative clinical decision-making, and it helps structure patient narratives visually, allowing patients to reframe unclear aspects of their health journey (13, 25–27). In practice, the osteopath uses a whiteboard or paper to represent this process graphically, categorising clinical issues into the CF domains-clear (formerly “simple”), complicated, complex, and chaotic-together with the central domain of confusion (or disorder, or aporetic), in which the applicable domain has not yet been determined (13, 25–27). Practitioners encourage self-reflection, guiding patients to view unclear elements of their health process from different perspectives in order to enhance sense-making, improve their understanding of past interventions, and foster active participation in OC (13, 25–27). This integrative communication bridges the gap between illness (the subjective experience) and disease (biomedical alterations), enabling a personalised approach that combines symptom-oriented manual therapy with a broader health perspective. In this clinical case, the CF was applied as a retrospective interpretive heuristic. Cynefin-type reasoning informed the clinical decisions during care, and brief domain assignments were noted in the clinical record at the time; the complete mapping presented here (Figure 2, Table 2) was, however, assembled retrospectively for this report and was not produced as a formal instrument at the initial encounter. Presented in this way, the framework organises and communicates the clinical reasoning as a shared sense-making process: starting from the elements that the patient found confusing, each was reassigned to a more appropriate domain, its meaning negotiated with her, and shared decisions were reached about how to proceed. The sequence followed the clinical trajectory of this negotiation—first making sense of the patient's past care (the clear and complicated domains), then addressing the present course of care (the chaotic and complex domains). At first contact, the clinical picture resided in the central domain of confusion: the presentation was an entangled, undeciphered mix of persistent low back pain, kinesiophobia, distrust following prior treatment failures, an unaddressed sacral trauma from a fall ten years earlier, and multimorbidity, such that neither practitioner nor patient could yet determine which domain governed each element. The first operation of the framework was therefore not to intervene but to decompose the presentation and, together with the patient, to reassign each element to its appropriate domain. The patient's past care was addressed first, as a way of making sense of what had already been done. Both the glucocorticoid injections she had been offered and the advice to rest and avoid physical activity were framed within the clear (simple) domain, as they followed a linear, pathophysiological cause-and-effect logic—a presumed inflammatory source addressed by a local anti-inflammatory agent, and the intuitive “if it hurts, rest” rule. The osteopath explained that, although internally coherent, the patient's decision to forgo injections was ultimately aligned with clinical evidence, as such simplified logic is deemed inappropriate for CPLBP by the 2023 WHO guidelines. Specifically, these guidelines recommend maintaining physical activity and advise against the routine use of glucocorticoids (1); in this patient, however, the advice to avoid activity had fostered kinesiophobia and deconditioning, whereas the recommended injections had been declined. The prescribed physiotherapy and exercise, by contrast, were framed within the complicated domain: although guideline-concordant (1) and requiring professional expertise to deliver, they had been applied generically, without individualisation or graded exposure to the movements the patient perceived as threatening and had therefore not produced sustained benefit. Applying a “sense–analyse–respond” logic to this complicated element and re-reading the simple ones as outdated rules, these past interventions were discussed with the patient and, by shared decision, replaced with a personalised, progressive plan that reversed the activity-avoidance advice.

Table 2. Completed Cynefin Framework matrix: mapping of the patient's clinical issues and prior interventions onto the CF domains.

CF, Cynefin framework; CPLBP, chronic primary low back pain; SFCT, structure–function correlation testing; PAOA, patient active-participatory osteopathic approach; FNA, functional neuromyofascial activity; OMT, osteopathic manipulative treatment; NEP, neuroaesthetic-enactive paradigm; WHO, World Health Organization. The domain assignments are interpretive and reflect clinical judgement rather than a validated classification.

For each item, the table reports the assigned domain, the rationale for its placement, and the corresponding Cynefin decision logic and resulting clinical action. Items are ordered along the clinical trajectory of the shared sense-making process: from the central domain of confusion, through the patient's past care (clear and complicated domains), to the present course of care (chaotic and complex domains).

Attention then turned to the present course of care. At the initial encounter, no exploratory osteopathic touch-like provocation reproduced a workable movement pattern on structure–function correlation test (SFCT); cause-and-effect relationships were therefore not yet reconstructable, placing this phase in the chaotic domain. The osteopath explained this to the patient and proposed, as a shared decision, a PAOA -specifically FNA- as an “act-sense-respond” strategy: rather than applying a technique to a pattern that did not yet exist, FNA would gradually and safely expose her to functional movements, building biobehavioural synchronisation and rapport until a workable pattern could emerge (24). FNA guided the patient into comfortable postures while incorporating affective, touch-based cues, with the explicit aim of allowing a clinical pattern to surface over time.

Once the administration of FNA began to evoke an emergent pattern on SFCT, care transitioned into the complex domain, guided by a “probe-sense-respond” strategy. Here the emergent pattern itself directed treatment: drawing on the neuroaesthetic-enactive paradigm (NEP) (28), the osteopath and patient collaboratively probed, evaluated, and selected therapeutic strategies through touch and movement involving body regions associated with SD. The intensity and type of touch were iteratively adjusted according to the patient's real-time response, in an interaction framed within the NEP as an embodied, perceptual dialogue rather than as a demonstrated mechanism. SD-related areas—such as the sacral region, highlighted by the structural examination and meaningful to the patient because of her past trauma- served as focal points. Functional movements, such as rolling-unrolling flexion–extension along the anterior and posterior midlines to pick up an object from the ground and place it high, were introduced as exploratory probes and progressively refined as the pattern consolidated. The step-by-step mapping of the patient's narrative, past interventions, and therapeutic trajectory across the CF domains is illustrated in Figure 2 and Table 2; the domain assignments are interpretive, were not tested for inter-practitioner reproducibility, and should be read as a reasoning aid rather than a validated classification.

2.4.2 Patient-reported outcome measures and pain assessment

The guide to writing a case report of an osteopathic patient encourages authors to utilize Patient-Reported Outcome Measures (PROMs) that are both reliable and valid, with a preference for those developed and used in primary care contexts (17). PROMs should also be selected based on their alignment with the OC goals established with the patient and should be used throughout the course of OC to measure progress (17). In the present case report, Health-Related Quality of Life (HRQoL) was evaluated using the RAND 36-Item Health Survey, Version 1.0 (RAND-36) (29). The patient completed the Italian translation of the 36 items (30), which were subsequently scored according to the standard RAND-36 scoring algorithm (29). Although the RAND-36 shares its 36 items with the Short Form-36 (SF-36), it employs a distinct, non-proprietary scoring system (29) This self-administered tool consists of 36 items measuring health across eight domains: physical functioning, limitations in roles due to physical health, limitations in roles due to emotional problems, energy/fatigue, emotional well-being, social functioning, pain, and general health (29, 30). Higher scores indicate better health status. The RAND-36 was scored at the first and third encounters (4 March and 16 April 2025). At the fourth (28 May 2025) and fifth (20 January 2026, approximately 10.6 months after baseline) encounters, the patient reviewed and confirmed her previous RAND-36 responses; no independent repeat completion or rescoring of the instrument was performed. This confirmation of unchanged responses is a patient-reported continuation of the previously recorded scores rather than a formally repeated longitudinal measurement; the resulting indication of maintained health-related quality of life through the final follow-up is therefore descriptive rather than an independent re-measurement. Long-term status was additionally documented by the serially recorded VAS and FNA screening scores and by patient report. Lumbar range of motion was assessed and documented only at baseline and was not repeated as a serial quantified measure. LMC testing (22) was assessed before the first OMT and documented as poor LMC, with the patient reporting pain at the onset of extension, flexion, and rotation/lateral flexion. It was reassessed at the end of the first OMT, when a correct LMC was documented, the patient being able to perform extension, flexion, and rotation/lateral flexion without pain. LMC was then reassessed qualitatively at the beginning of each subsequent encounter, at which a correct LMC was documented; these assessments were descriptive and were not quantified with a validated scale. Additionally, we incorporated the Visual Analogue Scale (VAS) to assess pain intensity, as it remains widely supported in clinical practice (31). While multidimensional assessment tools are recommended to capture the complexity of the pain experience, the VAS is valued for its simplicity, reliability, validity, and sensitivity to clinical changes, making it a practical and efficient instrument for monitoring pain intensity in daily practice (31). The patient completed the VAS, where 0 represents no pain and 10 the maximum pain level (32). The VAS referred to current pain (i.e., pain at the time of assessment) and was recorded numerically at every encounter, including at the final encounter (approximately 10.6 months after baseline); these serial current-pain ratings are reported in Figure 3. No changes to the patient's analgesic or other medication, and no additional co-interventions, occurred between the first and second encounters, during which the VAS decreased from 7 to 2. In addition, the pain evoked during the execution of the FNA movements was appraised qualitatively as part of the SFCT; this activity-related appraisal, together with the patient's real-time response, informed the selection and tolerance-led dosing of the OMT, but was not recorded as a numerical VAS score.

2.4.3 Personalized osteopathic structural examination and osteopathic manipulative treatment selection

All assessments and treatments were delivered by an osteopath (D.O.) trained and practising in Italy, with over 10,000 h of experience in osteopathic education and clinical practice, consistent with operational definitions of professional expertise (33). The diagnostic process followed osteopathic principles and evidence-informed guidance for evaluating and managing low back pain, using the structured framework of the American OMT guidelines for patients with low back pain (34). First, the osteopath assessed the patient's tolerance of and safety for OMT, considering factors such as age and comorbidities. The OSE that followed focuses primarily on the neuromusculoskeletal system, reflecting its interplay with other physiological systems within comprehensive patient care. It was performed to identify SD, defined as impaired or altered function of the related components of the body framework: skeletal, arthrodial, and myofascial structures and their related vascular, lymphatic, and neural elements (35). The OSE was carried out in two stages.

2.4.3.1 Stage 1—detection of somatic adaptations and grading of severity (operator-dependent)

This stage comprises inspection, motion testing, and palpation of the neuromusculoskeletal elements potentially associated with SD. The clinically detectable palpatory signs of SD are tissue texture abnormalities (T), asymmetry of position (A), restriction of motion (R), and tenderness (T), summarized by the acronym TART. The SD is characterized at a general level (TART findings throughout the body), a regional level (findings in one or more body regions), and a segmental level. The number of TART signs grades severity: none (0), mild (1), moderate (2), or severe (3 or more) (35).

2.4.3.2 Stage 2—identification of the SD relevant to the patient's functional profile and clinical context (dependent on the practitioner–patient relationship)

Interpretation of the palpatory findings from Stage 1 was informed by the NEP (28), which frames osteopathic interaction as an embodied, perceptual dialogue between practitioner and patient, integrating the affective and cognitive dimensions of touch and its potential to modulate interoceptive processing. Within this approach, palpatory assessment was not limited to detecting mechanical restrictions but extended to how the patient's experience of pain is enacted and sustained through her perceptual-motor patterns and relational dynamics (27). This stage evaluates the interrelationship between the most severe palpatory findings from Stage 1, the patient's functional profile (for example, FNA personalized according to her daily routine), and the characterization of the reported disorder through validated tests (for example, LMC, the thigh thrust or posterior shear test, and the Thomas test). Using SFCT, any change in the functional profile following an exploratory, osteopathic technique-like touch is evaluated: a positive change (an improvement in an examination-test result) guides the osteopath and patient toward the technique that emerges as potentially useful for that patient's functional profile and clinical context. Importantly, the SFCT outcome is not used to infer a causal relationship between the SD and the patient's disorder, but to identify a useful interface through which the effects of touch and movement can be delivered in a personalized manner. Read through the osteopathic principles of body unity, self-regulation, and structure–function interrelationship, these findings guide the practitioner toward the most appropriate treatment (27, 28).

The following account describes the OSE as applied to the present case. For a detailed account of the identified and treated SD, see Section 2.4.4 (Osteopathic manipulative therapy and Follow-up). SD and the related OC procedures were coded within the ICD-10 as M99.0 (36, 37), which standardizes clinical documentation and facilitates communication across disciplines.

Operationally, in Stage 1 the osteopath first identified the palpatory findings as an area of interest mutually recognized by patient and practitioner, forming a hypothesis based on a shared perception of discomfort on touch and a lack of integration relative to the surrounding regions. The examination revealed a general fascial SD pattern involving the whole body—the functional and superficial back lines and the meningeal fascial tissues—together with regional SD associated with the head, cervical, sacral, lower-limb, and abdominal regions.

In Stage 2, the hypothesis regarding the area of interest was then tested through the SFCT, combining touch, active and assisted movements (i.e., FNA) (24, 27, 38), and patient positioning to assess changes in functional capacity, as well as physical-examination tests (the LMC battery and the provocation tests, such as the thigh thrust or posterior shear and Thomas tests): positive changes guided the shared decision toward a personalized approach, whereas negative results led the practitioner to adopt strategies supported by evidence from similar clinical contexts. FNA testing, as described by Baroni et al. (24), enables observation of real-time neuromyofascial responses—adaptive strategies, tensional coherence, and load distribution within myofascial continuities—conceptualizing movement as an emergent property of the interplay between the nervous system and the fascial network, in which mechanical, proprioceptive, and emotional factors interact to sustain postural and functional equilibrium (24, 27, 38). FNA assessment comprises a sequence of fascia-oriented movements (using mental imagery, slow dynamic stretch, and rebound elasticity)—rolling–unrolling, hinge–squat, step–walking–lunge, upside-down “V”, and reclining back-bending—that are qualitatively analysed and quantitatively scored to identify asymmetries, diminished adaptability, and altered coordinated tension, providing insight into the patient's functional organization and compensatory strategies (24, 27, 38). The FNA screening and the home FNA-snacks were performed as a “work-in” rather than as a conventional “work-out.” In contrast to exercise aimed at external exertion and measured in fixed repetitions or duration, a work-in is a low-load, perception-oriented motor practice: the movement is explored slowly and attentively, guided by interoceptive and proprioceptive awareness, and applying the fascia-oriented exercise principles of sensory-refinement motion, slow and dynamic stretching, and elastic-recoil motion. The activity is not prescribed as a set number of repetitions or a fixed time; instead, it continues until the patient can execute the movement while applying these principles and then stops. Duration and repetitions are therefore intrinsically variable and determined by the quality of movement achieved rather than by a predefined dose. Each movement is scored from 0 to 3 on the basis of the patient's reported perception and the osteopath's observation of coordination and fluidity during its execution: a score of 3 denotes functional motor ability, with spontaneously observable coordination and fluidity; 2 denotes regional motor dysfunction, in which coordination and fluidity emerge only after regional touch-based cues provided by the osteopath; 1 denotes general motor dysfunction, improving only after global touch-based cues addressing the myofascial chains; and 0 denotes an inability to complete the movement, accompanied by diffuse pain. Higher scores therefore indicate better motor function. Across the five screened movements, the summed score ranges from 0 to 15: 11–15 indicates functional motor ability; 6–10 regional motor dysfunction; 1–5 general motor dysfunction; and 0 is assigned when the patient shows movement inability and reports diffuse pain, such that the requested movement cannot be completed. In this report the FNA score was used as an internal, clinically oriented tool to support shared decision-making and to monitor progress; it has not been psychometrically validated, and no minimal clinically important change has been established for it. As an illustrative example, the first execution of the rolling–unrolling FNA at the initial encounter was scored 0, as the patient exhibited movement limitations, reported diffuse pain, and could not complete the requested movement. On a second execution during the same encounter, performed within the SFCT using an exploratory Myofascial Release (MFR)-type contact to the sacral region—a light, test touch used to gauge tissue response and thereby determine whether a direct or indirect MFR would subsequently be applied (a direct response guiding a direct technique, and vice versa)—the score improved to 2: the patient could now perform the movement, though with regional dysfunction that resolved with touch-based cues. Following affective, touch-based cues applied to areas associated with SD, intended to support the patient's proprioceptive and interoceptive awareness (for example, the sacrum and upper cervical spine), the patient reported an emergent perception, and the osteopath observed improved coordination and fluidity during the FNA. This within-encounter change represents an immediate response to touch rather than a durable outcome; the emergent pattern, indicating improvement in the functional profile, guided the selection of an MFR approach to the sacral region (35, 39). The same shared decision-making process, informed by the patient's nonverbal body representation and emergent functional pattern, guided the additional approaches: BLT (35, 39) applied to the cervical spine, right knee, and right hip, and FNA applied to the generalized fascial pattern (i.e., the meningeal fascia and the superficial back line) (24).

Within the SFCT, these physical-examination tests, together with the VAS and the FNA, served two distinct and complementary purposes, consistent with the NEP. First, they informed clinical decision-making: the patient's real-time response to touch and assisted movement during the SFCT guided both the selection of OMT (27, 28, 40) and active-participatory approaches (24, 38, 41)—MFR, BLT, and FNA—and their tolerance-led dosing across each body region. Second, they monitored the progression of outcomes: repeated within and across encounters, they gave practitioner and patient a shared reading of change in pain, movement control, and functional adaptability over time. In this sense, these instruments functioned not only as outcome measures but as an integral part of the shared, response-led reasoning through which the personalized treatment was assembled. These considerations on personalized osteopathic assessment and OC planning are further detailed in Figure 4.

2.4.4 Osteopathic manipulative treatment and follow-up

The OC delivered in this case was multimodal, comprising four therapeutic components delivered by a single osteopath: shared decision-making; OMT (i.e., MFR and BLT); PAOA, comprising in-session FNA screening (movement assessment performed with the patient) and assisted-FNA (patient-performed graded movement combined with affective, touch-based cues and OMT), with autonomous home continuation from the fourth encounter (FNA self-screening and fascia-oriented FNA-snacks); and informal reassurance and education addressing kinesiophobia. Their respective contributions cannot be separated in a single uncontrolled case (see Limitations); they are described below (Tables 3, 4). The manual techniques [MFR, BLT, and Indirect Diaphragm MFR (39)] and the participatory approach [PAOA with FNA (24, 38)] used SD as a body-framework interface and were selected to address the tissue changes and movement patterns relevant to the patient's functional profile; effects on overall function and long-term healing were not assessed and are not claimed.

Table 3. Osteopathic encounters: structural examination, manipulative treatment, and follow-up*.

For each encounter, the table reports the somatic dysfunctions identified at the osteopathic structural examination (region, area, TART findings, and severity), the techniques applied, their typical duration, and the corresponding ICD codes. Duration values for the manual techniques are the treating osteopath's typical retrospective estimates for these technique types, not measured encounter-specific durations; for PAOA/FNA the duration was response-led and is reported as “variable.” Care was response-led, with a release-based (not time-based) endpoint, so the exact per-technique duration, number of repetitions, and within-session sequence were not contemporaneously recorded. The contemporaneously recorded, patient-specific data comprise the techniques and body regions treated at each encounter and the serially recorded VAS and FNA screening scores; the 90–120 s and 3–15 min figures cited elsewhere are literature-derived reference ranges for the technique class, not measured doses.

*Within the table, an “X” denotes that the specified reference criterion has been documented, whereas a “–” indicates that the criterion was not observed. The anatomical regions used for diagnosing and coding SD are categorized in the ICD-10-CM under codes M99.0-M99.9, where the final digit (0–9) identifies the corresponding body region. OMT interventions are classified according to both anatomical location and therapeutic approach using codes 7W00-7W09 (with 00–09 indicating the treated region) and X0–X9Z (where 0–9 specifies the technique performed.; Abbreviation. ICD: International Classification of Diseases; OSE: osteopathic structural examination; SD: somatic dysfunction; OMT: osteopathic manipulative treatment; MFR: myofascial release; BLT: balanced ligamentous tension; PAOA: patient active-participatory osteopathic approaches; FNA: functional neuromyofascial activity.

Table 4. Applied principles, patient position, direct/indirect character, and termination criteria by technique.

MFR, myofascial release; BLT, balanced ligamentous tension; FNA, functional neuromyofascial activity. Fascia-oriented exercise principles: sensory-refinement motion, slow and dynamic stretching, and elastic-recoil motion.

Consistent with the response-led, neuroaesthetic-enactive paradigm, dose was not fixed in advance: manual techniques were sustained until a tissue release was palpated, and FNA screening and FNA-snacks are performed as a “work-in,” continuing until the patient can execute the movement applying the fascia-oriented exercise principles, so their duration and number of repetitions are intrinsically variable. Force was low-load throughout, and an immediate structure–function reassessment followed each technique. The literature-derived reference ranges (an initial 90–120 s inductive-touch phase; 3–15 min for PAOA/FNA) are distinguished from the contemporaneously recorded, patient-specific data (techniques and regions per encounter, and the serial VAS and FNA screening scores) and from the treating osteopath's typical retrospective estimates of per-technique duration reported in Table 3; the actual durations were not contemporaneously recorded.

The ∼90–120 s figure denotes engagement of the fascial barrier (a value recurring across osteopathic techniques), not a prescribed technique duration; the operative endpoint throughout was the palpated tissue release or the correct fascia-oriented execution, determined jointly by practitioner and patient.

MFR is a passive technique—direct or indirect—that addresses myofascial tissue changes and restores motion between regions affected by SD and the integrated fascial system (39). Gentle pressure is applied at a restrictive barrier or at a position of ease until release occurs, after which the tissues are returned slowly to prevent re-binding. Importantly, the operator-perceived barrier is not treated as a pathological deficit to be corrected but as a clinical interface guiding personalized touch, whose goals and delivery are co-constructed with the patient after SFCT evaluation. A recent review reported that MFR may influence inflammation, immune response, and fibroblast function (39); these are proposed mechanisms and were not measured here. In this case, indirect MFR was applied to the abdomen near symptomatic post-surgical scars, guided by the VAS severity elicited on palpation of the scarred areas (40). BLT is an indirect, passive procedure based on the proprioceptive feedback that ligaments provide when tension is balanced across the joint complex (39): compression and small movements (rotation, flexion, extension, side-bending) bring the joint to a point of balanced tension, restoring motion and reducing restriction. Reference execution times reported for BLT (39) were not applied as fixed durations; as for the other techniques, the endpoint was response-led. As an evidence-informed addition, Indirect Diaphragm MFR—positioning the ribcage and surrounding tissues away from restrictive barriers during maintained deep breathing to improve diaphragmatic mobility—was incorporated for its reported reduction of pain in chronic low back pain (34, 42); because the diaphragm is anchored to the thoraco-lumbar spine, ribs, and surrounding muscles, addressing SD in this region has been proposed to affect multiple body systems (34, 42), effects that were not measured here.

PAOA is a patient-active, participatory approach centred on FNA. FNA screening lets osteopath and patient assess motor function and movement patterns and share the OSE findings related to SD, using a simple scoring system and a body scan focused on bodily sensations (24, 41); it enhances functional awareness and informs treatment decisions. It is followed by assisted-FNA, performed by the patient under the osteopath's verbal and tactile guidance (affective touch), intended to support the patient's proprioceptive and interoceptive awareness, focusing on the regions and movement patterns associated with SD. In this framework, OMT is integrated within PAOA to facilitate environmental synchronization, thereby applying treatment effects directly to functional activities that mirror the patient's daily context. PAOA is performed in sequential phases—functional movement for postural stabilization; auxiliary fascia-oriented movements (fascial stretching, rebound elasticity, and sensory refinement through intentional breathing and body scanning); and transition through functional movement to a neutral posture—and, in the form of walking FNA with motor pauses (a “work-in” integrating a body scan in motion), combines conscious walking with mindfulness-based body scans and OMT applied during movement to enhance mobility and encourage adherence to physical activity and self-management (24, 38, 41). FNA was thus delivered in four forms differing in who performs the activity and when: FNA screening and assisted-FNA were carried out in session from the first encounter, whereas the autonomous home forms—FNA self-screening (the same assessment, performed and self-scored independently) and FNA-snacks (independently performed fascia-oriented exercises)—were introduced only after the fourth encounter, once the patient reached a screening score of 11 (functional motor ability) and was judged able to work safely on her own (see Section 2.4.5). The FNA screening score served to monitor motor function and support shared decision-making; as an internal, non-validated monitoring tool it enhances engagement rather than serving as a research instrument (24, 38), and it is not a measure of adherence. Home practice was not recorded (no diary, session count, or structured report), so adherence remains unknown. OC was delivered over five encounters, each of which included clinical reassessment and OMT when residual SD was identified, so there were no assessment-only visits. The fourth and fifth encounters, initially scheduled as longer-term follow-ups of a clinically stable patient (a maintained VAS of 2), were conducted as treatment sessions delivered with preventive intent upon detection of residual SD relevant to her functional profile. We do not imply that treating residual SD reduced the patient's risk of recurrence or chronicity, which was not evaluated.

In terms of treatment dose and fidelity, the intervention's duration, dosage, and application mode (e.g., direct vs. indirect) were not standardized a priori but set by the patient's response; consistent with the guiding NEP and the literature, technique parameters were continuously adapted to the joint practitioner–patient perception of real-time shifts in the patient's functional profile (27, 28). The endpoint of every technique was release-based rather than time-based, defined jointly by the osteopath's perception of tissue findings' progressive changes—TART—and by the patient's real-time feedback, namely reduced symptoms related to the presenting complaint, decreased tenderness on palpation of the treated areas, increased relaxation, and reduced arousal. Regarding the temporal parameters reported in the literature for these modalities, fascia-oriented OMT (e.g., MFR and BLT) typically involves an initial direct or indirect inductive-touch phase lasting 90–120 s, followed by a second phase of variable duration guided by shared osteopath–patient feedback; consistent with a release-based endpoint, the time required to achieve a palpable tissue release has been reported to vary with symptom chronicity—on average approximately 2.6 min in sub-acute and 3.3 min in chronic presentations (43). Additionally, literature on PAOA/FNA reports durations of the order of 3–15 min (24, 38). Notably, these published timeframes characterize the general technique class rather than the specific dose delivered to the present patient. For transparency, each encounter lasted approximately one hour. The treating osteopath's typical retrospective estimates of per-technique duration are reported in Table 3; these are typical estimates for these technique types, not measured encounter-specific values, and the exact per-technique and per-encounter durations, number of repetitions, and within-session sequence were not contemporaneously recorded. For each technique, Table 4 reports the applied principle, patient position, direct/indirect character, and the termination criterion.

2.4.5 Outcome measures and patient progress during osteopathic manipulative treatment

The outcome measures used to assess the patient's progress throughout OC—principally the RAND-36 Health Survey and the VAS—are reported below. The RAND-36 results (Table 5 and Figure 5) show substantial numerical improvements across multiple domains, temporally associated with the course of OC. As this is a single-patient report, no inferential statistics were applied. The RAND-36 was completed and scored before the first OMT (4 March 2025) and at the third OMT (16 April 2025), whereas the VAS was recorded at every encounter. At the fourth (28 May 2025) and fifth (20 January 2026, approximately 10.6 months after baseline) encounters, the patient reviewed and confirmed her previous RAND-36 responses; no independent repeat completion or rescoring was performed. This confirmation of unchanged responses is a patient-reported continuation of the previously recorded scores rather than a formally repeated longitudinal measurement, so the maintained result is reported descriptively; long-term status was additionally documented by patient report and by the serial VAS and FNA screening scores.

Table 5. Patient scores on the RAND-36 health survey before the first osteopathic manipulative treatment (OMT) and at the third OMT session*.

Higher scores indicate better health status.

*Patient scores on the RAND-36 Health Survey before the first osteopathic manipulative treatment (OMT) and at the third OMT session. At the fourth and fifth encounters (28 May 2025 and 20 January 2026, ∼10.6 months), the patient reviewed and confirmed these scores as unchanged; no independent repeat completion or rescoring was performed. The table presents the patient's health status across the eight domains, with higher scores indicating better health outcomes.

The VAS, referring to current pain, was recorded at every encounter and is shown in Figure 3. The score was 7 at the first encounter, decreased to 2 by the second encounter, and was maintained at 2 at the third encounter and at the fourth and fifth encounters (the latter two being follow-up visits at which treatment was also delivered; see Section 2.4.4). No changes to the patient's medication or other co-interventions occurred between the first and second encounters, during which the VAS decreased from 7 to 2. These serial values indicate a marked reduction in pain, consistent with—though, in an uncontrolled single case, not attributable to—the course of the personalized treatment. During the treatment period, the patient's medication (ibuprofen as needed, sertraline, and cardiovascular and lipid-lowering therapy) remained unchanged, CPAP use was maintained regularly, and body weight, glycaemic control, bowel and bladder function, and work, family, and social circumstances showed no relevant change; the main change reported was the resumption of valued physical and social activities, including walking and dancing. Throughout the course of treatment, the patient reported no adverse or unintended effects related to the osteopathic interventions, and all procedures were well tolerated.

The FNA screening score was recorded at every encounter and is reported in Table 6 (and Figure 6). The summed score was 4 at the first encounter, 7 at the second, 7 at the third, 11 at the fourth, and 13 at the fifth, corresponding to a progression from general motor dysfunction toward functional motor ability. Once the patient reached a score of 11 (fourth encounter), she was considered able to work independently at home, performing both the FNA self-screening (self-assessment) and the FNA-snacks (daily fascia-oriented exercises); she was asked to contact the osteopath by telephone if her FNA self-screening score fell below 11 and did not return above 10 within a few days despite repeating the FNA-snacks, so that a follow-up visit with possible treatment could be considered. She made no such contact before the fifth encounter, at which she scored 13. As an internal, non-validated measure, the FNA score is reported as a clinically oriented indicator rather than a validated functional outcome.

Table 6. Serial FNA screening scores across the five encounters.

The summed score (five movements, each scored 0–3; range 0–15) is reported with the interpretive band. Higher scores indicate better motor function. From the fourth encounter (score 11), the patient performed the FNA self-screening (self-assessment) and the FNA-snacks (daily fascia-oriented exercises) independently at home.

FNA, functional neuromyofascial activity. Interpretive bands: 1–5, general motor dysfunction; 6–10, regional motor dysfunction; 11–15, functional motor ability; 0, movement not completable with diffuse pain. The FNA score is an internal, non-validated tool without established psychometric properties or a defined minimal clinically important change; the bands are operational descriptors, not validated cut-offs.

3 Discussion

This case report describes the integration of osteopathic principles, a complexity-based sense-making and decision-making strategy (the CF), and a personalized osteopathic approach in the management of CPLBP in a 60-year-old woman with a complex clinical history. Complexity-based, Cynefin-type reasoning appeared to inform the understanding of the patient's health journey by addressing internal contradictions and unexplained body representations, and to support shared decision-making between osteopath and patient. This reasoning helped identify the multifaceted nature of the patient's pain—somatic, emotional, and social—which had substantially affected her trust in previous treatments; the complete domain mapping presented here was, however, reconstructed retrospectively. In recent years, traditional osteopathic practice has increasingly aligned with person-centred, evidence-informed care, integrating manual intervention with a biopsychosocial understanding (13, 26, 27, 44, 45). The present case combines elements of traditional osteopathic philosophy—hands-on, holistic assessment and individualized treatment—with contemporary strategies emphasizing patient education, self-management, and functional restoration, while also incorporating standardized evidence-informed approaches to CPLBP. Within this landscape, practitioners bridge foundational osteopathic principles—respectful patient engagement, comprehensive somatic and functional evaluation, and individualized therapeutic strategies—with current expectations for measurable outcomes and culturally sensitive practice (13, 26, 27, 44, 45). This case illustrates how OC's emphasis on whole-person assessment and manual skills may contribute to the management of complex conditions such as CPLBP, where symptoms arise from multifactorial physiological, psychological, and contextual factors. The CF, derived from complexity science and cognitive theory, supported clinical reasoning by categorizing findings into distinct domains and helping interpret palpatory, functional, and contextual data in a structured yet flexible manner (13, 25–27). Retrospectively mapping the patient's symptoms and prior interventions onto the CF domains (Table 2, Figure 2) provides a structured account of how interventions were adapted to the patient's evolving needs, integrating somatic and manual assessment with patient-centred strategies (13, 26, 27, 44, 45). The shared decision-making process, underpinned by proximity and non-verbal communication—particularly touch—can enhance therapeutic engagement. Frame-worked within the NEP, functional improvements combined with pleasant sensations elicited by targeted touch to SD-related regions have been proposed to amplify non-specific therapeutic factors, such as placebo responses (28). In the present case, this integrative experience appeared to foster a deeper understanding of both her clinical condition and the osteopathic rationale, particularly when interventions were applied to regions distant from the symptomatic site. Integrating SD mapping, neuroaesthetic-enactive interpretation, and FNA findings allowed a functional profile spanning both biomechanical and psychosocial dimensions of the patient's pain; these findings were interpreted as consistent with chronic compensatory behaviour and reduced functional variability, an interpretation that was not independently measured. This multidimensional approach is consistent with current osteopathic philosophy (27) and with WHO recommendations for non-pharmacological, person-centred, and function-oriented management of CPLBP (1). Beyond the individual level, a complexity-informed, person-centred approach may support functional ability more precisely than strategies that treat older adults as a generic “vulnerable group” (46, 47); these broader implications are hypothesis-generating and are not established by a single uncontrolled case. The observations in this case are consistent with existing literature on OC for CPLBP. A retrospective cohort study by Licciardone et al. (2023) reported that OC integrated into medical management was associated with reduced pain intensity and improved physical function and health-related quality of life in patients with CPLBP (14). A randomized clinical trial by Hartz et al. (2025) reported effects of OMT on pain, flexibility, parasympathetic modulation, and energy in CPLBP (48). In a randomized controlled trial, Mandara et al. (2008) reported reductions in pain and disability with OMT compared with sham treatment (49). A systematic review and meta-analysis by Dal Farra et al. (2021) concluded that osteopathic interventions, particularly MFR, were more effective than control interventions in reducing pain and improving function in non-specific CPLBP (50). These findings provide a context consistent with the present observations, while noting that a single case cannot establish comparative effectiveness. More broadly, this case is consistent with a complexity-informed model of chronic pain that considers biological, psychological, and social factors as components of a complex system (51). Such approaches may help personalize chronic pain care through a co-produced process (51), further supported by patient-active participatory approaches (41), and may complement traditional evidence-based models (1, 7, 14, 34).

3.1 A hypothesis for the observed improvement

While a single uncontrolled case cannot establish a mechanism, a clinically plausible and testable hypothesis can be proposed, linking this patient's baseline findings to the intervention components and the observed changes. At baseline she presented with marked kinesiophobia, eight months of physical inactivity, altered LMC, and low self-reported functioning. Within this picture, the improvement may plausibly have arisen through several interacting behavioural and non-specific pathways rather than through a specific tissue effect: a reduction in fear of movement through informal reassurance and graded, patient-active exposure to feared movements (8, 9); a consequent restoration of movement confidence and self-efficacy, supported by the FNA self-screening and shared decision-making (27); a resumption of physical activity (walking and dancing) after prolonged inactivity; short-term modulation of pain through the contextual and non-specific effects of therapeutic touch (52), consistent with the rapid early change in current-pain VAS; and changes in movement strategy or load tolerance, consistent with the altered movement-control findings. These pathways are offered as hypotheses to be tested in controlled research, not as established mechanisms. Mechanistic processes sometimes associated with manual techniques—such as fascial release, modulation of inflammation or immune response, fibroblast function (43), or neuroaesthetic enactive updating (28)—were not measured in this case and are therefore not invoked to explain the improvement; the neuroaesthetic-enactive paradigm is used here as the framework informing the clinical interaction rather than as a demonstrated cause of recovery.

3.2 Feasibility and implementation barriers of the Cynefin framework

While integrating the CF with OC provided a useful heuristic for navigating this patient's CPLBP, several barriers to broader clinical implementation must be acknowledged. First, applying complexity-science principles demands extended consultation time for thorough sense-making and iterative reassessment—a resource often severely constrained in time-limited primary care. Second, translating the framework into routine manual therapy requires formal practitioner training in complexity science, sense-making models, and person-centred communication; without it, clinicians may default to linear diagnostic paradigms. Third, the mapping presented here is necessarily interpretive: the assignment of a given issue to a domain reflects clinical judgement rather than a validated classification, and different practitioners might categorize the same presentation differently. The framework should therefore be regarded as a reasoning aid rather than a standardized diagnostic instrument. Future prospective studies should evaluate its feasibility, training requirements, inter-practitioner reliability, and cost-effectiveness before routine adoption in primary and secondary musculoskeletal care.

3.3 Limitations

Several factors limit the attribution of the observed improvement to the specific manual techniques. Baseline expectations were not measured with a validated instrument; the low baseline RAND-36 scores together with the rapid, large early change are compatible with a substantial contribution from regression to the mean, natural fluctuation, expectancy, and the therapeutic alliance. Progression was monitored over the course of care through the VAS and the FNA screening score, both recorded serially; lumbar range of motion was documented only at baseline, whereas lumbar movement-control testing was reassessed qualitatively at each encounter but was not quantified with a validated instrument. None of these is a validated objective measure of functional performance: the VAS is a subjective measure of pain intensity, the physical-examination tests are diagnostic and provocation tests rather than performance measures, and the FNA score is an internal self-assessment tool that has not been psychometrically validated. Standardized, validated low-back-specific instruments (e.g., the Oswestry Disability Index or Roland–Morris Disability Questionnaire), a Patient-Specific Functional Scale, and objective functional tests (e.g., gait speed or the five-times sit-to-stand) were not administered; walking, sitting, and standing tolerance were not quantified, and the resumption of walking and dancing is reported as the patient's own account. We do not imply that these measures would have been clinically inappropriate—only that they were not used—and their absence limits the objective corroboration of the reported improvement. In addition, although the Italian translation of the 36 RAND-36 items was used and scored with the standard RAND-36 algorithm, a validation of the RAND-36 scoring system specifically in the Italian population was not available; the quality-of-life scores should therefore be interpreted with corresponding caution. In particular, at the fourth and fifth encounters (28 May 2025 and 20 January 2026, approximately 10.6 months after baseline) the patient reviewed and confirmed her previous RAND-36 responses; no independent repeat completion or rescoring of the instrument was performed. This confirmation of unchanged responses is therefore a patient-reported continuation of the previously recorded scores rather than a formally repeated longitudinal measurement, and this indication of maintained quality of life is descriptive and should be interpreted with caution. Future studies should administer validated low-back-specific patient-reported outcome measures and objective functional performance tests independently, at predefined time points including a final independent follow-up. These measurement choices also reflect the pragmatic, real-world nature of a case report, which documents care as delivered in routine private practice rather than under a standardized research protocol. Monitoring relied on brief, low-burden measures suited to daily practice—principally the VAS and the FNA screening score—rather than a battery of standardized questionnaires and performance tests; the VAS, although unidimensional, is a practical, change-sensitive pain measure that has been used to monitor osteopathic care within a patient-centred approach that incorporates patients' preferences and expectations into clinical decision-making (53), while the routine use of longer, multidimensional patient-reported instruments is itself constrained by well-documented completion and implementation burden (54). Consistent with this orientation, the patient's own preferences were respected at the later encounters (17, 26, 27). We report these choices transparently, so that the trade-off between ecological validity and measurement standardization is explicit, while recognizing that it constrains methodological rigor.

A focused post-traumatic coccygeal assessment was not performed, so a specific coccygeal source of pain was not formally evaluated. Although complexity-based sense-making guided clinical reasoning in real time during the encounters, the formal Cynefin mapping presented here (Table 2) is a retrospective interpretive reconstruction assembled from brief contemporaneous domain notes; the domain assignments are interpretive, were not tested for inter-practitioner reproducibility, and should be regarded as a reasoning aid rather than a validated classification. SD assessment itself has recognized limitations. The TART criteria (tissue texture abnormality, asymmetry, restriction of motion, and tenderness) used here to characterize SD have clinical value within an individual therapeutic encounter, but their reliability and validity as diagnostic constructs remain debated: inter-examiner agreement for individual palpatory signs is heterogeneous and generally lower than intra-examiner agreement (55, 56), and reliability and validity are distinct properties that must be established separately, with many osteopathic tests still lacking an accepted reference standard (57). Moreover, manual contact may elicit biological and perceptual responses in the patient that cannot necessarily be detected or accurately interpreted by the practitioner through palpation alone. The SD findings reported here should therefore be read as pragmatic, operator-dependent clinical judgments that informed a shared, response-led process rather than as validated diagnostic measurements. A further limitation concerns adverse-event assessment. Although standardized methods for adverse-event monitoring are available—structured prospective monitoring, severity grading systems, and causality assessment algorithms (58), together with reporting frameworks such as the CARE guidelines (59)—these were not systematically implemented here. Adverse events were monitored through routine clinical follow-up and patient self-report, without validated severity scales, predefined classification criteria, or formal causality algorithms. This absence may lead to underreporting of minor reactions and limits the reproducibility and external validity of the safety findings. In real-world practice, formal adverse-event scales are not always ideal, as they may add patient burden and may affect adherence; although this has been shown mainly for pharmacological treatments, similar considerations may extend to non-pharmacological manual therapy (60, 61). Finally, as an uncontrolled single case, the observations reported here cannot separate technique-specific effects from the contextual and non-specific effects discussed above, and should be read accordingly.

3.4 Concluding remarks

Because this is a single, uncontrolled case, these observations support only the finding that clinical improvement occurred during a course of OC in this patient; they cannot distinguish specific treatment effects from natural symptom fluctuation, regression to the mean, patient expectancy, or the influence of the therapeutic alliance. Within these limits, the case may offer a modest, preliminary illustration of how a person-centred, evidence-informed osteopathic approach can be organised around the optimization of functional ability and the support of patient autonomy in a 60-year-old adult. Whether individual-level approaches of this kind could contribute to broader, prevention-oriented goals for healthy ageing—including tertiary-prevention objectives such as supportive and rehabilitative services that minimize morbidity and maximize functional and psychosocial recovery in long-term conditions, and as articulated in United Nations Sustainable Development Goal 3 (Good Health and Well-Being) (62) and in the WHO Decade of Healthy Ageing (63)—is a question that a single case cannot address; any such connection is hypothesis-generating and would require dedicated health-services research, in line with recently proposed research agendas for evaluating the impact of OC (64). Controlled prospective and multi-centre studies remain indispensable to evaluate clinical efficacy, to elucidate the underlying mechanisms, and to determine whether a complexity-informed approach of this kind is feasible, reproducible, and applicable across larger and more diverse ageing populations. This case does not establish the effectiveness of OC for chronic primary low back pain; it describes one patient's course and offers hypotheses for such future research.

3.5 Patient perspective

“I wanted to thank you for the experience I had. When I first came to you, I could no longer move my back and legs with fluidity, and my spirits were very low. Through your professionalism, you restored me completely—I now live my life with renewed enthusiasm, have resumed walking, moving freely, and dancing. I truly feel reborn, both physically and mentally. My deepest thanks”.

This statement reflects the patient's subjective experience and should not be interpreted as evidence of complete clinical recovery, which would require confirmation through standardized long-term outcome assessments.

Informed consent. This case report was conducted in accordance with the Declaration of Helsinki. All clinical data were generated during routine OC and documented retrospectively for this report; they were not collected under a prospective research protocol. In Italy, a single-patient retrospective case report reporting anonymised data from routine clinical care, published with the patient's written consent, is not classified as a clinical study requiring ethics-committee review; accordingly, no formal ethics approval or waiver was issued for this report, and none was required. Written informed consent for osteopathic treatment was obtained from the patient at the first visit (4 March 2025). The patient's personal narrative was recorded as part of her care, at the fourth encounter (28 May 2025), and not for the purpose of publication; the decision to prepare this case report, and separate written informed consent for its publication—including the patient's personal narrative and clinical data—were made subsequently, with consent obtained on 20 January 2026.

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Footnotes

Edited by: Orlando Conde-Vázquez, University of Vigo, Spain

Reviewed by: Yonghyun Yoon, Kangnam Sacred Heart Hospital, Republic of Korea

Nanjian Xu, Ningbo No.6 Hospital, China

Abbreviations BLT, balanced ligamentous tension; CF, cynefin framework; CPAP, continuous positive airway pressure; CPLBP, chronic primary low back pain; FNA, functional neuromyofascial activity; ICD, international classification of diseases; LMC, lumbar movement control; MFR, myofascial release; NEP, neuroaesthetic enactive paradigm; OC, osteopathic care; OMT, osteopathic manipulative treatment; OSE, osteopathic structural examination; PAOA, patient active-participatory osteopathic approaches; PROMs, patient reported outcome measures; SD, somatic dysfunction; SFCT, structure-function correlation test.