The case centers on a 60-year-old Italian woman, a retired hairdresser, who arrived at an osteopathic clinic carrying a decade of accumulated suffering. Her low back pain had begun roughly ten years earlier, coinciding with a sacral trauma from a fall, and had since spread its misery outward—radiating to her coccyx, entangling her shoulders, and triggering recurrent cervicogenic headaches. But her clinical picture was far more tangled than a simple spine problem. She lived with type 2 diabetes managed by metformin, essential hypertension treated with valsartan and aspirin, pre-existing depression dating back to 1994 and managed with sertraline, and sleep disturbances requiring a CPAP machine. She was, in the language of modern medicine, a textbook case of multimorbidity—precisely the kind of patient for whom standard protocols so often fall short.

Her prior encounters with the healthcare system had, if anything, deepened the problem. An orthopedic specialist had offered her two options: physiotherapy and glucocorticoid injections. She began only the structured exercise component—motor control and core strengthening work—and abandoned it after perceiving no benefit. When an acute flare-up struck, the specialist prescribed steroid injections and delivered what the report describes as alarming advice: stop working, avoid physical activity, give up even light exercise. She obeyed the activity-avoidance directive but refused the injections, worried about adverse effects and drug interactions with her existing medications. The result was eight months of physical inactivity, a spiral of kinesiophobia—the fear of movement itself—and a progressive erosion of her daily functioning, social participation, and sense of well-being.

What happened next is what makes this case scientifically fascinating. Rather than reaching for another standardized protocol, the treating osteopath turned to the Cynefin Framework, a sense-making tool derived from complexity science originally developed for organizational decision-making. The framework sorts problems into distinct domains—clear, complicated, complex, and chaotic—each demanding a different decision logic. At the first encounter, the researchers note, the patient’s entire clinical picture sat in the central domain of confusion: an entangled, undeciphered mix of persistent pain, movement fear, distrust born of failed treatments, an unaddressed decade-old trauma, and layered chronic disease. Neither practitioner nor patient could yet say which rules applied to which piece of the puzzle.

The first act of care, therefore, was not a technique but a decomposition. Together, osteopath and patient systematically reassigned each element of her story to its proper domain. The glucocorticoid injections and the rest advice were reframed as belonging to the clear domain—linear, pathophysiological if-it-hurts-rest logic that, however internally coherent, the 2023 World Health Organization guidelines explicitly reject for chronic primary low back pain. The generic physiotherapy she had abandoned was placed in the complicated domain: guideline-concordant in principle, requiring expertise, but delivered without individualization or graded exposure to the movements she feared. Her diabetes, hypertension, and sleep disorder were classified as complicated problems governed by known rules and specialist management. The truly stubborn elements—her nociplastic pain and her kinesiophobia—landed squarely in the complex domain, where cause and effect emerge unpredictably and can only be understood in retrospect.

This reclassification was not academic hair-splitting; it dictated entirely different treatment strategies. For the chaotic phase, where no exploratory touch could yet reproduce a workable movement pattern, the osteopath proposed functional neuromyofascial activity—an active-participatory approach in which the patient performs fundamental movements like rolling, squatting, and walking under gentle guidance, allowing a clinical pattern to gradually surface. Once patterns emerged, care shifted into the complex domain’s probe-sense-respond logic: osteopathic manipulative treatment, including myofascial release applied to the sacral region and balanced ligamentous tension applied to the cervical spine, right hip, and right knee, was iteratively adjusted to the patient’s real-time response. Every technique’s endpoint was the palpated tissue release itself, not a fixed timer—a response-led philosophy in which dose was co-constructed moment by moment between practitioner and patient.

The results, documented across five encounters spanning roughly 10.6 months, were striking. Her Visual Analogue Scale pain score plummeted from 7 out of 10 at baseline to 2 by the second encounter, just seven days later, with no changes to her medication or any co-interventions in between—and it held steady at 2 through the final follow-up in January 2026. Her RAND-36 Health Survey scores, measured before the first treatment and again at the third session, showed dramatic numerical improvements across all eight domains: physical functioning leapt from 25 to 85, physical limitations from 0 to 75, social functioning from 25 to 80, and emotional role limitations from 33 to a perfect 100. Her functional neuromyofascial activity screening score climbed from 4—general motor dysfunction—to 13, firmly in the functional motor ability range. Perhaps most tellingly, she resumed walking and dancing, activities she had surrendered years earlier.

Yet the authors are refreshingly, rigorously honest about what this case can and cannot prove. In a single, uncontrolled report, clinical improvement cannot be attributed to the intervention alone. Regression to the mean, natural symptom fluctuation, expectancy effects, and the therapeutic alliance all remain plausible contributors—particularly given the low baseline scores and the rapid early change. The RAND-36 scores at later encounters were confirmed by patient recall rather than independently re-administered, making the long-term maintenance descriptive rather than a formal re-measurement. The Cynefin mapping itself was assembled retrospectively from brief contemporaneous notes, and the authors explicitly caution that domain assignments reflect clinical judgment, not a validated classification. Even the somatic dysfunction findings rest on TART criteria—tissue texture, asymmetry, restriction, tenderness—whose inter-examiner reliability remains debated in the literature.

What the case does offer is a testable hypothesis and a provocative conceptual bridge. The authors propose that improvement likely arose through interacting behavioral and non-specific pathways: reduction of movement fear through graded exposure and reassurance, restoration of self-efficacy via shared decision-making and self-screening, resumption of physical activity after prolonged deconditioning, and short-term pain modulation through the contextual effects of therapeutic touch. Mechanistic claims about fascial release, inflammation, or fibroblast function were deliberately not invoked, since none were measured. The neuroaesthetic-enactive paradigm—the idea that touch operates as an embodied perceptual dialogue—served as a framework for the clinical interaction rather than a demonstrated cause of recovery.

The broader implications reach well beyond one patient’s spine. The authors situate their findings within the WHO’s 2023 guideline calling for age-sensitive, multidisciplinary, non-pharmacological care for adults over 60, and within global frameworks like the UN Sustainable Development Goal 3 and the WHO Decade of Healthy Ageing. They argue that complexity-informed, person-centered approaches may support functional ability in older adults more precisely than strategies that treat them as a generic vulnerable group. But they are equally candid about implementation barriers: the framework demands extended consultation time, formal training in complexity science, and remains interpretive rather than standardized. Controlled, prospective, multi-centre studies remain indispensable to determine whether this approach is feasible, reproducible, and effective across larger populations. For now, this single woman’s journey—from eight months of immobility to dancing again—stands as a hypothesis-generating beacon, suggesting that when chronic pain refuses to obey simple rules, the answer may lie in learning to navigate complexity itself.

Subject of Research: Complexity-informed osteopathic care for chronic primary low back pain in an older adult with multimorbidity

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

Article References: De Rosa, U., Cairoli, A., Conti, E., Marcucci, M., Baroni, F., & Lunghi, C. (2026). Complexity-informed osteopathic care for chronic low back pain in a 60-year-old woman: a case report. Frontiers in Musculoskeletal Disorders, 4, Article 1872226. https://doi.org/10.3389/fmscd.2026.1872226

Image Credits: AI Generated

DOI: 10.3389/fmscd.2026.1872226

Keywords: chronic low back pain, osteopathic manipulative treatment, Cynefin framework, complexity science, case report, kinesiophobia, biopsychosocial approach, myofascial release, healthy ageing, person-centered care, multimorbidity, non-pharmacological care