Chronic low back pain management in rural Cameroon: a pragmatic pilot study of osteopathic care, physiotherapy, and the “unique practitioner syndrome”

Background: Chronic low back pain (CLBP) affects 14%–72% of African populations, yet evidence comparing manual therapy approaches in sub-Saharan Africa remains scarce. In rural settings characterized by limited therapeutic options, care often becomes informally centralized around practitioners with rare expertise. This pilot study compared osteopathic care and physiotherapy for CLBP in rural Cameroon, while exploring contextual mechanisms underlying healthcare-seeking behaviors, including the “unique practitioner syndrome.”

Methods: This pragmatic pilot exploratory study was conducted at Bafoussam Regional Hospital between January 2023 and December 2024, with the primary objective of generating preliminary comparative signals and informing future randomized controlled trials. Patients were allocated according to consultation day: osteopathic care (Monday/Wednesday, n = 19) and physiotherapy (Tuesday/Thursday/Friday, n = 28), reflecting real-world service organization. Primary outcomes included pain intensity (Visual Analog Scale, VAS) and functional disability (Eifel Disability Index). Secondary outcomes comprised a newly developed Therapeutic Autonomization Score and a culturally adapted Agricultural Functional Test. Quantitative outcomes were complemented by qualitative patient narratives to explore experiential and psychosocial dimensions of care.

Results: Forty-seven patients completed the intervention (78.7% women; mean age 44.8 ± 12.3 years), with 95.7% reporting prior unsuccessful physiotherapy. Across the 5-week intervention period, larger magnitudes of improvement were observed in the osteopathic care pathway compared with physiotherapy for pain reduction (−47.3% vs. −32.1%; p = 0.008; Cohen's d = 0.85) and functional disability (−42.8% vs. −31.5%; p = 0.018; Cohen's d = 0.73). Higher autonomization scores were also observed in the osteopathy group (16.2 ± 2.3 vs. 13.8 ± 3.1; p = 0.005). Osteopathic care required fewer treatment sessions (9.8 ± 0.9 vs. 14.1 ± 1.2; p < 0.001), with associated reductions in direct treatment costs. Qualitative narratives highlighted distinct experiential patterns, supporting contextual mechanisms such as credential-based therapeutic authority and therapeutic scarcity dynamics.

Conclusions: This pragmatic pilot study identified preliminary between-group differences favoring the osteopathic care pathway in a highly selected population with prior treatment failure. However, non-randomized allocation, unequal treatment dose, investigator involvement in care delivery and assessment, and strong contextual influences substantially limit causal inference and generalizability. These findings should be interpreted as exploratory comparative signals rather than evidence of treatment superiority. Confirmation through rigorously designed, adequately powered randomized controlled trials with blinded assessment and extended follow-up is required. Nonetheless, the study provides valuable methodological, contextual, and conceptual insights to guide future rehabilitation research and service organization in resource-limited African settings.

Introduction

Chronic low back pain represents a substantial global health burden, with prevalence rates in sub-Saharan Africa ranging from 14% to 72%, comparable to developed nations but occurring within resource-constrained healthcare systems (1, 2). Rural populations face particular challenges due to limited access to specialized musculoskeletal care and dependence on agricultural activities that exacerbate spinal disorders (3, 4). The informal centralization of musculoskeletal care around rare practitioners has emerged as a significant phenomenon in Cameroon, particularly regarding osteopathic services (5).

Physiotherapy represents the standard of care for chronic low back pain in Cameroon's healthcare system, being the primary and often only rehabilitative option available in public facilities. This standard approach typically combines electrotherapy, manual techniques, and exercise, delivered through standardized protocols adapted to local resource constraints. Despite its widespread implementation, physiotherapy services face significant challenges related to equipment limitations, high patient-to-practitioner ratios, and variable treatment consistency. The comparison between osteopathic treatment and conventional physiotherapy therefore represents a clinically relevant assessment within the actual healthcare delivery context of rural Cameroon, examining whether an alternative manual therapy approach might offer advantages in settings where standard care often produces suboptimal outcomes.

This study examined the implementation and preliminary effectiveness of osteopathic care compared to conventional physiotherapy in rural Cameroon, while exploring the psychosocial mechanisms underlying healthcare-seeking behaviors in resource-limited settings. The investigation was conducted within the unique context of healthcare centralization around a single practitioner offering rare expertise in a public facility serving predominantly agricultural populations.

Theoretical framework: the unique practitioner syndrome

“Several of the conceptual elements mobilized in this framework (including informal care centralization and credential-based therapeutic authority) have been previously introduced and theoretically discussed in a peer-reviewed publication in Kinésithérapie, la Revue (Elsevier France), and are here extended and empirically illustrated within a new clinical context.” (5).

We propose the concept of “unique practitioner syndrome” as a phenomenon where disproportionate therapeutic attraction develops around a professional exercising rare competencies in contexts characterized by structural absence of local alternatives (5, 6). This syndrome encompasses several interconnected mechanisms that influence patient behavior and treatment outcomes. The syndrome represents more than simple practitioner preference, constituting a complex interaction between perceived expertise, cultural factors, and healthcare accessibility that fundamentally alters the therapeutic landscape.

The emergence of unique practitioner syndrome reflects broader challenges in healthcare delivery within resource-limited environments where individual expertise can create functional healthcare hubs independent of institutional infrastructure. Understanding these mechanisms becomes crucial for healthcare policy development and professional training in settings where specialized care remains scarce (7, 8).

Novel theoretical constructs

Building upon established concepts in medical anthropology and health services research, this study proposes four interconnected theoretical constructs that emerged from the observed phenomena:

1. Credential-Based Therapeutic Authority represents the cognitive and affective overvaluation of practitioners with specific training credentials, particularly those obtained from internationally recognized institutions (9, 10). This mechanism extends beyond simple placebo effects to encompass complex cultural dynamics where educational pedigree functions as a primary determinant of therapeutic legitimacy. In our study, participants frequently referenced the “French diploma” as a source of confidence and treatment expectation (operationally defined through patient narratives citing training origin as motivation for treatment-seeking).

2. Therapeutic Scarcity Dynamics describes how limited availability of specialized healthcare creates concentrated patient migration patterns and intensified healing expectations around rare practitioners (11, 12). This phenomenon is operationally defined through geographical catchment analysis and patient-reported travel distances, with documentation of cases traveling over 200 kilometers specifically to access osteopathic care unavailable elsewhere. This construct combines elements of therapeutic polarization and directional migration observed in our sample.

3. Treatment Experience Saturation characterizes the development of categorical therapeutic resistance following multiple unsuccessful treatment experiences with a specific modality (13, 14). This mechanism was empirically documented through structured interviews revealing that 95.7% of participants had experienced prior physiotherapy failures, generating treatment-specific pessimism that required alternative approaches to overcome. Operational measurement included quantification of previous treatment episodes and standardized assessment of modality-specific treatment expectations.

Practitioner-Centered Therapeutic Orientation encompasses the shift from technique-focused to provider-focused healing expectations, where therapeutic confidence becomes embodied in the person of the practitioner rather than specific procedures (7, 8, 15). This construct was operationally defined through content analysis of patient narratives, with quantification of practitioner-referencing vs. procedure-referencing terminology in treatment descriptions. These constructs, while preliminary and requiring further validation, offer a conceptual framework for understanding the complex social, psychological, and cultural factors that influence therapeutic effectiveness in resource-limited settings with uneven distribution of specialized care.

These theoretical constructs become particularly relevant within the African healthcare landscape, where chronic low back pain affects substantial populations with prevalence rates comparable to developed nations but within markedly different healthcare delivery contexts (15). The scoping review by Karhade et al. demonstrates that despite the significant burden of chronic low back pain across sub-Saharan Africa, evidence-based treatment approaches remain limited, creating gaps that may be filled by alternative therapeutic modalities and practitioner-centered care models (15).

Furthermore, management standards for low back pain at primary care level in African settings often fall short of international guidelines, as documented by Major-Helsloot et al. in South Africa, highlighting systemic deficiencies that may amplify the importance of individual practitioner expertise and patient-provider relationships in achieving therapeutic outcomes (16). This context of limited institutional capacity and variable care quality creates conditions where the unique practitioner syndrome and associated mechanisms may have heightened influence on treatment effectiveness and patient satisfaction.

Study context and rationale

The Bafoussam Regional Hospital represents the only public facility in West Cameroon offering osteopathic services, delivered by a Sorbonne University-trained practitioner who also maintains academic affiliations with multiple African institutions (5). This creates a natural experimental context for examining comparative effectiveness while exploring broader implications of healthcare centralization around rare expertise in resource-limited settings.

This pilot study aimed to: (1) generate preliminary hypotheses regarding potential comparative effectiveness of osteopathic care vs. conventional physiotherapy in rural Cameroon; (2) explore novel theoretical frameworks for understanding healthcare-seeking behaviors in resource-limited settings; (3) develop and test culturally adapted assessment instruments; and (4) inform the methodological design of future confirmatory randomized controlled trials. The primary purpose was hypothesis generation rather than definitive effectiveness demonstration.

Methods

Study design and setting

This pilot exploratory study was conducted at the Department of Physical Medicine and Medical Osteopathy, Bafoussam Regional Hospital, Cameroon, spanning from January 2023 to December 2024. The study received institutional ethical approval (N°43/DRSO/HRB/55/2023) and adhered strictly to Helsinki Declaration principles regarding human research ethics (17). All participants provided informed consent, delivered in French and local Bamiléké language according to individual preferences.

The study was explicitly designed as exploratory and hypothesis-generating rather than confirmatory. Primary aims included: (1) identifying preliminary effectiveness signals to inform sample size calculations for future randomized trials; (2) testing the feasibility and cultural acceptability of novel assessment instruments; (3) exploring theoretical mechanisms underlying healthcare-seeking behaviors in resource-limited settings; and (4) documenting methodological challenges requiring resolution in future research.

No confirmatory hypotheses were established a priori, consistent with the exploratory nature of this pilot investigation. The pragmatic design reflects real-world healthcare delivery patterns in resource-limited settings, providing externally valid insights that must be complemented by future randomized controlled trials before establishing clinical recommendations.

Participants and eligibility

Inclusion criteria comprised patients aged 18–65 years presenting with common low back pain evolving for more than six months, initial Visual Analog Scale scores ≥4/10, first consultation at the service during the study period, and complete medical documentation. Exclusion criteria included lumbar sciatica with radicular symptoms, specific pathologies such as infection, tumor, or fracture, pregnancy, previous spinal surgery, and incomplete medical records (18, 19) (see Figure 1).

Figure 1

Figure 1. CONSORT-adapted flow diagram for pilot comparison of osteopathic treatment vs. physiotherapy in rural Cameroon. Patients were allocated based on consultation day scheduling (Monday/Wednesday: osteopathy; Tuesday/Thursday/Friday: physiotherapy), reflecting the pragmatic design of this exploratory study.

The study population reflected the regional demographic characteristics, with predominant representation of women engaged in agricultural activities and domestic responsibilities that impose significant biomechanical stress on the lumbar spine (20, 21). This population represents a clinically important group often underrepresented in international musculoskeletal research despite bearing a disproportionate burden of chronic pain conditions.

Intervention allocation and treatment protocols

Patient allocation followed pragmatic care conditions based on consultation day scheduling, reflecting real-world healthcare delivery constraints. Patients consulting on Mondays and Wednesdays received osteopathic treatment (n = 19), while those attending on Tuesdays, Thursdays, and Fridays received physiotherapy (n = 28). This allocation method was non-randomized and introduces potential selection bias, precluding causal inference regarding intervention-specific effects (22, 23).

Standardized osteopathic protocol

The osteopathic intervention consisted of ten sessions delivered over five weeks, with two sessions per week lasting 45 min each. The protocol was structured in three distinct phases designed to address different aspects of musculoskeletal dysfunction and patient autonomization.

Sessions 1–2 focused on comprehensive assessment and structural normalization. Treatment included global mobility testing using Schober measurements and lateral flexion assessment, systematic palpation of somatic dysfunctions from L1 to S1 vertebral levels, application of high-velocity thrust techniques when clinically indicated and not contraindicated, posteroanterior joint mobilizations targeting specific movement restrictions, and myofascial release techniques addressing psoas and quadratus lumborum tension patterns.

Sessions 3–6 emphasized correction of lesional chains and regional interdependencies. These sessions incorporated evaluation of ascending and descending kinetic chains, diaphragmatic normalization techniques to address respiratory-postural interactions, application of Still's costal techniques targeting T11-T12-L1 transitional zones, thoracolumbar fascial release to improve tissue mobility, and correction of iliac bone rotational and flexional dysfunctions.

Sessions 7–10 concentrated on stabilization and therapeutic autonomization. Final sessions included progressive strengthening of deep spinal stabilizer muscles, agricultural activity-specific postural correction education, comprehensive gestural education focusing on load carrying and hoeing techniques commonly used in local farming practices, and validation of acquired autonomy through practical demonstration and competency assessment.

Standardized physiotherapy protocol

The physiotherapy intervention comprised fifteen sessions delivered over five weeks, with three sessions per week lasting 30 min each. The protocol followed conventional evidence-based approaches adapted to local resource availability and patient characteristics.

Phase 1 (sessions 1–5) emphasized analgesic intervention and passive mobilization. Treatment included transcutaneous electrical nerve stimulation (TENS) application for 20 min at frequencies of 80–100 Hz, thermotherapy using infrared radiation for 15 min to promote tissue relaxation, progressive passive lumbar flexion-extension mobilizations, assisted lateral flexion exercises, controlled rotational movements, and decontracting massage techniques lasting 15 min per session.

Phase 2 (sessions 6–10) focused on active strengthening and movement re-education. This phase incorporated specific muscle strengthening exercises including static core stability training with progressive difficulty, gluteal bridge exercises performed in sets of three with fifteen repetitions, alternating quadruped exercises to enhance spinal stability, comprehensive stretching protocols targeting psoas-iliac, hamstring, and piriformis muscle groups with each stretch held for thirty seconds and repeated twice.

Phase 3 (sessions 11–15) emphasized functional re-athletization and work-specific preparation. Final sessions included agricultural functional exercises such as hoeing simulation to prepare patients for return to farming activities, progressive load carrying exercises starting with 5 kg and advancing to 15 kg based on individual tolerance, ground object collection exercises to improve functional bending capacity, and specialized gestural education focusing on biomechanically sound movement patterns for common agricultural tasks.

Patient testimonials and qualitative insights

Patient narratives provided rich phenomenological evidence illuminating the perceptual differences between the two therapeutic modalities and the underlying mechanisms shaping therapeutic preference patterns. These qualitative insights, obtained through semi-structured feedback at treatment completion, revealed distinct experiential trajectories consistent with the quantitative outcomes.

Osteopathy group: immediate structural relief and embodied awareness

Patients receiving osteopathic care consistently reported immediate sensations of release and structural correction, often accompanied by vivid metaphors and emotional relief:

“When the doctor pressed on my back, I felt something click back into place. It made a cracking sound and immediately the pain calmed down. It was like unlocking a door that had been stuck for months.”

—Mrs. Fotso Thérèse, 52 years old, farmer (traveled five hours from Yaoundé)

“During the treatment, I felt something releasing in my back—as if someone was unlocking a door that had been closed. Now I can bend to weed without suffering.”

—Mrs. Nguepi Marie, 47 years old

“At first I was afraid when it cracked, but afterward I felt light. The doctor explained that it was normal. Now I understand my body better.”

—Mr. Kamga Paul, 54 years old

One patient explicitly questioned the absence of the characteristic audible release, reflecting emerging therapeutic literacy and reassurance needs:

“Why didn’t it crack today like last time? Does the treatment still work?”

—Mrs. Takou Brigitte, 43 years old

These testimonies illustrate three key mechanisms:

1. Embodied therapeutic confidence, where perceived bodily change reinforces trust;

2. Immediate feedback loops, associating audible cues with effectiveness;

3. Patient education, crucial to decouple perceived success from sensory markers (e.g., cavitation sounds).

Together, they underscore the experiential immediacy and cognitive clarity induced by osteopathic interventions, fostering adherence through perceptual congruence between intervention and expectation.

Physiotherapy group: gradual improvement and practical constraints

In contrast, patients in the physiotherapy group described a progressive and effort-dependent recovery process, characterized by delayed gratification and logistical challenges:

“The exercises are difficult at first, but gradually I feel my muscles getting stronger. The massage helps too, but I have to come often.”

—Mrs. Nkengue Claudine, 48 years old

“The machines that heat feel good, but you have to come frequently. Sometimes I don't have time because of field work.”

—Mrs. Djouaka Rosine, 51 years old

“The stretches the physiotherapist showed me, I do them at home. They help a little, but the pain returns when I work hard.”

—Mr. Fomekong Jean, 46 years old

“Today you didn't use the red light that heats? I like that — it relaxes my muscles. The TENS also relieves me during the session.”

—Mrs. Tchuente Antoinette, 49 years old

These narratives reveal four characteristic patterns:

• A recognition of progressive benefit tied to consistency and repetition;

• Dependence on external modalities (heat, electrotherapy) for symptomatic relief;

• Structural barriers to adherence (distance, agricultural workload);

• A preference for passive interventions perceived as more immediately comforting.

Interpretative synthesis

Across groups, the qualitative data highlight a fundamental divergence in therapeutic temporality:

• Osteopathy evokes instantaneous relief and embodied transformation, satisfying expectations for rapid, visible change;

• Physiotherapy cultivates gradual functional strengthening, demanding sustained engagement.

These perceptual and experiential distinctions provide critical insight into why patients in resource-limited rural contexts may migrate toward rare practitioners offering immediate relief, reinforcing the conceptual framework of the “Unique Practitioner Syndrome.”

Methodological considerations and limitations

Several methodological limitations must be acknowledged, as they fundamentally constrain the interpretation of this pilot study's findings. First, patient allocation based on consultation days, although pragmatically imposed by institutional constraints, resulted in a non-randomized design that introduces potential selection bias and precludes causal inference regarding intervention-specific effects. Second, the principal investigator (INM) simultaneously delivered the osteopathic intervention and conducted outcome assessments, creating an inherent investigator-related measurement and expectancy bias, particularly for subjective outcomes. Although standardized assessment procedures were used, patient-reported outcomes (VAS and EIFEL) were self-completed prior to clinical examination, and a second evaluator (ANM) participated in functional assessments (TAS and AFT), this dual therapist–assessor role remains a major methodological limitation that cannot be fully mitigated within the present design as detailed in Box 1. Third, the highly specific study population, characterized by a very high proportion of patients with prior physiotherapy failure (95.7%), limits external validity and reduces generalizability to broader chronic low back pain populations in rural Africa. Finally, the unequal treatment dose, frequency, and duration between groups, along with the absence of long-term follow-up and the relatively small sample size, further restrict comparative interpretation. Taken together, these limitations position this study as exploratory and hypothesis-generating rather than confirmatory of comparative effectiveness. The observed between-group differences should therefore be interpreted as preliminary signals requiring validation through adequately powered randomized controlled trials with independent blinded assessment.

Box 1

Box 1. Conceptual framework: novel assessment instruments.

Statistical analysis

Statistical analyses were performed using SPSS version 26.0. Quantitative variables were expressed as means with standard deviations, and qualitative variables as frequencies and percentages. Between-group comparisons were conducted using Student's t-test for continuous variables and Chi-square tests for categorical variables, in order to describe observed differences between care pathways. Effect sizes were calculated using Cohen's method to quantify the magnitude of between-group differences. The statistical significance threshold was set at p < 0.05 for all analyses (24, 25).

Given the exploratory nature of this study, the non-randomized pragmatic allocation, and the pilot objectives, no formal a priori sample size calculation was performed. The analyses were intended to generate preliminary comparative signals and to inform the design and sample size estimation of future randomized controlled trials rather than to support confirmatory causal inference (26).

Results

The following results represent preliminary findings from this pilot exploratory study conducted under real-world clinical conditions with inherent methodological limitations. While statistically significant differences were observed between treatment groups, these findings should be interpreted as hypothesis-generating signals requiring confirmation through properly designed randomized controlled trials rather than definitive evidence of comparative effectiveness.

Baseline demographics and clinical characteristics

Forty-seven patients completed the full treatment protocol and were included in the final analysis, comprising 19 patients in the osteopathy group and 28 in the physiotherapy group. Baseline characteristics indicated good comparability between groups without statistically significant differences (Table 1). The mean age across both groups was 44.8 ± 12.3 years, with a marked female predominance of 78.7% reflecting the demographic characteristics of the regional agricultural population. The average duration of low back pain symptoms was 28.4 ± 15.8 months, indicating a predominantly chronic patient population consistent with the study inclusion criteria.

Table 1

Table 1. Baseline demographic and clinical characteristics.

The occupational profile revealed that 85.1% of participants were engaged in agricultural activities or homemaker roles, reflecting the rural nature of the study population and their exposure to repetitive biomechanical stress patterns. Remarkably, 95.7% of all participants had experienced prior physiotherapy treatment failures, indicating that this population represented therapeutic challenges requiring alternative intervention approaches.

Clinical effectiveness outcomes

This pilot study generated preliminary signals suggesting potential differences between treatment groups across primary and secondary outcome measures, though causal interpretation remains limited by methodological constraints (Table 2). Pain reduction, as measured by Visual Analog Scale improvement, reached −47.3% in the osteopathy group compared to −32.1% in the physiotherapy group (p = 0.008, Cohen's d = 0.85). However, this observed difference may reflect methodological factors including non-randomized allocation and investigator involvement rather than true treatment reflect a distinct care approach. Functional improvement, assessed using the Eifel Disability Index, showed −42.8% improvement with osteopathy vs. −31.5% with physiotherapy (p = 0.018, Cohen's d = 0.73). These differences, while statistically significant, require confirmation through properly controlled studies before establishing clinical effectiveness.

Table 2

Table 2. Comparative clinical outcomes at treatment completion.

To contextualize these effect sizes, it is important to note that for chronic low back pain, Cohen's d values above 0.5 generally represent clinically meaningful changes, with values above 0.8 considered substantial. The observed effect sizes (0.73–0.85) exceed the established minimal clinically important differences for both VAS (1.5 points) and EIFEL (4 points) in chronic low back pain populations. However, we must emphasize that these effect sizes likely represent an upper bound estimate due to the identified methodological limitations, particularly the non-blinded assessment and non-randomized allocation. The preliminary nature of these findings requires confirmation through methodologically rigorous randomized controlled trials before establishing definitive clinical effectiveness.

The Therapeutic Autonomization Score showed particularly striking differences, with osteopathy patients achieving 16.2 ± 2.3 points compared to 13.8 ± 3.1 points for physiotherapy patients (p = 0.005, Cohen's d = 0.87). This preliminary finding suggests potential benefits of osteopathic treatment for patient empowerment, though replication in randomized trials is necessary to establish true effectiveness. This outcome may be crucial in resource-limited healthcare settings where ongoing professional support may be limited.

The evolution of pain intensity give numerically larger changes trajectories between treatment groups, as illustrated in Figure 2. The osteopathic intervention produced a steeper decline in pain scores from baseline (7.6 ± 1.1) to treatment completion (4.0 ± 1.4), representing a 47.3% improvement. In contrast, the physiotherapy group showed a more gradual decline from 7.2 ± 1.3 to 4.9 ± 1.6, representing a 32.1% improvement. The between-group difference reached statistical significance by week 4 and remained significant through treatment completion (p = 0.008). However, the unique practitioner syndrome and allocation bias may have contributed to these observed patterns.

Figure 2

Figure 2. Comparative evolution of pain intensity according to therapeutic approach (osteopathy vs. physiotherapy). Comparative evolution of pain intensity over the 5-week treatment period. The graph shows Visual Analog Scale (VAS) scores (0–10, where 0 = no pain and 10 = maximum imaginable pain) for both treatment groups. The osteopathy group (blue line, n = 19) bring steeper pain reduction from baseline (7.6 ± 1.1) to treatment completion (4.0 ± 1.4), representing 47.3% improvement. The physiotherapy group (orange line, n = 28) showed more gradual improvement from 7.2 ± 1.3 to 4.9 ± 1.6, representing 32.1% improvement. Shaded areas represent 95% confidence intervals. Statistical significance was reached by week 4 and maintained through treatment completion (p = 0.008), though methodological limitations preclude causal interpretation. W, Week.

Patient satisfaction scores were significantly higher in the osteopathy group (8.4 ± 1.2 vs. 7.3 ± 1.4, p = 0.007), reflecting not only the observed clinical changes but also potentially enhanced treatment experience and patient engagement related to the unique practitioner syndrome. The number of treatment sessions required was significantly lower for osteopathy (9.8 ± 0.9 vs. 14.1 ± 1.2, p < 0.001), representing potentially important resource optimization implications for healthcare systems with limited capacity, though this efficiency advantage requires validation in properly controlled studies.

Economic analysis and resource utilization

In this pilot study, descriptive economic observations indicated differences in direct treatment costs and patterns of resource utilization between the two care pathways within this specific clinical setting. Average direct treatment costs were lower in the osteopathic care group (47,500 FCFA; $77 USD) compared with the physiotherapy group (62,800 FCFA; $101 USD), corresponding to a 24.4% difference in direct expenditure. These figures reflect observed service delivery characteristics rather than formal economic evaluation outcomes.

Similarly, descriptive cost-per-outcome ratios based on EIFEL score changes were calculated for exploratory purposes only and should not be interpreted as evidence of cost-effectiveness. Given the non-randomized design, investigator involvement, and simplified economic assumptions, these observations are presented solely to illustrate potential patterns of resource use within a highly specific context and do not support comparative economic conclusions.

Beyond direct costs, the reduced session number requirement for osteopathy generated significant indirect economic benefits for this rural population. Each hospital visit involves substantial transportation costs and lost agricultural productivity, with the average patient in this study traveling 2–4 h each way for treatment. The 4.3-session reduction achieved with osteopathy translated to approximately 32,400 FCFA ($52 USD) savings in lost agricultural productivity per patient, based on regional daily income estimates of 6,000 FCFA ($10 USD).

Manifestations of the unique practitioner syndrome

The study population exhibited clear features consistent with the unique practitioner syndrome, with 95.7% of participants reporting prior physiotherapy failure before seeking osteopathic care. This therapeutic saturation may have shaped patient expectations and receptivity to alternative care pathways, influencing subjective perceptions of change and engagement through psychosocial mechanisms such as renewed hope and therapeutic optimism.

Patient narratives highlighted distinct experiential patterns associated with each treatment modality. Osteopathic care was frequently described as producing immediate sensations of structural change or bodily realignment, whereas physiotherapy was more often perceived as promoting gradual strengthening and progressive improvement requiring sustained engagement over time. These contrasting experiential trajectories reflect differences in patient perception and meaning-making rather than demonstrable differences in clinical effectiveness.

The manifestations of the unique practitioner syndrome are illustrated through the theoretical model presented in Figure 3. This hierarchical framework demonstrates how patient confidence progressively increases from protocol-based care through qualified professionals, recognized specialists, and unique practitioners, culminating in embodied therapeutic confidence. The model integrates six interconnected mechanisms that collectively explain the observed therapeutic dynamics: the France-diploma effect providing cultural legitimacy, therapeutic rarity polarization concentrating healing expectations, directional therapeutic migration organizing geographical displacement, therapeutic nominalism creating semantic coherence, kinesiotherapeutic saturation generating treatment resistance, and informal centripetal therapy facilitating spontaneous convergence toward perceived expertise.

Figure 3

Figure 3. Theoretical model of unique practitioner syndrome—hierarchical therapeutic confidence framework. Conceptual framework illustrating the hierarchical progression of therapeutic confidence from standardized protocols to embodied confidence around unique practitioners. The pyramid demonstrates five levels of increasing patient confidence: standardized protocol (base), qualified professional, recognized specialist, unique practitioner, and embodied confidence (apex). Six interconnected mechanisms contribute to this phenomenon: France-diploma effect (cultural overvaluation of European training), therapeutic rarity polarization (concentration of healing expectations), directional migration (organized geographical displacement toward expertise), therapeutic nominalism (linguistic association of practitioner title with therapeutic action), kinesiotherapeutic saturation (resistance following multiple treatment failures), and centripetal therapy (spontaneous convergence toward perceived expertise). Colored arrows indicate the influence of each mechanism on the confidence hierarchy.

The France-diploma effect was evident in patient preferences and expectations, with many specifically referencing the practitioner's European training as a source of confidence in treatment outcomes. This effect extended beyond simple credential recognition to encompass complex cultural attitudes toward educational hierarchy and perceived expertise quality that significantly influenced therapeutic relationships and patient engagement.

Safety profile and adverse events

Both treatment modalities demonstrated acceptable safety profiles with minimal adverse events. The osteopathy group experienced no adverse events throughout the treatment period. In the physiotherapy group, two patients (7.1%) developed minor superficial burns following prolonged infrared thermotherapy application, which resolved completely within 48–72 h after parameter adjustment and enhanced monitoring protocols.

These minor adverse events highlight the importance of careful technique application and patient monitoring, particularly when using physical modalities in populations that may have different skin sensitivity characteristics or limited experience with technological therapeutic interventions (27, 28).

Discussion

Novel theoretical contributions to healthcare delivery research

This pilot study generated preliminary signals suggesting potential differences between treatment groups across primary and secondary outcome measures, though causal interpretation remains limited by methodological constraints. The unique practitioner syndrome represents more than individual practitioner preference, constituting a complex sociocultural phenomenon that can fundamentally alter healthcare delivery patterns and treatment outcomes in specific contexts.

The France-diploma effect exemplifies how post-colonial educational hierarchies continue to influence healthcare perceptions and patient behavior in African settings. This effect operates through multiple mechanisms including enhanced credibility attribution, increased treatment expectation, and strengthened therapeutic alliance formation that collectively contribute to improved clinical outcomes beyond specific technical interventions (29, 30).

Therapeutic rarity polarization describes a phenomenon where scarcity of expertise creates concentrated healing expectations that may enhance treatment effectiveness through psychological mechanisms including hope restoration, increased adherence, and enhanced placebo responses. This polarization can create therapeutic environments where individual practitioners become focal points for community healing expectations, potentially amplifying intervention effectiveness (31, 32).

Community involvement and cultural adaptation

The implementation of novel therapeutic approaches in rural African settings necessitates substantial community engagement beyond individual patient interactions. Studies in similar contexts have indicated that community-based rehabilitation programs achieve significantly higher adherence and effectiveness when they incorporate local leadership structures and cultural frameworks (3, 33). In our study, several community-level mechanisms facilitated the therapeutic implementation and assessment processes.

Local community leaders were engaged as cultural mediators during the development of both intervention protocols and assessment tools. Their input was particularly valuable in identifying culturally appropriate analogies for explaining biomechanical concepts and establishing functional relevance of therapeutic exercises. This approach aligns with ecological systems theory as applied to rural health interventions, which emphasizes the need for multi-level engagement spanning individual, family, and community domains (3, 4).

The systematic integration of agricultural task analysis into functional assessment represents a methodological innovation that bridges clinical measurement and community-relevant outcomes (33, 34). By directly connecting therapeutic success to economically meaningful activities, the intervention establishes legitimacy within local value systems that prioritize agricultural productivity and self-sufficiency. This approach addresses the cultural gap frequently observed in Western-developed therapeutic programs implemented in rural African contexts without appropriate contextual adaptation (1, 2).

Community participation additionally facilitated the emergence of informal knowledge dissemination networks, where patients voluntarily shared therapeutic exercises and ergonomic principles with family and community members (12, 13). This organic diffusion pattern suggests potential for amplifying therapeutic impact beyond direct intervention recipients and warrants further investigation through community-based participatory research methodologies (7, 8).

Clinical effectiveness within the context of treatment failure

The highlight a specific model of care outcomes observed with osteopathic treatment must be interpreted within the specific context of this study population, where 95.7% of participants had experienced prior physiotherapy failures. This population represents therapeutic challenges requiring alternative approaches, and the effectiveness differences observed may partially reflect the appropriateness of osteopathic interventions for treatment-resistant chronic pain conditions (35, 36).

The effect sizes observed in this study (Cohen's d = 0.60–0.91) exceed those typically reported in osteopathic systematic reviews (d = 0.43–0.59), likely reflecting the combination of treatment-resistant population characteristics, cultural factors enhancing treatment acceptance, and the unique practitioner syndrome effects that created optimal conditions for therapeutic response (37, 38).

The reduced session requirement for osteopathy (9.8 vs. 14.1 sessions) provides crucial resource optimization benefits for rural populations where healthcare access involves significant time and financial investments. This efficiency advantage becomes particularly important in African healthcare contexts where treatment adherence may be limited by practical constraints rather than clinical factors (39, 40).

Integration with international evidence base

Our findings align with recent systematic reviews demonstrating modest but significant effects of osteopathic interventions for chronic low back pain while extending this evidence base to African populations previously underrepresented in international research (41, 42). The study contributes unique insights into cultural adaptation of manual therapy approaches and the influence of practitioner characteristics on treatment effectiveness in diverse populations.

The therapeutic autonomization approach indicated in this study addresses a critical gap in international guidelines, which emphasize patient education and self-management but often lack specific strategies for implementation in resource-limited settings. The development and validation of culturally adapted autonomization assessment tools represents an important methodological contribution for future research in similar populations (43, 44).

Methodological innovations and cultural adaptation

This study introduces several methodological innovations specifically designed for African healthcare research contexts. The Therapeutic Autonomization Score represents the first validated instrument for measuring patient empowerment in sub-Saharan African populations, incorporating cultural values and practical considerations relevant to agricultural communities (45, 46).

The Agricultural Functional Test provides a culturally appropriate assessment method that evaluates functional capacity within the specific context of subsistence farming activities common to rural African populations. This adaptation addresses limitations of Western-developed assessment tools that may not accurately reflect functional demands and capabilities relevant to different cultural contexts (47, 48).

Economic implications for healthcare policy

Economic considerations observed in this pilot study extend beyond direct treatment costs and must be interpreted within the specific organizational and contextual characteristics of rural healthcare delivery. Within this pragmatic setting, the osteopathic care pathway was associated with lower direct treatment costs and reduced session requirements compared with physiotherapy, resulting in a 24.4% difference in direct expenditure. These observations should not be interpreted as evidence of cost-effectiveness but rather as descriptive signals reflecting differential resource utilization within a highly specific service configuration (49, 50).

Beyond financial aspects, these findings resonate with the emerging framework of proprioceptive neurorehabilitation conceptualized by Moumeni (51), which emphasizes the role of sensory–motor integration, learning density, and patient engagement in shaping functional recovery. From this perspective, therapeutic value in low-resource environments may derive not solely from economic optimization but from the capacity of an intervention to concentrate meaningful sensorimotor stimuli within limited care opportunities, potentially enhancing functional learning and patient autonomy.

In resource-constrained African healthcare systems facing competing public health priorities, such patterns of care utilization may have implications for service organization and accessibility. However, any inference regarding system-level efficiency or policy relevance remains premature. The observed economic differences should be viewed as context-dependent observations requiring confirmation through rigorously designed economic evaluations embedded within randomized controlled trials before informing healthcare policy or service integration decisions.

Study limitations and methodological considerations

This pilot study presents several critical limitations that fundamentally constrain causal interpretation and generalizability of findings. These limitations must be explicitly acknowledged to prevent overinterpretation of results and to guide appropriate design of future confirmatory studies.

Critical methodological limitations

Non-randomized allocation bias: The systematic allocation by consultation day, while pragmatic, creates substantial risk of unknown confounding variables that may explain observed differences independently of treatment effects. This quasi-experimental design precludes causal inference regarding comparative effectiveness and limits the study's evidentiary value to hypothesis generation rather than effectiveness demonstration.

Investigator bias and conflict of interest: The principal investigator's dual role as both the osteopathic practitioner and primary outcome assessor represents a fundamental methodological flaw that likely inflated effect sizes in favor of osteopathic treatment. Despite standardized assessment procedures, the absence of blinded evaluation creates systematic bias that cannot be statistically controlled or adequately addressed post-hoc.

Highly selective population characteristics: The 95.7% rate of prior physiotherapy failures creates a uniquely treatment-resistant population that may not represent typical chronic low back pain patients in rural Africa. This selection bias severely limits external validity and prevents generalization to broader patient populations, healthcare settings, or clinical contexts.

Unique practitioner syndrome confounding: The specific combination of European training, institutional affiliation, and individual practitioner characteristics creates conditions that cannot be replicated in most healthcare settings. The observed effectiveness may reflect practitioner-specific factors rather than osteopathic intervention effects, fundamentally limiting reproducibility and scalability of findings.

Temporal and follow-up limitations: The five-week assessment period prevents evaluation of treatment durability, long-term safety, or sustained clinical benefits. Chronic pain management requires extended outcome assessment to establish clinically meaningful and sustainable improvements.

Sample size and statistical power: The small sample size (n = 47) precluded multivariate analysis, subgroup identification, or adequate control for potential confounding variables. post-hoc power calculations indicate insufficient statistical power for definitive comparative effectiveness conclusions.

Measurement bias potential: Despite standardized instruments, the novel cultural adaptation tools (TAS, AFT) lack extensive validation in diverse African populations, potentially introducing measurement error that could artificially enhance between-group differences.

Economic analysis limitations: The economic observations reported in this study relied on simplified assumptions regarding transportation costs and productivity losses, without comprehensive economic modeling or sensitivity analyses, which limits the robustness and interpretability of the economic findings.

Implications for evidence interpretation

These limitations collectively indicate that the observed differences, while statistically significant, cannot be interpreted as evidence of causal or comparative clinical effectiveness between the two interventions.

The promising signals observed warrant further investigation through properly designed randomized controlled trials incorporating blinded assessment, multi-site implementation, representative patient populations, extended follow-up periods, and adequate sample sizes for definitive comparative effectiveness evaluation.

Future research directions and recommendations

These preliminary findings warrant confirmation through properly designed randomized controlled trials that address the methodological limitations identified in this study. Future research should incorporate blinded outcome assessment, multi-center designs across diverse African contexts, extended follow-up periods of twelve months or longer, and adequate sample sizes for multivariate analysis and subgroup identification.

The validation of cultural adaptation tools, including the Therapeutic Autonomization Score and Agricultural Functional Test, requires confirmation in larger populations and different African contexts to establish reliability and validity across diverse cultural and linguistic groups. Additionally, economic evaluation incorporating comprehensive productivity impact assessment would provide valuable information for healthcare policy development.

Investigation of the mechanisms underlying the unique practitioner syndrome and related phenomena could inform healthcare delivery strategies and professional training programs designed to optimize therapeutic relationships and treatment effectiveness in resource-limited settings. Recent work on systematic therapeutic pessimism among healthcare professionals in Cameroon (52) suggests that practitioner attitudes significantly influence treatment expectations and outcomes, particularly in chronic conditions. This underscores the importance of addressing provider-level cognitive frameworks alongside technical competencies in future interventional research.

Furthermore, exploring the interface between biomedical and traditional healing approaches (53) could enhance understanding of how osteopathic interventions might be optimally integrated within pluralistic healthcare environments. The learned helplessness paradigm identified in chronic neurological conditions (54) provides a valuable theoretical framework for investigating similar patterns in musculoskeletal disorders and developing targeted interventions to overcome therapeutic resistance.

Future research should also consider broader health system implications, particularly regarding medical education reform and rehabilitation access (55). The transfer of clinical competencies from European training contexts to African practice settings (56) represents a crucial area for investigation, potentially identifying key mechanisms for successful knowledge translation and contextual adaptation in osteopathic and rehabilitation services.

Conclusions

This hypothesis-generating pilot study achieved its primary exploratory objectives by producing preliminary signals regarding potential differences between osteopathic and physiotherapy interventions for chronic low back pain in rural Cameroon. The study generated initial data suggesting possible benefits of osteopathic approaches in this specific population context, though causal interpretation remains fundamentally constrained by critical methodological limitations including non-randomized allocation, investigator bias, and highly selective sample characteristics.

The investigation successfully developed and preliminarily tested novel theoretical frameworks for understanding healthcare dynamics in resource-limited settings, including concepts such as credential-based therapeutic authority, therapeutic scarcity dynamics, treatment experience saturation, and practitioner-centered therapeutic orientation. These mechanisms may offer conceptual tools for analyzing healthcare delivery patterns, though they require further validation through more rigorous methodology before establishing their generalizability.

Preliminary economic observations suggest potential considerations regarding patterns of resource utilization within this specific care context, while the culturally adapted assessment tools indicated initial feasibility and acceptability, representing methodological contributions that require further psychometric validation.

However, the interpretability of these findings is substantially limited by the methodological constraints of this pilot investigation. The non-randomized design, dual-role investigator function, and specific population characteristics fundamentally restrict generalizability and causal inference. These limitations position the study's primary value in demonstrating feasibility and generating hypotheses rather than establishing clinical effectiveness.

Future research should address these limitations through properly designed randomized controlled trials incorporating blinded assessment, multi-site implementation, representative patient populations, extended follow-up periods, and adequate sample sizes. The preliminary signals observed provide justification for investment in such confirmatory research, which is necessary before establishing evidence-based clinical or policy recommendations (57).

The potential public health implications suggested by these exploratory findings highlight the importance of developing culturally adapted and contextually appropriate rehabilitation approaches for rural African populations, who remain substantially underrepresented in international musculoskeletal research despite bearing significant burden of chronic pain conditions (58).

Data availability statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving humans were approved by Approval Certificate Number: N°43/DRSO/HRB/55/2023. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants' legal guardians/next of kin. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

IM: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. A-NM: Investigation, Data curation, Writing – review & editing. TO: Investigation, Data curation, Writing – review & editing. FA-T: Investigation, Validation, Writing – review & editing.

Funding

The author(s) declared that financial support was received for this work and/or its publication. As the corresponding author based in Cameroon, a lower-middle-income country, I kindly request a full waiver of the article processing charge (APC) according to BMC’s Open Access Waiver Policy.

Acknowledgments

The authors thank the staff of the Department of Physical Medicine and Osteopathy, Bafoussam Regional Hospital, for their invaluable assistance in patient recruitment and data collection. The authors also acknowledge that this manuscript extends theoretical reflections previously introduced in Kinésithérapie, la Revue (51), while presenting original empirical data and conceptual reinterpretation. Supporting materials, including clinical photographs and detailed scoring sheets for the Therapeutic Autonomization Score (TAS) and Agricultural Functional Test (AFT), are available as supplementary information.

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fmscd.2025.1716794/full#supplementary-material

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