Coaching-informed osteopathic care for chronic non-specific low back pain: a reflection on pain self-efficacy and autonomous motivation.

Chronic non-specific low back pain is the leading cause of years lived with disability worldwide, and international evidence syntheses agree that the strongest determinants of outcome are not structural. Manual therapists widely endorse the biopsychosocial model yet report having no usable procedure for enacting it. This reflective essay examines that gap from the perspective of an osteopath in private practice. Reading the conventional manual therapy consultation against self-determination theory, I argue that its ordinary structure, comprising clinician-authored explanation, prescribed exercise, and palpatory language that locates expertise in the practitioner and defect in the patient, can plausibly undermine autonomy, competence and relatedness, and with them pain self-efficacy, one of the more robust prognostic factors in chronic musculoskeletal pain. I describe why I turned to the competency framework of health and wellness coaching for the procedural layer that psychologically informed practice has specified only loosely, and how autonomy support, motivational interviewing's righting reflex, and a capacity-oriented rather than deficit-oriented interview have changed my consultations. I consider the objection that this dissolves osteopathy into conversation, and suggest that the distinctive contribution of manual therapy is to arrange disconfirming experience within a session, while the conversation determines whether that experience is attributed to the patient's resilience or to the practitioner's skill. I set out four continuing uncertainties: the boundary of scope, the risk of coaching language as veneer, the cultural portability of autonomy support beyond high-income Western settings, and the absence of evidence that any of this works.