Doctor Still was a man with many skills. As a teenager growing up in Virginia in the 1830s and 40s, he was an avid and able hunter, his catch providing not only dinner for the family but also dissecting material to satisfy his growing curiosity about the body and its workings. Rural life was for the self-reliant and Still learned about farming and building early on. Later qualifying in medicine, he was enlisted as a surgeon during the American civil war.

Unsatisfied with the efforts of his student's to convey the meaning of his new science in the written word, Still became an author. Although not a sophisticated writer, Still had a way with words, and a bluff, droll turn of phrase. His observations on osteopathy and learning liberally employ hunting, agricultural, engineering and military metaphors. In his writing he was a philosopher, a humorist, an eccentric. He devotes an entire chapter of one of his works to ear wax, as he was convinced that it had hitherto unrecognised and important physiological significance – it was produced by the brain to lubricate the nerves, he supposed.

In life Still was an original, and a man with a mission. His mind focussed by the failure of chemical drugs to save his children, he aimed single-mindedly and single-handedly to establish a new and better medical system. His hatred of drugs was matched only by his firm faith in the wisdom of nature. He “unfurled the banner of osteopathy to the wind” in 1874, and founded the first school of osteopathy in Kirksville, Missouri, in 1892. Interspersed were years of itinerant practice, experimenting and developing his method and his ideas.

Still’s idea was simple, intuitive and profound. He had found out for himself as a youngster that mechanical effects could cure physical symptoms (in that case resting the back of his neck against a swing seat to ease a headache). He had marvelled at the intricate machine-like make up of the musculo-skeletal system in the animals he dissected, and observed how each part seemed designed perfectly for its role. (Structure governs function, he was later to state). He had come to the conclusion from medical experience that the body possessed an inherent healing mechanism. He reasoned that this might become compromised by mechanical derangements and that manipulation could restore the anatomy to its functional state.

But Still was an absolutist. He did not just say mechanical derangement was a possible cause of pathology, but the underlying cause of all pathology. He believed that a detailed knowledge of anatomy and “the knife of reason” were the fundamental tools needed to cure any ill.

“The osteopath must learn that his first lesson is anatomy, his last lesson is anatomy, and all his lessons are anatomy”

In Still’s world the existence and the ultimate wisdom of the Creator were fundamental. Often, he refers to the “master mechanic”. Often he invokes the wisdom of nature, and one wonders whether God and nature were not intimately intertwined in Still’s mind. Often he reasons that disease would not exist in a perfect body – perfect from a mechanical point of view that is – nature would not have been so foolish. Still, evidently, new or thought little of his contemporaries Mendel and Darwin.

Still’s world also was dominated by mechanistic thought, and a fascination with advances in technology, which was of course largely mechanical in those days – the Victorian age back in Britain. Thought processes were linear, with a desire to search for and find one clean and clear cut line between one cause and one effect, like a rod connecting a piston to a crank.

Engineering is guided by physics, in which Newtonian variety the workings of the universe were described by laws. This requirement to seek and find natural laws expanded to other fields, such was their success in physics and such was the success of physics. Thus was the need expressed again and again by Still, to regard the human machine in terms of immutable “natural laws”, and illness in terms of their not having been observed.

Still was driven to build a scientific medical system, but his idea of science was very different from our modern way of science. He used the word to countermand the empiricism of the medicine of the day, which he abhored. To the Old Doctor, “science” meant the rigorous use of rational thought. He often stated that we must reason from the given facts, by which he largely meant the anatomy before us.

But his reason depended upon something which he thought were facts, but were actually articles of faith – his osteopathic principle that the deep cause of all illness was to be found in abnormal anatomy. In fact Still’s relationship with factual reality often tended to be of the kind, I think, therefore it is (apologies to Descartes). In one paragraph, for example, he muses on the cause of “bilious fever”:

Science does not yet know the cause. What if the diaphragm blocked venous return to the thorax? Surely the liver would suffer. Since my osteopathic principles are absolute, and they must be right in all cases, the case is proved! Bilious fever is caused by a disorder of the diaphragm. (Apologies to Still).

The aetiology of all disease was expressed in one of Still’s best known aphorisms: The rule of the artery is supreme. Health depended upon the arterial blood supply as well as unimpeded venous drainage, lymph flow, nerve activity, and cerebrospinal fluid flow. If any of these were impeded by a “dislocated” bone or muscle, illness would soon follow. Still was about 100 years ahead of his time in the importance he placed on the fascia, the “hunting ground” where to find the origin of disease as well as its cure.

A brilliant anatomist, Still’s knowledge physiology was less solid, but spiced up with wild guesswork: the lymph vessels were filled by lymph directly from the cerebrospinal fluid; fever was produced by heat from nerve electricity, and served to transform wastes into gas; food was transformed into gas in order to be digested and assimilated by the body, the lungs (“the clouds of the body”) were the body’s major source of water. Very soon at Kirksville, Still installed a physiology teacher by the name of Littlejohn.

There is little record of the technique of Still, as he never described it. By the available accounts it was simple. Many treatments were effected with the patient seated or on foot, and he invented his technique on the spot according to necessity and circumstances. He made use of articulation, leverages and thrusts. He often spent much time on soft tissue work, even several sessions, before attempting bony adjustment. He states in one of his works that the osteopath is “no lightening bone setter”, yet one of his original business cards recently came to light claiming to be just that! He scorned general non-specific massage (“engine wiping”) and did not believe in the least necessary: “Find it, fix it, then leave it alone”.

What balance can we draw? On the positive side we can say that Still insisted that his medicine must be based on reason, that he recognised the importance of the somatic component of disease, that he would accept no dogma nor adhere to any orthodoxy, that he abounded in original thought, that he recognised no limits, that he was an enthusiast.

"The explorer for truth must first declare his independence of all obligations or brotherhoods of any kind whatsoever". (A.T. Still)

Against this must be set the clear fact that his reasoning was limited by the paradigms of his time: mechanistic thought, absolutism, unifactorialism, and that his vision was at times tunnelled by the sheer force of his belief.

However Dr Still's basic premise, that the body's macro-structure and it's dynamic relations are fundamental to the deep workings of physiology, was ahead of it's time and is supported by recent findings in modern science. Still recognised that his new system was in its infancy and would develop enormously in the years after his death, and so it has scientifically and technically. But despite the relative simplicity of the original idea and methods, they have provided the main contribution to many manipulators’ work, with quite remarkable success.

My favourite of his aphorisms is the one I believe expresses best the essence of the success of manipulation as a treatment. The saying is his simplest: “Movement is life”.

Many people reading this will perhaps be surprised to learn that according to scientists the evidence for much of osteopathy is weak. In fact, it has only unequivocally been proven effective for low back pain.

Let me take a step back and take a brief look at the early history of osteopathy, and the nature of modern science, before coming back to add some qualifications to the surprising sentence above. I will then take the bull by the horns and face the question of how one can justify the provision of "unproven" treatments. Finally, I will consider the scientific future of osteopathy.

Early history of osteopathy

Osteopathy developed in the latter part of the 19th. century as a reaction to the irrational, brutal and dangerous medical treatments of the time, which employed the use of strong poisons and heavy blood-letting. The practice of osteopathy, in contrast to the orthodox medicine of the time, was based on the rational application of an encompassing theory. The founder of osteopathy, Andrew Still, used the word "scientific" to describe the application of reason within in an ordered system of notions, a use of the word which today would  be regarded as erroneous. "Science" today is defined instead by the use of experiments to test whether our hypotheses (formally stated ideas) are correct.

The experimental method

Modern science uses the experimental method. This is how it works:

Firstly, a hypothesis (or precisely formulated and testable proposition about a specific thing or phenomenon) is formulated based on some phenomenon that has been repeatedly but more or less informally observed. This hypothesis is then put to the test in an experiment. Good experimental design requires careful thought to avoid fatal errors such as: (1) not testing what one thinks one is testing; (2) introducing bias into the experiment; (3) failing to control confounding variables; (4) producing meaningless (uninterpretable) results. Experimental results are often in the form of numerical data. These need to be analysed using special statistical tests to establish whether or not they deviate significantly from what one could expect by pure chance. If there is a statistically significant deviation in the direction predicted by the hypothesis, the hypothesis is confirmed. But not proven: proof is only established if the study design was good, and the results consistently repeatable by similarly well-designed experiments.

This method has been perfected in the proving of pharmaceutical drugs. In this special case, the "gold standard" of clinical research into the effectiveness of drugs is called the "randomised controlled trial" (RCT). "Controlled" refers to the fact that the improvement in a given condition that occurs in patients taking the drug is compared with a "control" group of people with the same condition who have not taken the drug. Usually this group of people is given a placebo: something that looks exactly like the real drug but is in fact pharmacologically inactive. A feature of these trials is that they are usually "double blind", which means that neither the personnel dispensing the medicine/placebo, nor the patients themselves, know who is getting the real drug and who is getting the placebo. This avoids what is called "bias" in the results due to psychological influences. The numbers of patients needed for experiments of this kind are large, typically hundreds. This is so that, firstly, your experimental sample is reasonably representative of the general population of people with the same disease, and secondly, the analysis of the results may be statistically meaningful.

Notwithstanding the success of the RCT in the study of medicinal drugs, it may not be such an appropriate method in the study of other medical systems such as osteopathy. I discuss below the two most important reasons why this may be so:

1. Classification of illness

Orthodox medicine classifies illness according to a system of "named diseases" i.e. it pigeon-holes and labels illness. In trials, drugs are tested for named diseases. But this approach is alien to osteopathy. Osteopathy does not ask, "What disease does this patient have?", but rather, "Why did this person become ill?" Osteopathy considers each case of an ill person as unique, recognising that the variation between cases is infinite. Thus whereas drug trials use samples of hundreds or thousands of patients with the "same" disease, osteopathy deals with unique samples of one! This is not to say that a trial could not be designed to test the hypothesis that osteopathy is effective, say, for "people with vertigo". But it does have important implications for the selection of suitable experimental subjects.

2. Patient selection

Responsible practitioners of any discipline would not claim to be able to cure all of the people all of the time, even those suffering from minor complaints. Many will respond well to treatment, some won't. This is as true of osteopathy as it is of drug medicine. Clinicians and drug trials have to try to select which patients are likely to benefit. Drug trials select patients for inclusion by setting strict criteria based on age and the absence of complicating conditions or factors. On the other hand, in osteopathy it is the individual osteopath who must decide whether a single patient will benefit from his or her treatment, based on the myriad circumstances which, taken together, are unique to that person. It is inevitable, and I would say to the good, that to a degree such decisions rely on experience and instinct as well as the rational consideration of distinct features such as age, general health, and gravity of illness. But the important point I wish to make about this is that in the clinical setting patients are taken on according to criteria which are not fixed and are to a degree unique to the time, the place and the people present (individual patient, individual osteopath). A conventional "trial" of osteopathic treatment "for vertigo" would have a sample of trial participants selected according to standardised criteria which in no way reflect clinical decisions. All you might prove with such a trial is the inadequacy of the experimental method employed.

3. The human dimension

There is a human dimension to real medicine which osteopathy celebrates. Patients are individuals as are osteopaths, and no two encounters are the same. The number of factors influencing the outcome of each encounter and the course of treatment are innumerable. In osteopathy, it is virtually impossible to separate out the specific effects of method and technique, from the specific effects of the individual osteopath's personality, and the non-specific effects of human contact and touch-based treatment. Until research methods have been perfected which can address this major limitation of RCTs, the interpretation of results from research into the efficacy of osteopathy will remain uncertain.

The ethics of offering "unproven" treatments

Scientists and sceptics often argue that it is unethical to offer to the paying public treatments which are unproven by science. They say scientific method is the established "gold standard" for determining "what we know". An extreme view is that no treatment should be available that does not have this mark of approval. Some even say, according to this reasoning, that osteopaths are fools or cheats to go on offering many of the kinds of treatments that they do. (Remember, it has only been "proved" effective for low back pain).

Here are some counter arguments:

1. Evidence-shackled or evidence-guided practice?

One interpretation of evidence-based medicine (EBM) that is doing the rounds is that nothing unproven should be offered as treatment. To me this is evidence-shackled medicine. Absence of proof is not proof of ineffectiveness. There are several reasons why the extreme interpretation above is flawed. My own sense is that a more enlightened interpretation, or evidence-guided medicine, would mean:

• Treatments proven unequivocally to fail would be abandoned.


• Treatments proven to pose an unacceptable risk of adverse effects would be abandoned.

However, in my mind it would be insane to abandon treatments believed to be effective by patients and practitioners simply because scientific proof of efficacy is currently lacking.

2. The hierarchy of evidence

It is considered that there is a hierarchy of evidence with the best being that from good quality scientific experiments (specifically randomised controlled trials) and the worst being word-of-mouth (anecdote). Between these extremes there come such forms of evidence as:

• Lesser quality scientific studies such as "pilot studies" (preliminary studies using small numbers of patients) and uncontrolled experiments (where there is no control group to compare the treatment group with).


• Case studies (formal studies of single cases) and case series (a series of case studies of patients with the "same" condition).


• Supporting evidence of plausibility from closely related fields e.g. physiology.


• Expert consensus.


• Individual experience.

There is a valid argument for allowing reference to evidence that is lower in the hierarchy if better quality evidence is unavailable or inconclusive. Even personal anecdote (the least reliable form of evidence, when taken singly) becomes worthy of consideration if overwhelming. Compelling anecdotal evidence of benefit is one reason why it was deemed political to formally recognise and regulate osteopathy by the 1993 act of parliament.

There is also an argument for accepting different levels of evidence according to the real possibility of carrying out the kinds of studies involved. To obtain unequivocal evidence from repeated, good quality RCTs is very expensive. Osteopathic organisations do not have the resources of the pharmaceutical industry. Of necessity, studies will be smaller and progress slower. (It is interesting to note that even with the vast resources at the disposal of the pharmas, RCTs of non-steroidal anti-inflammatory drugs - often with methodological flaws - only prove a "small" effect for low back pain: Pepijn D. D. M. et al. Nonsteroidal Anti-Inflammatory Drugs for Low Back Pain: An Updated Cochrane Review. Published 08/13/2008 on Medscape - accessed 08/10/2009).

Osteopathy at present is at the intermediate stage in terms of the quality of evidence gathered: what we have mostly is anecdote, experience, supporting evidence of plausibility and evidence from small scale pilot studies.

3. The devaluation of experience

It seems to me that one of the things that patients value most highly in a practitioner is experience. Paradoxically, the knowledge that comes by experience is one of the least valued by science, only a notch above anecdote. It is almost scorned.

The answer to this apparent paradox is that the meeting been health professional and patient does not take place either in the laboratory or in the ivory tower of "pure" science, but "at the coal face" and in the here and now. Science has not explained everything about the workings of the body and the mind. This means that inevitably there will be many decisions at every therapeutic encounter that are guided by experience, either in part or in whole. If such decisions were expunged from medicine, as some propose, medicine's fabric would be very thin indeed.

4. Dogma is the enemy of truth

It is a fair criticism of osteopathy that historically it has relied on dogma more than scientific enquiry. Science is a threat to dogma, and many a beautiful theory has been shattered by a brutal fact. We should abandon dogma and forever seek the truth. On the other hand there exists a current in the scientific establishment that expounds another kind of dogma, which says: "Nothing that science does not know has any validity", and: "There is nothing worth knowing that science cannot know". It seems to me that this position is just as unbalanced as the one which ignores or denies an inconvenient scientific fact in favour of a beloved theory. There is though, between these attitudes, a place where sense reigns, a green vale spread out between the rocky peaks of radical scepticism and the mire of dogged belief.

5. It is evidence-shackled medicine that is abnormal

Clinical psychology, dentistry, physiotherapy, and surgery are some of the orthodox health professions that mix experience with science. This is normal and healthy in what are considered respectable professions. While it is inevitable and appropriate that all health professions will move to expand and be guided by a scientific evidence base, it would be damaging and wrong to limit current practice to methods which have already been scientifically proven, as proposed by a vocal minority of scientists and doctors.

The medical reality is that, depending on the branch of medicine and on the limitations of the studies undertaken, between 30% and 89% of current orthodox medical practice is not based on gold-standard scientific evidence, and between 3% and 58% is not supported by any scientific evidence at all. (Andrew Booth, http://www.shef.ac.uk/scharr/ir/percent.html - accessed 05/08/2009).

6. Dangers to patients

The following argument has sometimes been used against osteopathy: that by treating people with osteopathy we are putting patients' health at risk by delaying "proper" treatment.

To this I would simply point out that while iatrogenic illness (illness caused by doctors, hospitals and medicines) is known to be a large percentage of all illness, the indications are that serious adverse effects from osteopathic treatment are extremely rare.

7. The provision of an alternative

There has been a tendency of late to regard osteopathy as complementary medicine. It goes without saying that there are conditions which, by way of severity or urgency, require medical treatment or surgery. There are other situations however in which osteopaths would affirm that osteopathy is the best treatment. So, if one takes complementary to mean "each in its own place" in the spectrum of illness, I would agree. There are other kinds of conditions in which both pharmaceutical drugs and osteopathy, or both surgery and osteopathy, may usefully combine to the benefit of the patient. Again, complementary well describes this situation.

On the other hand, it could be argued that once drugs or surgery are really and truly required, the body's capacity for self-healing has degenerated past the stage where it may be rallied. Before that stage, when the self-regulatory processes of the body may be appealed to, osteopathy and natural hygiene are perfectly adequate on their own. Here they provide an alternative model of healthcare for the increasing numbers of people who are not persuaded by the orthodox one.

8. Patient choice

Where I reside (one of the archetypal "alternative" social environments) many people would be appalled if they were one day not to be allowed to receive the particular forms of healing they believe in, no matter how fantastic these may appear in other people's eyes. Now I do not for a minute suggest that osteopathy should be compared with some of these practices. There are all kinds of them, most of which I would say are devoid of any rational basis at all. But I would resolutely defend their right to exist, because in any society people's beliefs are important, and, so long as they cause no harm, are worthy of respect.

The scientific future of osteopathy

As a profession osteopathy has relied for too long solely on authority opinion, tradition and experience as sources for its knowledge base. This has led to the transmission down through generations of osteopaths, of useless methods along with the useful ones. Greater attention to the scientific basis of knowledge will help to separate the wheat from the chaff. Science is sufficiently versatile to be able to develop methods of research that are suitable for assessing complex interventions like osteopathy. Osteopathy is currently moving in this direction, and will inevitably continue to do so. This can only be a good thing for patients and for osteopathy. But for the reasons set out in this essay, we should reject the extreme "evidence-shackled" position that is propounded by some.

The originator of osteopathy, Andrew Taylor Still (1828 - 1917) developed osteopathy as a medical system providing a radical and rational alternative to the unscientific, brutal, ineffective and dangerous treatment methods of the time. He always intended it to be a treatment for all kinds of conditions, not just those directly involving the joints and muscles. The early osteopaths from the late 19th century until the 1930s held fast to these original ideas.

During the latter half of the 20th century, with increasing efforts by osteopathic organisations to gain acceptance from medical orthodoxy and recognition from government, there became established in the profession an overwhelming emphasis on the treatment of musculoskeletal conditions, along with an attitude of embarrassment about any notions of a wider scope of osteopathy in treating other conditions. However, a few diehard osteopaths did not relinquish the original idea, and more recently there has been a revival in interest in this side of our work, an interest which I share.

But how can osteopathic treatment possibly affect the inner body?

First of all, osteopathy makes reference to a basic underlying principle which states that the organism functions as an integrated whole. Every single part affects the whole; every single function affects the whole function. This may sound like a reasonable general theory, but how could it work in practice?

There are two different methods which have been proposed and used by osteopaths as treatments for non-musculoskeletal conditions: (1) Manipulation of the muscles and bones to affect the internal organs. (2) Direct manipulation of the internal organs to affect their function.

The internal organs are attached to the musculoskeletal system which surrounds them by a kind of connective tissue called “fascia”. This same tissue also connects the organs to each other. The existence of these connections raises the possibility that things such as poor posture, abnormal spinal curves (scoliosis, hyperkyphosis), and abnormal muscle tension may not only affect the spatial arrangement of the internal organs, but set up abnormal restrictions and tensions between and within them. Adhesions from surgical procedures, infection and inflammation, may also do this. Osteopaths postulate that the ability of the internal organs to function well is influenced by their freedom to move (the rhythmic movements of the digestive system is a clear example) or to be moved (in response to normal breathing, for example) in their normal ways. Movement is essential for certain organs to perform their specific functions (e.g. the digestive tract) and promotes fluid, nutrient and waste-product exchange between tissues, all of which are essential for their health. Thus, the release of restrictions to normal movement, within the musculoskeletal system, between the latter and the internal organs, and between different internal organs is thought potentially to improve their function and their health.

There is also a fundamentally important connection between the musculoskeletal system and the internal organs by way of the nervous system. The nervous system is one of the major control systems of the body. (The others are the mind, the hormonal system and the immune system, all of which are intimately connected). One could think of the nerves as “information highways”. It is well-known in medicine that pain and/or muscle spasm in certain areas of the body may reflect disease in specific internal organs. Osteopaths say that the opposite also occurs: that disorders of the musculoskeletal system, particularly those affecting the spine, may influence the functions of the internal organs via the nervous system. Osteopaths recognise an entity which they call a “somatic dysfunction”, which comprises disorder in vertebral mobility/position, associated muscle tension, and localised vascular changes suggesting associated nervous excitation (such as a localised increase in reddening of the skin when pressed). Osteopaths reason that the nervous excitation affects not only the superficial blood vessels, but also the internal organs connected by nerves to the same spinal level, as well as their blood supply. So correction of the spinal dysfunction should correct the internal one, too.

Is all this plausible?

From a strictly theoretical point of view, considering human anatomy and its general workings, it is a possibility. On the other hand, medical science has strict criteria for allowing a proposition as scientifically plausible. The proposed mechanisms involved must have been demonstrated even if the final outcome has not been. For example, even though it may not be scientifically demonstrated that spinal manipulation can effectively treat problems of the internal organs, to allow plausibility, it should have been demonstrated that:

• The internal organs receive and respond to nerve signals from the muscles and joints of the spine.


• Spinal dysfunction can cause changes in the internal organs.

What's the evidence?

There is at present no good quality scientific evidence for effect or for the plausibility of the proposed mechanisms by which osteopathy might help non-musculoskeletal problems.

Please see my article science and osteopathy for a consideration of some of the difficulties with evidence and scientific proofs.

What's my personal experience?

Most of my patients come to me about musculoskeletal complaints, and when I started practice I only treated these kinds of complaints. However, I began to notice that patients who I had treated regularly for chronic complaints over longer time periods (over 12 months) reported that long term complaints other than the ones they came for seemed to have improved. After many of these experiences, I eventually began to offer treatment for other kinds of complaints in selected patients.

Specifically, my experience to date in the field of non-musculoskeletal complaints has been in the treatment of:

• Vertigo, in cases where no medical cause has been established. I have quite extensive experience here, and benefits have usually been apparent.


• Asthma. Osteopathy seems to improve patients’ breathing. It is not a substitute for medication.


• Dysmenorrhoea (period pains). Only a few cases, treated with osteopathy and herbs. More improvements than failures. It is not possible for me to say whether the positive effects are attributable to osteopathy or herbal treatment.

So, do I treat non-musculoskeletal conditions?

Yes I do, in selected cases, if there are compelling clinical grounds for believing that osteopathy could help. That is, I will be prepared to carry out treatment if two conditions are satisfied:-

(a) The physical examination produces findings of treatable dysfunction that could reasonably explain the patient's condition.

(b) There is no evidence of predominant other causes for the condition in the case in question.

In these cases, I will explain my reasoning to the patient, making clear however, that there is little scientific support for this kind of treatment.

There are two ways of knowing: the objective and the subjective. Objective knowledge is that which can be demonstrated. This is not as easy as it sounds. It requires method, discipline, clarity of thought, logic, and complete intellectual honesty. These are the bases of what has come to be known as the scientific method.

Subjective knowledge is the result of perceptions. I can feel this in the here and now. I may give my feeling an interpretation which may be more or less valid. All I can really say is that "this is what it feels like to me here and now". It may not be true to anybody else, or in any other place, or at any other time. It cannot be said that, "It is so", as a general truth.

Objective and subjective knowledge are complementary. Both ways of knowing are are equally valid if used with awareness and within their own limits. They are complementary but not inter-transferable. Grave error may arise, for example, if one mistakes subjective knowledge for objective knowledge, while humanity is diminished if subjective knowledge is excluded. Both are in their own ways illusory.

Water is H2O: two atoms of hydrogen attached to an atom of oxygen. We know a lot, objectively, about its physico-chemical properties. But this has nothing to do with the knowledge we have of a cool glass of water on a hot dry day, or the beauty of a high waterfall in the mountains, which will be perceived differently by each of us.

The practice of osteopathy requires both ways of knowing. One without the other will not do. For this, it is science and art. However, the subjective aspects must always be based on solid scientific foundations. Otherwise it is not osteopathy, which is a rational approach to health based on known biological facts. That is what we feel, must always be referred to the framework of known anatomy, physiology and psychology. A beautiful idea will not do. At the very least it must be scientifically plausible, or evidence must be strongly suggestive, or else the intervention must be clearly presented to the patient as experimental or experiential.

However, without sensitivity, intuition and craft, the practice of osteopathy would be impossible, or so drastically reduced as to be ineffectual.

An acrobat rang me one Monday and asked for an appointment for his colleague who had injured his shoulder and had to do a show the next Saturday. I backpeddled. You cannot impose deadlines on nature. I said I couldn't see him until Friday (true), so it wasn't likely I could get him better by Saturday, I suggested he go to his doctor in the meantime. "Mmm", came down the telephone line, and I could sense the implied scorn for doctors and medicine. He accepted the Friday appointment. The colleague didn't turn up, as I had half expected.

I do not like this kind of work, and I do not say this in a mean way, it is just not really the job I have chosen. I have chosen to be an osteopath and this is not, in my opinion, osteopathic work. Let me explain. It is a common scenario with athletes, for example. They've "done themselves in" last Saturday or in training and they have to play next Saturday. If they are professionals, like the acrobats, they put injuries on the balance sheet of their careers as an accepted risk, for which they plan with adequate preparation and conditioning, and with full medical support. Or they should. If they are amatuers, there is a certain element of the "self-inflicted" about injuries: rarely is physical conditioning as it should be in order to engage in the chosen activity. Either way though, the demands placed upon the body by having at all costs to play when injured, goes very fundamentally against nature's attempts at healing.

The first medical principle is, "Do no harm", and in osteopathy this translates as, "Do nothing to hinder nature's own efforts at cure". Let us stop to consider for a moment, "What is illness (and hence needs treatment)?" Say the acrobat had recently strained his shoulder, it became painful and difficult to move. Is this an illness? No, inflammation is a healing response of the body, and pain on movement is the central nervous system telling you to rest the affected part. What is the most logical, natural way to respond to assist healing? It is so simple: rest the part and wait. Do nothing else. It will heal.

There are two possible human objections to this reasoning (not my reasoning, nature's!): (1) But it hurts very very much and I can't stand it. (2) But I have to work because I have to eat and I'm not so wealthy I can afford not too. I understand and sympathise with these arguments, and there is a ready made solution: it is called orthodox, allopathic medicine. If you need to, or want to go against nature and get a quick fix, osteopathy is not for you, medicine is.

On the other hand, you do have a choice. Consider what will happen if, by some miracle of manipulation, or under the influence of anti-inflammatories, the acrobat is able to return to work pain-free but with an incompletely healed shoulder. (1) He/she will probably worsen the original injury. (2) If this becomes a pattern and anti-inflammatories are used so the acrobat can train and work, he/she may develop gastrointestinal disturbances and other side-effects, some of which could be serious. (3) It is demonstrated that long term anti-inflammatory use destroys joint cartilage (and if that's not ironical I don't know what is). (4) Gradually the body will develop altered movement and postural patterns to compensate for the limitations produced by the original injury, leading to further problems elsewhere in the body. Now, I do not say never take an anti-inflammatory. It is just that there is sensible use and there is abuse, and the latter is rife.

So, I have said the best treatment for acute, recent strains is "do nothing", meaning that rest and time will heal. Heat / cold may be used sensibly to help (not hinder) nature's healing efforts. When then, does that point come when we can speak of "illness"? When should treatment be sought? This point is when it becomes evident that healing has stalled. After the initial acute symptoms (a few days), there should normally be a gradual return to normal. However, if the improvement levels out, if symptoms linger, something is impeding healing. This is illness, this is when treatment is useful. When dealing with musculoskeletal strains and mild sprains, two weeks is a useful "rule-of-thumb" measure of when you should, naturally, be feeling better. In any case, a return to the activity that caused the problem should be taken in easy steps, with suitable pre-conditioning. This latter is an excellent reason to seek advice, rather than looking for a quick fix to short-circuit the natural process of healing.

In Osteopathy, Research and Practice (1910), the originator of osteopathy, Dr. A.T. Still, wrote:

"One asks, "how must we pull a bone to replace it?" I reply, pull it to its proper place and leave it there. One man advises you to pull all bones you attempt to set until they "pop." That "popping" is no criterion to go by. Bones do not always "pop" when they go back to their proper places nor does it mean they are properly adjusted when they do "pop." If you pull your finger you will hear a sudden noise. The sudden and forceful separation of the ends of the bones that form the joint causes a vacuum and the air entering from about the joint to fill the vacuum causes the explosive noise. That is all there is to the "popping" which is fraught with such significance to the patient who considers the attempts at adjustment have proven effectual. The osteopath should not encourage this idea in his patient as showing something accomplished."

Just read that last line again please: The osteopath should not encourage this idea in his patient.

I am writing this article in exasperation. Yet another patient has consulted me expecting and wanting me to "crack" their back. The only patients who expect this are ones who have been to other osteopaths. Patients who have been to other osteopaths almost invariably want their backs or necks cracked.

They think something has "clicked out" (the "cause" of their pain) and should be "clicked in", to the relief of all. But spines do not click in and out like some old-fashioned mechanical toy (a jack-in-the-box, maybe). Spines sometimes click. They sometimes sprain. Sometimes they click at the same time as they sprain. The click means nothing. Spines are complicated. Spines are intelligent. Spines learn behaviour. They are sophisticated and intricate computer-commanded biomachines, not jack-in-the-boxes. Would you hit your expensive laptop with a mallet?

The osteopath should not encourage this idea in his patient.

Why are some of my colleagues doing this? Why are they being taught this themselves? I have no answer to this. All I can do is explain my own, generally negative, attitude to these techniques.

Bone-cracking techniques (technically "high velocity low amplitude thrusts" or HVLAT) were not especially prominent in early osteopathy. Indeed Dr Still seemed to have preferred to use other kinds of techniques. HVLAT gained in prominence during the twentieth century, to the extent that graduates of certain schools seem to use them as standard and to be aware of little else in the osteopathic toolbox. There are indeed a few occasions in which the rapid reduction of acute pain that HVLAT sometimes produces cannot be matched by other kinds of techniques. It is also quick, saving time for the busy practitioner, who should however, be giving a more complete treatment. But mostly I think its popularity is because the noise produced by the joint when rapidly opened is somehow psychologically satisfying to both patient and practitioner. The feeling that something has been achieved.

The osteopath should not encourage this idea in his patient.

But it has important disadvantages. I treat mainly chronic cases (formally defined as symptoms of more than six months duration). In chronic cases bone-cracking is usually useless, and can even do harm. Indeed, I have seen a fair few patients who have previously been harmed, or felt they have been harmed, by injudicious, clumsy, too frequently repeated, or shotgun HVLT manipulation.

Chronic dysfunction in tissues is characterised by long-standing stiffness, and ingrained habit. It involves the whole body in compensatory muscle activity, postures and movement patterns. These too become hardened, ingrained habits. Treatment of chronic conditions should be viewed as a gradual, gentle unwinding of the whole body, not knocking isolated bits of it "back into place". The very idea would make me laugh, if it didn't make me cry that some of my colleagues encourage this idea in their patients.

The osteopath should not encourage this idea in his patient.

As a technique HVLAT lends itself to application according to wrong criteria such as "manipulate the painful joint" or "manipulate the stiff bit" or simply "manipulate to make a nice satisfying noise", without taking into consideration the whole body pattern which needs unwinding. "The painful joint" or "the stiff bit" rarely has a purely local cause. This vital work never gets done if the focus is on single bits in isolation, or on the production of satisfying "clicks" or illusory quick fixes.

Biological tissues should not be forced. If a joint has to be thrust in order to "adjust" it, it is not ready for adjustment. When it is ready, it does not need to be thrust. Why use HVLAT when gentler, effective and risk-free alternatives abound? It defies sense and defies, I would say, responsible practice.

Unfortunately, the rise of HVLAT has been such that many people identify osteopathy with this technique. I have a very satisfied patient who once told a friend of his that he had been going to an osteopath for his back pain. "Did he crack your back?" the friend enquired. "No? You must be mistaken then. He can't be an osteopath." Another patient, a rally driver, asked me after his first treatment, "Aren't you going to manipulate my back?" I explained that I had just spent half an hour doing just that. "But I know that a good osteopath always cracks the spine", he said. I suggested then he'd better go to a good osteopath.

Osteopathy is defined by its approach to human problem-solving, not by techniques.

The osteopath should not encourage this idea in his patient.

Eddie Izzard on bone cracking.


September 3, 2010

It is a frequent occurrence that a patient comes to me and, after the preliminaries, on asked the reason for the consultation (or even before), the first response is to get out x-ray or scan results or to give me their medical diagnosis. There is initial incomprehension when I say, "For the moment let's leave aside your diagnosis, tell me instead what it is I can help you with?" My assumption is that if a patient has come to me as an osteopath, it is because he or she is looking for an alternative, not more of the same i.e. the same system of diagnostic pidgeon-holing and magic bullets which has failed them so far. Therefore, to start by recounting to me as an osteopath what the medical diagnosis is, rather than what your suffering is and the reason for your seeking help in the first place, seems to me paradoxical.

The bare fact is that there are fundamental differences between the osteopathic mindset and the conventional medical mindset. I would even go so far as to say they are incompatible. Here is a brief synopsis of the reasons why:

The medical mindset believes all people are the same: exactly the same in fact as that hypothetical average person that drug trials say might get better 80% of the time on those pink pills. It assumes this person to be an assembly of parts which have little to do with each other: so you go to the gastroenterologist for your gut and the dermatologist for your skin, the proctologist for your butt and the orthopod for your elbow. Medicine is fixated on what it calls "disease". It believes all diseases are different and is happiest if they can all be well-separated in little boxes with neat labels. Diseases are caused by distinct, preferably single, well-defined aggressions on the organism and their symptoms are bad, they must be fought and suppressed. It believes there are specific treatments for each symptom or disease. It only really believes in and knows drugs and surgery. Medicine, however, so often concentrates on what is unchangeable. That being so, its only options are to compensate by diverting the physiology, or to suppress symptoms. Medicine asks, "What is the name of this disease?" "What drug can be used to compensate for it or suppress its symptoms?"

In contrast, osteopathy believes that people are all different, they cannot be treated the same way even if they have been given the same "disease label". It assumes people to be whole, intricately sophisticated systems, in which any significant stimulus has potential effects in every cell in the body. Osteopathy believes all ill-health to be fundamentally the same: it is a response, or a lack of response, to external or internal conditions. That is why it is possible to observe predictable progressions through a lifetime, of states of ill-health conventionally considered as quite separate diseases. It is multifactorial: single causes are largely a myth. Symptoms are most usually not bad, they are evidence of positive, necessary, physiological reactions of the body. They should generally be supported, not suppressed, and their reason for existing should be obviated or resolved. Osteopathy does not believe in specific treatments for specific diseases, because the concept of specific disease does not come into its mindset. Osteopathy believes in individualised treatment indicated by characteristics specific to the person, as determined by osteopathic assessment. Osteopathy concentrates on what is changeable, and attempts to effect positive change. It asks, "Why did this person fall from health?" "What can be done to return them to normal function?"

Unfortunately a whole lifetime of cultural "education" has militated against a wholistic understanding of health and disease in the western world. We have been conditioned to believe that "diseases" are discrete, objective, malign entities with single, discrete, objective, malign causes, which have to be "combatted" with chemical drugs or cut out with knives. Osteopathy says there is another viewpoint. This alternative mindset is not considered to be irrefutable "truth", nor is it an unbending dogma. It is however, a preferential stance, which we believe to be more rational, and generally to provide better answers.

El tema de este artículo es lo que yo veo como un robo infame y perniciosa que en este momento están planificando en el mundo de la sanidad española: el robo de la osteopatía. Las ideas que puede leer a continuación son mi opinión personal, basada en mi mejor interpretación de los hechos.

En los dos últimos años se han hecho esfuerzos agresivos por las organizaciones españoles de fisioterapia para enmarcar la osteopatía como una parte de la fisioterapia y hacer su práctica legalmente restringido a los fisioterapeutas. Su argumento es que la osteopatía es una técnica de terapia manual, y que sólo los fisioterapeutas deben tener derecho a practicar la terapia manual. Proponen a capacitarse para la práctica la osteopatía con un breve curso de posgrado. No sé si reír o llorar, ya que por una parte este razonamiento demuestra una total y absoluta falta de comprensión de la osteopatía, y por otra, es potencialmente peligroso para los pacientes.

Primero, vamos a piensar un poco a la historia. La osteopatía precede a la fisioterapia por 100 años, habiendo comenzado su desarrollo en el medio del siglo 19 como una alternativa a las prácticas médicas establecidas. La fisioterapia es una disciplina desarrollada a partir del medio del siglo 20, como complemento a la práctica médica estándar. Esta historia continúa en la actualidad: la osteopatía rechaza el modelo médico y se desarrolla por la experiencia clínica, la fisioterapia es hija del modelo médico y se compromete a lo que hoy se llama "Medicina Basada en la Evidencia" o "MBE" (en teoría sólo debería ofrecer tratamientos que se han demostrado científicamente de ser eficaces). El hecho de que los fisioterapeutas españoles están dispuestos a comprometer sus principios fundamentales para la adopción de un método como la osteopatía, que generalmente es despreciado por la MBE, huele fuertemente de hipocresía. ¿Podría ser que finalmente se han despertado y que reconozcan el éxito de la osteopatía, han tomado conciencia de que los pacientes lo piden, y de manera codiciosa esperan de aumentar sus ingresos y prestigio? Sí, creo que podría ser así.

En segundo lugar, los fisioterapeutas parecen considerar la osteopatía como una técnica para anexar a su práctica, que se utilizará eclécticamente junta con todas sus otras técnicas más convencionales. Consideran la quiropráctica y la acupuntura en la misma manera. Así, estos tienen la misma importancia, como meras técnicas, como el masaje, electroterapia, terapia de ultrasonidos, terapia con láser, etc. Esta es la absoluta falta de comprensión a la que me referí anteriormente. La verdad es que la osteopatía no es una técnica, ni siquiera un método, es una disciplina que implica una manera fundamental de pensar acerca de la salud, la enfermedad y la terápia que no es un extra opcional, y está en contraste directo con la empleada en fisioterapia. Los dos no son compatibles - no se puede ser osteópata y también fisioterapeuta.

¿Cuáles son las diferencias fundamentales? Yo les he descrito en mi artículo "The osteopathic mindset". En pocas palabras, la mentalidad medica (y de la fisioterapia) es:

• Considera que todas las personas son uguales. Todas las personas con el mismo diagnóstico son tratados de acuerdo a los protocolos estándar.


• Una persona es un conjunto de partes que tienen poco que ver entre sí. Un síntoma de cabeza es un problema de cabeza, un síntoma de la cadera es un problema de cadera, un síntoma intestinal es un problema intestinal, etc.


• Se fija en lo que llama "enfermedad". Se trata de curala, o si no puede curarla (en la mayoría de los casos) suprimir los síntomas.

Por el contrario, la mentalidad osteopática:

• Considera que las personas son todas diferentes. No pueden ser tratados de la misma manera, incluso si se les ha dado el mismo diagnóstico.


• Supone que los seres humanos son sistemas complejos y sofisticados, en los que cualquier estímulo significativo tiene efectos potenciales en todas las células del cuerpo. Un síntoma de cabeza, un síntoma de la cadera, un síntoma intestinal son todos problemas de toda la persona.


• No es obsesionado con los "diagnósticos" médicos. Cree que todos los problemas de salud son fundamentalmente el mismo proceso: se trata de una respuesta, o la falta de respuesta, a las condiciones externas o internas.

En tercer lugar, la "osteopatía-light", practicada por los fisioterapeutas después de un breve curso de formación de postgrado, constituye un peligro potencial para la población. Los osteópatas debidamente cualificados tienen años de formación técnica. También tienen un amplio conocimiento de la filosofía, los principios, la teoría de la osteopatía, sin el cual las técnicas son de uso muy limitado. Además, están bien versados en la fisiología, patología, métodos clínicos y el diagnóstico diferencial. Esto les permite conocer y actuar sobre cualquier contraindicación al tratamiento, y seleccionar las técnicas apropiadas para cada caso en particular. Estas cosas no se pueden aprender hasta un nivel adecuado en un curso breve.

Por favor, ayuda a prevenir un robo y proteger la osteopatía real, al firmar la petición.

I have a special interest in the treatment of chronic and more complex problems. The word "chronic" means that a problem has been present for a long time, technically more than 6 months.

Some problems, such as generalised osteo-arthritis, have a naturally chronic course. In the case of osteo-arthritis, this is because joint wear is, to an extent, part of the natural aging process. Note however, that phrase "to an extent", the corollary of which is that to an extent it is not, and to that extent there are some very useful things we can do to help prevent it. We can also help to prevent the inflammatory response which makes the worn joint painful.

Other problems become chronic because they never properly resolved after their first appearance. If you strain a joint, a series of reactions are set up in the body to heal any tissue damage that has occurred, but also postural and behavioural adaptations occur to favour the strained joint by removing load from it. If the healing inflammatory response is effective, the necessity for these adaptations is short-lived, and soon everything returns to normal. If however, the healing response is inadequate, pain and inflammation linger on and postural and behavioural adaptations become more and more "fixed". At this stage they are interfering with the proper function of the joint that was injured originally, thus adding to its problems.

But why should the initial inflammatory response be inadequate? One reason may be a general lack of vitality. Another frequent reason is that the area that the strain is only the final result of years of development of postural and movement patterns that have rendered the local area vulnerable. In this context the body's healing response has the odds stacked against it.

How may chronic problems be effectively treated? Simply working to relieve local strain may give temporary relief, but it is not a long term solution. To achieve long-term improvement, it is necessary to improve the way in which the whole body distributes the load placed upon it, as well as removing unnecessary load from the body. Furthermore, taking off the strain means removing excessive load, or improving the organism's handling of it, in various spheres: the mechanical, the psychological and the nutritional. Only by addressing all these aspects can the organism's self regulatory mechanisms be fully adjusted towards their maximum healing potential.

This takes quite a long time. In conditions which have evolved over several years, a few osteopathic treatments plus some brief counselling is not enough. An ongoing effort is required over at least eighteen months is necessary to achieve what can be achieved. There are several points to bear in mind before embarking on such a journey:

1) One cannot prioritise healing - the body itself does that. For example, you may consider your neck pain to be a priority and wish that to be treated first. Unfortunately, it does not work like that. All we can do is help the organism into the right conditions for healing responses to occur. The body will then decide on its priorities.

2) A corollary to this is that we do not treat "problem X", we treat the whole person. In some circumstances, we may not even touch the symptomatic part, but treat the context in which it is found.

3) Some things may get worse before they get better. It is as if the body needs an acute response to resolve the chronicity.

Palliation of symptoms does not bring long term solutions, and can even make matters worse. One reason for this is simply by smothering a symptom, underlying causes are ignored and left unchecked. Another reason is that the treatment itself may cause long-term damage. Two examples: (1) If heavy manipulation is repeatedly used to batter a vertebra "into place", firstly that vertebrae may become unstable, and secondly the body will find another way of compensating its underlying problems. (2) The use of non-steroidal anti-inflammatory drugs (commonly used to treat pain) in the long-term treatment of osteo-arthritis, has been shown to increase the rate of joint degeneration.

On the other hand, the osteopathic treatment of chronic problems is not all plain sailing, but it is the approach which goes furthest to restoring general health.

To a large degree our health is in our own hands. The worlds most effective medicines are produced by and contained within the body. However, their production and effectiveness depends on certain conditions being met. These are easy, pleasant and cheap things, available to everybody. By achieving these conditions, we can multiply our chances in life of avoiding an uneasy dependence on the quack, the sawbones and the chemical drug peddlars.

1. Nutrition

Hippocrates said, "Let your food be your medicine and your medicine be your food". It should be obvious that the human body can only work effectively and in maximum health with good nutrition. What is less certain is what actually constitutes a "good" diet. When one studies whole populations, the kind of diet that is consistently found to offer sufficient essential nutrients while avoiding the modern nutritional killer diseases such as obesity, heart disease and diabetes, has the following characteristics:

• Relatively small quantities of animal foods.
• Wholegrain cereals.
• Very little refined carbohydrate (e.g. white bread, sugar).
• Abundant vegetables and fruits.

There has been much controversy about the supposed benefits of organic foods, with several studies showing that they do not contain any more essential nutrients than ordinary foods. However, I would maintain that organic foods are still preferable, as they probably contain lower levels of toxic herbicides and pesticides.

Another area of modern research is the individuality of nutritional needs, that is, the idea that different people will function optimally on different kinds of diets. For example, some people may require more animal protein than others. Methods of biochemical typing exist, which attempt to classify people more precisely as to dietary needs.

Another aspect of this individuality is that some people are affected by symptoms of various kinds caused by idiosyncratic intollerances. These may be suspected if medical or psychological causes have been excluded.

Finally, I personally believe that eating foods that are in season, preferably locally grown, will best provide for our dietary needs.

2. Sleep

Sufficient good quality sleep leaves you facing the day refreshed and energetic, so that everything seems easier. On the other hand insuffient or poor quality sleep result in waking up feeling still tired, unable to cope with the tasks of the day effectively. The Sleep Council gives the following tips for a good night's sleep:

• Keep regular hours. Going to bed and getting up at roughly the same time, all the time, will programme your body to sleep better.
• Create a restful sleeping environment. Your bedroom should be kept for rest and sleep and it should be neither too hot, nor too cold; and as quiet and dark as possible.
• Make sure your bed is comfortable. It's difficult to get deep, restful sleep on one that's too soft, too hard, too small or too old.
• Take more exercise. Regular, moderate exercise such as swimming or walking can help relieve the day's stresses and strains. But not too close too bedtime or it may keep you awake!
• Cut down on stimulants such as caffeine in tea or coffee - especially in the evening. They interfere with falling asleep and prevent deep sleep. Have a hot milky drink or herbal tea instead.
• Don't over-indulge. Too much food or alcohol, especially late at night, just before bedtime, can play havoc with sleep patterns. Alcohol may help you fall asleep initially, but will interrupt your sleep later on in the night.
• Don't smoke. Yes, it's bad for sleep, too: smokers take longer to fall asleep, wake more often and often experience more sleep disruption.
• Try to relax before going to bed.. Have a warm bath, listen to some quiet music, do some yoga - all help to relax both the mind and body. Your doctor may be able to recommend a helpful relaxation tape, too.
• Deal with worries or a heavy workload by making lists of things to be tackled the next day.
• If you can't sleep, don't lie there worrying about it. Get up and do something you find relaxing until you feel sleepy again - then go back to bed.

3. Activity

Physical activity is wonderful medicine. It keeps the breathing and circulation efficient, muscles toned and joints mobile, improves the mood and reduces pain by stimulating endorphin production, and favours good quality sleep. People who are chronically inactive can become so unfit that the slightest movement outside their normal range causes discomfort. Everybody should do regular physical activity, according to their age and physical condition. For example, if you do not wish to or cannot practise a sport or go to the gym, a daily fast walk of half an hour is sufficient to produce the above beneficial effects. Any new activity needs to be introduced slowly and gradually, and before beginning, be sure to get a health check with your doctor.

4. Rest and relaxation

In the stress of the modern world, it is important that we get enough rest and relaxation. A stressed body is like an engine in a car running too fast when the car is stationary, and in too low a gear while the car is running: it will soon overheat and wear out. By allowing ourselves time to rest, our body's self-regulatory systems can readjust, allowing us to function well and improving our performance in the tasks we have to perform. Rest and relaxation also allows our mind freedom to roam without any particular aim, and it is in this state of mind that our creative abilities can come to the fore. Many people have found that solutions to problems have arisen spontaneously when they have not actually been thinking of the problem, but allowing their minds free space and time.

5. Sex

Sexual intimacy with the person you love and who loves you of course brings great pleasure and fulfilment, resulting long term in a sense of contentment which permeates your days and your life. But it does more too, at a biological level. Sex increases levels of circulating endorphins, making one feel happier and more peaceful.

6. Laughter

Along with exercise and sex, laughter is the third great natural endorphin booster in our lives. So it's good to indulge in opportunities to make a joke or simply to see the funny side of life.

7. Optimism

It is well established scientifically that on average, optimistic people live longer, healthier lives, and feel greater satisfaction with life. Thus it seems a good life strategy to view oneself, the world and the future in a positive light.

8. Relationships

It is equally well established that the existence of plentiful supportive social relationships is protective against stress and illness. People with little social support tend to have worse health and increased risk of early death.

9. Transcendence

In this category I would put all those aspects of life that nurture feelings of life-purpose, creativity, inspiration and existential joy, some might say "spiritual" aspects. To some this may be a religious feeling, to others the deep joy to be felt listening to music or poetry, contemplating art, experiencing the natural world, or being utterly engaged with one's work.

There may be various reasons why clients go to an osteopath:

• They may know nothing about osteopathy, but just want to be out of pain and have received a recommendation about the osteopath.


• They may know something about osteopathy, and think it will complement the conventional treatment of their condition.


• They have tried conventional medicine and are not looking for more of the same. They are seeking an alternative think osteopathy may help them.

Often I am asked by clients of the first two groups questions such as: "Should I take something for the pain?"

I find this interesting. Why would somebody go to an osteopath to ask about drugs?! Perhaps there is a widespread misconception about osteopathy? Osteopaths are experts in osteopathic treatment and its therapeutic benefits. We are not concerned with the conventional medical treatment of minor orthopaedic problems (unless the individual osteopath chooses that path). That is why we are osteopaths and not medics - there is a fundamental difference!

Most osteopaths in Europe (unless they are also doctors) are not allowed to give specific advice on medicines. However, I am allowed to express a general opinion here. And my opinion is, this is the bottom line:

1. Nobody can tell you whether or not to take medicine, they can only advise, you must decide for yourself.

2. If you "just want to be out of pain", take the medicine that your doctor prescribes to you.

3. But take into consideration that taking drug medicine may prevent complete healing and rehabilitation, resulting in a chronic condition. This is because pain and inflammation exist for good reasons - they have a healing function - if they are suppressed, healing will be incomplete. Secondly, it is likely that the underlying mechanical reasons for your injury will remain unresolved because, with the pain (for the moment) gone, you will see no reason to seek deeper resolution.

This may be an uncomfortable truth, but the power of choice is in your hands.

"The phenomena of pain belong to that borderline between the body and the soul about which it is so delightful to speculate from the comfort of an armchair but which offers such formidable obstacles to scientific enquiry." (J. H. Kellgren, 1948)

Here are three relatively unknown or frequently ignored aspects of pain which however are commonly evident in clinical practice:

1) The presence or intensity of pain is not well related to medical diagnostic findings (x-ray, scanning, blood tests). Thus two people of the same age, sex and similar general physical condition, with similar spinal x-rays or scans, can have vastly different degrees of spinal pain, from virtually none, to virtually unbearable.

2) Contrary to what many osteopaths and chiropractors like to think musculoskeletal pain in the general population is not well related to postural features, bodily asymmetries or load-bearing. Some people are highly sensitive to minute sources of pain, others are unaffected by potentially large ones.

3) To even begin to understand such aspects as these, one must take into account a number of phenomena:

The multifactorial nature of pain

Except in the simplest circumstances (e.g. you cut yourself, you drop a large rock on your foot, etc.), the question, "What is the cause of my pain?" has no clear cut answer. The experience of pain is a final result of numerous inputs from both past and present. These may include, just for example: your constitution and general physical and mental condition; the accumulation of trauma, physical and emotional, and its effect in sensitising the nervous system; energy levels and fatigueability; biochemical balance and nutritional factors; stressful life events and situations, and your ability and resources to cope with them; personality traits and psycho-emotional factors; your knowledge, beliefs and past experiences; the existence of musculoskeletal pathology like arthritis or slipped disks; and yes, also "mechanical" triggers like actual physical insult and the soundness of the physical structure of your body to absorb it. But for any realistic appraisal of pain it is essential to realise that the actual triggering event is in many cases by no means the most important input in all of this that determines the experience of pain.

The neural network

All of this information is processed and interpreted by the central nervous system (brain and spinal cord). Here, in the course of your life a "virtual" blueprint is born and develops, partly from your genes, partly from your experiences, which determines how you will interpret and handle noxious impulses. It is called the neural network. Will you interpret the slightest abnormal sensation "catastrophically" and experience extreme pain and anxiety? Will you ignore painful signals, brush them aside and carry on as normal? Or will your system discriminate the important from the insignificant correctly most of the time, assigning appropriate levels of pain and behaviour to each occasion? These questions are not answered by you entirely voluntarily, but by your neural network working unbeknown to you in the background.

Nociception

Nociception is the name given to the activation of specialised nerve endings which cause "pain" signals to be transmitted towards the spinal cord and brain. It is an unconscious process: at this stage pain is not necessarily felt, as these signals are just the raw information, unprocessed as yet by the brain. These specialised nerve endings are activated by stimuli such as mechanical loading, tension, pressure, stretching, shock, or abrasion, real or potential tissue damage, chemical irritation and heat. Nociceptors are being activated in our bodies all the time and we are largely unaware of this. This is because not all potentially damaging stimuli are in fact important: the brain has to make this distinction and act accordingly (as explained in "the neural network" above), which in most instances is to ignore the stimuli.

Pain sensitivity and tollerance

People talk about having a high or low "pain threshold", but in fact there are two different pain thresholds: sensitivity and tollerance. Pain sensitivity is how much one perceives pain. Pain tollerance is how much one reacts to it. You could, for example, have high pain sensitivity and low pain tollerance, or vice versa. Pain sensitivity and tollerance are modified by all of the factors listed in "the neural network" above. In some circumstances, due to the summation of numerous factors, some of which have been listed, people can become highly sensitized to the extent that stimuli only very slightly more intense than normal cause pain. (This is called "central sensitisation", as it is the central nervous system that is "sensitized"). Often, anxiety follows as the person understandably, but wrongly, attributes the pain to injury or illness.

Psychological aspects of pain

In all of us psychological influences have an enormous influence on pain (its occurrence, characteristics and intensity) and our behavioural response to it. These include your personality traits, general mental condition, past and present emotional trauma, stressful life events and situations, and your ability and resources to cope with them, mood, knowledge, beliefs and past experiences, the presence of anxiety or depression. This much is known fact. And yet, when it is suggested that a person's pain may have important psychological influences requiring specialised help, there is frequently an astonishing level of resistance to the idea. The person thinks psychologists are for people who are mentally ill. "No", they object, "my pain is real".

"Real" pain

This, however, is meaningless: all pain is a subjective experience, and all pain is real to the sufferer (except in those rare cases when people actually fake it). Whether its origin is mostly physical or mostly psychological, it is equally real.

The significance of pain

It is clearly likely that pain evolved in response to injury and illness in order to determine life-saving behavioural responses such as withdrawal from the source of pain, or seeking help. These are normal (functional) responses. However, pain does not always mean there is injury or illness. In certain common circumstances, people's response to pain may become maladapted (dysfunctional). This happens for example in central sensitization (see above), "neuropathic" pain, and in some cases of chronic pain.

In central sensitization pain results from insignificant stimuli, and is erroneously believed to be from some injury or illness. In neuropathic pain, "sensitized" nerves spontaneously produce painful sensations even long after the original reasons for the pain reaction (e.g. a physical injury) no longer exist.

In chronic pain, the pain can be maintained by inappropriate behavioural responses such as excessive avoidance of activity, excessive focussing on the pain, or unconsciously soliciting secondary benefits from one's symptoms such as sympathy or relief from responsibilities or demands (e.g. sexual). The obtaining of these benefits unconsciously reinforces the pain and the behaviour.

In essence, in these situations, the fault is not so much with the body's structure itself, but with the body's responses to stimuli, or the person's responses to pain. In some cases the individual roles of the whole family may become so defined by one family member's illness that a self-maintaining system evolves. These phenomena are much more common than is generally recognised.


June 2, 2011

(This article should be read in conjunction with my article, "Pain").

Sometimes a patient comes to me with the self-made diagnosis of "a bone out of place", and the implied requirement that I "correct its position". Hence the question in the title. The reader who has paid close attention to my site will already know the answer it. It is, "No!"

The idea a "bone out of place" as a common cause of pain in the back or neck should be consigned to history. It was certainly current among the bone-setters of the 19th century, and even the early osteopaths. However, within the more enlightened osteopathic circles it was quickly replaced by more sophisticated models. And in the light of all we now know about the way the spine works and behaves, the notion of a bone "out of place" is simply untenable. And yet some osteopaths and chiropractors still peddle this explanation of pain to their patients. It has come to its maximum expression of the ridiculous in a currently fashionable method (nothing to do with osteopathy or chiropractic, I am happy to say) of "atlas profilax"®. This promises to solve your health problems by correcting the position of your atlas, which it assures you is likely to have been badly positioned since birth. My advice is to save your money.

The idea a "bone out of place" as a common cause of pain is simplistic to the point of being wrong. Why? Here are a few reasons:

1) Osteopaths do recognise abnormal states of the spine, in the absence of any disease, which may be localised (e.g. affecting the immediate area around one vertebra) or more extensive. We call them "dysfunctions". The word "dysfunction" means "not working properly". One of the functions of spine is to allow movement in certain ways and to certain degrees. If it is not doing this normally, it is dysfunctional.

We recognise dysfunction by various palpable and/or visible signs. Some of these are: tension or other abnormalities in the texture of the body tissues (e.g. muscle), asymmetry (e.g. of a vertebra), restriction (of the spinal movement), tenderness to palpation. Sometimes one finds that a specific vertebra seems to be oriented differently from the others, judging from the asymmetrical positions of its bony prominences. However, it is a leap too far to say it is "out of place".

Firstly, the bony prominences of the spine are often naturally asymmetrical. Secondly, even if a whole vertebra is oriented differently from its neighbours, we can still not normally say it is "out of place". "Out of place" means dislocated: a gross displacement with serious tissue injury. Let us take the example of a door which should at this time be shut. Imagine it sticks in its frame so that it cannot be completely closed. It is not off its hinges, it is just stuck in an inappropriate place at an inappropriate time.

The same with the dysfunctional vertebra. Imagine you bend down and twist slightly to pick up an object from the floor. When you straighten up, you feel pain in your low back which wasn't there before. It is quite likely that for some reason a vertebra has not been able fully to regain the erect position appropriate to your erect posture. It is not "out of place", but it is "stuck".

2) Let us go further. This abnormally behaving part which we have called a spinal dysfunction (not a bone out of place!) does not exist in isolation. In anything longer than the short term (a few days at most) it can only be maintained by virtue of its wider relations. The natural tendency of a healthy body is towards the normal. Why then is a dysfunction maintained? Because the wider context (the body) is accommodating it. The problem is not in the individual dysfunction, but the wider dysfunctional pattern involving the whole body. These things are maintained by a complex network of relationships within the body, involving not only the musculoskeletal system, but also the internal organs, the circulatory, nervous, hormonal and immune systems. Within the organism, it also involves the mind, with our thoughts, beliefs and emotions. And outside of the organism the relations extend to our physical and social environments.

Trying to "adjust", in isolation, one part of this system is hopeless, and if done forcefully is asking for trouble. Imagine a twisted piece of string. If you keep it taut and keep twisting, at a certain point it will it will double on itself and a kink will form. Try to straighten the kink and another one will appear elsewhere. This is a good analogy for the behaviour of a single dysfunctional part within a complex whole. (While I am tempted to claim this analogy as my own original, I have to say my thanks go to Kuno Van Der Post for providing it). 3) If I examined ten healthy and symptomless people, I would find a whole array of spinal dysfunctions in all of them. What does this tell us? Firstly, it tells us that at any time all of us have spines which, if examined in minute detail, are not functioning in perfect coordination and harmony. Secondly, it tells us that in many people, most of the time, this situation is perfectly well tollerated. I have a cardinal rule: "If it ain't broke, don't fix it". Spines are extremely complex, intelligent, biological machines. There is are normally ample tollerance limits for less than 100% efficient function. In fact I would say that less than 100% efficient function is the normal condition. I am not more intelligent in the ways of your spine than your spine itself. A significant problem will be made evident by pain or discomfort. If there are no symptoms, hands off!

4) Even if you are suffering pain or discomfort, it is illuminating to realise that a symptom (e.g. pain) has no single cause. It follows that there is no single remedy. I believe that spinal dysfunction can most helpfully be regarded with reference to the "stress" model. "Stress", in popular parlance, has come to mean "feeling under pressure", but in physiology "stress" refers to any demands which threaten to overwhelm the resources of the organism. These can be mechanical (e.g. daily work at a poorly set up work station), physical (e.g. radiation), biological (e.g. a virus), chemical (e.g. drinking water with high levels of heavy metals), or psychological (e.g. conflict in the workplace). The model I work with postulates that when the sum total of demands on the organism exceeds a certain individual threshold, the organism gets sick. Reducing the physical stress on the organism by improving the body's mechanical efficiency is one way (and only one way) in which osteopathy helps. I believe osteopathy also has significant physiological and psychological effects.

Conclusion: It is not about "correcting" the position of bones!


June 2, 2011

I have always thought the most satisfying work is helping people with complex, long-term problems. People naturally become alarmed by sudden episodes of acute pain, but I reassure them that it is normal to suffer from pain or other symptoms from time to time, just as it is normal for them begin to improve of their own accord within a week and to clear up completely within two. If you suffer from time to time, and this is what happens, congratulations, you are healthy, you need no help!

The problem is when the symptoms do not completely clear up, or when they frequently return. This means that for some reason your body has not been able to recover naturally, and so is incorporating the problem into its system and its very identity. In this way, the problem becomes self-maintaining. It is at the first signs that this process may be beginning that you need help, to nip in the bud, or to break the network of vicious cycles which are maintaining the problem.

When Emma first came to see me she was 61 years of age, widowed, a retired nurse. She was suffering from chronic low back and neck pain, the latter of which was accompanied by extreme susceptibility to cold, drafts, posture and sudden movement that she frequently had acute episodes of severe pain. Such was her sense of vulnerability about her neck that she consciously limited her head and neck movements, preferring to turn her whole body instead. Emma had been seeing my colleague at work, a nutritional therapist, for low weight and lack of energy of no pathological basis, as well as anxiety. A further symptom she reported was difficulty swallowing ("dysphagia"), which had been with her for several years, and was a constant source of worry for her, as she imagined that it might be caused by cancer. On the other hand, her fear of the necessary gastroscopic examination of her oesophagus and stomach had been the greater force so far, so she had declined to have it.

X-rays and scans of Emma's spine showed a slippage of the last vertebra at the bottom of her spine ("spondylolisthesis"), moderately serious degeneration and bulging of several intervertebral disks in her low back ("slipped disks"), and osteoarthritis ("wear and tear") of the small spinal joints in her neck. My initial examination found a mildly twisted pelvis, quite severe misalignment and stiffness of the bottom of her spine, a "flat" back with lack of "spring", and a stiff neck which was not helped by her conscious and unconscious "guarding" of it. The latter had produced chronically tight and excitable muscles at the front of her neck.

My first task was to allay her anxiety at the first treatment. "Are you going to crack my back?", she asked, apprehensive. I reassured her that this was not my favourite technique anyway, and that in view of her osteoporosis ("brittle bones") and generally delicate state, I would be treating her very gently.

When helping people with chronic conditions osteopaths have the happy advantage (compared, say with GPs) that as we see the patient over several sessions initially we are able to learn more not only about their condition, but also about them as a person: their hopes and fears, anxieties, aspirations, beliefs, values and demons, their ways of coping and the nature of their relationships, family and social support network. These aspects can often be crucial to a successful outcome from treatment.

From the outset Emma struck me as a gentle, sensitive person beset by worries and imprisoned by a pessimistic view of herself, the world and the future. Positive observations or suggestions were always met with responses beginning, "But.... ". Possible courses of action to improve her situation would invariably be considered "difficult". Pessimism is an important impediment to regaining health. Research shows that pessimism (as opposed to optimism) is associated with poorer outcomes in treatment. So sooner or later the issue must be recognised and tackled if optimum results are to be achieved.

The establishment of a good rapport between patient and therapist is essential before these issues may be broached. It typically takes a few sessions to nurture the necessary respectful confidence. In Emma's case, when this was established, I began to challenge her pessimistic outlook, first gently and obliquely, later more directly.

During the course of this process, we spoke about her worries about her health and her family, and about her desires and aspirations. A major worry for Emma was her dysphagia. I was able to persuade her to take positive action and return to her doctor to book a gastroscopic examination, which she eventually summoned up the courage to undertake. The result was negative and, because the condition was clearly not getting worse, it was labelled as "functional" (i.e. not due to disease) and benign. This set Emma's mind at rest on that score.

Emma was unsatisfied with her health. She was able to accept that no therapist could take responsibility for it. A simple thing which she had been stalling on for a long time, through inertia, pessimism that it would do any good, and fear that it may harm her, was physical activity. The right level of physical activity brings physical and psychological health. Too little or too much, or the wrong kind, can be harmful. Emma was getting too little, which she realised. She needed only a little encouragement and verbal reinforcement of her own decision in order to take the necessary step. During the course of treatment, she signed on for regular group sessions of Pilates exercises, happily with a very competent instructor.

Emma had long retired from nursing, her husband had died, her children had grown up. She felt that she needed to find some purpose in her life. There is a system in the area where Emma lives for older women to volunteer act as helps, companions, baby-sitters and mentors for young working mothers. Emma decided to volunteer and now has a fulfilling, mutually beneficial relationship with her assigned family, which she describes as her second family.

But what of the actual osteopathic treatment? There was nothing unusual about this. Treatment sessions involved whole body treatment tailored to the specific characteristics of her case, aiming to improve mobility, muscle tone and body alignment. A few simple stretching and mobility exercises were taught to be done at home. A simple breathing exercise was taught to promote a normal breathing pattern and to reduce anxiety. The treatment sessions were weekly over six weeks, then a six week break, then weekly again over 4 weeks. After that I saw Emma from once a month to once every three months over 18 months. Now she comes from time to time for specific issues or for a check-up.

The outcome of this process, in which Emma included osteopathic treatment, is that she is now healthier (less pain and stiffness, increase to normal weight), more relaxed, more optimistic and more fulfilled. Osteopathic treatment and a little counselling played their roles, but much of what has been acieved was about her beginning to take positive action to help herself: her own decision to seek help, her recognition that her negative attitude was a hinderance to progress, her decision to complete her medical investigations, to take up Pilates, to offer her help and support to a young mother.


June 2, 2011

Creo en:

1) Confiar en la inteligencia del cuerpo. Su cuerpo es mucho más inteligente que mi mente consciente. Su cuerpo se encarga de su economía interna para adecuarse a la acumulación de traumas y estrés a lo largo de la vida. Yo no puedo decirle cómo hacerlo, en qué plazo, o en qué orden. Yo sólo puedo ayudar a reducir las tensiones y las cargas excesivas, y asegurar que se cumplan las necesidades básicas del cuerpo. Esto ya es un tratamiento suficiente y completo. Los recursos del cuerpo entonces pueden se liberarse para permitir la autocuración en lugar de combatir la carga excesiva.

2) La curación lenta y suave. El cuerpo, incluso en condiciones óptimas, responde en su propio tiempo. No se puede cambiar las leyes de las ciencias naturales. Los cambios mejores y más duraderos son los que suceden con tanta naturalidad que a menudo son en gran parte inconscientes. No se llevarán a cabo de inmediato, pero en los días o semanas después del tratamiento.

3) Apoyar los propios esfuerzos de autocuración del organismo. La rigidez localizada, el dolor, y la inflamación son algunas de las respuestas protectivas y curativas del cuerpo. Sólo un sistema de medicina que se ha vuelto loco querría sofocarlas por completo. Un sistema racional de medicina, por otro lado, trabaja para hacerlas innecesarios, mediante la normalización de las condiciones en las que se han desarrollado.

4) La unidad del organismo. Un dolor de cabeza no es un problema de cabeza, un dolor de las cadera no es un problema de la cadera, una úlcera gástrica no es un problema de estómago. La cabeza, la cadera, el estómago no están flotando en el espacio divorciado de todo lo demás. Todo es un problema global.

5) La vitalidad. El único antídoto para los problemas de salud es la salud, también conocido como vitalidad. Un organismo vital responde de forma rápida y eficiente a sus problemas de salud. Si usted tiene un persistente dolor en el codo, no es (normalmente) solamente porque algo es "malo" con el codo. Ya sea que usted está cargando la parte dolorida demasiado para permitir la curación, o su cuerpo no es lo suficientemente vital para responder a la lesión. La respuesta no es tratar el codo, (y a continuación la rodilla, el hombro, etc), sino descansar la parte lesionada y trabajar para mejorar las respuestas vitales del cuerpo.

No creo en:

1) El tratamiento sintomático. Los síntomas se manifiestan en las zonas de mayor carga o tensión. La carga o tensión se acumula en estas zonas debido a las distorsiones de todo el cuerpo. El tratamiento sólo del área afectada por los síntomas puede hacer que se sienta mejor temporalmente, pero sólo temporalmente. Y la carga/tensión general pronto producirá síntomas también en otra parte. Así que resulta mejor no tratar las partes por separado, sino la totalidad.

2) El tratamiento heroico. No se deben hacer ajustes forzados. Una zona rígida puede ser rígida por una buena razón (ver “confiar en la inteligencia del cuerpo" más arriba). En cualquier caso, si algo necesita ser forzado, no está listo para ser liberado. Si y cuando está listo, de acuerdo con las prioridades y plazo del propio cuerpo, no necesitará ser forzado.

3) Las curas de una sola sesión de tratamiento. Consulte la sección "la curación lenta y suave” más arriba.

4) La compartimentación y la microgestión. Su cuerpo es mucho más inteligente que mi mente consciente (véase la "confiar en la inteligencia del cuerpo" más arriba). Tratar de gestionar todas sus partes y funciones detalladamente y por separado sería presuntuoso y, a largo plazo, ineficaz. Por lo tanto es preferible hacer tratamientos generales en lugar de “ajustar” cada parte dolorosa.

En conclusión, si se está buscando una solución rápida con una o dos sesiones de tratamiento, esto es el lugar equivocado. El enfoque que sugiero probablemente necesitará más tiempo, tal vez mucho más tiempo, de lo que podría haber esperado. Por otro lado, es sin riesgo, y produce resultados más profundos y más duraderos para la salud general.


Abril 24, 2012