On the one hand osteopaths can hardly claim to treat anyone or anything, but on the other hand millions of people visit osteopaths for anything and everything, and are delighted with the results. And nowhere in osteopathic theory does it say that manipulation cures back pain. What is going on? (Opinion)
1) I’m the first to admit osteopathy can’t cure anything. Yet millions of people consult osteopaths and are extremely happy with the results.
2) There is very little proof that osteopathy can make a difference outside of back pain and a few associated issues. But when osteopaths need help with their own general health, most will ask another osteopath for an opinion before anybody else.
3) The accepted evidence for osteopathy is contradictory or inconclusive, even in everyday matters like back pain. And yet our patients swear by the benefits, and send their friends too.
And the more bizarre, confusing and complex the problem seems to be, the more some people feel let down by conventional medicine, and the more they seem drawn to alternatives such as osteopathy.
Alternative therapy makes more sense to many people, because it seems to match their own world views. In particular, osteopaths do not settle for labelling the patient and consigning them to a lifetime of incurability and drugs: we look for practical, easy, cheap and safe steps to make life better, whatever the problem. And alternatives obey the Hippocratic prime-directive far better than mainstream medicine: that is, to do no harm.
There is no shortage of research into alternative medicine, so why is there so little official acceptance for the benefits?
Do not adjust your reality, there is a fault in research…
When I learned about science, it was not observation that was supposed to validate theory: it was theory that was supposed to explain observation. It no longer seems to be that way.
Until now, the mismatch between research findings and the clinic experience has been blamed on many things, such as deluded practitioners or over-optimistic patients. But at some point we need to turn the spotlight onto research itself and see if that is where the problem lies. Is it really testing what it needs to test, in a way that will find out the truth? Or is it asking all the wrong questions, and relying on false assumptions?
The thing is, osteopaths don’t claim to take a medical diagnosis and then cure it with a prescription, and so it is a mistake to test whether or not we can. For instance, nowhere in osteopathic theory does it say that a consistentlly specified product called manipulation cures a disease called back pain. There have been many rigorous studies asking the question, but absolutely none deconstructing the question itself. If there were, they would reveal the logical holes very quickly. For one thing, back pain is not a disease: it is a symptom with countless possible causes. We keep telling people we don’t treat symptoms, don’t we?
This is why I pay no attention to research into manipulation and back pain, whether the findings are supportive or not. It is like asking if spanners fix engines. I have a box of spanners at home, and I have never seen them fix an engine. That doesn’t mean all engineering is rubbish: but this is the sort of inference many commentators seem entitled to make.
The latest study on neural mobilisation and cervical radiculopathy is really a glorified example of ‘manipulation vs. pain’. No matter that it shows the technique in a positive light, because the whole question is meaningless.
Osteopathic theory starts with a different kind of analysis of the situation, and different outcome intentions. Yes, your symptoms are important, but if the medical paradigm – symptoms: disease: diagnosis: treatment – so often leads nowhere except a worsening of health, then we really should challenge the value of this construct.
What is far more important is why the problem has occured. And the reasons are different for everybody. When the bulk of researchers in our field finally cotton on to this, then they might at last find answers that match the experience of millions of people.
If you want to test what osteopaths do, you need to research what osteopaths do
Forget manipulations and back pain for a minute, and even manipulations and colic. I am far more interested in whether osteopathic principles form a good overall strategy for raising health, and if that is a better route to lasting recovery. Over a century of real world observation suggests they do, and it is. When research begins there, I want to be involved.
It is inconvenient for research that health cannot be measured precisely. We can’t count the people who have avoided illness, or the times we have prevented worsening and complications. When our highest aim is to promote spontaneous natural recovery from within, there is no direct way to measure the difference made by our involvement. I have nothing against measuring outcomes, except that I have no idea how to measure the outcomes osteopathy is concerned with. Too bad: that is the problem researchers have to get over.
Furthermore, trials cannot encompass a patient simply ‘feeling better’ who cannot articulate why, or who gets better in an unexpected way or after a trial is finished. Exceptional recoveries are dismissed as outliers, and complex cases (the sort we are often really good at) don’t qualify for trials because of ‘confounding factors’. Individual case-studies, once the mainstay of medical learning, are now ‘anecdotes’ and not ‘evidence’. And all by some miraculous set of God-given rules, apparently.
For every critic who says osteopaths are resistant to research, there must be hundreds or thousands of people who say things like ‘I no longer need to take my antacids’, or ‘I made it to my grandchild’s wedding’, and who unequivocally credit osteopathy with making a difference.
Patient satisfaction is probably as good a way as any to find out if ‘osteopathy works’. And if something a little more objective is required, we could see how many users live to be 100, or something like that. To be any more precise, there first needs to be a thorough deconstruction of the dogma embedded in research theory.
Positive patient and practitioner experience is largely dismissed as ‘unqualified’, or ‘lacking in objectivity’. Typical justification is circular – there is no evidence this is possible: therefore the practitioner is biased, the patient is probably wrong: therefore we dismiss their testimony etc. Accepting those experiences might require the research community to do some explaining, and so the tail is wagging the dog. Clinicians are expected to alter their own narrative instead, and it isn’t on.
An inappropriate research question is one obvious flaw. On the results side, narrow outcome measures can miss an important effect when it is there. The researcher may be interested in whether a certain intervention will reduce the specified symptom within a month. But I am interested that a general strategy will, via a bespoke intervention, lead to improved overall well-being. In some way. At some point in time. And with no permanent downside. Benefit is benefit.
Take migraine. Stopping a migraine is one thing: I don’t call it much of an accomplishment. Drugs can do it cheaply and easily, while still leaving the patient in a total maze. Stopping the patient from getting migraines every week: that is something else altogether. If we do our job properly, we treat the patient, not the migraine: migraines cease to be a feature in their life, and credit goes to Mother Nature. This isn’t hypothetical: I have seen case after case go like that. Wise patients appreciate that long-term improvement may be incompatible with a quick, direct fix.
The key to all of this is in whether we treat diseases, or whether we treat patients: things we say, but what do they really mean?
We humans heal ourselves. Osteopathy assumes a fundamental acceptance of this, because we would otherwise all be dead. Even doctors promote the idea, I just seldom see clinicians betting their reputations on it. The trick is to remove the obstacles to recovery. We see all the time the staggering ability of the human body to recover once obstacles are addressed, and so that is what the smarter patients are asking for.
[This relates to the osteopatic principle that ‘the body has its own medicine chest’. This does not mean we secrete drugs from some gland: it means that our bodies are self-righting systems, always doing their utmost with the resources available. Health is the default, and symptoms are the manifestations of the body’s drive to maintain health.]
An Alternative Narrative of Health and Disease
In its broadest interpretation, osteopathy says that health is the only real solution to disease. It is a myth that you can make a disease just go away while life goes on unchanged. Once we get comfortable that the only cure comes from within, this is actually very empowering.
Even the idea of diseases – consistently identifiable syndromes with consistent causes and symptoms – may be a myth. It it were true, we ought to know by now the precise cause and cure of every disease. And the medical classification of disease conforms to no consistent rational system. It is totally haphazard in fact. If this paradigm were leading to cures, hospitals ought to be getting smaller, one might think, not bigger. The more we seek health by fighting against things called diseases, the more unhealthy and disease-prone we seem to become.
Our awareness of un-health is usually through healing processes – symptoms – which are generally the body’s healthy reactions to stress and strain. To call this disease is to misrepresent what is going on and then fire missiles at the wrong target.
A Holistic Osteopathy Paradigm
What we find is that two people with exactly the same symptoms can have completely different circumstances: the causes are not the same. And yet two people with similar lifestyles and similar patterns of stress can have completely different health problems.
Medical philosophy emphasises the weakest link in the chain, and makes that the diagnosis. Osteopathic diagnosis and treatment are more to do with the stresses upon or within the system, mechanical stress being number one. But there are many other forms of stress – emotional, nutritional, toxic, occupational, social, to name a few – and they can all create obstacles to healing. Sometimes the most osteopathic thing you can do is to drink a glass of water, or have an early night, because manipulating a tired and dehydrated body achieves absolutely nothing.
And so osteopathic scope of practice is not limited to certain types of disease (as medical specialists are), or to certain parts of the body (like physiotherapy), or to certain techniques (massage therapy). Our scope of practice is determined by the obstacles to recovery, and is as broad as our ability to address them.
Anybody who has ever felt they could sleep for a month after treatment will realise just how much stress can be held in the structure.
Most natural therapy focuses on diet, and rightly so. But complex disease also has structural and postural elements, a fact that modern diet-centred therapies have missed. The need for good mechanical adjustment was already appreciated in natural therapy before Osteopaths took it on. These ideas have very much gone out of fashion, but for mainly political reasons, not because they lack sound reasoning or clinical success.
[Note on osteopathic principles: ‘Structure governs function’, although true, was a later alteration of the much richer ‘Structural integrity, natural immunity’.]
So it is all very well eating the best nutrients possible, but if they aren’t being properly processed and distributed, they won’t solve your problems. Stress is a major disruptor to metabolism: at a fundamental level it alters the balance of circulation, and with it the internal economy of the body.
[Osteopathic principles: The ‘rule of the artery reigns supreme…’ etc. refers to the constantly changing diameter of the blood vessels. Diet is what we eat: nutrition is also about what our bodies do with nutrients. Structural adjustment addresses the processing and internal distribution of resources, by optimising regulation, and limiting unnecessary demands for energy.]
Whether or not the above ideas are currently accepted, they are what shaped Traditional Osteopathy theory and practice. One other vital point of the philosophy is that in a living system, you have to get the whole thing working, and that way all the parts are supported and can take care of themselves. Although we can learn lot from dead machines, they do not behave in this way.
[Osteopathic principles: ‘The body as a unit’ refers to treating the body as a whole, not as lots of parts.]
And hence Traditional or Classical Osteopathy is concerned first and foremost with tuning up the whole person, rather than going straight to the bit that hurts, and then understanding the natural reaction to the changes. And if you want to be safe, it makes sense to set out that way, and not go straight at inflamed tissue, hoping the diagnosis is correct.
A Traditional Osteopathic Method
Our job is not to create change, but to create the conditions for change, and then allow the intelligence of the body to determine what happens next. Osteopathic adjustment is very different from chiropractic manipulation, in a number of ways. The clicks and pops (if they happen) are the product of change not the cause, and so an audible release is not crucial to the result. Many people say osteopathy is gentler and more holistic than chiropractic, and hopefully this explains why. We are not putting bones back in place: we are looking to deal with the reasons they are out of place, and then allow them to adopt a position of better ease. We trust that the body knows what it is doing, and do not try to micromanage it. Acute symptoms are the body’s cure in action, and so we manage the acute, while treating the underlying chronic background; the opposite of standard practice.
The difference these ideas make in technique is not something that can be explained in a hurry. Suffice to say not everybody gets their heads around it, even with one-to-one teaching. During osteopaths’ training there is a lot of academic discussion about concepts. But this is largely treated as a matter of historic interest, and it does not translate well into the environment of the modern teaching clinic. The number of teachers able to bridge the gap is very small indeed.
If Traditional Osteopathy is an antidote to anything, it is to high-tech medical healthcare that many feel they have exhausted. It is more concerned with the basic necessities of life than glamorous and heroic intervention. It addresses the bigger picture, because when we do that, the details tend to take care of themselves. It is about supporting the system to find a better equilibrium, rather than controlling everything in sight.
When influential critics (and there are some real busybodies out there) say something ‘works’ or doesn’t, we have to ask what they mean by ‘works’. Drugs don’t ‘work’ either, if what we mean is making sick people healthy by poisoning them.
Every other branch of science now recognises that complex systems behave in non-linear ways. There is no predictable mapping of cause onto effect as we would like, and so we have to find smarter ways of interacting with living things. Controlling all the bits is far too crude an approach. If healthcare is going to talk holism it is time we moved beyond the linear mechanical consciousness of the 20th century.
The pursuit of narrow outcome measures, means that helping the patient now, frequently stacks the odds against them in future, and with complete deniability for us. Most of us are blind to long-term benefit and harm because we are not trained to recognise these broader patterns.
We could say that the research community is to blame for this, by placing published trial data at the top of the totem pole, while arbitrarily downplaying or dismissing all other forms of human knowledge. But I think this feeds off a societal desire for short answers and encapsulated solutions, where complex and original ideas have to fight for survival. In fact it is researchers who have also shown us how badly modern medicine is failing, and who are now igniting the motivation to do things better. That requires better vision. Hopefully the old dinosaurs and their specious buzzwords – best practice (read: standardisation), treatment of choice (prescription) and hierarchies of knowledge etc – will soon move over for something more highly evolved.
If there appears to be any paradox in osteopathy, it is only because of asking the wrong questions; of saying one thing and doing another; of research doctrine putting square pegs into round holes. Patients say they get better, but tests in the lab say it doesn’t work. Well, this is a bit like when physicists proved mathematically that bumblebees can’t fly. Science never fails, but scientists frequently do…