Spinal Pain: An Alternative Approach

Without doubt the most frequent kind of problem with which I am asked to deal is pain coming from the spine. This can manifest as pain in the areas near the spine (the back and the neck) or in areas connected to the spine by nerves (frequently the legs, the arms or the thorax and chest). Sometimes there are other, associated symptoms in these connected areas, like tingling, pins and needles or numbness.

My approach to these problems is based on an osteopathic view of health and illness. It follows that it differs in fundamental ways from the usual approach of orthodox medicine or physiotherapy.

The medical approach to spinal pain

As medicine is generally practised it:

  • Allows little time for the doctor to spend talking to and examining the patient.
  • Aims to identify a distinct pathological cause (i.e. a “disease”).
  • Makes frequent use of x-rays, scans and blood tests to do this.
  • Tends to regard the painful or diseased part in isolation.
  • Uses the principal strategy of suppressing symptoms.
  • Relies on drugs as first line treatment, physiotherapy as second line, surgery as third line.
  • Physiotherapy reflects these characteristics of the medical approach.

My approach to spinal pain

In contrast, I:

  • Allow as much time as necessary for talking to and examining the patient.
  • Am more interested in why you have become unwell than in the name of your disease. Generally the kind of treatment you receive is not greatly affected by your medical “diagnosis”. It is determined much more by how your body is working mechanically, the factors in your life which are preventing you from getting better, and your general state of health.
  • Find only secondary and relative value in x-rays, scans and blood tests. That is because in most cases of uncomplicated spinal pain, they are not relevant to your treatment or management.
  • Try to relate your problem to what is happening in your whole body, your mind, and your life.
  • Believe that suppressing symptoms can cause bigger problems (symptoms are often part of the necessary healing response of the body), preferring instead to remove the reasons for the symptoms being necessary.
  • Rely on manual treatment and lifestyle changes: this is usually sufficient and complete treatment.

A complex system

The spine is not just a column of bones. It could be likened to an extremely sophisticated robotic machine controlled by extremely sophisticated computer circuitry. There is immense potential for glitches in its workings even with no sign of anything that might be labelled medically as a “disease”. Osteopaths call such glitches in spinal workings “dysfunction” or sometimes “osteopathic lesions” (an older term).

I use manual treatment to return function to as near normal as possible. Clearly, if joint or disk degeneration have significantly altered the basic shape or quality of the tissues of the spine, improvement may take longer or be incomplete. However, moderate improvements in function can turn a painful spine into a largely pain-free one even in the presence of what doctors call “disease” (for example, arthritis, disc hernias, etc.)

Craft, expertise, and modern science

Manual treatment, well practised, is demonstrably beneficial for patients who suffer from spinal pain. However, scientific knowledge of the workings of the spine and its problems is constantly expanding. As an expert in the care of patients with spinal problems, I keep myself continually abreast of the most recent research, none of which has given me reason to doubt the usefulness and effectiveness of the basic principles underpinning the treatments I offer, but on the contrary has continued to enhance my understanding of their useful application in this area.

Osteopathy – a general plan that is tolerant of our ignorance

One of my patients needed written clarification of the things we discussed at our first meeting. She writes:

Could please tell me again what your working hypothesis is of what is happening in my body to cause my symptoms? Also, what is your approach for treating this?

In my reply, as premises to the comments specific to her case, I made the following points:

  1. We don’t know everything (nor even a small part) about the way the body works, so we need an approach which is tolerant of our ignorance.
  2. In osteopathy, the working hypothesis is not as important as the general plan. The general plan says: “Be faithful to osteopathic principles and treat the patterns you find.” The beauty of this is that it allows you to do useful work even if your working hypothesis may actually be wrong.
  3. Especially in chronic cases, chasing a single, clear “cause” is a wild goose chase. It is much more realistic and useful to think in terms of a network of multiple, reciprocal influences, each of which contributes to the maintenance of the whole (dysfunctional) system.
  4. The more you focus on detail, the less you appreciate the basic general patterns.
  5. As an osteopath I approach all problems in the same way (see number 2 above). The most important principle for the osteopath is to reduce at least one general kind of stress and strain from the body (the mechanical kind), so that the whole organism, unloaded a little, frees up some of its resources for healing.

Lessons in Osteopathy

This series of “lessons” appeared recently on my Facebook Page, in order to let people know that there is more to osteopathy than just manipulation.

1. Fluid Flow

The first essential thing is flow, a word that will come up again. In this lesson I use it about the movement of bodily fluids. Blood (not bones!) has always been central to osteopathy. Blood brings life, that’s why there is the term “life blood”. It brings oxygen and nutrients, and carries away wastes and dead matter. If blood flow is compromised, the stage is set for illness. If blood flow is restored, we have the conditions for healing. Osteopaths call that “the rule of the artery”. But there are other important bodily fluids that have to flow or move normally for health to be maintained, such as the lymph, the cytosol (liquid inside cells) of nerve cells, and the synovial fluid (the lubricant of joints). Osteopaths reason that the proper flow of bodily fluids may be compromised by such things as tights muscles, stiff joints, poor posture, and poor breathing. Therefore osteopaths work to improve these things.

2. The Healer Within

Osteopaths believe that it is never the physician or therapist that heals the patient, it is the patient who heals by their own innate intelligence and energies. The therapist simply facilitates or catalyses the process, by helping to create a context for health rather than illness. In the case of osteopathy, this is seen to be done by removing obstacles to health. In particular, we attempt to reduce physical barriers to free flow, especially of body fluids (as explained in Lesson 1), nerve impulses, and indeed all of the body’s tissues (more of this in another lesson). There are other things involved, too, but this concept of improving body mechanics and hydraulics is fundamental to osteopathic thinking. That the body can organise and regulate itself is not a revolutionary concept. In science it is called “homoeostasis”, literally “staying the same”. But the phenomenon was observed by people for millennia before it was given a highfalutin name.

3. Vitality

In the first two lessons I touched upon the ideas of “life blood”, “flow”, and our inner “healer”. These are all aspects of what I will call “vitality”. Vitalism is an essential part of osteopathic thought, one at which sciency people scoff. They scoff at it because it is intangible and cannot be measured. And yet it is very simple really: vitality is the capacity for life (and by implication health). Of course it is an abstract idea, but if we consider vitality as a quality, then it is determined by many things; that is, it is a composite quality. That does not make it any less useful as an idea. Osteopaths will argue about this (they argue about many things), but personally I will say that I can feel good vitality in bodily tissues which are pleasingly elastic and responsive to my touch, neither too resistant nor too yielding; tissues through which the movement I solicit in them flows naturally without let or hindrance. There’s that word again: flow. Good flow is a prerequisite and an indicator of vitality.

4. Movement is Life

My favourite artist is without doubt Van Gogh. Have you noticed how everything in his pictures seems alive? Why? It’s the movement in them. In previous lessons I have connected the idea of “flow” to that of “vitality”. In a phrase, what I have said is “movement is life”. Obviously that cannot be taken as a literal truth. Many things move which are not conventionally considered to be alive: the air moves as a breeze or wind, and there are currents in bodies of water, to give just two examples. Yet if we turn it around, and take the movement out of a living organism, it would die. So movement of some kind is essential to all life. You might say, a tree doesn’t move, except when moved by an outside force such as the wind, yet it lives. But for one thing, yes, it does move – it grows! Secondly, if you looked inside its living tissues with a powerful microscope, you would see many things moving about to sustain the life of the tree, things to do with the transport of nutrients and metabolism. To qualify our simple and inexact aphorism that movement is life, I would say that all life depends upon intelligently directed movement. If this is diminished, impeded or distorted, the organism will lack vitality, and ill health will ensue. For this reason the osteopath’s work is to maintain, so far as possible, the free movement of the body’s tissues and fluids.

5. Congruence and Integration

Have you ever seen a flock (technically a “murmuration”) of starlings? Did you see how they group and fly together in coordinated, coherent, integrated dances? I have written in previous lessons about flow in the body’s tissues and what that feels like. Here I’d like to expand upon that as a little. Let’s say you are lying face down, head turned to one side, and I gently and repeatedly push on the side of your hips and release. Your body will rock gently from side to side with a certain rhythm, a rhythm determined by your own individual conformation. My other hand contacts your spine and with its fingers or the heel of the hand works up and down your spine, resting briefly between each vertebra and the next. What does my hand want to feel? It wants to feel each vertebra moving as predicted from years of experience, in an integrated way with the rest of the spine. That gives a sense of flow. Some things may prevent or upset this, things such as tight muscles large and small, shortened ligaments, damaged joints, even things you might not expect like internal problems and anxiety. My job is to restore flow, by whatever safe means. Let me analyse a little what makes “flow”. It is these things, applied to the feeling of movement through the body’s tissues:

  • Correlation: a mutual relationship between things.
  • Coordination: the organization of separate things into a complex process.
  • Coherence: logically or aesthetically ordered.
  • Congruence: being in agreement or harmony.
  • Integration: forming into a unified whole.

More generally speaking, these things are (literally) vital for life and health.

6. Making the Body Work Better

There is a rather opaque tenet of osteopathic thought, originally stated as “structure governs function”. That means basically that the shape of the physical structures of the body (the anatomy) determines what they do and how they work. Any disorder of anatomy causes things to work less well. While this sounds reasonable enough on the face of it, it is in fact one of the most argued about thoughts in osteopathy! I won’t go into the ins-and-outs of that argument, I will just tell you my interpretation. It is very simple. Tight muscles or other tissues, stiff joints and poor posture make the body work less well. Osteopaths work on the physical tissues of the body in order to improve their function, with a mind, in doing so, to improve the way the whole body works, too. In effect, we work on the physical structure of the body in order to affect change in the organism’s great control systems – the nervous system, the endocrine system, and the immune system – all under the overarching command of the mind.

7. An Alternative View

Federico Fellini said, “A different language is a different vision of life.” It is often difficult for people to understand that osteopathy is not about treating medical conditions… a herniated disk, for example, or arthritis. Osteopathy has limited use for such diagnoses. The thing to understand is this… knowing you do or don’t have a herniated disk or arthritis does not tell me much about what I need to do in treatment. In that regard your medical “diagnosis” is next to useless. What tells me how to treat you is observing how movement flows through your body. There’s that word again… flow… it is so important. So osteopathy is absolutely not an alternative way of dealing with your medical diagnosis; it is a completely different way of looking at health and illness, which has its own terms of reference coherent with what we are trying to achieve.

8. Tools Do Not a Craftsman Make

When I used to teach osteopathy, I noticed how my students were obsessed with collecting techniques. They thought the more techniques they knew, the better they would be as osteopaths. I used to tell them that knowing 200 techniques without attention to osteopathic thought was next to useless, while knowing ten techniques and and having a good appreciation of osteopathic thought could make a very good osteopath.

So the first thing I would like you to understand is that doing “osteopathic techniques” does not mean “doing osteopathy”. Doing osteopathy means paying attention to things such as those I have brought up in previous lessons, all the while developing the sensitivity to be able to apply them through technique. The technique without the thought behind it is nothing, or at most a hopeful shot in the dark. One technique performed for the right reasons (which doesn’t necessarily mean cracking your back where it hurts) is more valuable than fifty techniques performed without any good reason.
My students also used to look forward to learning those techniques that make cracking noises, thinking they were the “best” techniques. I used to tell them that the best technique is the one which gives the greatest benefit with the least risk. Clicks and cracks mean nothing. So the second thing I want you to understand is that osteopathic technique does not mean making the joints go “crack”. Osteopathy has a very large toolkit of manipulation techniques. The wise osteopath uses the less invasive techniques first and foremost.

And thirdly, many people need to reframe their idea of what our techniques are supposed to do. We are not knocking bones into line. We are moulding, reshaping, reworking the body into a more balanced, more harmoniously coordinated, working system. Let me repeat: WE ARE MOULDING, RESHAPING, REWORKING THE BODY INTO A MORE BALANCED, MORE HARMONIOUSLY COORDINATED, WORKING SYSTEM.

9. So What Do Osteopaths Treat?

If you remember your lessons, you will remember I said in Lesson 7 that osteopathy is not an alternative treatment for medical conditions. Do you remember what I meant by that? Did I mean that if you come to me with a “disease”, say degenerative joint disease (aka osteoarthritis, aka arthrosis) or degenerative disk disease (aka “a slipped disk”), I can’t help you? No, of course I didn’t mean that. But I will not be treating your “disease”. “Diseases” are the invention of modern medicine and treated by doctors. They consist of a more or less well defined description of the bodily changes involved in their development, and a name. Osteopaths think that in many cases the doctors are barking up the wrong tree. Why? Because a disease does not exist in isolation. It exists as one with a person, who lives in an physical environment and a society. Therefore, it seems to us, to give one person’s problem the same name as that of another person and to regard and treat it equally is nonsense. So, if we don’t treat diseases, do we then treat symptoms? A sore shoulder, dizziness, period pains? Not exactly. There is no one standard kind of treatment for each kind of symptom. So, what do osteopaths treat? We treat people. The people we treat obviously have symptoms, and may have diseases, and we intend that through our treatment these things should give them less trouble. But we do not treat the symptoms or the diseases, we treat the person who has them. That is, what we do in treatment depends on a series of factors unique to the person, and only in a minor way on the disease or symptom they have.

10. The Rate of Change

People naturally want to get better quickly, and that is normally possible to achieve if their problem is recent and uncomplicated. But if it has been developing for a long time, it is not realistic to hope for a complete cure in a few treatment sessions. Does that sound reasonable? Yet people often do expect that. Why? Sometimes the reason is this: that what appears to be a recent problem (because the symptoms have appeared recently) is actually something that has been developing for years. Another reason? Well, humanity is not renowned for its reasonableness. In any case, with problems that have been developing or producing symptoms for a long time, the beneficial effects of treatment accrue gradually, sometimes over many months, or even years. There will be ups and downs to get through, and change will not necessarily occur entirely as predicted. New symptoms may temporarily appear then subside. That is because the body has its own agenda. We can free the way for a healing, but only the body can dictate by what exact course and time scale. One thing is certain: healing and recovery are quicker and more certain if a person can eliminate from their life the things that have predisposed to, triggered, or are maintaining their condition.

11. Moving Pictures in Our Minds

In the late 1890s / early 1900s our founder Andrew Still got angry with one of the teachers in his school, who had been a pupil of his, for teaching physiology. “Anatomy, anatomy, anatomy!”, he shouted. Anatomy is the bits and pieces, physiology is how they work. Arguably we realise today that, while a visionary, sometimes Still was a little unreasonable in his fundamentalism. So today we are taught physiology. But his point was two-fold. Firstly, if you know your anatomy and how to work with it manually, it is a large part of what you need to get people better (he would probably have said “all you need”). Which, so far as manual treatment is concerned, is largely true. Secondly, I think he was saying that if you know your anatomy well, you should also be able to deduce all the physiology that actually matters in practice. After all, physiology has another name: “functional anatomy”. That means, why things are shaped the way they are in order to carry out their functions. Whatever, osteopaths are very well drilled in anatomy. When we handle your body, we have little moving pictures in our minds depicting what is happening inside. This is, we are watching your anatomy working, seeing physiology in action in our mind’s eye.

12. But You Haven’t Mentioned Back Pain!

You’re right. This is the twelfth lesson on osteopathy and I haven’t mentioned backs once, until now. How so? Back pain forms a large proportion of any doctor’s case load. All the more so for osteopaths as a lot of back pain seems to have an important mechanical component, and osteopathy is, on the face of it, a mechanical treatment. We also see lots of problems with necks, chests, shoulders, hips, knees, ankles and feet, elbows, wrists and hands, nerve pain like sciatica, and “muscle pain” (in inverted commas because frequently it isn’t actually muscle pain). All these are often perceived by people in the same way, as being in some way mechanical, so the osteopath seems a good choice. On the other hand guts, wombs, lungs, eyes, and things, or immunity, hormones, energy levels, general health, and things, are not perceived as “mechanical” and so not many people would think of going to an osteopath about them. But if you have taken away anything from this series of lessons, I hope it is that osteopathy is not just mechanical, it is also physiological, and that the aim of the osteopath is to improve physiology, vitality and health as a whole. Now, as a colleague of mine has said, the only cure for ill health is health. Paradoxically, as we focus more on health than illness, many experienced osteopaths are very good “problem-solvers” with ill health in general, particularly with those chronic (long term) conditions for which conventional medicine often seems to have little to offer. So it makes sense to see if an osteopath might contribute to your state of health, whatever your specific complaints.

13. And Finally

In the preceding lessons I have told you about MY osteopathy. That is, how I personally have interpreted and taken ownership of this discipline. Other osteopaths would say different things about it. In fact, if you have been to different osteopaths, you might have noticed how they can have different visions of what needs to be done, or they may have given you very different treatments. A wag said that the collective noun for osteopaths is a “disagreement”. But I think I am right in saying there are certain things which are common to most, if not all, of those using the title “osteopath”. What are they?

  1. Manual treatment.
  2. An appreciation of how the workings of the structural tissues of the body influence health.
  3. A tendency to look wider than the immediate area of pain or symptoms.
  4. An appreciation of, and trust in, the self-healing tendency of the body.
  5. An understanding that the health of an area is only as good as its fluid circulation (blood and lymph) and nerve supply.

This is my last “Lesson”. Is this all I have to say? Not at all. But I think what I have said in this series of lessons will have given the reader an overall idea of what osteopathy is all about, at least through my eyes.

Manifesto

This is the manifesto I operate under at my osteopathic practice. When you read it, bear in mind that I am mostly involved in treating more chronic conditions.

I believe in:

  1. Trusting your body’s intelligence. Your body is much more intelligent than my conscious mind. Your body arranges its internal economy to best accommodate a lifetime’s accumulation of trauma and stresses. I cannot tell it how to do that, in what time frame or in what order. I can only help to remove the strain and ensure that your body’s basic needs are met. This is sufficient and complete treatment. The body’s resources are then freed to heal rather than diverted to fight the strain.
  2. Slow, gentle treatment. The body, even under optimal conditions, responds in its own time. You cannot with impunity bend the laws governing biological processes. The best, longest lasting changes are the ones which happen so naturally they are often largely unconscious. They do not take place immediately, but in the days or weeks after treatment.
  3. Supporting the bodies efforts to heal. Stiffness, pain and inflammation are some of the body’s healing responses. Only medicine gone mad would want to smother them completely. A rational system of medicine, on the other hand, works to make them unnecessary by modifying the conditions in which they have developed.
  4. The unity of the organism. A headache isn’t only a head problem, a painful hip isn’t a only hip problem, a gastric ulcer isn’t only a stomach problem. The head, the hip, the stomach are not floating in space divorced from all else. Everything is a global problem.
  5. The only antidote to health problems is health. Also known as vitality. A vital organism responds quickly and efficiently to its health problems. If you have a lingering elbow pain, it is not (usually) just because something is “wrong” with your elbow. Either you are working it too hard for your body reasonably to endure, or your body is insufficiently vital to respond to the injury. The answer is not to treat the elbow, (then the knee, then the shoulder, etc.) but to rest the injured part and work to improve the body’s vital responses.

I do not believe in:

  1. Symptomatic treatment. Symptoms arise in areas of greatest strain. Strain accumulates in these areas because of distortions throughout the body. Treating only the symptomatic area may make it feel better temporarily, but only temporarily. And the overall strain will soon manifest elsewhere, too. So it is better not to treat the bits, but the whole.
  2. Heroic treatment. Things should not be forced with heavy clicks and crunches. A stiff area might be stiff for a good reason (see “Trusting the body’s intelligence” above). In any case, if something needs forcing, it is not ready for release. If and when it becomes ready, based on the body’s own priorities and time-scale, it will not need forcing.
  3. Single treatment cures. See “Slow, gentle treatment” above.
  4. Compartmentalisation and micromanagement. As I have mentioned, your body is intelligent (see “Trusting the body’s intelligence” above). To attempt to manage its every part and function would be presumptuous and ineffectual. It is far preferable to give general treatments rather than treating the minutiae of each painful part.

In conclusion, for those seeking a quick fix in one or two sessions, my place is the wrong place to come. The approach I propose may take longer than you might have envisaged. On the other hand it will be low risk, and it will produce deeper, longer-lasting results to your whole health.