An approach to chronic and complex health problems

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 osteoarthritis, have a naturally chronic course. In the case of osteoarthritis, this is because joint degeneration is, to an extent, part of the natural ageing process. Note however, the 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 damaged 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 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, not just the mechanical one. For example, psychological stress and poor nutrition can also contribute to the demands (the “load”) placed upon the organism. 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 manual treatments plus some brief advice is not enough. An ongoing effort is required over at least eighteen months 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 responsibly 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 directly “treat” the symptomatic part at all, 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 that 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 osteoarthritis, has been shown actually to increase the rate of joint degeneration.

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

Pain

“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 tolerance. Pain sensitivity is how much one perceives pain. Pain tolerance is how much one reacts to it. You could, for example, have high pain sensitivity and low pain tolerance, or vice versa. Pain sensitivity and tolerance 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 sensitised 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 “sensitised”). 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 poorly adapted (dysfunctional). This happens for example in central sensitisation (see above), “neuropathic” pain, and in some cases of chronic pain.

In central sensitisation pain results from insignificant stimuli, and is erroneously believed to be from some injury or illness. In neuropathic pain, “sensitised” 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 focusing 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.

Clicks, cracks and crunches: no thanks!

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.

Yet some new patients clearly expect me to make their spines make “cracking” noises. They think something has “clicked out” (the “cause” of their pain) and should be “clicked in”, to the relief of all. And since these are usually people who have previously been to other practitioners, and since they have obviously gained the impression that this is osteopathic reasoning and that the “crack” is what defines an osteopathic treatment, my only conclusion can be that the profession is indeed guilty of “encouraging this idea” in its patients.

But the whole idea is wrong (and it is not osteopathic reasoning). Spines do not click in and out like a broken part of some old-fashioned mechanical toy.
Spines sometimes click. They sometimes strain. Sometimes they click at the same time as they strain. Sometimes they don’t. The click means nothing. Spines are complicated. Spines are intelligent. Spines learn behaviour. They are sophisticated and intricate computer-commanded biomachines, not clockworks. Would you hit your expensive laptop with a hammer when it’s not working properly? Maybe you’d like to, but that wouldn’t solve any problems!

Remember: The osteopath should not encourage this idea in his patient.

So why are some of my colleagues doing this? Are they being taught this themselves? If not, where did they learn it? I have no answer to this. All I can do is explain my own 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 often however, would do better by the patient by 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.

“Bone cracking” has important disadvantages. I treat mainly chronic cases (formally defined as symptoms of more than six months duration). In chronic conditions 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 indiscriminate HVLT manipulation. Sometimes, I fear, it is used as a “shotgun” technique when a practitioner does not know or cannot be bothered to identify clearly what needs to be done.

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 so annoyed 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 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 forcefully 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.

Good practice and good treatment 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.

Osteomyths

1. Osteopathy is a therapeutic technique.

False. Osteopathy is not a “technique”, it is a discipline based on a particular way of thinking about health and ill-health.

2. Osteopathy is a kind of physiotherapy.

False. Physiotherapy is physiotherapy. Osteopathy is osteopathy. Physiotherapy comes from conventional medicine. It thinks in terms of treating this disease or that lesion in this place or that place. Osteopathy comes from a refutation of conventional medical thinking. It thinks in terms of finding global health.

3. Osteopaths are spine specialists.

False. Osteopaths know a lot about bones, muscles, and joints. Some specialise in the treatment of musculoskeletal complaints, others do not.

4. Osteopathy is just for back, joint and muscle problems.

False. Osteopathy has applications in a wide range of health problems, including but not exclusively back, joint and muscle problems. Osteopathy promotes general health. Good general health is an antidote to every health problem.

5. Osteopaths crack your bones.

False. Many use techniques that produce joint noises. Others never do. The osteopathic toolbox is vast. “Cracking” techniques are sometimes useful, but more often than not they are quite unnecessary.

6. Osteopaths try to cure your ailments by manipulation.

False. No doctor or therapist “cures” anything. Your own body heals itself within limits imposed by the nature of the problem and any impediments to self-regulation. Osteopaths help you to remove impediments to self-healing, whether that involves manual treatment or not.

7. Osteopathy is a discipline complementary to medicine.

False, in my opinion. There are many medical practices in direct opposition to osteopathic principles.

8. Osteopaths put your bones back in place.

False. Osteopaths do not do that, except in a few relatively rare circumstances. Osteopaths improve the workings of your body. That is not the same thing.

9. A pain in the neck is caused by a problem in the neck.

False. A pain in the neck is either caused by a short-term physiological reaction to direct trauma (in which case it is not a problem, it is part of the solution), or it is a global problem.

10. I strained my knee playing football. I need osteopathic treatment before the match on Saturday so I can play.

False. You cannot pretend it is osteopathic treatment to bend the laws of physics or disregard natural biological processes. First do no harm. You do not need to play again on Saturday. You need to rest. Otherwise, go to a physiotherapist or a magician!

11. Osteopathy is expensive.

False. My belief is that osteopathy has an excellent cost/benefit relationship. For example, in my experience many spinal surgeries have been avoided by osteopathic treatment. Compare a few hundred euros for a course of osteopathic treatment, with a few thousand for surgery. Osteopathy is for those who value their health and who value quality natural health care.