Why Don’t Osteopaths Practise Like Osteopaths?

Dr. Andrew Taylor Still laid down the philosophy and mechanical principles of a whole new approach to medicine at the end of the 19th and beginning of the 20th centuries. He named his new medicine “osteopathy”. Therefore it may be reasonable to assert that one can only claim to practise osteopathy if one works according to the philosophy and mechanical principles that he laid down. Let me be clear: I am not talking about techniques but about philosophy (way of reasoning) and the principles upon which the philosophy is based.

There are counter-arguments to this which may be equally valid. As times change, horizons open and needs change. When Still was developing his approach in the mid and late 19th century Midwest of America, he would have been treating many acute conditions: relatively simple cases of acute injury owing to the physical nature of life in that particular context, as well as acute states of infectious diseases. Such acute conditions have relatively simple aetiologies, which would tend to be compatible with Still’s method of linear reasoning from cause to effect. In the case of injury, the aetiology is usually clear. In the case of infection, Still saw the cause not as external (microbes), but internal to the organism, in terms of mechanical obstructions to blood and lymph flow and nerve action that rendered the organism vulnerable. In either case, clear cause and effect.

However, in recent decades, the major concern in developed countries has been chronic illness, in which it is recognised that the simple cause-effect view is unrealistic. Diseases, especially chronic diseases, are the result of an interaction between the organism and an array of environmental, social and lifestyle factors. That osteopathy had already changed quite early on is to be seen in the teachings of Still’s student, John Martin Littlejohn at the British School of Osteopathy in the early 20th century. Legend has it that the two men had an intense vocal disagreement over aspects of the syllabus Littlejohn had developed. But perhaps what led Littlejohn to deviate from Still’s osteopathy was an intuition about the complex multifactorial nature of disease.

So one reason why osteopaths might not be practising as Still envisaged is “needs change and osteopathy must to adjust to needs”.

There are other potential reasons too. Let us look at a few of them.

Modern osteopaths do not believe the old anecdotes. Still claimed to be able to treat all diseases by manipulation, even obesity. Many find such claims to be far-fetched. The 1918-19 flu pandemic killed 70 million people worldwide. In those days osteopaths routinely treated infectious diseases, not just bad backs, arthritic hips, sore shoulders and such like. This article by osteopath Walter McKone contains many accounts from osteopaths indicating that they obtained much better outcomes with flu patients during the pandemic than did the conventional medicine of the time. But are these accounts reliable, and are they realistic? We know that practitioners of any discipline tend to over-estimate or over-state their outcomes. Then, correlation does not imply causation. Perhaps there were other factors with the osteopathic patients, quite apart from receipt of osteopathic manipulation, for which they fared better: Fresh air? Non-use of aspirin? It is fair to ask whether that golden age of osteopathy – true osteopathy the knowledge of which is now long-lost – is a historical fact or a fanciful myth? I do not know the answer to that.

Nowadays, osteopathic students are taught that they must reflect critically on reports such as those in the influenza article (and critical thinking is a good thing so long as it does not degenerate into knee-jerk scepticism) but they are also taught to be “evidence-based”, and that some kinds of evidence (such as anecdotes) are not really worth the paper they are written on. The only evidence that counts, it seems, comes from randomised controlled clinical trials (RCTs). And yet, if the anecdotes are particularly numerous, should one not at least keep an open mind? This poses a problem, because clinicians are also taught that it is unethical routinely to run experiments on one’s patients. A certain kind of treatment should be given, it is said, only if it is proven (by RCTs). But while this works with standardised medicine, if one considers each patient’s case to be unique, is it not obvious and inevitable that each patient will be an experiment?

They believe the anecdotes but not the mechanism. For example, Still believed that blood flow to the viscera could be substantially affected by musculoskeletal disorder. He reasoned that this was an obvious fact. And yet time and time again what seems like common sense turns out to be wrong. This particular theory has never been demonstrated in any way. And many people who have suffered serious musculoskeletal trauma live long lives with well functioning internal physiology.

They have not been taught about Still’s work and have not read his books. Personally I was never formally taught about Still, nor was it a requirement to read his books. I did that off my own bat once already qualified. In recent years I have read from Still regularly so as to keep the fire of inspiration stoked. Many would never have bothered.

They discount Still’s ideas as irrelevant because they are old-fashioned, because they are over a century old. Old things, they think, cannot have too much modern relevance when we understand vastly much more about how the body works nowadays. I think people who think in this way mistakenly overvalue details, separate pieces of information, and tragically undervalue unifying first principles.

They have been exposed to Still’s ideas but do not understand them. I have heard that Still is difficult to understand. I have never found this. I expect those that say this would also say that that proves I don’t understand. Fair enough, but I find his writing to be clear, down-to-earth and eminently comprehensible (certainly more so than Littlejohn in my mind). Nevertheless, osteopath Richard Douglas has written intriguingly about his theory that for modern osteopaths very important linguistic obstacles stand in the way of understanding Still, in that the meanings of key words have changed radically since Still’s day. See here and here, for example. I have looked into this and reflected upon it, and to be honest I am not convinced that these obstacles are so great as Richard believes. But of course, I don’t understand.

Demand, and laziness. These factors, I think, constitute a major reason. Pain is one of the most unpleasant and disabling kinds of symptom. Consequently musculoskeletal pain is one of the largest contributors to every primary healthcare professional’s workload. The demand for relief is immense. There is money in it. It easily provides a livelihood. It is also relatively uncomplicated work, requiring less reasoning than internal disease, for example. It also allows one to specialise and so limit one’s special diagnostic knowledge to one field. Once practitioners have settled into the comfort zone of musculoskeletal medicine, why (many would reason) bother to venture and explore outside it? It pays the bills. Once a critical mass of osteopaths has begun to think in this way, the profession begins to lose its collective memory that the scope for their work is potentially much greater, and forgets how to apply its philosophy and principles in the rigorous way required to go there. At that point, even if they are pushed by enthusiasm or boredom to do so, they might well lack the confidence. And from this pool of amnesiacs come the next generation of teachers.

Copyright © Robert Hale 2022.

Robert Hale is an osteopath in Santa Eulalia del Rio, Ibiza.