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Wow! How does that work?

Children are imbued with a sense of wonder. Some people maintain this for the rest of their lives. Do you remember science lessons at school? Some of us found them interesting, some fascinating, some boring. But many of us learned wonderful stuff about a world which was for us mysterious. I am one of those who found science lessons fascinating and who are still filled with wonder at the world. It saddens me that many people, especially people of an “alternative” inclination, have become dismissive or cynical about science.

I remember teaching a technique workshop to a group of osteopathic students. Over lunch, among other less weighty and more amusing matters, we talked about the role of science in therapeutic practice. One of the people present, a mature student who was already an experienced practitioner of shiatsu, expressed the following: “I hope scientists don’t discover any more about anything”.

Unfortunately in my view, there are a significant number of people in the general public and in the holistic healing professions who reject science. I can understand the natural human urge to be defensive about something one perceives as threatening. In my field, science can certainly be considered a threat to cherished beliefs. But it seems to me the suspicion goes beyond this, and runs to a basic misunderstanding of science itself and the people who work with it.

Let me look at some popular negative beliefs about science which pervade the minds many people:

  1. “Science says one thing one day and its opposite the next. Therefore it is unreliable, and we shouldn’t pay it much attention.”
    Wrong. Science, unlike religion, doesn’t pretend to give definitive answers, absolute truths. It seeks the nearest approximation with the best practical tools available at the current time. Alternative hypotheses and better tools are being developed all the time, so naturally enough the answers can change. Another point to be made is that many scientific experiments give equivocal results which can be interpreted in different ways, or results which cannot be consistently reproduced. This doesn’t stop newspapers jumping on any preliminary results in areas in which there is public interest, to produce sensationalist headlines beginning, “Scientists discover…..”. To sell newspapers it helps if this week’s headline says the opposite of last week’s. If you are curious about science, my advice is to read the New Scientist, not the Daily Mail.
  2. Science always arrives late at the truth everybody already knew anyway.
    Wrong. In cases where science validates a long-held belief, it is not true to say “everybody already knew”. They didn’t “know”, they believed. And in many cases science disproves or casts serious doubts on long-held beliefs. Then people say, “Science is too reductionist to understand what is going on” (see point 3 below).
  3. Human beings are complex. Scientific method is too simplistic to investigate human phenomena.
    Wrong. People are extremely ingenious, and scientists are clever people. They can certainly develop methods adequate to investigate complex human phenomena. It isn’t easy but it can be done.
  4. Science cannot answer all questions, or give satisfactory explanations for all phenomena, therefore it is worthless.
    Wrong. It is true that science cannot answer every kind of question; it cannot, for example, prove or disprove the existence of a God. Neither can it, for instance, adequately define “water” in qualitative terms satisfying to the human psyche. It cannot satisfactorily answer the question, “What is our life here for?” These things lie outside the scope of scientific investigation. This represents a limit, but that doesn’t make science worthless. It is invaluable within its extremely wide area of applicability.
  5. Science takes away the wonder of the world.
    Wrong. Scientists share with poets a deep appreciation and a sense of marvel at the natural world, much more so than the average person, which often is what has inspired them to know more through their special line of work.

But it is easy for my generation to misunderstand science because actually, in science lessons we didn’t learn much about science! How so? Well, if for example you learn cool stuff like that there was a 12 m long predatory reptile called Tyrannosaurs rex that roamed the Earth 67 million years ago (Wow!), or how eye colour is determined by the genes, or the nature of water, or how one bacterium becomes a hundred million bacteria, or what a clone is, or how a drone flies… you are learning factual information but you are not learning science. Science is not facts, science is a process by which we can find things out.

We didn’t learn too much about that process during school science lessons in the 1970s, we only learned the information that has derived from it. And we didn’t learn that information gained from scientific work isn’t necessarily the same as facts. There were exceptions, but that was the general case. Things may have changed, but judging from what I read and hear from people around me, I think probably not. Not teaching children about the process of science in science lessons is responsible for a wholesale misunderstanding of science in the majority of people, who do not go onto study it at a higher level. And that misunderstanding is responsible for a widespread tendency to be cynical about or dismissive of science.

It is a pity because essentially the scientific process starts and ends with a sense of wonder. It starts with a “Wow… look at that!” and ends with another “Wow!”, which is also another beginning. In between there is some technical stuff. It goes something like this:

  1. Wow! Look at that! I wonder how that works?
  2. Here’s my theory. I think it works like this.
  3. Let’s carry out some sort of test to see if my theory can explain what we observed.
  4. OK. Now we have some information from our test. Hmm… just looks like a chaotic lot of numbers to me. We need to do some kind of maths to sort it out and see if there’s any meaningful pattern there.
  5. Hey! There is a meaningful pattern, and it seems consistent with my theory! Let’s see if when we do the whole thing again it gives the same sort of result. But let’s make the test bigger, including lots more examples of the thing we are investigating. That way we’ll get more reliable information.
  6. Yeah, same result! Now let’s tell people about it and wait and see if others can confirm what we seem to have found out.
  7. Yes, they can! So, let’s say my theory is right unless any further information contradicts it, then we’ll have to look at things again.
  8. Uh, oh. Look at that! My theory can’t explain that. I wonder how that works then! We might have to change my theory, or even ditch it. Let’s try to come up with a better theory.
  9. Come to think of it, think of all the possibilities this opens up. “Wow!” (Back to Nº1).

So, information isn’t facts. It just informs our current understanding of the world. New information might change that. But much of the general public, the press, and politicians think that science is supposed to “discover” and “prove” absolute, unassailable, timeless facts. This is mistaken. Science does not do that and doesn’t say it does that. That is not what is written on the tin. So it is not fair to be upset with science when it fails to do what it is unrealistic to expect it to do. It still does lots of other good things!

And the mistaken belief that information is the same as facts leads to disastrous results: of the general mistrist in science that we have been talking about.  In one thing though, the cynics have a point. And that is that the orthodoxy, guardian of the scientific consensus, may achieve such an inflated view of its own importance and gravity that it is unreasonably dismissive of new ideas which challenge the orthodox view. Scientists are humans too, and sometimes display the very human tendency to defend their big ideas aggressively and against good reason. But this does not mean, that science, used but not misused, is anything other than a wonderful tool for improving our understanding of our wonderful world. It is not the only way to learn about our world, and it has its limitations, but it still is a wonderful tool.

I will continue to walk the world in childlike awe.

Holism, Spirit, Work, Healing

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Holism is supposed to involve a consideration of body, mind and spirit as one. But what is “spirit”? There are many explanations but to me, while alive on this Earth, I relate it to feelings of joy, deep engagement, enthusiasm, inspiration.

In fact…

Enthusiasm. From Greek theos = god; entheos = possessed by god.

Inspire. From Latin: spirare = breathe, related to spiritus = breath, spirit; inspirare = breathe into.

Thus, a truly inspired work (of whatever form), every task carried out with deep enthusiasm, is a work of the spirit.

On a personal note, I found I had “lost my spirit” while recovering from an accident. I had no enthusiasm and nothing inspired me. Like most people in similar situations, this would tend to add a layer of anxiety. I realised of course, at an intellectual level, that this was not helpful, and yet I could not fully control it, because I had never experienced such a situation before. Now I have come through and am regaining my enthusiasm, and so I know at an experiential level that what happened to my spirit was bound holistically with what was happening with my body.

I reflect that it was probably necessary, as a way of resting both body and mind. Thus, at times like this, one must positively accept a depression of the spirit confident in the knowledge that this is a healing process from which body, mind and spirit can rise again refreshed and regenerated.

(Photo: Inspiration via a temple dome, by dksesh: Sun shining through a temple dome, taken in the Srinivasa temple located at Tividale, Dudley, Midlands, England. Reproduced according to Creative Commons licence CC BY-SA. Downloaded from Wikimedia.)

 

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.

 

What You Need to Be an Osteopath

1. Anatomy. An excellent knowledge of how the body is made is essential. For an osteopath there are three kinds of anatomy. The first is the theory, that is the names, locations, and forms of every body part. The second is what we call functional anatomy, or ‘what things do and how’. Another word for this is ‘physiology’, but osteopaths like the term ‘functional anatomy’ because it relates function with form, which is one of our basic principles. The third kind of anatomy is palpatory anatomy, that is, what all the parts of the body feel like to the hands.

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2. An appreciation of relationships. Relationships between body parts, between form and function, between each part or function and the whole, between the body and the mind, between the body-mind and the outside world. The inseparability of all of these. This is what osteopaths deal in.

3. Problem-solving. The ability to analyse a situation, to see its essential elements, and to understand where and how we may most effectively make changes, is fundamental.

4. Manual skill. We need to attain the same kind of skill level that one sees in expert musicians, for example.

5. Medical knowledge. This enables us to know what not to do in treatment in specific cases, what lifestyle advice is most appropriate, and when to refer a patient to a medical practitioner.

 

(Image by Piotr Siedlecki, from PublicDomainPictures.net)