On Clicks, Cracks and Crunches

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 of place» (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 biological machines, not pieces of clockwork. 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 that he’d better go to a «good» osteopath.

Good practice and good treatment is defined by its approach to human problem-solving, not by spectacular technique.

The osteopath should not encourage this idea in his patient.


Copyright (c) Robert Hale 2022. Robert Hale is an Osteopath in Santa Eulalia, Ibiza.

Public domain photo downloaded from https://www.keesler.af.mil/.


Eddie Izzard on bone cracking…

Holistic Medical Systems Do NOT Treat the Cause

I am going to say something controversial. Holistic health systems do not «treat the cause». It is so often stated that they do, in contrast to conventional («allopathic») medicine which «just dispenses drugs and surgery». This is not true. «Finding the cause» is proper to good conventional medicine.

You are feeling weak and tired and your complexion is dull and pale. Your doctor arranges blood tests and it turns out that your blood lacks iron and your red blood cells are few and small. Your doctor prescribes an iron supplement and you begin to feel better. Your doctor has correctly diagnosed that iron deficiency anaemia is the cause of your symptoms. Your doctor goes further. Why are you lacking iron? Is your diet providing sufficient iron? If you are a woman, are your periods very heavy or are you bleeding between periods? Have you abdominal pain? Is there blood in your stools? These are all questions for good conventional medicine. The way it is practised is not always good. But the fact that a doctor may not be thorough does not damn the discipline of medicine as such. Its aim and its technical abilities are geared to finding out a cause. That is its strength and also its blind spot.

It is a blind spot because health and ill health, life itself in fact, are not that simple. To speak of «the cause» is frequently a distorted portrayal of reality. To do so habitually is a symptom of a deeply ingrained, distorted view of the world. Just say that you continued the «why game». Your anaemia, your doctor has found out, has its origin in a bleeding duodenal ulcer. That is successfully treated, but why was it there? From that point on it often becomes a complex interplay of genetic, environmental, behavioural and emotional factors. There is no one cause, it is multifactorial. At this point it should be a question of assessing influences then joining the dots rather than looking for a single cause. But here conventional medicine is inclined to stop in its tracks with a prescription of omeprazol.

Do holistic systems manage better? Perhaps the one that comes closest is true naturopathy (not the mix-and-match assortment of «techniques» that often passes for it), which focuses on diet and lifestyle. A criticism that might be levelled against the typical naturopathic mindset however, is a reluctance sufficiently to acknowledge psychological factors. I believe this to be on the one hand a reaction to the perceived tendency in conventional medicine to brand any unexplained symptoms as «psychological», and on the other the ego tendency of some naturopaths (untrained in clinical psychology or psychotherapy) to convince themselves that with their special insights they can be all things to all people.

What of other disciplines? I will speak of those I know best: osteopathy and acupuncture. The truth is, these systems do not seek out and treat «the cause», instead they find ways of:

  • Reducing strain in the organism so that it can free up resources for self-healing.
  • Improving function in certain parts, systems or domains of the organsim.
  • Improving the body’s interaction with its environment, and its resilience to environmental stressors.
  • Providing psychological cues which promote healing.

But many osteopaths also have a naturopathic mindset and many acupuncturists also have a rounded knowledge in diet and lifestyle from a traditional Chinese perspective, so all in all, they can set up a context for healing both within and without the body.

Copyright (c) Robert Hale 2022. Public domain image from Pixabay.com.

Robert Hale is an osteopath, acupuncturist and naturopath in Santa Eulalia del rio, Ibiza. / Robert Hale es un osteopata, acupunturista, y naturopata en Santa Eulalia del Rio, Ibiza.

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 in the long term.

But why should the initial inflammatory response be inadequate? One reason may be a general lack of vitality. Another frequent reason is that 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 load, or improving the organism’s handling of it, in various spheres, not just the mechanical one. For example, psychological stress, smoking and junk food 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 for 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.

Copyright (c) Robert Hale 2022.

Image: The original uploader was Harrygouvas at Greek Wikipedia, Creative Commons licence CC BY-SA 3.0 , via Wikimedia Commons.

Robert Hale is an osteopath in Santa Eulalia, Ibiza.

Tratamiento del Dolor por Osteopatía y Acupuntura

El alivio del dolor es una gran parte del trabajo de la mayoría de los profesionales de la salud. En mi profesión como profesional sanitario, el tratamiento del dolor es una de mis áreas de especial interés. Déjame contaros un poco sobre el dolor y cómo lo abordo.

Hay dos tipos generales de dolor:

  1. Dolor proveniente de alguna parte dañada del cuerpo («dolor nociceptivo»).
  2. Dolor generado por el sistema nervioso sin daño al cuerpo («dolor neuropático»).

¡Espera! ¿Cómo puede haber dolor sin daño? Bueno, aquí hay un par de maneras. Primer ejemplo: Es posible que haya habido un daño que ahora se ha curado, pero el sistema nervioso no se ha ajustado de nuevo a la normalidad. Segundo ejemplo: El sistema nervioso puede haberse sensibilizado por numerosos traumas físicos u emocionales previos, de modo que produce una respuesta de dolor a estímulos físicos menores. hay que tener en cuenta que todo el dolor se produce en el cerebro, aunque se sienta en el pie, en el estómago o en la cabeza. La diferencia es que en el primer caso está relacionado con un daño actual real y en el segundo caso no lo está.

El primer tipo de dolor (dolor nociceptivo) puede dividirse en dolor proveniente de la estructura externa del cuerpo como la piel, los músculos y las articulaciones («dolor somático») y dolor proveniente de los órganos internos del cuerpo («dolor visceral»). Este último puede ser confuso porque a menudo se experimenta primero en los músculos exteriores del cuerpo. El osteópata está excepcionalmente preparado para distinguir entre estos tipos de dolor, una distinción que es fundamental en su tratamiento.

Arriba dije que el tratamiento del dolor es una de mis áreas de especial interés. Eso no es exacto. Sería más exacto decir que el tratamiento de la persona con dolor es mi área de especialización. La diferencia es que, como terapeuta holístico, trato a las personas, no a los síntomas ni a los enfermedades. Al tratar a la persona, el síntoma desaparece o al menos mejora, lo que indica una mejora en cualquier trastorno subyacente.

Las disciplinas que practico, la osteopatía y la acupuntura, son excelentes para tratar a las personas que padecen el dolor. En mi experiencia, la osteopatía es el tratamiento de elección para la mayoría de los tipos de dolor comunes, mientras que la acupuntura a veces es preferible para ciertos tipos de dolor neuropático y algunos tipos de artritis inflamatoria. En este último caso también haría uso de mis conocimientos de fitoterapia.

Mis estudios formales me han equipado bien para reconocer condiciones que requieren tratamiento médico convencional o que serían mejor manejadas por otros profesionales de la salud. Por ejemplo, mi gran interés es ayudar a las personas con dolor crónico (dolor que ha estado presente durante meses o más), una condición en la que siempre hay factores psicológicos y de comportamiento involucrados. Cuando me di cuenta de esto, hice una curso de Master de tres años en psicología de la salud para poder ayudar mejor a estas personas. Sin embargo, no soy un psicólogo, y si hay problemas de trauma o depresión graves, conflictos emocionales profundos o adicción, entonces recomendaría a un profesional de la salud competente para este aspecto del cuidado de la persona.

Los Dolores Más Comunes

  • Dolor de columna (dolor de espalda o de cuello causado por lesiones menores o degeneración estructural)
  • Tensión muscular
  • Dolor de cabeza (por problemas de la columna cervical o tensión muscular)
  • Tendinitis (del hombro, codo, por ejemplo, codo de tenista, muñeca, rodilla, cadera y tobillo, por ejemplo, tendón de Aquiles)
  • Hombro congelado (capsulitis adhesiva)
  • Artrosis (de la cadera, la rodilla, el tobillo, el hombro, el codo, los dedos de las manos)
  • Dolor en el pie (por ejemplo, dolor plantar, dolor metatarsiano)
  • Ciática
  • Neuralgia braquial (dolor nervioso en el brazo)
  • Esguinces y torceduras
  • Dolor en la caja torácica
Copyright (c) Robert Hale 2022.
Foto de dominio público de Pikist.com. 

Robert Hale ofrece tratamiento para el dolor mediante osteopatía y acupuntura en Santa Eulalia, Ibiza.