Still’s Osteopathy – its roots and reasoning

Introduction 

ATSTillIn this hopefully provocative set of blogs I will painstakingly examine A.T. Still’s seminal Osteopathic text “The philosophy of Osteopathy”.

My aim is to tease out the roots of our profession and openly discuss his original philosophical axioms with reference to the modern medical era.

Should we discarded Still work as out dated? or are there underlying truths about the human experience that still hold true?

Chapter 1 Medication is not medicine

To begin – even in the preface Still is immediately making his stance very clear, he is utterly opposed to drug driven medicine.

“When I saw others who had not more than skimmed the surface of the science, taking up the pen to write books on Osteopathy, and after having carefully examined their productions, found they were drinking from the fountains of (the) old schools of drugs, dragging back the science to the very systems from which I divorced myself so many years ago, and realized that hungry students were ready to swallow such mental poison, dangerous as it was, I became fully awakened to the necessity of some sort of Osteopathic literature for those wishing to be informed.” (Still, 1899)

It must be admitted here that Modern Osteopathy has long been wedded to the stand point Still was criticising here, due in large part to the profound success of antibiotics in the treatment of bacterial infections, such as cholera, typhus, syphilis, staphylococcus, etc and to a lesser extend to the efficacy of NSAIDs. However with the advent of antibiotic resistant strains of bacteria the time to rethink our adherence to medication driven medicine may have come again.

Still’s horror at medication was due primarily to the use of laudanum and alcohol in the era referred to as ‘heroic medicine’, during and after the American civil war when Still founded Osteopathy. However, Still’s concern for a medicine based on chemical compounds has found advocates in unexpected places in recent times as well.

Danish physician Dr Peter Gotzsche, medical researcher and co-founder of the Cochrane Collaboration, the world’s foremost organisation for the assessment of medical evidence, has stated that our most commonly used drugs, even when used as prescribed, are lethal and cause the death of over 100,000 American’s per year.

Gotzsche warns us off the following drugs; antidepressants as they don’t work, all psycho-active and anti-psychotic drugs for children or the elderly, non-steroidal anti-inflammatories for headaches, arthritis or muscular pain, chemotherapy and drugs for incontinence. A quick reminder here – Gotzsche is a co-founder of the Cochrane Collaboration; the world’s leading medical evidence assessors.

Pain is in the brain – part 2

In part one we were introduced to the work of Dr Michael Moskowitz from the Department of Anaesthesiology and Pain Medicine from the University of California, who has identified eight section of the brain responsible for up regulating the pain sensation in people with chronic pain; posterior cingulate, amygdala, insular, supplementary motor, prefrontal, anterior cingulata, somatosensory and posterior parietal. In Part 1 we had a cursory look at the first four. In the second party we will be addressing prefrontal, anterior cingulate, somatosensory and posterior parental regions involved in pain modulation.

The prefrontal cortex covers the front part of the frontal lobe and is thought to be responsible for executive functions or top down control of behaviour and memory, mimicry and mirror behaviours (Goldman-Rakic, Cools, & Srivastava, 1996).

The role of this part of the brain is of great significant, as this part of the brain appears to be responsible for mapping the connections and controlling behaviour. It remembers what caused pain in the past and it seems to be the part of the brain that provides the expectation that pain will return if the same behaviour is enacted. It is why I ask my clients to walk without stopping for a minimum of 15 minutes and to walk through the pain and as naturally as they can. Eventually this part of the brain will change its focus to other memories and the counter productive muscle guarding patterns and the pain can completely disappear is some instances.

Anterior cingulate is a part of the frontal cortex that wraps like a collar around corpus callous, a central bundle of white matter (like a bundle of electrical wires) dividing the hemispheres of the brain. Important in the autonomic control of blood pressure and heart rate, that increase during episodes of pain, it also plays a part in reward or penalty anticipation and impulse control along with the prefrontal cortex. Learning new activities can be rewarding here.

Located along the post central gyrus of the brain, the somatosensory cortex is responsible for perception of sensory inputs from the body. Home of the sensory homunculus or sensory body map of tactile perceptions, neuroplasticity in this region can cause areas of pain to expand due to the increased sensations being produced there. So the region of the homunculus responsible for the perception of stimuli from a painful knee may increase, while synapses responsible for thigh or calf tactile information may be sheared away. As a consequence providing pain free or pleasurable stimuli to those  regions around the painful site such as the calf or thigh may help reduce the central sensitisation of chronic pain.

Finally the posterior periatal region of the brain is thought to have significant responsibility for planned movements, spatial reason and attention. We can distract this section of the brain by learning a new activity – any activity. A new sport, a new craft or skill. For example learning how to ‘juggle’ can effect the perception of pain in a profound way and for clients open to new experiences,  juggling could be a positive boon.

This blog is in no way comprehensive or heavily researched – it is a grab bag of ideas to inspire and entertain people suffering chronic pain and offer them some hope. People suffering with long term pain should seek help with skilled professional and via your local pain clinic.

Thanks for reading – Laurence

Pain is in the brain – part 1

According to the work of Dr Michael Moskowitz from the Department of Anaesthesiology and Pain Medicine from the University of California, brain scans indicates that pain is perceived in eight section of the brain; posterior cingulate, amygdala, insular, supplementary motor, prefrontal, anterior cingulata, somatosensory and posterior parietal.

In part 1 – I do a relatively brief investigation of the first four regions of the brain involved in pain and postulate how neurones involved in chronic pain might be able to be stolen back.

Each of these regions is responsible for a number of things other than just pain and by encouraging people to engage these other actions and perceptions chronic pain can be down regulated; or as Dr Moskowitz puts it – we can steal back our neurones.

So lets break them down these regions of the brain and start a discussion on how we can help people free themselves from persistent pain.

  1. Anterior cingulate has been referred to as the default mode network of the brain, it is most active when we are daydreaming or in a state of wakeful rest. It is involved in episodic memory retrieval and pain perception (Buckner, Andrews-Hanna, & Schacter, 2008)

Could we daydream our way to a pain free state? Is this section of the brain utilised in meditation? Certainly thinking happy thoughts fits the bill. Not such an easy thing to do when you are in chronic pain.

2. Amygdala is a distinct part of the anterior temporal lobe and a vital part of the limbic system, and is active in memory, decision making and emotional reactions. Larger in men than women, and it is hypothesised it is a critical in evaluating the environment for potential dangers (Amaral, 2006).

As a consequence if we could provide people with a change of environment we might be able to change the focus of the amygdala from pain perception to other risk assessments.

3. The insular cortex is part of the cerebral cortex involved in a wide range of functions from emotional state to homeostasis; these include motor control, self-awareness, cognition, perception and interpersonal interactions, and it is theorised that it is responsible for offering a sense of spiritual certainty; removing all fear of uncertainty (Gschwind & Picard, 2016).

Perhaps this part of the brain could explain why people stubbornly hold onto the belief that the pain is in the tissues that have long since healed?

So many options for treatment here. Interpersonal interaction – changing your friends or how your friends talk to you, learn a new activity, catch your negative self talk, practice positive affirmations, even find religion?

4. Supplementary motor is a part of the cerebral cortex involved in the control of movement and it neurones project directly into the spinal cord. It has been hypothesised that it is involved in control of movement including postural stabilisation, bilateral coordination and sequential movements – and the perception of pain (Graziano & Aflalo, 2007).

This section of the brain is thought to initiate movement independent of external stimuli, and consequently could be a good place to reduce central sensitisation. There are a any number of balance related exercises from simply stating on one leg to standing on a board on a roller. A complex and repeated pattern of these could steal back some vital pathways. Again remember I’m only hypothesising here – all of the management ideas are experimental.

 

 

Osteopathy 2017 – the confluence of the conference

The confluence of concepts that were accepted and genuflect toward were these. Pain is perceived by the brain, signals from the peripheral nervous system are given pain status by the brain – before that they are just signals. The brain screens out 90% of all signaling from the peripheral nerves. Sensations from the periphery can be inhibited or up regulated by the nervous system at the nerve root or in nine separate sections of the brain. If a signal from the periphery can be up-regulated so can it down regulated. The regions of the brain involved in this process are; posterior cingulate, amygdala, insula, supplementary motor, prefrontal, anterior cingulata, somatosensory and posterior parietal. I will go into the specific roles of these sections of the brain in my next post.

Each of these regions governs differing behaviour and thought processes  – if we increase those behaviours and thoughts  – those apart from pain – we can down regulate pain.

In neuroplasticity, as in somatoplasticity, we know three things. Repetition builds super pathways (practice makes perfect). Change is unbelievably rapid if it is emotionally embraced  – imagine how felt about a partner just before they betrayed you, and then just after you caught them betraying you – so sudden and so complete? Yes. Thirdly and I would propose most importantly, although there are a 100 billion neurological connections in our brains that number is a set and full, so when a part of our brain starts to think something new – it has to discards another possible connection. If you factor these things together you stumble upon the chance of sudden transformation. Lightening transformations.

Think about it – what we think about we think about more, we can change what we think/believe in seconds and every new thought makes some other thought redundant. Such a powerful force  – for positive or negative outcomes.

These are the realisations inherent in this year’s national conference. That is the confluence of study over the last 60 years. I can never recollect a time when our science has so clearly and explicitly stated that ‘with our thoughts we make the world’. Nor has the effect of our determination to be positive or negative been so clearly marked and generally accepted.

 

National Conference – Auckland 2017

The annual conference always creates interest for me where there are inconsistencies; rather than in the confluence of ideas that typifies the experience; I’m drawn toward the break downs; the notional clashes.

My first point of interest is the significant disagreement between speakers on the use of questionnaires. The effusive Phil Parker deconstructed a number of questionnaires in a stinging rebuke of their negative psychological focus, while Micheal Mulholland ended the conference singing their praises as fundamental tools in the management of chronic pain. My thoughts are that many of the government’s questionnaires need review and should be used selectively and even in an edited form.

Doctor Iain Bell’s presentation existed almost in a bubble all it’s own, without reference or even comprehension of the underlying message of the entire conference; that being that pain happens in the brain and that nociception in the peripheral tissues itself is not pain. Furthermore, Bell’s work didn’t even make mention of how little pathology correspond to pain and yet so much of his proposed interventions where to address pain rather than the physical pathologies that they were actually addressing.

Jim Webb, a physio who worked for Manchester City in the premier league for decades, provided a tremendous presentation on the end of cryotherapy in the treatment of acute injury. Despite Webb’s damning evidence of the efficacy of ice therapy, Mulholland wound up the conference maintaining the use of RICE (Rest Ice Compression and Elevation) for acute injury. I’ve doubted the efficacy of ice for many years and I was reassured by Webb work on the issue.

As an Osteopath I was much relieved by the final presentation on AT Still, that drew me back to the structural nature of my profession. Still believed that many illnesses can be treated successfully by normalising the anatomical structures. A good deal of the conference was about how cognitive behavioural therapy and grammatical correct communication is vital to the treatment of chronic illness. I have no issue with having a positive and amusing approach but for me our power remains in how hands on we are.

The biggest inconsistency for me was restricting the perception of pain into only two distinct types, acute and chronic. There is a complex and dynamic set of processes that weave acute and chronic pain together. Furthermore tissues we perceive to hold long term pain can be hypertonic or hypotonic, they can be cold or hot, they can vary wildly and it’s that palpatory differentiation between these states that is so very important to appropriate treatment.

 

 

 

 

 

 

 

 

 

 

Osteopaths – what makes them special

I am regularly asked what is the difference between an osteopath and a chiropractor; or a physiotherapist and an osteopath. The usual scripted answer is philosophy; and osteopaths do have an axiomatic set of principles that guide their work. However, thats not what really sets osteopaths apart. Chiropractors, physiotherapists and osteopaths all have five years of university training, each is taught the same clinical assessment skill, special orthopaedic assessments, neurological assessments, and simple active, passive and active resisted range of motion assessments. What differentiates an osteopath as a manual therapist can be summed up in two words; palpatory assessment – they focus of their examine is by touch.

This is not to say that chiropractors, physiotherapists don’t touch people or use this sense to assess but osteopaths from their very first class are taught to focus on their palpatory assessment. Osteopaths are taught to assess TART; texture, asymmetry, range of motion and tenderness in a very palpatory way. Texture and tenderness are obviously about touch sensation but osteopaths are interested in how the range of motion feels; its end feel, the quality of the movement in their hands and the feeling of symmetry in the tissues under their hands. Over many years of practice the hands of the osteopath become palposcopes capable of perceiving the integrity of bones and ligaments, the quality of the vascular perfusion of tissues, the neurological integrity as well as the tonicity of muscles and tendons. Studies indicate that after 20 years of practice something extraordinary seems to happen to osteopaths – their bookings and earns suddenly increase substantially (Orrock, PJ 2009, ‘Profile of members of the Australian Osteopathic Association: part 1 – the practitioners’, International Journal of Osteopathic Medicine, vol. 12, no. 1, pp. 14-24.). What is the driver behind this profound change hasn’t been thoroughly teased out but palpatory knowledge must be high on the list of causes.

The same is true of treatment as well as assessment, chiropractors, adjustment trained physiotherapists and osteopaths are all trained to stretching, massage, adjust and perform muscle energy techniques and they all have access to and prescribe exercise regimes – what differentiates the professions is the focus. What is important? Cavitating joints? The exact degree of movement a joint ? Or how it feels to move for both the practitioner and the patient. For the experienced and well regarded osteopath the answer is the last of these. It is their aim above all to assist their patient to find pain free movement as a basis for their recuperation and prolonged quality of life.

 

Neck pain

Neck pain, headaches and radiating pain in the arms requires a thorough history and clinical examination, and Laurie enjoys these aspects of his practice. A good quality history allows the client time to explain their complaint in detail. Laurie has also tutored in clinic assessment and his knowledge of clinical, neurological, orthopaedic testing is of a university standard.

Diagnosis may also require referral for imaging and Laurie likes to work with general practitioners to ensure that these test are thorough and affordable for the patient.

Neck pain can be divided into primarily musculoskeletal causes, neurological causes, and combination neurological-musculoskeletal. Differentiating between the primary cause of the complaint requires experience and a good knowledge of the structures involved. Laurie has been working on bodies for 20 years and his knowledge allowed him to graduate as the graduate of the year.

If you would like to look at the complexity involved in neck assessment and management  please follow the link. clinicalkey to neck and arm pain

 

Lower back pain

Lower back pain (LBP) is suffered by a large majority of people in our society, and it can and does ruin the quality of their lives. There are a host of pathologies that have been implicated in acute lower back pain; everything from cancer to spinal stenosis, from disc herniation to reactive arthritis. Being able to differentiate between these diagnostically is absolutely imperative for appropriate referral and correct treatment and management. That is where osteopaths, physiotherapists and exercise physiologists working together with radiologists have such a vital role to play.

However lower back pain isn’t just restricted to individuals with identifiable pathologies, in fact a great many cases of lower back pain have no identifiable pathological cause and are referred to as simple mechanical lower back pain. Of all the interventions exercise has the strongest evidence base, and Laurie prescribes exercises and stretches for this condition. That said a great deal of study is going in to the relief of lower back pain, particularly chronic LBP and where more exact identification of the specific somatic dysfunction is possible, adjustment and soft tissue treatments, may well be highly cost effective. Larger studies to prove this are underway.

 

Laurie encourages clients to read the guidelines for the management of lower back pain and to stay active, stay warm and well hydrated.

http://www.aafp.org/patient-care/clinical-recommendations/all/back-pain.html

Knee pain

In Lismore the prevalence of knee pain and injury is significant due to the age of the residents, the large number of people involved in sports and the increasing number of full knee replacements (FKR) being undertaken by the populous.

Laurence Axtens – Osteopath follows up to date practices and procedures in knee assessment and management. Click the above text to see the latest information base.

Correct diagnosis is vital and a thorough knowledge of the anatomy and biomechanics of the knee provides clients with appropriate referral, good quality treatment and a doable and fun exercise program. Apart from fulfilling the requirement of the Osteopathic Masters in anatomy and physiology with high distinction, Laurie has also tutored in both these subjects.

Patients are encouraged should they have ever suffered knee pain or are involved in sports that place their knees at risk to read the information at the following link. basic-knee-injury-prevention.