Il Dottor Andrew Still (1828-1917) era un uomo straordinario con molteplici abilità ed interessi. Da giovane, crescendo in Virginia (Stati Uniti) negli anni 1830 e 1840, era un abile cacciatore e le prede fornivano non solo la cena alla famiglia, ma anche il materiale per soddisfare la sua crescente curiosità per il corpo e la sua anatomia. La vita rurale di quell’epoca era per persone di stampo indipendente ed autosufficiente, e Still imparò presto tutto sull'agricoltura e sulla costruzione. Passati gli anni, Still ottene la qualifica in medicina, e si arruolò come chirurgo per le forze abolizioniste durante la guerra civile Americana.

Verso la fine della sua vita Still scrisse varie opere. Come scrittore, se non sofisticato, era sicuramente ispirato, con senso dell’ umorismo e nello stesso tempo ironico e compassionevole. Le sue osservazioni sull'osteopatia e sull’istruzione osteopatica impiegano liberamente metafore venatorie, agricole, militari e dell’ingenieria. Era filosofo, umorista, eccentrico, originale.

Il Dottor Still era un uomo con una missione. Il fatto che i farmaci chimici non protessero i suoi giovani figli dalla meningite, lo indusse a ricercare tenacemente, senza alcun aiuto e con l’ ostacolo dei colleghi, una metodica medica nuova e migliore. Come tanto odiò i farmaci chimici, così tanto fermamente credette nella saggezza della natura, che invoca ripetutamente nei suoi scritti. Erano degli anni di pratica ambulante, sperimentando e sviluppando il suo metodo e le sue idee. Lui “lanciò alla brezza lo stendardo dell’ Osteopatia” nel 1874, fondando la prima scuola di osteopatia in Kirksville, Missouri, nel 1892.

La grande idea del Dottor Still era semplice, intuitiva e profonda. Fin da ragazzo aveva scoperto, provando su se stesso, che delle azioni meccaniche avrebbero potuto curare sintomi fisici. In un’occasione notò che appoggiando la parte posteriore del collo sul sedile di un’altalena, gli riduceva il mal di testa. Si meravigliava dell’intricata struttura muscoloscheletrica dei piccoli animali che osservava, notando come ogni piccola parte fosse disegnata perfettamente per il suo ruolo. Anni dopo dichiarò: “La struttura governa la funzione”. La sua esperienza di medico lo convinse ad asserire che il corpo possiede la capacità di autoguarigione, ma che i disordini meccanici potevano compromettere tale capacità. Era convinto che il trattamento manuale avrebbe potuto riportare l’anatomia al suo stato funzionale.

Il Dr. Still era assolutista. Non disse che il disturbo meccanico fosse solo una causa possibile di patologia, ma che era la causa sottostante tutta la patologia. Credeva che una dettagliata conoscenza dell’anatomia e “il coltello della ragione” fossere gli attrezzi fondamentali, necessari e sufficienti per curare qualunque malato.

"Lo studente di osteopatia deve imparare che la sua prima lezione è l'anatomia, la sua ultima lezione è l'anatomia, e tutte le sue lezioni sono l’anatomia."

Nel mondo di Still l’esistenza del Creatore e della Sua sagezza infinita erano fondamentali. Spesso, fa riferimento al "Maestro Meccanico". Frequentamente invoca la saggezza della natura, e si è obbligati a chiedere se Dio e la natura non fossero intimamente connessi nella mente di Still. Ripetutamente Still propone che la malattia non esisterebbe in un corpo perfetto – perfetto dal punto di vista meccanico, si intende – la natura non sarebbe stata cosí sciocca.

Il mondo di quell'epoca era dominato dal pensiero meccanicistico, e Still era affascinato dagli avanzamenti tecnologici (che all'epoca – l’epoca della rivoluzione industriale nel vecchio continente - erano maggiormente di tipo meccanico-termodinamico). I modelli conoscitivi erano lineari: per ogni fenomeno si cercava di tracciare una linea netta tra una singola causa e un singolo effetto, come una biella che collega il pistone all’albero motore.

L'ingegneria è guidata dalla fisica Newtoniana, per la quale il funzionamento dell'universo era determinato e descritto da leggi naturali. Il desiderio di cercare e trovare delle leggi naturali immutabili, oltre che all'ingegneria, si allargò ad altri campi della scienza. Questa tendenza dell’epoca spiega la necessita sentita ed espressa ripetutamente da Still, di considerare la macchina umana in termini di "leggi naturali immutabili", e la malatia in termini di una non osservanza di queste leggi. Still voleva costruire un sistema medico basato sulla ragione, in contrasto con l’ empirismo della medicina dell’ epoca. La “scienza” per Still significava l’uso rigoroso del pensiero razionale, basandosi sui fatti “evidenti da se”, ovvero l’anatomia.

L'eziologia di tutte le malattie, secondo Still, viene espressa in uno dei suoi aforismi più conosciuti: "La regola dell'arteria è suprema". La salute dipende dalla libera circolazione ed interscambio dei fluidi: il sangue arterioso e venoso, la linfa, i fluidi intracellulare ed interstiziale, il fluido cefalorachidiano, ed il citoplasma nervoso. I fluidi nutrono, forniscono ossigeno, trasportano le cellule del sistema immunologico, e drennano i tessuti, portando via gli scarti metabolici e biologici. Se la circolazione dei fluidi viene ostacolata, per esempio da un muscolo troppo teso o da un osso fissato in una posizione anormale, la parte del corpo rifornito o drennato da quella circolazione si ammalerà. Still chiamava i fluidi fisiologici “i fiumi della vita”.

Still dava molto importanza anche alla fascia, il matrice di tessuto connetivo che mantiene la nostra forma. Quando la definì il “terreno di caccia” dove cercare il principio della malattia come pure il mezzo della sua cura, era in anticipo di 100 anni rispetto alla scienza biomedica. Infatti, oggi la scienza moderna riconosce i ruoli che gioca la fascia nel sistema immunitario e per la circolazione dei fluidi.

Esistono poche notizie sulle tecniche adoperate dal Dottor Still; lui stesso non le descrisse nelle sue opere. Dai racconti disponibili, le sue tecniche erano molto semplici. Molti trattamenti venivano effettuati col paziente seduto o in piedi, e lui inventò le sue tecniche li sul posto, secondo la necessità e secondo le circostanze. Sappiamo che utilizzò delle tecniche articolatorie, sfruttava il posizionamento ed il principio delle leve, ed adoperò quello che oggi viene chiamato “tecnica indiretta”. Impiegò molto tempo lavorando i tessuti molli, anche diverse sessioni, prima di tentare qualsiasi correzione osteo-articolare. Disprezzò il massaggio non-specifico, che paragono alla pulizia superficiale di un motore, piuttosto della correzione del guasto meccanico al suo interno. Crede nell'applicare il minimo trattamento necessario per corregere la lesione: “Trovatela, aggiustatela, e poi lasciatela stare”.

Il Dottor Still insistette sulla base razionale della la sua nuova medicina, riconobbe l'importanza del componente somatico delle malattie, non accettò nessuna dogma né aderò a nessuna ortodossia, abbondò di pensieri originali, non riconobbe nessun limite, era un entusiasta. Riconobbe che il suo sistema nuovo era nella sua infanzia e che si sarebbe sviluppato enormemente negli anni dopo la sua morte, e cosi è successo sia scientificamente che dal punto di vista tecnico. Tuttavia, malgrado la semplicità dell'idea originali e dei metodi originali, questi hanno fornito il contributo principale all’operato di moltissimi osteopati nelle generazioni successive, con un successo eccezionale.

Dei molti aforismi del Vecchio Dottore, il mio preferito è quello che credo esprime meglio il senso, e l'essenza del successo, della terapia manuale osteopatica. Il detto è il suo più semplice: "Movimento è vita".

Many people reading this will perhaps be surprised to learn that according to scientists the evidence for much of osteopathy is weak. In fact, it has only unequivocally been proven effective for low back pain.

Let me take a step back and take a brief look at the early history of osteopathy, and the nature of modern science, before coming back to add some qualifications to the surprising sentence above. I will then take the bull by the horns and face the question of how one can justify the provision of "unproven" treatments. Finally, I will consider the scientific future of osteopathy.

Early history of osteopathy

Osteopathy developed in the latter part of the 19th. century as a reaction to the irrational, brutal and dangerous medical treatments of the time, which employed the use of strong poisons and heavy blood-letting. The practice of osteopathy, in contrast to the orthodox medicine of the time, was based on the rational application of an encompassing theory. The founder of osteopathy, Andrew Still, used the word "scientific" to describe the application of reason within in an ordered system of notions, a use of the word which today would  be regarded as erroneous. "Science" today is defined instead by the use of experiments to test whether our hypotheses (formally stated ideas) are correct.

The experimental method

Modern science uses the experimental method. This is how it works:

Firstly, a hypothesis (or precisely formulated and testable proposition about a specific thing or phenomenon) is formulated based on some phenomenon that has been repeatedly but more or less informally observed. This hypothesis is then put to the test in an experiment. Good experimental design requires careful thought to avoid fatal errors such as: (1) not testing what one thinks one is testing; (2) introducing bias into the experiment; (3) failing to control confounding variables; (4) producing meaningless (uninterpretable) results. Experimental results are often in the form of numerical data. These need to be analysed using special statistical tests to establish whether or not they deviate significantly from what one could expect by pure chance. If there is a statistically significant deviation in the direction predicted by the hypothesis, the hypothesis is confirmed. But not proven: proof is only established if the study design was good, and the results consistently repeatable by similarly well-designed experiments.

This method has been perfected in the proving of pharmaceutical drugs. In this special case, the "gold standard" of clinical research into the effectiveness of drugs is called the "randomised controlled trial" (RCT). "Controlled" refers to the fact that the improvement in a given condition that occurs in patients taking the drug is compared with a "control" group of people with the same condition who have not taken the drug. Usually this group of people is given a placebo: something that looks exactly like the real drug but is in fact pharmacologically inactive. A feature of these trials is that they are usually "double blind", which means that neither the personnel dispensing the medicine/placebo, nor the patients themselves, know who is getting the real drug and who is getting the placebo. This avoids what is called "bias" in the results due to psychological influences. The numbers of patients needed for experiments of this kind are large, typically hundreds. This is so that, firstly, your experimental sample is reasonably representative of the general population of people with the same disease, and secondly, the analysis of the results may be statistically meaningful.

Notwithstanding the success of the RCT in the study of medicinal drugs, it may not be such an appropriate method in the study of other medical systems such as osteopathy. I discuss below the two most important reasons why this may be so:

1. Classification of illness

Orthodox medicine classifies illness according to a system of "named diseases" i.e. it pigeon-holes and labels illness. In trials, drugs are tested for named diseases. But this approach is alien to osteopathy. Osteopathy does not ask, "What disease does this patient have?", but rather, "Why did this person become ill?" Osteopathy considers each case of an ill person as unique, recognising that the variation between cases is infinite. Thus whereas drug trials use samples of hundreds or thousands of patients with the "same" disease, osteopathy deals with unique samples of one! This is not to say that a trial could not be designed to test the hypothesis that osteopathy is effective, say, for "people with vertigo". But it does have important implications for the selection of suitable experimental subjects.

2. Patient selection

Responsible practitioners of any discipline would not claim to be able to cure all of the people all of the time, even those suffering from minor complaints. Many will respond well to treatment, some won't. This is as true of osteopathy as it is of drug medicine. Clinicians and drug trials have to try to select which patients are likely to benefit. Drug trials select patients for inclusion by setting strict criteria based on age and the absence of complicating conditions or factors. On the other hand, in osteopathy it is the individual osteopath who must decide whether a single patient will benefit from his or her treatment, based on the myriad circumstances which, taken together, are unique to that person. It is inevitable, and I would say to the good, that to a degree such decisions rely on experience and instinct as well as the rational consideration of distinct features such as age, general health, and gravity of illness. But the important point I wish to make about this is that in the clinical setting patients are taken on according to criteria which are not fixed and are to a degree unique to the time, the place and the people present (individual patient, individual osteopath). A conventional "trial" of osteopathic treatment "for vertigo" would have a sample of trial participants selected according to standardised criteria which in no way reflect clinical decisions. All you might prove with such a trial is the inadequacy of the experimental method employed.

3. The human dimension

There is a human dimension to real medicine which osteopathy celebrates. Patients are individuals as are osteopaths, and no two encounters are the same. The number of factors influencing the outcome of each encounter and the course of treatment are innumerable. In osteopathy, it is virtually impossible to separate out the specific effects of method and technique, from the specific effects of the individual osteopath's personality, and the non-specific effects of human contact and touch-based treatment. Until research methods have been perfected which can address this major limitation of RCTs, the interpretation of results from research into the efficacy of osteopathy will remain uncertain.

The ethics of offering "unproven" treatments

Scientists and sceptics often argue that it is unethical to offer to the paying public treatments which are unproven by science. They say scientific method is the established "gold standard" for determining "what we know". An extreme view is that no treatment should be available that does not have this mark of approval. Some even say, according to this reasoning, that osteopaths are fools or cheats to go on offering many of the kinds of treatments that they do. (Remember, it has only been "proved" effective for low back pain).

Here are some counter arguments:

1. Evidence-shackled or evidence-guided practice?

One interpretation of evidence-based medicine (EBM) that is doing the rounds is that nothing unproven should be offered as treatment. To me this is evidence-shackled medicine. Absence of proof is not proof of ineffectiveness. There are several reasons why the extreme interpretation above is flawed. My own sense is that a more enlightened interpretation, or evidence-guided medicine, would mean:

• Treatments proven unequivocally to fail would be abandoned.


• Treatments proven to pose an unacceptable risk of adverse effects would be abandoned.

However, in my mind it would be insane to abandon treatments believed to be effective by patients and practitioners simply because scientific proof of efficacy is currently lacking.

2. The hierarchy of evidence

It is considered that there is a hierarchy of evidence with the best being that from good quality scientific experiments (specifically randomised controlled trials) and the worst being word-of-mouth (anecdote). Between these extremes there come such forms of evidence as:

• Lesser quality scientific studies such as "pilot studies" (preliminary studies using small numbers of patients) and uncontrolled experiments (where there is no control group to compare the treatment group with).


• Case studies (formal studies of single cases) and case series (a series of case studies of patients with the "same" condition).


• Supporting evidence of plausibility from closely related fields e.g. physiology.


• Expert consensus.


• Individual experience.

There is a valid argument for allowing reference to evidence that is lower in the hierarchy if better quality evidence is unavailable or inconclusive. Even personal anecdote (the least reliable form of evidence, when taken singly) becomes worthy of consideration if overwhelming. Compelling anecdotal evidence of benefit is one reason why it was deemed political to formally recognise and regulate osteopathy by the 1993 act of parliament.

There is also an argument for accepting different levels of evidence according to the real possibility of carrying out the kinds of studies involved. To obtain unequivocal evidence from repeated, good quality RCTs is very expensive. Osteopathic organisations do not have the resources of the pharmaceutical industry. Of necessity, studies will be smaller and progress slower. (It is interesting to note that even with the vast resources at the disposal of the pharmas, RCTs of non-steroidal anti-inflammatory drugs - often with methodological flaws - only prove a "small" effect for low back pain: Pepijn D. D. M. et al. Nonsteroidal Anti-Inflammatory Drugs for Low Back Pain: An Updated Cochrane Review. Published 08/13/2008 on Medscape - accessed 08/10/2009).

Osteopathy at present is at the intermediate stage in terms of the quality of evidence gathered: what we have mostly is anecdote, experience, supporting evidence of plausibility and evidence from small scale pilot studies.

3. The devaluation of experience

It seems to me that one of the things that patients value most highly in a practitioner is experience. Paradoxically, the knowledge that comes by experience is one of the least valued by science, only a notch above anecdote. It is almost scorned.

The answer to this apparent paradox is that the meeting been health professional and patient does not take place either in the laboratory or in the ivory tower of "pure" science, but "at the coal face" and in the here and now. Science has not explained everything about the workings of the body and the mind. This means that inevitably there will be many decisions at every therapeutic encounter that are guided by experience, either in part or in whole. If such decisions were expunged from medicine, as some propose, medicine's fabric would be very thin indeed.

4. Dogma is the enemy of truth

It is a fair criticism of osteopathy that historically it has relied on dogma more than scientific enquiry. Science is a threat to dogma, and many a beautiful theory has been shattered by a brutal fact. We should abandon dogma and forever seek the truth. On the other hand there exists a current in the scientific establishment that expounds another kind of dogma, which says: "Nothing that science does not know has any validity", and: "There is nothing worth knowing that science cannot know". It seems to me that this position is just as unbalanced as the one which ignores or denies an inconvenient scientific fact in favour of a beloved theory. There is though, between these attitudes, a place where sense reigns, a green vale spread out between the rocky peaks of radical scepticism and the mire of dogged belief.

5. It is evidence-shackled medicine that is abnormal

Clinical psychology, dentistry, physiotherapy, and surgery are some of the orthodox health professions that mix experience with science. This is normal and healthy in what are considered respectable professions. While it is inevitable and appropriate that all health professions will move to expand and be guided by a scientific evidence base, it would be damaging and wrong to limit current practice to methods which have already been scientifically proven, as proposed by a vocal minority of scientists and doctors.

The medical reality is that, depending on the branch of medicine and on the limitations of the studies undertaken, between 30% and 89% of current orthodox medical practice is not based on gold-standard scientific evidence, and between 3% and 58% is not supported by any scientific evidence at all. (Andrew Booth, http://www.shef.ac.uk/scharr/ir/percent.html - accessed 05/08/2009).

6. Dangers to patients

The following argument has sometimes been used against osteopathy: that by treating people with osteopathy we are putting patients' health at risk by delaying "proper" treatment.

To this I would simply point out that while iatrogenic illness (illness caused by doctors, hospitals and medicines) is known to be a large percentage of all illness, the indications are that serious adverse effects from osteopathic treatment are extremely rare.

7. The provision of an alternative

There has been a tendency of late to regard osteopathy as complementary medicine. It goes without saying that there are conditions which, by way of severity or urgency, require medical treatment or surgery. There are other situations however in which osteopaths would affirm that osteopathy is the best treatment. So, if one takes complementary to mean "each in its own place" in the spectrum of illness, I would agree. There are other kinds of conditions in which both pharmaceutical drugs and osteopathy, or both surgery and osteopathy, may usefully combine to the benefit of the patient. Again, complementary well describes this situation.

On the other hand, it could be argued that once drugs or surgery are really and truly required, the body's capacity for self-healing has degenerated past the stage where it may be rallied. Before that stage, when the self-regulatory processes of the body may be appealed to, osteopathy and natural hygiene are perfectly adequate on their own. Here they provide an alternative model of healthcare for the increasing numbers of people who are not persuaded by the orthodox one.

8. Patient choice

Where I reside (one of the archetypal "alternative" social environments) many people would be appalled if they were one day not to be allowed to receive the particular forms of healing they believe in, no matter how fantastic these may appear in other people's eyes. Now I do not for a minute suggest that osteopathy should be compared with some of these practices. There are all kinds of them, most of which I would say are devoid of any rational basis at all. But I would resolutely defend their right to exist, because in any society people's beliefs are important, and, so long as they cause no harm, are worthy of respect.

The scientific future of osteopathy

As a profession osteopathy has relied for too long solely on authority opinion, tradition and experience as sources for its knowledge base. This has led to the transmission down through generations of osteopaths, of useless methods along with the useful ones. Greater attention to the scientific basis of knowledge will help to separate the wheat from the chaff. Science is sufficiently versatile to be able to develop methods of research that are suitable for assessing complex interventions like osteopathy. Osteopathy is currently moving in this direction, and will inevitably continue to do so. This can only be a good thing for patients and for osteopathy. But for the reasons set out in this essay, we should reject the extreme "evidence-shackled" position that is propounded by some.

The originator of osteopathy, Andrew Taylor Still (1828 - 1917) developed osteopathy as a medical system providing a radical and rational alternative to the unscientific, brutal, ineffective and dangerous treatment methods of the time. He always intended it to be a treatment for all kinds of conditions, not just those directly involving the joints and muscles. The early osteopaths from the late 19th century until the 1930s held fast to these original ideas.

During the latter half of the 20th century, with increasing efforts by osteopathic organisations to gain acceptance from medical orthodoxy and recognition from government, there became established in the profession an overwhelming emphasis on the treatment of musculoskeletal conditions, along with an attitude of embarrassment about any notions of a wider scope of osteopathy in treating other conditions. However, a few diehard osteopaths did not relinquish the original idea, and more recently there has been a revival in interest in this side of our work, an interest which I share.

But how can osteopathic treatment possibly affect the inner body?

First of all, osteopathy makes reference to a basic underlying principle which states that the organism functions as an integrated whole. Every single part affects the whole; every single function affects the whole function. This may sound like a reasonable general theory, but how could it work in practice?

There are two different methods which have been proposed and used by osteopaths as treatments for non-musculoskeletal conditions: (1) Manipulation of the muscles and bones to affect the internal organs. (2) Direct manipulation of the internal organs to affect their function.

The internal organs are attached to the musculoskeletal system which surrounds them by a kind of connective tissue called “fascia”. This same tissue also connects the organs to each other. The existence of these connections raises the possibility that things such as poor posture, abnormal spinal curves (scoliosis, hyperkyphosis), and abnormal muscle tension may not only affect the spatial arrangement of the internal organs, but set up abnormal restrictions and tensions between and within them. Adhesions from surgical procedures, infection and inflammation, may also do this. Osteopaths postulate that the ability of the internal organs to function well is influenced by their freedom to move (the rhythmic movements of the digestive system is a clear example) or to be moved (in response to normal breathing, for example) in their normal ways. Movement is essential for certain organs to perform their specific functions (e.g. the digestive tract) and promotes fluid, nutrient and waste-product exchange between tissues, all of which are essential for their health. Thus, the release of restrictions to normal movement, within the musculoskeletal system, between the latter and the internal organs, and between different internal organs is thought potentially to improve their function and their health.

There is also a fundamentally important connection between the musculoskeletal system and the internal organs by way of the nervous system. The nervous system is one of the major control systems of the body. (The others are the mind, the hormonal system and the immune system, all of which are intimately connected). One could think of the nerves as “information highways”. It is well-known in medicine that pain and/or muscle spasm in certain areas of the body may reflect disease in specific internal organs. Osteopaths say that the opposite also occurs: that disorders of the musculoskeletal system, particularly those affecting the spine, may influence the functions of the internal organs via the nervous system. Osteopaths recognise an entity which they call a “somatic dysfunction”, which comprises disorder in vertebral mobility/position, associated muscle tension, and localised vascular changes suggesting associated nervous excitation (such as a localised increase in reddening of the skin when pressed). Osteopaths reason that the nervous excitation affects not only the superficial blood vessels, but also the internal organs connected by nerves to the same spinal level, as well as their blood supply. So correction of the spinal dysfunction should correct the internal one, too.

Is all this plausible?

From a strictly theoretical point of view, considering human anatomy and its general workings, it is a possibility. On the other hand, medical science has strict criteria for allowing a proposition as scientifically plausible. The proposed mechanisms involved must have been demonstrated even if the final outcome has not been. For example, even though it may not be scientifically demonstrated that spinal manipulation can effectively treat problems of the internal organs, to allow plausibility, it should have been demonstrated that:

• The internal organs receive and respond to nerve signals from the muscles and joints of the spine.


• Spinal dysfunction can cause changes in the internal organs.

What's the evidence?

There is at present no good quality scientific evidence for effect or for the plausibility of the proposed mechanisms by which osteopathy might help non-musculoskeletal problems.

Please see my article science and osteopathy for a consideration of some of the difficulties with evidence and scientific proofs.

What's my personal experience?

Most of my patients come to me about musculoskeletal complaints, and when I started practice I only treated these kinds of complaints. However, I began to notice that patients who I had treated regularly for chronic complaints over longer time periods (over 12 months) reported that long term complaints other than the ones they came for seemed to have improved. After many of these experiences, I eventually began to offer treatment for other kinds of complaints in selected patients.

Specifically, my experience to date in the field of non-musculoskeletal complaints has been in the treatment of:

• Vertigo, in cases where no medical cause has been established. I have quite extensive experience here, and benefits have usually been apparent.


• Asthma. Osteopathy seems to improve patients’ breathing. It is not a substitute for medication.


• Dysmenorrhoea (period pains). Only a few cases, treated with osteopathy and herbs. More improvements than failures. It is not possible for me to say whether the positive effects are attributable to osteopathy or herbal treatment.

So, do I treat non-musculoskeletal conditions?

Yes I do, in selected cases, if there are compelling clinical grounds for believing that osteopathy could help. That is, I will be prepared to carry out treatment if two conditions are satisfied:-

(a) The physical examination produces findings of treatable dysfunction that could reasonably explain the patient's condition.

(b) There is no evidence of predominant other causes for the condition in the case in question.

In these cases, I will explain my reasoning to the patient, making clear however, that there is little scientific support for this kind of treatment.

An acrobat rang me one Monday and asked for an appointment for his colleague who had injured his shoulder and had to do a show the next Saturday. I backpeddled. You cannot impose deadlines on nature. I said I couldn't see him until Friday (true), so it wasn't likely I could get him better by Saturday, I suggested he go to his doctor in the meantime. "Mmm", came down the telephone line, and I could sense the implied scorn for doctors and medicine. He accepted the Friday appointment. The colleague didn't turn up, as I had half expected.

I do not like this kind of work, and I do not say this in a mean way, it is just not really the job I have chosen. I have chosen to be an osteopath and this is not, in my opinion, osteopathic work. Let me explain. It is a common scenario with athletes, for example. They've "done themselves in" last Saturday or in training and they have to play next Saturday. If they are professionals, like the acrobats, they put injuries on the balance sheet of their careers as an accepted risk, for which they plan with adequate preparation and conditioning, and with full medical support. Or they should. If they are amatuers, there is a certain element of the "self-inflicted" about injuries: rarely is physical conditioning as it should be in order to engage in the chosen activity. Either way though, the demands placed upon the body by having at all costs to play when injured, goes very fundamentally against nature's attempts at healing.

The first medical principle is, "Do no harm", and in osteopathy this translates as, "Do nothing to hinder nature's own efforts at cure". Let us stop to consider for a moment, "What is illness (and hence needs treatment)?" Say the acrobat had recently strained his shoulder, it became painful and difficult to move. Is this an illness? No, inflammation is a healing response of the body, and pain on movement is the central nervous system telling you to rest the affected part. What is the most logical, natural way to respond to assist healing? It is so simple: rest the part and wait. Do nothing else. It will heal.

There are two possible human objections to this reasoning (not my reasoning, nature's!): (1) But it hurts very very much and I can't stand it. (2) But I have to work because I have to eat and I'm not so wealthy I can afford not too. I understand and sympathise with these arguments, and there is a ready made solution: it is called orthodox, allopathic medicine. If you need to, or want to go against nature and get a quick fix, osteopathy is not for you, medicine is.

On the other hand, you do have a choice. Consider what will happen if, by some miracle of manipulation, or under the influence of anti-inflammatories, the acrobat is able to return to work pain-free but with an incompletely healed shoulder. (1) He/she will probably worsen the original injury. (2) If this becomes a pattern and anti-inflammatories are used so the acrobat can train and work, he/she may develop gastrointestinal disturbances and other side-effects, some of which could be serious. (3) It is demonstrated that long term anti-inflammatory use destroys joint cartilage (and if that's not ironical I don't know what is). (4) Gradually the body will develop altered movement and postural patterns to compensate for the limitations produced by the original injury, leading to further problems elsewhere in the body. Now, I do not say never take an anti-inflammatory. It is just that there is sensible use and there is abuse, and the latter is rife.

So, I have said the best treatment for acute, recent strains is "do nothing", meaning that rest and time will heal. Heat / cold may be used sensibly to help (not hinder) nature's healing efforts. When then, does that point come when we can speak of "illness"? When should treatment be sought? This point is when it becomes evident that healing has stalled. After the initial acute symptoms (a few days), there should normally be a gradual return to normal. However, if the improvement levels out, if symptoms linger, something is impeding healing. This is illness, this is when treatment is useful. When dealing with musculoskeletal strains and mild sprains, two weeks is a useful "rule-of-thumb" measure of when you should, naturally, be feeling better. In any case, a return to the activity that caused the problem should be taken in easy steps, with suitable pre-conditioning. This latter is an excellent reason to seek advice, rather than looking for a quick fix to short-circuit the natural process of healing.

Nella sua opera Osteopathy, Research and Practice (1910), il creatore di osteopatia, Dr. AT Still, scrisse:

Si chiede, "come si deve tirare un osso per metterlo al suo posto?" Io rispondo, tirarlo al suo proprio posto e lascialo li. Uno vi consiglia di tirare tutte le ossa che cercate di aggiustare finché non “schioccano”. Quel schiocco non è un criterio da seguire. Le ossa non sempre “schioccano” quando rientrano in sede, né significa che sono aggiustate bene quando “schioccano”. Se vi tirate un dito, sentirete un rumore. La separazione rapida e forzata delle superficie terminali delle ossa che formano l'articolazione causa un vacum, e l'aria che entra nell'articolazione dall'intorno per riempire il vacum provoca il rumore esplosivo. Questo è tutto il significato del “schiocco”, che viene caricato con grande significato dal paziente, che pensa che i tentativi di correzione sono stati efficaci. L'osteopata non dovrebbe incoraggiare quest'idea del suo paziente, come se dimostrasse qualcosa riuscita.

Il lettore è pregato di rileggere l'ultima riga: L'osteopata non dovrebbe incoraggiare quest'idea del suo paziente.

Sto scrivendo questo articolo nella esasperazione. Ancora un altro paziente che mi consulta si aspetta e desidera che faccio un "crack" alla schiena. I pazienti che si aspettano solo questo sono quelli che sono stati precedentemente da altri osteopati. I pazienti che sono stati trattati da altra osteopati quasi sempre vogliono che faccio "crack" alle loro colonne vertebrali.

Credono che qualcosa sia "fuori posto" (la "causa" del loro dolore) e dovrebbe essere "rimesso al suo posto", evidenziato da un rumore suggestivo, per il grande sollievo di tutti noi. Ma le vertebre non vanno "fuori" e "dentro" come qualche specie di giocattolo meccanico antico. La colonna vertebrale a volte schiocca, a volta subisce danni da sovraccarico o distorsione, a volta schiocca al momento che subisce un danno, ma lo schiocco non significa nulla. Le colonna vertebrali sono complicate. Sono intelligenti. Imparano dei comportamenti che possono essere più o meno funzionali. Sono delle biomacchine comandato da sistemi informatici, sono sofisticate e complesse, non sono dei giocattoli meccanici. Colpirebbe il suo computer portatile con una mazza?

L'osteopata non dovrebbe incoraggiare quest'idea del suo paziente.

Perché alcuni dei miei colleghi fanno questo? Perché gli viene insegnato questo? Non ho una risposta a queste domande. Posso solo spiegare il mio atteggiamento, generalmente negativo, rispetto a queste tecniche.

Le tecniche che fanno scroccare le ossa ("thrust" o "tecniche ad impulso di alta velocità e bassa ampiezza") non sono stati particolarmente evidente nell'osteopatia originale. Infatti il Dottor Still, come anche il Dottor Littlejohn (allievo di Still e fondatore della British School of Osteopathy), sembrava più inclino utilizzare altri tipi di tecniche. I thrust sono diventati più prominenti nel corso del Novecento, nella misura che oggi i laureati di alcune scuole sembrano utilizzarli come standard, e di essere a conoscenza di poco altro nel vasto armamentario osteopatico. A dire il vero, ci si presentano alcune occasioni in cui la rapida riduzione del dolore acuto che i thrust a volte sono in grado di produrre, non può essere prodotta da altri tipi di tecniche. È anche veloce, risparmiando tempo per il professionista indaffarato, che dovrebbe comunque effettuare un trattamento più completo. Ma soprattutto credo che la sua popolarità derive dal rumore prodotto quando le articolazioni vengono aperte rapidamente, che risulta in qualche modo psicologicamente soddisfacente per entrambi paziente e osteopata. La sensazione che qualche obiettivo è stato raggiunto.

L'osteopata non dovrebbe incoraggiare quest'idea del suo paziente.

Ma i thrust presentano degli svantaggi importanti. Personalmente, io tratto principalmente dei casi cronici ("cronico" = sintomi di più di sei mesi di durata). Nei casi cronici osso i thrust sono praticamente inutili (eccetto per le eventuali riacutizzazioni), e possono anche far male. Infatti ho visto un buon numero di pazienti che precedentemente sono stati danneggiati, o che credono di essere stati danneggiati, dalle manipolazioni thrust imprudenti, goffi, ripetuti con eccessiva frequenza, o "sparate nel buio".

La disfunzione cronica nei tessuti è caratterizzata dalla rigidità di lunga data, e dall'abitudine radicata. Essa coinvolge tutto il corpo nelle attivazioni muscolari, le posture e gli schemi di movimento compensatori. Anche questi diventano delle abitudini radicate. Per questo il trattamento dei problemi croniche dovrebbe essere visto come uno "svolgimento" graduale, dolce di tutto il corpo, non come un mettere "al loro posto" dei pezzi anatomici isolati. L'idea stessa farebbe sorridere, se non facesse piangere il fatto che alcuni dei miei colleghi la incoraggiano nei loro pazienti. Perché...

L'osteopata non dovrebbe incoraggiare quest'idea del suo paziente.

Come tecnica il thrust si presta all'applicazione in base a criteri sbagliati, come "manipolare la parte dolorosa" o "manipolare la parte rigida" o semplicemente "manipolare per fare un bel rumore soddisfacente", senza prendere in considerazione il schema globale dell'organismo. "La parte dolorosa" o "la parte rigida" raramente ha una causa prettamente locale. Il lavoro vitale di "svolgere" il schema globale non viene mai fatto, se l'attenzione è focalizzata sulle singole parti in isolamento, o sulla produzione di "click" soddisfacenti o illusorie soluzioni rapide.

I tessuti biologici non devono mai essere costretti o forzati. Se una parte deve essere forzata al fine di "aggiustarla", essa non è pronta per essere "aggiustata". Quando sarà pronta, non avrà bisogno di essere forzata. Perché utilizzare i thrust quando esistono alternative più dolci, efficaci e senza rischi? Esso sfida il buon senso e, direi contrasta con la pratica terapeutica responsabile.

Purtroppo, la risalita del thrust è stata tale che molte persone identificano l'osteopatia con questa tecnica. Ho una paziente molto soddisfatto che una volta disse ad un suo amico che era stato da un osteopata (il sottoscritto) per il suo mal di schiena. "Ha schioccato la tua schiena?" domandò l'amico. "No? Devi essere sbagliato allora. Egli non può essere un osteopata." Un altro paziente, un pilota di rally, mi ha chiesto dopo il suo primo trattamento, "Non hai intenzione di manipolare la mia schiena?" Spiegai che avevo appena trascorso mezz'ora facendo proprio questo. "Ma so che un osteopata bravo fa sempre schioccare la colonna vertebrale", disse. Io suggerii quindi che sarebbe meglio che andasse da un osteopata bravo.

L'osteopatia è definito dal suo approccio alla soluzione dei problemi umani, non dalle tecniche.

L'osteopata non dovrebbe incoraggiare quest'idea del suo paziente.

It is a frequent occurrence that a patient comes to me and, after the preliminaries, on asked the reason for the consultation (or even before), the first response is to get out x-ray or scan results or to give me their medical diagnosis. There is initial incomprehension when I say, "For the moment let's leave aside your diagnosis, tell me instead what it is I can help you with?" My assumption is that if a patient has come to me as an osteopath, it is because he or she is looking for an alternative, not more of the same i.e. the same system of diagnostic pidgeon-holing and magic bullets which has failed them so far. Therefore, to start by recounting to me as an osteopath what the medical diagnosis is, rather than what your suffering is and the reason for your seeking help in the first place, seems to me paradoxical.

The bare fact is that there are fundamental differences between the osteopathic mindset and the conventional medical mindset. I would even go so far as to say they are incompatible. Here is a brief synopsis of the reasons why:

The medical mindset believes all people are the same: exactly the same in fact as that hypothetical average person that drug trials say might get better 80% of the time on those pink pills. It assumes this person to be an assembly of parts which have little to do with each other: so you go to the gastroenterologist for your gut and the dermatologist for your skin, the proctologist for your butt and the orthopod for your elbow. Medicine is fixated on what it calls "disease". It believes all diseases are different and is happiest if they can all be well-separated in little boxes with neat labels. Diseases are caused by distinct, preferably single, well-defined aggressions on the organism and their symptoms are bad, they must be fought and suppressed. It believes there are specific treatments for each symptom or disease. It only really believes in and knows drugs and surgery. Medicine, however, so often concentrates on what is unchangeable. That being so, its only options are to compensate by diverting the physiology, or to suppress symptoms. Medicine asks, "What is the name of this disease?" "What drug can be used to compensate for it or suppress its symptoms?"

In contrast, osteopathy believes that people are all different, they cannot be treated the same way even if they have been given the same "disease label". It assumes people to be whole, intricately sophisticated systems, in which any significant stimulus has potential effects in every cell in the body. Osteopathy believes all ill-health to be fundamentally the same: it is a response, or a lack of response, to external or internal conditions. That is why it is possible to observe predictable progressions through a lifetime, of states of ill-health conventionally considered as quite separate diseases. It is multifactorial: single causes are largely a myth. Symptoms are most usually not bad, they are evidence of positive, necessary, physiological reactions of the body. They should generally be supported, not suppressed, and their reason for existing should be obviated or resolved. Osteopathy does not believe in specific treatments for specific diseases, because the concept of specific disease does not come into its mindset. Osteopathy believes in individualised treatment indicated by characteristics specific to the person, as determined by osteopathic assessment. Osteopathy concentrates on what is changeable, and attempts to effect positive change. It asks, "Why did this person fall from health?" "What can be done to return them to normal function?"

Unfortunately a whole lifetime of cultural "education" has militated against a wholistic understanding of health and disease in the western world. We have been conditioned to believe that "diseases" are discrete, objective, malign entities with single, discrete, objective, malign causes, which have to be "combatted" with chemical drugs or cut out with knives. Osteopathy says there is another viewpoint. This alternative mindset is not considered to be irrefutable "truth", nor is it an unbending dogma. It is however, a preferential stance, which we believe to be more rational, and generally to provide better answers.

Dal punto di vista osteopatico, la decisione sul fare/non fare un intervento di ortodonzia si divide in due parti:

1) La giustificazione in termini di necessità. Se prendiamo come principio base l'idea di non "interferire" con un processo naturale se non è necessario o importante farlo, possiamo chiederci: Qual'è la necessità di questo intervento? E quali sarebbero le conseguenze del non intervenire?

2) I possibili effetti indesiderati del intervento nel medio/lungo periodo.

L'importante è che il bilancio tra queste due considerazioni (rapporto costi/benefici) sia positivo. Ciò che segue è basato sul mio bagaglio conoscitivo ed esperienza come Osteopata. Si tratta per la maggior parte di opinioni, basate sulla teoria, e sull'esperienza collettiva, dato che in molti argomenti mancano degli studi scientifici di buona qualità sui quali basarsi.

Punto primo. La necessità di fare il lavoro.

Per quanto riguarda il lato dentale, ovviamente la voce competente è quello del dentista. Per quanto riguarda il sistema muscolo-scheletrico, è ben saputo che la occlusione dentale ha delle relazioni con delle caratteristiche posturali specifiche. Per esempio, la retrognathia mandibolare (in chiusura della bocca, un cambio di rapporto tra incisivi superiori ed inferiori in orizzontale, con gli incisivi inferiori eccessivamente posteriori) è relazionato con l'estensione occipito-atlantoidea (la testa bascula all'indietro sul collo) e la protrazione del collo/la testa (testa/collo portati in avanti rispetto al tronco).

Questo tipo di "associazione" tra delle carateristiche posturali si possono chiamare "compensazioni". È importante rendersi conto che le compensazioni muscolo-scheletriche locali non succedono in isolamento dal resto del corpo: nel breve o nel medio/lungo periodo si collocano dentro un "modello" compensatorio del corpo intero. L'iperlordosi lombare, per esempio (e tra l'altro, frequentissima), è una manifestazione di questo fenomeno, associandosi con la protrazione del collo/la testa.

Quando si parla del modello posturale globale negli, due errori concettuali sono frequenti:-

1) Che esiste una "disfunzione primaria" che determina tutto il resto.
2) Che se si agisce su una parte "primaria" o "chiave" del complesso, il resto "si risolve".

Il primo argomento, a mio avviso, nella maggior parte dei casi non corrisponde alla realtà, in modo particolare quando stiamo parlando di modelli di lunga evoluzione. È tutt'uno, non esiste una parte più importante dell'altra. Con questo voglio puntualizzare che un'iperlordosi, per esempio, non è "colpa dei denti".

Il secondo argomento è erroneo perché l'inerzia del tutto è più potente dell'influenza indotta dalla modifica di una delle sue parti. Al limite "l'interferenza" locale creerà un altro livello di compensazione sovraimposto sul modello globale preesistente. Comunque, nei bambini e nei ragazzi, il processo della crescita (durante il tempo di crescita che ancora gli rimane) dovrebbe favorire la buona compensazione globale all'eventuale modifica dentale/craniofaciale portata da un intervento ortodontico attento.

Da questi ragionamenti, si può concludere che:
(a) L'ortodonzia può contribuire a promuovere uno sviluppo posturale più "corretto".
(b) L'ortodonzia non è sufficiente, da sola, per promuovere uno sviluppo posturale più "corretto".

Due altri aspetti da considerare, che rendono il problema ancora più complesso:

1) Dietro i modelli posturali esiste un fattore genetico importante. Normalmente i geni ci lasciano un certo lasco, però non possiamo sapere, a priori, fino a che punto sarà possibile modificare la postura.
2) Sarà positivo modificare la postura? Sono scettico sul concetto che ci sia una postura ideale. Esiste un'ampia tolleranza, a livello della specie umana, per le variazioni posturali. All'interno di questa comunque, esistono anche le tolleranze individuali, difficile davalutare. Bisogna valutare quale grado di funzionalità esista già .

Secondo punto: I possibili effetti indesiderati del intervento nel medio/lungo periodo.

Ho accennato a questi nei punti precedenti. Sostanzialmente si tratterebbe dei rischi di:

1) "Correggere" un sistema che è già accettabilmente funzionale.
2) Intervenire localmente senza un intervento sinergico globale.
3) Forzare una modifica localmente quando l'impronta genetica ci limita nel tentativo di modificare il modello globalmente.

I possibili effetti negativi potenzialmente si mediano non solo per via delle compensazioni posturali, ma anche per le risposte neuromuscolari "difensive" allo stimolo anomalo, e per le restrizioni della mobilità suturale a livello cranio-faciale.

In ultima analisi, l'intervento ortodontico può essere positivo anche per la postura se:

• Indicato per motivi di funzionalità dentale o mandibolare.
• Se gli adeguamenti progressivi dell'apparecchio dentale sono effettuate in modo molto lento e graduale.
• Viene abbinato il trattamento osteopatico durante tutto il periodo del intervento ortodontico.

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 osteo-arthritis, have a naturally chronic course. In the case of osteo-arthritis, this is because joint wear is, to an extent, part of the natural aging process. Note however, that 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 worn 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 area 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 excessive load, or improving the organism's handling of it, in various spheres: the mechanical, the psychological and the nutritional. 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 osteopathic treatments plus some brief counselling is not enough. An ongoing effort is required over at least eighteen months is necessary 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 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 touch the symptomatic part, 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 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 osteo-arthritis, has been shown to increase the rate of joint degeneration.

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

To a large degree our health is in our own hands. The worlds most effective medicines are produced by and contained within the body. However, their production and effectiveness depends on certain conditions being met. These are easy, pleasant and cheap things, available to everybody. By achieving these conditions, we can multiply our chances in life of avoiding an uneasy dependence on the quack, the sawbones and the chemical drug peddlars.

1. Nutrition

Hippocrates said, "Let your food be your medicine and your medicine be your food". It should be obvious that the human body can only work effectively and in maximum health with good nutrition. What is less certain is what actually constitutes a "good" diet. When one studies whole populations, the kind of diet that is consistently found to offer sufficient essential nutrients while avoiding the modern nutritional killer diseases such as obesity, heart disease and diabetes, has the following characteristics:

• Relatively small quantities of animal foods.
• Wholegrain cereals.
• Very little refined carbohydrate (e.g. white bread, sugar).
• Abundant vegetables and fruits.

There has been much controversy about the supposed benefits of organic foods, with several studies showing that they do not contain any more essential nutrients than ordinary foods. However, I would maintain that organic foods are still preferable, as they probably contain lower levels of toxic herbicides and pesticides.

Another area of modern research is the individuality of nutritional needs, that is, the idea that different people will function optimally on different kinds of diets. For example, some people may require more animal protein than others. Methods of biochemical typing exist, which attempt to classify people more precisely as to dietary needs.

Another aspect of this individuality is that some people are affected by symptoms of various kinds caused by idiosyncratic intollerances. These may be suspected if medical or psychological causes have been excluded.

Finally, I personally believe that eating foods that are in season, preferably locally grown, will best provide for our dietary needs.

2. Sleep

Sufficient good quality sleep leaves you facing the day refreshed and energetic, so that everything seems easier. On the other hand insuffient or poor quality sleep result in waking up feeling still tired, unable to cope with the tasks of the day effectively. The Sleep Council gives the following tips for a good night's sleep:

• Keep regular hours. Going to bed and getting up at roughly the same time, all the time, will programme your body to sleep better.
• Create a restful sleeping environment. Your bedroom should be kept for rest and sleep and it should be neither too hot, nor too cold; and as quiet and dark as possible.
• Make sure your bed is comfortable. It's difficult to get deep, restful sleep on one that's too soft, too hard, too small or too old.
• Take more exercise. Regular, moderate exercise such as swimming or walking can help relieve the day's stresses and strains. But not too close too bedtime or it may keep you awake!
• Cut down on stimulants such as caffeine in tea or coffee - especially in the evening. They interfere with falling asleep and prevent deep sleep. Have a hot milky drink or herbal tea instead.
• Don't over-indulge. Too much food or alcohol, especially late at night, just before bedtime, can play havoc with sleep patterns. Alcohol may help you fall asleep initially, but will interrupt your sleep later on in the night.
• Don't smoke. Yes, it's bad for sleep, too: smokers take longer to fall asleep, wake more often and often experience more sleep disruption.
• Try to relax before going to bed.. Have a warm bath, listen to some quiet music, do some yoga - all help to relax both the mind and body. Your doctor may be able to recommend a helpful relaxation tape, too.
• Deal with worries or a heavy workload by making lists of things to be tackled the next day.
• If you can't sleep, don't lie there worrying about it. Get up and do something you find relaxing until you feel sleepy again - then go back to bed.

3. Activity

Physical activity is wonderful medicine. It keeps the breathing and circulation efficient, muscles toned and joints mobile, improves the mood and reduces pain by stimulating endorphin production, and favours good quality sleep. People who are chronically inactive can become so unfit that the slightest movement outside their normal range causes discomfort. Everybody should do regular physical activity, according to their age and physical condition. For example, if you do not wish to or cannot practise a sport or go to the gym, a daily fast walk of half an hour is sufficient to produce the above beneficial effects. Any new activity needs to be introduced slowly and gradually, and before beginning, be sure to get a health check with your doctor.

4. Rest and relaxation

In the stress of the modern world, it is important that we get enough rest and relaxation. A stressed body is like an engine in a car running too fast when the car is stationary, and in too low a gear while the car is running: it will soon overheat and wear out. By allowing ourselves time to rest, our body's self-regulatory systems can readjust, allowing us to function well and improving our performance in the tasks we have to perform. Rest and relaxation also allows our mind freedom to roam without any particular aim, and it is in this state of mind that our creative abilities can come to the fore. Many people have found that solutions to problems have arisen spontaneously when they have not actually been thinking of the problem, but allowing their minds free space and time.

5. Sex

Sexual intimacy with the person you love and who loves you of course brings great pleasure and fulfilment, resulting long term in a sense of contentment which permeates your days and your life. But it does more too, at a biological level. Sex increases levels of circulating endorphins, making one feel happier and more peaceful.

6. Laughter

Along with exercise and sex, laughter is the third great natural endorphin booster in our lives. So it's good to indulge in opportunities to make a joke or simply to see the funny side of life.

7. Optimism

It is well established scientifically that on average, optimistic people live longer, healthier lives, and feel greater satisfaction with life. Thus it seems a good life strategy to view oneself, the world and the future in a positive light.

8. Relationships

It is equally well established that the existence of plentiful supportive social relationships is protective against stress and illness. People with little social support tend to have worse health and increased risk of early death.

9. Transcendence

In this category I would put all those aspects of life that nurture feelings of life-purpose, creativity, inspiration and existential joy, some might say "spiritual" aspects. To some this may be a religious feeling, to others the deep joy to be felt listening to music or poetry, contemplating art, experiencing the natural world, or being utterly engaged with one's work.

Ci possono essere vari motivi per cui i clienti si rivolgono da un osteopata:

• Può essere che non sanno nulla dell'osteopatia, ma vogliono solo liberarsi dal dolore, e hanno ricevuto una buona raccomandazione rispetto all'osteopata.
• Può essere che sanno qualcosa dell'osteopatia, e pensano che andrà ad integrare la terapia medica convenzionale della vostra condizione.
• Hanno provato la medicina convenzionale, e non vanno alla ricerca della stessa cosa ancora. Essi sono alla ricerca di una alternativa, e pensano che l'osteopatia può aiutarli.

Spesso mi viene chiesto dai clienti delle prime due categorie, domande come: "Devo prendere qualcosa per il dolore?"

Questo lo trovo interessante. Perché dovrebbe qualcuno andare da un osteopata per chiedere di farmaci?! Forse esiste un'idea equivoca diffusa sull'osteopatia? Gli osteopati sono esperti nel trattamento osteopatico e i suoi benefici terapeutici. Non ci interessiamo della terapia medica convenzionale di piccoli problemi ortopedici (a meno che l'osteopata individuo no scelga questa impostazione). Questo è il motivo per cui siamo osteopati e non medici - vi è una differenza fondamentale!

La maggior parte degli osteopati in Europa (a meno che non sono anche medici) non sono abilitati a fornire consulenza specifica sui medicinali. Tuttavia, mi permetto esprimere qui un giudizio generale. È la mia opinione che:

1. Nessuno può dirle se prendere o no un farmaco, possono solo consigliare, la persona deve decidere per se.

2. Nel caso che voglia "solo liberarsi dolore", prenda la medicina che il Suo medico le prescrive.

3. Però, prenda in considerazione che l'assunzione dei farmaci può impedire la guarigione completa, determinando l'instaurazione di una condizione cronica. Questo succede perché il dolore e l'infiammazione esistono per buoni motivi fisiologici - hanno una funzione guaritrice. Se vengono soppresse, la guarigione sarà incompleta. In secondo luogo, è probabile che le cause meccaniche di fondo del problema rimarono irrisolte perché, liberato (per il momento) da ogni dolore, non vedrà nessuna ragione per cercare una risoluzione più profonda.

Questa può essere una verità scomoda, ma è così: il potere di scelta è nelle vostre mani.

"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 tollerance. Pain sensitivity is how much one perceives pain. Pain tollerance is how much one reacts to it. You could, for example, have high pain sensitivity and low pain tollerance, or vice versa. Pain sensitivity and tollerance 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 sensitized 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 "sensitized"). 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 maladapted (dysfunctional). This happens for example in central sensitization (see above), "neuropathic" pain, and in some cases of chronic pain.

In central sensitization pain results from insignificant stimuli, and is erroneously believed to be from some injury or illness. In neuropathic pain, "sensitized" 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 focussing 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.


June 2, 2011

(This article should be read in conjunction with my article, "Pain").

Sometimes a patient comes to me with the self-made diagnosis of "a bone out of place", and the implied requirement that I "correct its position". Hence the question in the title. The reader who has paid close attention to my site will already know the answer it. It is, "No!"

The idea a "bone out of place" as a common cause of pain in the back or neck should be consigned to history. It was certainly current among the bone-setters of the 19th century, and even the early osteopaths. However, within the more enlightened osteopathic circles it was quickly replaced by more sophisticated models. And in the light of all we now know about the way the spine works and behaves, the notion of a bone "out of place" is simply untenable. And yet some osteopaths and chiropractors still peddle this explanation of pain to their patients. It has come to its maximum expression of the ridiculous in a currently fashionable method (nothing to do with osteopathy or chiropractic, I am happy to say) of "atlas profilax"®. This promises to solve your health problems by correcting the position of your atlas, which it assures you is likely to have been badly positioned since birth. My advice is to save your money.

The idea a "bone out of place" as a common cause of pain is simplistic to the point of being wrong. Why? Here are a few reasons:

1) Osteopaths do recognise abnormal states of the spine, in the absence of any disease, which may be localised (e.g. affecting the immediate area around one vertebra) or more extensive. We call them "dysfunctions". The word "dysfunction" means "not working properly". One of the functions of spine is to allow movement in certain ways and to certain degrees. If it is not doing this normally, it is dysfunctional.

We recognise dysfunction by various palpable and/or visible signs. Some of these are: tension or other abnormalities in the texture of the body tissues (e.g. muscle), asymmetry (e.g. of a vertebra), restriction (of the spinal movement), tenderness to palpation. Sometimes one finds that a specific vertebra seems to be oriented differently from the others, judging from the asymmetrical positions of its bony prominences. However, it is a leap too far to say it is "out of place".

Firstly, the bony prominences of the spine are often naturally asymmetrical. Secondly, even if a whole vertebra is oriented differently from its neighbours, we can still not normally say it is "out of place". "Out of place" means dislocated: a gross displacement with serious tissue injury. Let us take the example of a door which should at this time be shut. Imagine it sticks in its frame so that it cannot be completely closed. It is not off its hinges, it is just stuck in an inappropriate place at an inappropriate time.

The same with the dysfunctional vertebra. Imagine you bend down and twist slightly to pick up an object from the floor. When you straighten up, you feel pain in your low back which wasn't there before. It is quite likely that for some reason a vertebra has not been able fully to regain the erect position appropriate to your erect posture. It is not "out of place", but it is "stuck".

2) Let us go further. This abnormally behaving part which we have called a spinal dysfunction (not a bone out of place!) does not exist in isolation. In anything longer than the short term (a few days at most) it can only be maintained by virtue of its wider relations. The natural tendency of a healthy body is towards the normal. Why then is a dysfunction maintained? Because the wider context (the body) is accommodating it. The problem is not in the individual dysfunction, but the wider dysfunctional pattern involving the whole body. These things are maintained by a complex network of relationships within the body, involving not only the musculoskeletal system, but also the internal organs, the circulatory, nervous, hormonal and immune systems. Within the organism, it also involves the mind, with our thoughts, beliefs and emotions. And outside of the organism the relations extend to our physical and social environments.

Trying to "adjust", in isolation, one part of this system is hopeless, and if done forcefully is asking for trouble. Imagine a twisted piece of string. If you keep it taut and keep twisting, at a certain point it will it will double on itself and a kink will form. Try to straighten the kink and another one will appear elsewhere. This is a good analogy for the behaviour of a single dysfunctional part within a complex whole. (While I am tempted to claim this analogy as my own original, I have to say my thanks go to Kuno Van Der Post for providing it). 3) If I examined ten healthy and symptomless people, I would find a whole array of spinal dysfunctions in all of them. What does this tell us? Firstly, it tells us that at any time all of us have spines which, if examined in minute detail, are not functioning in perfect coordination and harmony. Secondly, it tells us that in many people, most of the time, this situation is perfectly well tollerated. I have a cardinal rule: "If it ain't broke, don't fix it". Spines are extremely complex, intelligent, biological machines. There is are normally ample tollerance limits for less than 100% efficient function. In fact I would say that less than 100% efficient function is the normal condition. I am not more intelligent in the ways of your spine than your spine itself. A significant problem will be made evident by pain or discomfort. If there are no symptoms, hands off!

4) Even if you are suffering pain or discomfort, it is illuminating to realise that a symptom (e.g. pain) has no single cause. It follows that there is no single remedy. I believe that spinal dysfunction can most helpfully be regarded with reference to the "stress" model. "Stress", in popular parlance, has come to mean "feeling under pressure", but in physiology "stress" refers to any demands which threaten to overwhelm the resources of the organism. These can be mechanical (e.g. daily work at a poorly set up work station), physical (e.g. radiation), biological (e.g. a virus), chemical (e.g. drinking water with high levels of heavy metals), or psychological (e.g. conflict in the workplace). The model I work with postulates that when the sum total of demands on the organism exceeds a certain individual threshold, the organism gets sick. Reducing the physical stress on the organism by improving the body's mechanical efficiency is one way (and only one way) in which osteopathy helps. I believe osteopathy also has significant physiological and psychological effects.

Conclusion: It is not about "correcting" the position of bones!


June 2, 2011

I have always thought the most satisfying work is helping people with complex, long-term problems. People naturally become alarmed by sudden episodes of acute pain, but I reassure them that it is normal to suffer from pain or other symptoms from time to time, just as it is normal for them begin to improve of their own accord within a week and to clear up completely within two. If you suffer from time to time, and this is what happens, congratulations, you are healthy, you need no help!

The problem is when the symptoms do not completely clear up, or when they frequently return. This means that for some reason your body has not been able to recover naturally, and so is incorporating the problem into its system and its very identity. In this way, the problem becomes self-maintaining. It is at the first signs that this process may be beginning that you need help, to nip in the bud, or to break the network of vicious cycles which are maintaining the problem.

When Emma first came to see me she was 61 years of age, widowed, a retired nurse. She was suffering from chronic low back and neck pain, the latter of which was accompanied by extreme susceptibility to cold, drafts, posture and sudden movement that she frequently had acute episodes of severe pain. Such was her sense of vulnerability about her neck that she consciously limited her head and neck movements, preferring to turn her whole body instead. Emma had been seeing my colleague at work, a nutritional therapist, for low weight and lack of energy of no pathological basis, as well as anxiety. A further symptom she reported was difficulty swallowing ("dysphagia"), which had been with her for several years, and was a constant source of worry for her, as she imagined that it might be caused by cancer. On the other hand, her fear of the necessary gastroscopic examination of her oesophagus and stomach had been the greater force so far, so she had declined to have it.

X-rays and scans of Emma's spine showed a slippage of the last vertebra at the bottom of her spine ("spondylolisthesis"), moderately serious degeneration and bulging of several intervertebral disks in her low back ("slipped disks"), and osteoarthritis ("wear and tear") of the small spinal joints in her neck. My initial examination found a mildly twisted pelvis, quite severe misalignment and stiffness of the bottom of her spine, a "flat" back with lack of "spring", and a stiff neck which was not helped by her conscious and unconscious "guarding" of it. The latter had produced chronically tight and excitable muscles at the front of her neck.

My first task was to allay her anxiety at the first treatment. "Are you going to crack my back?", she asked, apprehensive. I reassured her that this was not my favourite technique anyway, and that in view of her osteoporosis ("brittle bones") and generally delicate state, I would be treating her very gently.

When helping people with chronic conditions osteopaths have the happy advantage (compared, say with GPs) that as we see the patient over several sessions initially we are able to learn more not only about their condition, but also about them as a person: their hopes and fears, anxieties, aspirations, beliefs, values and demons, their ways of coping and the nature of their relationships, family and social support network. These aspects can often be crucial to a successful outcome from treatment.

From the outset Emma struck me as a gentle, sensitive person beset by worries and imprisoned by a pessimistic view of herself, the world and the future. Positive observations or suggestions were always met with responses beginning, "But.... ". Possible courses of action to improve her situation would invariably be considered "difficult". Pessimism is an important impediment to regaining health. Research shows that pessimism (as opposed to optimism) is associated with poorer outcomes in treatment. So sooner or later the issue must be recognised and tackled if optimum results are to be achieved.

The establishment of a good rapport between patient and therapist is essential before these issues may be broached. It typically takes a few sessions to nurture the necessary respectful confidence. In Emma's case, when this was established, I began to challenge her pessimistic outlook, first gently and obliquely, later more directly.

During the course of this process, we spoke about her worries about her health and her family, and about her desires and aspirations. A major worry for Emma was her dysphagia. I was able to persuade her to take positive action and return to her doctor to book a gastroscopic examination, which she eventually summoned up the courage to undertake. The result was negative and, because the condition was clearly not getting worse, it was labelled as "functional" (i.e. not due to disease) and benign. This set Emma's mind at rest on that score.

Emma was unsatisfied with her health. She was able to accept that no therapist could take responsibility for it. A simple thing which she had been stalling on for a long time, through inertia, pessimism that it would do any good, and fear that it may harm her, was physical activity. The right level of physical activity brings physical and psychological health. Too little or too much, or the wrong kind, can be harmful. Emma was getting too little, which she realised. She needed only a little encouragement and verbal reinforcement of her own decision in order to take the necessary step. During the course of treatment, she signed on for regular group sessions of Pilates exercises, happily with a very competent instructor.

Emma had long retired from nursing, her husband had died, her children had grown up. She felt that she needed to find some purpose in her life. There is a system in the area where Emma lives for older women to volunteer act as helps, companions, baby-sitters and mentors for young working mothers. Emma decided to volunteer and now has a fulfilling, mutually beneficial relationship with her assigned family, which she describes as her second family.

But what of the actual osteopathic treatment? There was nothing unusual about this. Treatment sessions involved whole body treatment tailored to the specific characteristics of her case, aiming to improve mobility, muscle tone and body alignment. A few simple stretching and mobility exercises were taught to be done at home. A simple breathing exercise was taught to promote a normal breathing pattern and to reduce anxiety. The treatment sessions were weekly over six weeks, then a six week break, then weekly again over 4 weeks. After that I saw Emma from once a month to once every three months over 18 months. Now she comes from time to time for specific issues or for a check-up.

The outcome of this process, in which Emma included osteopathic treatment, is that she is now healthier (less pain and stiffness, increase to normal weight), more relaxed, more optimistic and more fulfilled. Osteopathic treatment and a little counselling played their roles, but much of what has been acieved was about her beginning to take positive action to help herself: her own decision to seek help, her recognition that her negative attitude was a hinderance to progress, her decision to complete her medical investigations, to take up Pilates, to offer her help and support to a young mother.


June 2, 2011