Anno Dolore (In the Year of Pain)

A Thoroughly Modern World

The belief system I came away with once I’d finished my osteopathic training was based in traditional teachings from a founder who studied some of the natural sciences, and meshed that knowledge with spiritual convictions. A.T. Still’s influence resonates today with ideas and thoughts that are passed on through the osteopathic profession as the last word, not the first.

Since then, my beliefs have been challenged and I’ve asked aloud some hard questions around the merits of such ‘traditional’ teachings in a thoroughly modern world. Some in my profession have mused as to where I get off not just questioning the greats of my profession, but questioning the teachings themselves. It’s not that I claim any such greatness and so am equal to the challenge; far from it. The world has moved on since Still had his revelations. A good portion of the reasoning he used to explain why manual manipulation helped people with pain, or even medical conditions, is not congruent with current knowledge.

Some of my questions have prompted people to contact me and share their own experiences of cognitive dissonance around an insular osteopathic education and the wider world of science. I recognize their journey, or perhaps they recognize something in mine. They ask what I do differently now compared with what I did before and I’ve had a hard time articulating an answer.

A Need for Context

Some of the difficulty explaining the difference was because the journey wasn’t over. I have since realized that it likely never will be, but there has been a shift that can be marked by time.

For context it might help to have an idea of what I did BC so the AD makes more sense.

My education was from a Canadian private school in a country where osteopathy is relatively unknown and the profession itself is unregulated. Though there are some differences in the education I received versus that provided in other countries through universities and accredited schools, there is enough that is recognizably the same.

There are four main differences in how I practice now, compared to then.

1. How I think of myself
2. How I think of the person in front of me
3. What I do
4. What I don’t do

Keep in mind that the following descriptions are retrospective and unavoidably coloured by how I see my world now.

Before Change

1. How I Think of Myself

I am both great, and terrible.

By great I mean I have powers beyond what I could have imagined. With observation and movement testing I can assess joint alignment and dysfunction. Through skilled palpation I can tell if a colon is rotated and deferentially diagnose a somatovisceral problem – a joint affecting an organ – or a viscerosomatic issue – an organ affecting a joint. I know how the hierarchy of lesions affect one another and in what order they should be treated. If PRM vitality is low, I can boost that and I must in order for the changes I make to hold. A light touch is my greatest asset and a most powerful tool.

Yet terrible because with every person who walks through the door I negotiate a fear I shouldn’t have … will I get it right, will I be able to help them, can I really fix their pain and dysfunction? I am often uncertain in my abilities, always uncertain in any outcome. With so much time spent with my hands in one place on the patient’s body, listening for the correction and return of vitality I think it’s impossible to have done anything for them. I feel bad. Uncertain. Fraudulent.

But they come back and say “I don’t know what you did last time but …” and though I brace for impact, the outcome is good and I’m surprised. Delighted. Relieved. My confidence sours equally as high as it falls. For those who walk out of the door feeling better than they did when they walked through it, I take credit. For those who call the next day in more pain, I relinquish blame. In just one hour I can help them. But in the other 23 hours they could mess that up.

2. How I Think of The Person in Front of Me

If it wasn’t for the person in front of me my powers would be all but useless, so I am grateful. But their human foibles can be demanding. Sometimes they come with answers they’ve researched themselves or that some other (clearly not as skilled) therapist has told them. They tell me what they want treated, because it’s what hurts. They tell me what is and isn’t connected. “Everything’s connected,” I tell them with a knowing smile. I ask them if they know anything about their birth, an untreated trauma that can have a lasting impact.  It’s not their fault; they don’t know that I treat what I find no matter what they say. My training has taught me that I don’t need their story; that it’s a distraction.

They need me. There are not that many of us, and who else but an osteopathic practitioner could find and treat their osteopathic lesions?

Post-education I am the expert and if they have come to me for my expertise then they should listen. I cannot help them if they don’t listen and I want, more than anything, to help them.

3. What I Do

I determine what is physiologically wrong, and I fix it. But first, after my assessment, I explain to the patient the problems they have as I see them. It’s uncanny how many times I can be right on the money and find things wrong in all the places that hurt. I explain the connections, but sometimes it’s too complicated to provide an understanding of what I mean when I say “one of your vertebrae is stuck in rotation.” It cannot be coincidence that their left ankle is so much more restricted than their right given the severe sprain they suffered 17 years ago. It cannot be coincidence that I can trace restriction through muscle, joint, fascia and viscera from their left ankle to their right shoulder, the site of the pain. But not the cause of it.

To fix dysfunction I use an incredible array of techniques. For the rotated ilium alone the choices are almost paralyzing … but can be narrowed depending on the lesion type. Physiological or non-physiological. With or without respect of an axis. Is there a compaction, or just a restriction? I could choose structural or functional normalizations or a mix of the two; muscle energy; GOT; tug; decompaction, distraction; toward ease or toward restriction.

For almost an hour I will shift, tug, unwind, adjust, mobilize, release and balance according to my findings. Then reassess and integrate. I will have, to some degree, treated the whole person. I might provide an exercise or movement for integration, but more likely advise taking it easy for a day or two. Don’t work out, so as not to waste the treatment; the ultimate results of which can be precariously reliant on post-treatment actions.

4. What I Don’t Do

I am not fooled into chasing pain, a symptom for which the underlying cause is often distant to the presentation. I may need to adjust the cuboid bone to treat a headache. The possibilities are endless depending on the presentation, and what I find through palpation.

I won’t let their pain dictate my treatment.

Hold Music …

2010 BC is where the change started and I’ve written several stories about it ^[1]Stories I’ve written: Palpation, Cranial, Lesions, Cognitive Dissonance, for example. An epic struggle where disparate beliefs clash mightily with reason and logic but only one survives. The charge was led by my palpation skills, which could not, even after a valiant struggle, establish they were any better than anyone else’s, or even good enough on their own.

With that failure, everything I could supposedly detect by palpation was left unprotected. Science swept by on thundering hooves and left my osteopathic beliefs bloodied and dying.

2014 AD was a new beginning. After the change reason and science ruled, and everything I thought I knew was fair game.

 

Anno Dolore

1. How I Think of Myself

I am a service provider and I have a different understanding of my place in the larger scheme of healthcare. It’s a smaller, more collaborative role and my expertise is limited by the science I’ve not considered.

There is no longer a delineation between manual therapy professions. Research and science have provided a neurophysiological umbrella under which all manual therapies reside. We can be different in applications of touch, and have different clinical reasoning for that touch depending on our knowledge, but we are not better than one another. Just as some treatments work for people in pain, others fail them, and others still are adequate with room for improvement.

I no longer hold myself responsible for the pain experiences I hear about or give myself credit for any resolution of them (except my own, of course).

There is still uncertainty in both my abilities and their outcome, but that is as it should be. What I do know is just how much I don’t know and that it’s ok, in fact preferable, not to speculate to the point that known science cannot support.

2. How I Think of The Person in Front of Me

I am still grateful for the person in front of me. They come with amazing stories of their struggles with pain. Often they’ve researched the symptoms themselves, or have been provided possibilities of cause and resolution by others in field. They tell me what hurts and if I ask the right questions, they might reveal some contributors like what they believe about their pain, or their body, or what is happening around them or within them when their pain is at its worst.

They are the expert in their experience and it’s my privilege and responsibility to listen without judgement or assumption.

3. What I Do

I try and help the person in front of me make sense of their experience. That might look different depending on the person. I’ve taken to asking if they would like to know more about the neurophysiology, or the other possible contributors to their experience. We proceed depending on their goals. I provide information and resources so the person in front of me might be able to change their experience when I’m not in front of them.

Thanks to my education in massage and osteopathy, I have at my disposal an incredible array of manual techniques. Sometimes a light touch is not the right touch for the time, but often it is. Clinical reasoning can help determine what techniques might be of use in a particular situation. But my clinical reasoning is covered by the neurophysiological umbrella under which touch and movement reside, and comes with a biopsychosocial perspective to help me remember that there are many reasons for any experience. Including resolution of pain after manual therapy.

For almost an hour I provide a service I hope will help someone feel better, and not just right after treatment. Included in that service are movement strategies or modifications that could act as interruptions to associated patterns and habits, or ways to refocus thought and movement away from the pain.

If a person feels better after treatment and they thank me, I thank them back because it could not have occurred without them. I’m just glad that what I did provide was taken up in a positive way.

When the treatment doesn’t meet their expectations I question the treatment. Did I miss, impose, assume too much? Was my clinical reasoning relevant to the situation? Did I over-enthusiastically provide more information than that person was ready to take in?

4. What I Don’t Do

• Attribute more to a person’s experience than they share with me.
  • Their pain is what they say it is, and WHERE they say it is.
• See as abnormal what is really a normal and possibly functionally advantageous adaptation to experiencing pain.
• Provide the person in front of me with problems where none exist.
• Assume that I know the experience of someone I’ve never met before.
• Remember that each time I see a person it’s a snapshot of their life, not a key to it.

After AD

My version of AD is really more of an ideal. Do I meet my own expectations? I wish. Each interaction is a new learning experience, but there are starting to be more times than not when I think I’ve nailed it. And by nailed it I mean provided a treatment that included manual therapy, information and strategies that helped with understanding, had a positive post-treatment effect and offered some hope for future.

But I can’t always mark my time, or theirs, by the year things changed. Having an anniversary like that might start another tradition that could narrow choices. There is not just before and after, there is also now, in between and beyond.

If everything I think I know is fair game then the only certainty I have is that there will be change. In 2017 I’ve started a new educational journey, which will likely impact again how I see myself, the person in front of me, what I do and don’t do.

So far these changes have been necessarily for my benefit. I needed the change, despite or perhaps because of how difficult it was. But now that my ducks are more in a row, so to speak, I can start to think about how these changes might be of benefit (or not) for the person in front of me.

I wonder what the new year will bring.