An osteopathic sea change?

This is a riff on a recent blog by Osteofm because she’s dropped some content and started a conversation that I want to get behind. I’m excited to see her posts, she writes eloquently, displays an aspiring honesty, and her About page is especially to be admired. I support her aim and hope to join her in working “to make osteopaths feel less isolated and more supported” because coming across these posts has helped to do that for me.

There is a sea change coming for osteopathy, she sees it and is honestly and cleverly exploring its boundaries and encouraging conversation around these explorations. So, I was a little taken aback by the title of this post: Bluff your way into the osteopathic zeitgeist. An update – what you need to know in 2016 | osteofm.

It was the word bluff that got me, because it implies posturing and there is more than enough posturing in the osteopathic world already. An overwhelming plethora of answers are available from an osteopathic perspective for any single issue. So much so that bluffing the ‘what’, ‘why’ and ‘when’ of a technique is par for the course.

My own exploration of the sea change Osteofm is exploring is from a Canadian manual osteopathic perspective and I suspect, because manual osteopathy is a comparatively unknown brand here, that there are some Canadian educational challenges the UK osteo’s seem more prepared to face. I’m not going to go into all the headings Osteofm discusses, just the ones to which I have something to add.

Persistent pain is in, chronic pain is out.

As a word usage that is correct, but the bigger point is that persistent pain is, unfortunately, in. It cost’s a lot of money on a personal and societal level for people to remain in pain.

Osteopathic manual practitioners treat people in pain all the time, but at the end of my seven + years of osteopathic education, I could not have given you a good answer to the question “what is pain?” A brief exploration of osteopathic education (and this goes for several other manual therapies) shows a huge deficit in neuroscience, the science needed to effectively answer that question.

There may be reason for that. Exploring the neuroscience of pain has blown the lid off osteopathic presupposition for me and I can no longer attribute a perceived osteopathic cause to a perceived pain symptom. So, though pain is a subject for which word usage is extremely important, simply changing the words without knowing the pain science behind them really is a good example of bluffing.

One of the most accessible ways I found into the subject of pain is from the NOI Group in Australia and their book Explain Pain. It’s lighter reading than say Gifford – Aches and Pains, for which Osteofm kindly shared a review post by Mark Andrews, but what Mark said of Aches and Pains also applies here too.

 “A word of warning however, sacred cows are slaughtered and gurus questioned, if you want to avoid cognitive dissonance then don’t pick it up. If however you are interested in a paradigm shift towards a modern, evidence based approach to musculoskeletal pain and dysfunction I cannot recommend it highly enough.”

Placebo is not a dirty word, but a lively issue for debate.

I’m going to quote Osteofm’s recent update for this section.

“In a recent development, the shine has been taken off some of this excitement by David Colquhoun amongst others. He suggests that our whole understanding of placebo is distorted by years of trials which compare treatment to placebo, but don’t compare those to people who have no intervention at all, real OR sham. He thinks the success attributed to placebo is merely “regression to the mean”, or people who improve with time i.e it’s not some magical placebo effect, those people just would have got better anyway. Read his post  “Placebo effects are weak”. If he’s right, the placebo effect could be vastly overrated, although if the effect is there, it is more likely to work with pain than most other conditions.”

David discusses the concept of regression to the mean (RTM) with relation to trials. “The responses seen in the group of patients that are treated with placebo arise from two quite different processes. One is the genuine psychosomatic placebo effect. This effect gives genuine (though small) benefit to the patient. The other contribution comes from the get-better-anyway effect. This is a statistical artefact and it provides no benefit whatsoever to patients. There is now increasing evidence that the latter effect is much bigger than the former.”

Not being particularly comfortable with statistical formula (the book Statistic’s Without Tears made me cry) the concept can be somewhat difficult to integrate. What is clear, however, is that RTM should be taken into account when reviewing or critiquing any complimentary alternative medicine (CAM) study.

For a bit more of an in depth look at the concept and its application here and here are a couple of sites that provide simple and complex examples and formula’s. Keeping in mind that RTM must be a consideration of CAM trial results it might be helpful to consider that “Almost every measure of behaviour has a chance and a skill component to it” and that RTM involves outcomes that are partly due to chance.

It might also be useful to consider the meaning of placebo effect. A placebo is a treatment (pill or other type of therapy) that is considered inert and in that way should have no measurable effect on considered symptoms. The placebo effect is a positive response in that symptoms that have no earthly reason to be relieved by an inert treatment are relieved after the patient is given that treatment. The point really is after, and not because of the treatment.

As with any initially hyped concept, considering the impact of RTM on placebo effect should give pause for context, for clearer heads and hard questions. Without applying RTM the placebo effect is made up of the whole non-specific treatment result of any given trial and has become somewhat mythical in status as not just a part of every manual treatment, but perhaps one of the most important parts.

In his book The Placebo Effect in Manual Therapy, Brian Fulton states of trial control groups that had symptom improvement when given inert substances “Clearly, something is going on with the patient’s own healing system.” The book’s perspective includes tapping into the patient’s own healing abilities in order to maximize the effect. Taking RTM into account in manual therapy studies that, let’s be honest, largely do not have study designs or analysis that can overcome the phenomenon means that a positive therapeutic effect should not be confused with a ‘healing’ effect that would occur whether we could tap into their system or not.

If RTM is not considered there are larger ethical questions that should go with the hype. These questions may not be applicable in every situation, but should not be ignored in any situation where a therapist is essentially acknowledging that if a placebo effect exists, the treatment effect is essentially inert. If that is the case then maximising the placebo effect involves deception. In his book Healing, Hype, or Harm?: A Critical Analysis of Complementary or Alternative Medicine, Eddie Ernst suggests that “… in order (for CAM) to maximise the placebo effect, it will be important to lie to the patient as much as possible …”. This might be reasonable if the patient was in the middle of a trial for which they had provided informed consent, but is not reasonable if the patient is paying for the treatment. 

“Evidence-Based” is still there, but “Evidence-Informed” is more appropriate, and “Real Evidence-Based” is your trump card. If you want a curve ball, “Values-based” is the brand new kid on the block.

Though Tricia Greenhalgh isn’t writing her critique of EBM for the benefit of CAM she eloquently points out many of its problems. So does the Science-Based Medicine group who claim to provide a “… much needed “alternative” perspective — the scientific perspective.” Like Greenhalgh they are not shy in pointing out the limitations of EBM, but include a perspective that Greenhalgh does not: “The idea of SBM is not to compete with EBM, but a call to enhance it with a broader view: to answer the question “what works?” we must give more importance to our cumulative scientific knowledge from all relevant disciplines.” These two perspectives are not antithetical to each other but provide a fuller picture of the problems and solutions related to current uses of EBM.

Neither of these perspectives is inherently supportive of CAM just because it is critical of EBM but for some reason criticism from within the scientific community arms the CAM crowd with what they consider ammunition in order to dismiss the “where’s the evidence” question to any healthcare claims being made. I’ve seen this paper dropped several times by osteo’s to avoid answering or to justify not answering the evidence question, and here’s why that’s just plain wrong. There is a considerable amount of the osteopathic community that actively dismisses EBM or the scientific method because these concepts are not kind to osteopathy. Nor should they be. They are neither kind or unkind. They are methods, perspectives and procedures, which brings me to the next point.

Biopsychosocial sounds so much more serious than holistic.

And that’s because it is. But it is also a framework. An approach and a perspective that has a definition the world holistic can’t match. Though holistic contains within it a concept that a human being is multi-dimensional, there isn’t much of a structure beyond that.

From an osteopathic perspective a holistic treatment does take into account systems and their interaction, but much of that account is based on anatomy, observation and conjecture. So sure, I can connect treatment of the cranial system to health benefits for the immune system, but I can’t tell you for sure that these connections with relation to my treatment actually exist. Science and research doesn’t tend to support these kind of system connections in the same way osteopathic presumption does.

While Osteofm describes a play on words (read between the lines), I’m going to just get blunt and describe a complete 180 in concept. Taking on a BPS perspective in a pain science context puts current osteopathic explanations into the ‘curiosities’ box quite quickly. As was noted before “…sacred cows are slaughtered and gurus questioned.” Treating the whole person is too vague to be a useful concept in healthcare. It could mean simply touching almost every part of the patient or it could include those system connections I alluded to before. It could mean anything and everything.

Biopsychosocial, however, has some definition to it.

“The biopsychosocial model is both a philosophy of clinical care and a practical clinical guide. Philosophically, it is a way of understanding how suffering, disease, and illness are affected by multiple levels of organization, from the societal to the molecular. At the practical level, it is a way of understanding the patient’s subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care.”

It is this last part that has a huge impact on the osteopathic manual practitioner. Though manual osteopaths will argue against the following statement, manual osteopathic philosophy and treatment are deeply rooted in a biomedical approach as in ‘I will tell you what is wrong and I will fix what is wrong’. But, if we include the patient in their own experience within a biopsychosocial framework, what I as practitioner ‘think’ is wrong with my patient is very likely the least of it. What I ‘tell’ my patients I ‘think’ is wrong with them may actually be the most detrimental part of the treatment in the long run.

Let me explain. At its most basic level osteopathy sees proper anatomical structure as distinctly related to proper function. So if one hip is considered to be higher than another and shows relative movement deficit there is a probable ’cause’ of pain. Depending on the movement deficit we might then go on to describe it as an upslip, or an SI that is locked, jammed, sheared or compacted. Assurances are provided that we can ‘fix’ this problem, which should in turn alleviate the symptoms. Though symptom alleviation can often be the case we’ve created another problem by providing our patients with a negative vision of their bodies and a sense that they no longer have autonomy over even musculoskeletal issues.

On top of this we now know that structure and function are actually not well correlated for either pain or dysfunction. If MRI and X-ray cannot be used to correlate a visualized spinal stenosis and nerve impingement with pain and dysfunction, what hope do we manual therapists have of confidently assessing a “stuck” SI?

A biopsychosocial approach is not just acknowledgement of a multi-faceted human being, it is an approach that actually includes those multi-faceted aspects in and around the treatment. It means that the patient’s contribution is not just as important as the practitioner’s but so much more important … the most important.

If you are an osteopathic manual practitioner think on that for a moment. What happens if you actually take into account the patient’s own healing ability?

It means you can’t ‘fix’ anything, only they can. Pop goes the ego balloon pretty damn fast because it’s no longer about what you did as a practitioner, but what their system did with what was provided. It doesn’t mean their innate healing system was tapped into, it means the type of stimuli (physical contact, therapeutic interaction) provided was in that situation, the right type of stimuli.

Physiotherapists are getting pretty cool.

What do you mean by getting? Actually Osteofm acknowledges that that some PT’s are cutting edge in the BPS pain science department. There are some in osteopathy and massage therapy riding the cutting edge with them.

For the most part however, osteopathic hypothesis rather than being ahead of its time is stuck in the late 1800’s and has not embraced the revolutionary changes in medicine that have come since then and, like pain science, are still coming thick and fast.

A sea change, a profound or notable transformation, doesn’t happen apropos of nothing. We, the osteopathic practitioners who challenge the presumptions of our profession are the catalysts for that change, and it is long overdue.

I’m going to end with a quote from Osteofm because it’s right on point.

“If as a profession we don’t embrace and accept the times we live in, we are in danger of ending up in a box marked “Nineteenth-century curiosities” along with phrenology and Mesmerism.”