Friday, November 16, 2007
How fantastic are these machines ! They make some noises, vibrate, send some electric shocks, alter your magnetic field and boost your cellular regeneration ! They are widely use by physiotherapists and other physical therapists.
You may know these machines by the name of TENS, Ultrasound, Sonic wave..
The US and TENS are not really effective
Human kind loves these types of gadgets and tends to rely blindly on it, while their effectiveness is in fact relatively approximative.
TENS (Transcutaneous Electric Nerve Stimulation) does not seem to do much better than a placebo (http://intl.elsevierhealth.com/e-books/pdf/135.pdf)
UltraSound does not do any better, it has been used for more than 35 years in the treatment of musculo-skeletal pain and studies clearly shows that it is not more effective than a placebo treatment (http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=11444997&dopt=AbstractPlus&holding=f1000%2Cf1000m%2Cisrctn).
The machine : a good excuse
These machines are an answer to the inhability of the conventionnal medical field to deal with the dysfunctions of the body classified as musculo-skeletal problems.
The therapist uses the machine as an "excuse" for not being able to help the patient :
"I use the best machine for your pain and yet you do not get better... You really suffer from a chronic problem !"
It sounds much better than saying :
"I can't help you, I don't know what is going on, and my therapeutic competency is really questionable as you are not getting any better".
The machine is used symptomatically
If these machines really help to relax a muscle or an organ, their lack of effectiveness on treatment could rely on the fact that their are not used at the right place ! As we have seen in the previous posts treating the symptom is rarely effective compared to treating the cause. If the patient complains of a chronic knee pain caused by an old ankle injury it might be more interesting and effective to use the US on the ankle rather than on the knee for example.
The machine will always be obsolete, the hand will never be
In 10 years time the most modern machine will look like a prehistoric equipment, and 10 years later it will be the same for the latest model.
The human hand has been used for thousands of years and is still not obsolete ! Far from it ! More and more people seek massages, and other manual therapies.
The Human Hand has fantastic abilities
The hand is able to massage, to drain, to push, to pull, to vibrate, to twist, to be firm, to be soft, to warm up, to cool down, to feel and to adapt to the patient' s body response.
The hand is the part of the body which is the most represented in the cortex (in the brain) this means that it is one of the most sensitive and precise part of your body. It can detect variation of temperature as little as 0.1 Cdeg.
J.P. Barral (One of the most talented Osteopath) says : "The hand is at the Osteopath what the nose is at the Oenologue". It is recognised that wine testers can differenciate and recognise different vignards and different years of production. The Osteopath with a bit of experience can easily pick up old injuries and with more experience can even date them.
The Hand cares the Machine does not
Physical contact is very important. I do believe that during the treatment an Osteopathic hand talks to the patient's body. A treatment is a real physical communication between the patient and the practitioner.
Does the hand of a serial killer around your neck will feel the same than the hand of your lover ? Certainly not ! The "ruffness", stiffness, heavyness, "speedness", clumsyness (actually if it is a real serial killer he may not be that clumsy), coldness(...) will clearly give you a different feeling.
The hand of the practitioner cares about you but the machine does not.
The human hand is definitely winning this contest, no appeal !
Monday, November 12, 2007
The Shoulder is made of 4 joints : the gleno-humeral joint, the acromio-clavicular joint, the sterno-clavicular joint and the scapulo-thoracic "joint".
Adhesive capsulitis or "frozen shoulder" is a retraction and stiffening of the capsule of the gleno-humeral joint. This retraction limits anatomically the range of movement of the G/H joint and therefore limits the shoulder itself.
While all movement are severely impaired, the most limited ones are the abduction, the internal rotation and flexion.
It affects predominently women at the menauposal age. People with diabetes, stroke, lung disease, rheumathoid athritis and heart disease, are at risk. History of a fall or a physical/emotionnal trauma in the previous year is not unusual.
The good news is :
-the recovery is generally good, you should be able to recover more than 90 % of the range of movement.
-it is very unlikely to develop twice on the same shoulder
-women are more often affected than men (good news for us ;))
What is the evolution of the condition and how long does it last ?
There are three stages in this condition :
- the first stage is called the freezing stage :
This stage last from 6 weeks to 9 months. Insidiously the shoulder becomes stiffer and the range of movement is more limited. The patient may feel some pain at night and with any movement involving the affected shoulder. Some discomfort may arise all around the shoulder (neck, upper back, and down the arm) as the three other shoulder joints try to compensate for the lack of movement and pain from the "freezing" joint.
- the second stage is the frozen stage :
The shoulder is now stiff and the range of movement is limited but does not get any worse . During the first part of this stage the shoulder is still quite painful. Slowly the pain decreases unless extreme range of movements are reached but the stiffness remains. This stage lasts for a period between 6 weeks to nine months. At that point muscle pain and tension are clearly felt all around the neck and shoulder area due to compensation/adaptation.
- the third stage is the defreezing stage :
What are the common conventionnal treatments ?
-Cortico-steroid injections are applied locally. The aim is to reduce the inflammation but after a temporary relief the pain comes back and the movement is still restricted.
-Use of anti-inflammatories, parcetamol, muscle relaxant. This does not improve the mobility of the shoulder it merely masks the symptoms and long term use is not advisable.
-Manipulation under aenesthetic : the aim is to stretch and force the shoulder to move while asleep. As your shoulder is generally excruciating as soon as you arrive at the limit of the movement I do not dare to imagine how traumatising it is for the tissue and the surrounding structure. Risk of tearing the capsule exists, which enhances the presence of scar tissue and therefore limits the movement of the shoulder even more in the long run.
The outcome is uncertain, if you choose to have it done you need to be regular and disciplined with the following up physiotherapy treatments
-Physiotherapy : the physio will give you different exercises, may mobilise the shoulder and use various "machines" on the shoulder (TENS, sonic wave, electro-stimuation... welcome to the 21st century !)
What can I expect from osteopathic treatment?
As each Osteopath is different and they practice differently, I will describe the way I approach and "treat" frozen shoulder.
In general I believe that pain should be avoided at all cost !
Because as soon as the pain is experienced all the muscles protecting the shoulder will tense up and this will definitely not help the patient to relax and recover some mobility.
While the treament approach of the shoulder itself will depend on what stage the patient is at, the aim is first of all to treat and realign the rest of the body : rebalancing the pelvis, improving the mobility of the spine and treating any dysfunctional organs. The organs will have a great influence on the mobility of the ribs and diaphragm as well as on the posture of the patient. The biomechanic of the shoulder being greatly influence by the thorax it would be foolish to hope a good recovery without treating this part of the body.
The osteopathic approach of the shoulder itself :
- Beginning of the first stage :
At the beginning of the first stage the restriction is relatively minor and the pain bearable. It is often misdiagnosed as a rotator cuff syndrom or as osteoarthritis of the acromio-clavicular joint.
I do believe that mobilisation of the glenohumeral joint at that point is benificial as long as it is not too painful. It is important to quickly restore a maximum of mobility through the other joints of the shoulder.
The complex first rib and clavicle is vital as the brachial plexus and artery might be slightly impinged (thoracic outlet syndrome) which can perturb the neuro-vascular activity around the G/H joint. Increasing the mobility of this area improves any slight "thoracic outlet syndrome".
The biomechanic of the clavicle is crucially important and needs to be restored to its "normal" state. It is important to understand that the sterno-clavicular joint is the only real joint linking the shoulder to the body !
Deep soft tissue massage is helpful to release the muscular tension emanating from the compensation pattern ; we may insist on the trapezius, levator scapulae, rhomboids, supraspinatus, infraspinatus, subscapularis and of course the pectoralis major and minor.
After a few treatments, the shoulder should improve and the condition avoided. It is true that as the condition is avoided it is hard to know if it really was a "beginning of frozen shoulder".
- Middle of first stage to middle of second stage :
The patients often come to see an Osteopath at that stage of the condition, because they generally tried with poor results the conventionnal therapy. At that moent the pain is very bad and the limitation of movement is severe.
This is a long and fastidious stage. It is difficult to know how much the treatment is helpful because there are often tiny or no improvement. The patient may report some ease in the intensity of the pain, or improvement in the sleep pattern, but the mobility of the shoulder stays more or less the same. Some patient find it benificial enough for coming once a week. I want to believe that the treatment helps to shorten this period of the condition
The treatment will focus on the structures cited above but mobilisation will be avoided because of the pain it will create. The aim is to calm down the inflammation. Once the inflammation stopped we move to the next step of the treatment.
- Middle of second stage to end of third stage :
At the middle of the second stage the shoulder is limited in its range of movement but free of pain. The recovery is coming at last !
During that period the Osteopathy can clearly helps the recovery. As well as using the techniques described above we can now use a combination of Muscle Energy Techniques (MET) and gentle mobilisation. The MET is a type of stretch applied after a gentle isometric contraction of a muscle. This technique gently stretches the G/H joint while respecting its integrity. The mobilisation techniques gently explore the joint mobility.
At that stage we can clearly notice some improvement between two treatments.
A frozen shoulder will definitely take time to recover fully It is frustrating for the patient as well as for the practitioner.
While the help from osteopathy is relevant straight at the beginning of a frozen shoulder and after the middle part of the second stage, it is hard to know how effective it is during the "painful-freezing" and "painful-frozen" part. A recent study has shown that physiotherapy mobilisations and stretches of the shoulder during this period actually increases the length of recovery. Remember that pain should be avoided at all cost...
Do not hesitate to use your arm within the pain free range of motion and keep any type of stretches for the later stage. An alternance of hot and cold pack might help (30 min hot, wait 15 min, then 30 min cold...) and position the pack all around the shoulder. you can repeat this procedure 2-3 times a week.
Sunday, September 2, 2007
(You can find a french translation of this article here)
"Low back pain is our daily bread", Mr D. Triana ( a teacher)was telling us. Actually I think he was saying that about nearly every type of complaints...
"You are as old as your back is" mentionned a brazilian tatooist.
In the UK, low back pain is one of the most common reason for time lost from work. The NHS spends more than 1 billion GBP/year and lost of productivity and sickness benefits cost the taxpayer another 20 billion GBP/year.
In this post, I'll expose the Osteopathic perspective of a low back pain, explaining different reasons that can cause this discomfort and what can be done to prevent it.
A quick anatomy review :
The low back comprises 5 lumbar vertebrae (L1 to L5), the sacrum, the coccyx (tail bone), 2 iliac bones which, with the sacrum constitutes the sacro-iliac joints. All of these bones are held together with rather thick ligaments (eg : ilio-lumbar, sacro-iliac, ischio-coccygeal ligament...)
Between each vertebrae there are discs which are composed of two parts : a liquid part in the middle, the nucleus and a fibrotic part which surrounds it the "annulus fibrosus".
A lot of muscles are present in the low back, long and short one :
The long one are generally attached to different bones or fasciae and will have an important postural "role"(eg : psoas, piriformis, QL, thoraco-lumbar fascia, gluteus...)
The short ones are little muscles which are attached from one vertebrae to another. These are the ones that if in spasm will "lock" a vertebrae and create an osteopathic lesion. if an "intertransversarii" muscle on the right gets into spasm between L2 and L3 then L2 will side bend on the right. To counteract this, a bigger muscle, the left Quadratus Lumborum will contract to counter balance and neutralise the lumbar spine.
AN OSTEOPATHIC PERSPECTIVE :
This is the essence of Osteopathy : the "Osteopathic lesion" (please report to previous post for a definition). This concept is really interesting at a vertebral level. After a trauma, a compensation or a visceral dysfunction (...) little muscles attached to the vertebrae will spasm. Often this reflex mechanism aims at protecting the surrounding structures by limiting the movement of the vertebrae. What seems to be beneficial on a short term is quite pathogenic on the long run : as this reflex has difficulties to relax it creates a series of compensations which in return makes a lot of muscles to work harder and put strain on different surrounding structures. A vertebral lesion might be described as follow : L2 is in Flexion, Left side bending , Right rotation. This means that this vertebrae moves easily in these directions but poorly in the opposite directions.
- Pelvic imbalances :
The pelvis is crucially important : this is where the ascending forces (from the legs) and the descending forces ( from the spine) interact with each other. Each articulation of the pelvis (both Sacro-iliac joint and the pubic symphysis) needs to be relatively free. It will help the pelvis to adapt and compensate forces interacting at that place. Over time and traumas, some of the joints of the pelvis tend to become restricted. They often do so by adopting an excessive pattern.
The coccyx (also known as the "tail" bone ) is a very important little bone : we can compare it to the "rudder" of the spine. Any fall on it will restrict its movement and will heavily compromise the biomechanic of the pelvis and therefore the biomechanic of the whole body.
The most common pelvic patterns :
-anterior rotation of one of the ilium
-posterior rotation of one of the ilium
-upper slip of one of the ilium
-inflare or outflare of an ilium (opening or closing)
-the sacrum will be described through its flexion/extension, side bending and rotation
-the coccyx will be mostly described through its flexion/extension and side-bending
Example of a common pelvic pattern :
Anterior tilt of the right ilium associated with a flexion, left rotation and left side-bending of the sacrum.
A "healthy" pelvis is not necessary a balance pelvis, but a pelvis in which all the joints are mobile. If the pelvis is rigid, one has more chance to injured a ligament, a muscle or a disc as the transmission of the force will be quicker and the adaptation poorer.
- The Visceral Sphere :
The organs are very important and have a great influence on the musculo-skeletal system. The medical field acknowledge that in acute cases one may feel some reffered pain from an organ but it seems to completely forget that a dysfunctional organ can also give some musculo-skeletal pain and greatly affect the posture of a patient.
There are different ways an organ can affect the complaint of a patient :
- imagine a patient with a spastic colon; the colon is attach on the psoas and on the diaphragm. If the colon tenses up, the psoas may react the same way and the diaphragm will see its amplitude decreases. In the case of the ascending colon, the patient might complain of a low back pain on the right side from the sacro-iliac joint to the lower ribs.
-In the case of a ptosis of the stomach (or hook shape stomach) the patient will adopt an increase flexion of the upper thoracic. One way of preserving the balance can be for the lumbar erector spinae muscles to contract in order to pull back the body of the patient. The low back muscles will work more than needed and the patient will complain of a tired low back at the end of the day.
-Other organs can affect the low back such as the kidneys, the duodenum, small intestine, uterus, ovaries, sigmoid, prostate... The influence of an organ can be mechanic, fluidic or neurologic (and psychologic ?)
-Don't forget that the diet (food, liquid, drug intake) is very important and may influence greatly an organ and therefore the body.
-Scars may also inluence the posture and therefore influence on a low back pain (see post on scar and posture)
- Ascending Chain :
Ascending chain is a term which designs any osteopathic lesions coming from below (in this case the leg) which will influence a compensation above. A short leg, a long one, a flat foot, an old knee injury(...) are factors which will influence on our gate and therefore on our pelvic pattern. Again, an excessive pelvic adaptation increases greatly our chances to develop a low back pain.
- Descending Chain :
Descending chain is the opposite. It is a lesion coming from above which will affect below. An old fractured clavicle will limit the range of movement of a shoulder. The gait of the patient might be affected as the arm does not swing as it should during the walk. A scoliotic pattern of the spine is developped which will affect the low back and the pelvis of the patient.
Some Osteopaths claim that a TMJ problem (jaw joint) or dental problem can create a low back pain. Why not !? Personnally I never met such a case, maybe I should say : I never diagnosed such a case. I am certainly still too narrow minded in my osteopathic approach.
Any Osteopathic lesions will increase the biomechanical stress on the body. It is believed amongst Osteopaths that such stress on the long run make muscles, joints, ligaments work harder than they should. After years of poor compensations, one is more likely to develop some wear and tear: some osteoarthritis. Increasing the mobility of the body, reduces the mechanical stress which affects it and over the years "should" decrease the severity of osteoarthritis (the "should" is there as I am not aware that any studies have been done to verify this ascertion).
The medical and osteopathic diagnosis are not opposite the one with the other. The medical diagnosis gives an idea of the state of the painful structure while the osteopathic diagnosis tries to understand the reason of this problem. While the allopathic approach will concentrate on the symptom, the osteopathic approach tries to "treat" the cause.
Wednesday, August 15, 2007
It took more than 30 years for this recognition, yes... that's France. It takes time to change things.
Generally I believe that this is a good thing for Osteopathy to move towards regulation and medical acceptance. But there are a few points that are a bit bitter, unfair, obscure....
1. The Formation:
In France most schools provide an Osteopathic syllabus with a minimum of 5-6yrs of studies and practice. In general the number of hours accumulated is between 4500 and 5000hrs. In the UK, where Osteopathy is recognized as a primary health care profession, schools provide the same number of hours of teaching/practice but it is "compressed" into 4-5 years of syllabus.
From the official article concerning the syllabus of Osteopaths in France you need : 2030 hrs of studies! What a move from the Ministry of Health for the safety of the patients and to promote the competence of the future Osteopaths!
Why is this ? I believe that the lobby from the medical field was important : In France to become a GP you undertake a 9 years course. How as a doctor can you accept that another person can become qualified as a medical practitioner by studying for a mere 5-6 years ? How is it possible to accept that a profession that was so criticised (osteopathy) may now need more study than physiotherapy (3-4 years)? This is simply unacceptable : this is why it is necessary to cut the number of hours of the course to destroy the competence and the validity of Osteopathy.
Osteopathic Schools in France apparently decided not to follow the minimal course structure and agreed on a common programme spread over 5 years. Well done !
2. Restriction of certain manipulations :
With the regulation of Osteopathy in France came some restrictions concerning certain manipulations. It is forbidden for an Osteopath to practice :
-gyneco-obstetrical manipulations :
Personally I do not practice internal techniques (yet), but some Osteopaths do, and they have had good track record of success or various problems related to that area of the body. I do use external techniques on uterus, ovaries and coccyx. I believe that a lot of my female patients' complaints (lower back pain, hip pain, even headaches or neck pain) are often related to this area (eg :see article on scar/posture). The fact that I can palpate and feel any anatomical abnormalities (eg : cysts) helps me to refer the patient for some additional investigations and therefore enhances the safety of the patient.
-"touchers pelviens" : that's a good one! The translation is "pelvic touch". Well the pelvis is a wide area, it comprises : the sacrum and coccyx, the 2 ilium's, and a whole bunch of ligaments and muscles (sacro-iliac lgts, ischio-coccyx lgt, obturator membranes...). If there is ONE area that EVERY Osteopaths check and touch this is the ONE ! Any biomechanic's disturbances of the pelvis is likely to create some problems. Again not checking the pelvis leads to a poor osteopathic diagnosis and poor treatments...
-"cervical manipulations" must be recommended by a GP : It means that if anything happens during the manipulation the Doctor is responsible. There is a myth amongst some doctors that there is grave danger in this type of manipulation. In fact the risk is extremely low between 1/1000000 to 1/1500000 death per manipulations against 500/1000000 for taking NSAID (anti inflammatory) (see article on cervical manipulations). It is more dangerous to self prescribe and take NSAID for a neck pain...
Personally if I was a GP, I would not sign a lot of these letters : I would not put my career in the hands of a potential "death grip ninja" as I couldn't possibly vouch for every individual Osteopath...So you imagine how many referrals we will get through this route..
In most of the schools we start practicing cervical manipulations from the second year of study. We practice this techniques at least for 2 years before using it in clinic, under supervision of a trained Osteopath.
Some Doctors in France claim to be Osteopaths or to be able to manipulate the spine after a course, and can practice these techniques with force and extreme range of movement training directly on their patients. Don't worry ! they are Dr's, They know what they are doing ! In who's hands are you the safest ? This is your choice...
-There are also restrictions for treatments of pregnant women and babies under 6 months. Again a Dr. must refer the patient to the Osteopath. Why not, even if I still believe that an Osteopath should be competent enough to treat these types of patients.
3. Different types of Osteopaths ?
In France we have three major groups of Osteopaths:
The Doctor-Osteopaths :
Generally he is s GP who became osteopath after a part-time course. The type of course here is really important. The most serious part-time course consists of 6 weeks a year over 6 years (1100 hrs + extensive homework) but some others are ridiculously short (few hundred hours). It is important to know if the Dr is a full time or part time practitioner, as the more you practice the better you are.
The Physio-Osteopaths :
The physiotherapist is in France a "masseur-kinesitherapeute". The courses taken to become Osteopaths are generally the same as above (serious or less serious). Now once they have their diploma either they leave their initial title of "kine" and become full time Osteopath or they keep their original title of "kine" and call themselves "kine-osteo".
I have a lot of respect for the "kine" who have abandoned their title to become Osteopaths. Some of my teachers followed this route and are fantastic Osteopaths. They exposed themselves to difficulties by carrying the Osteopath title to prosecution from Dr's, for illegal practice of medicine.
On the other hand "kine-osteo" use the title of "kine" to receive patients from Doctors : that way the patient does not pay for the treatments (because it is covered by the french NHS) and the practitioner can keep his practice busy... Ethically this is a bit dubious.
-The Osteopaths-Osteopaths :
This type are only practicing Osteopathy and their course lasted at least 5 years. They usually have the title DO (diploma in Osteopathy).
These are the Osteopaths I would recommend fr you to see, if you have any "osteopathic problems". The price is higher than a physiotherapy treatment (45 to 60 euros) and it is not covered by the Securite Sociale, the"french NHS". They are generally registered at the ROF (registre des Osteopathes de France) or at the UFOF (Union Federale des Osteopathes de France).
It is of course the patient who decides which practitioner to choose. Keep the one you feel comfortable with but keep in mind that in France the NHS is largely in debt. We are not used to paying for our own health but is it such a bad thing to pay for it ? To a certain extent, wouldn't it make us more responsible for our own health?
Saturday, August 11, 2007
Nothing at all...
In Fact Osteopathy does not treat anything but helps the patient to treat himself. The Osteopath just sign-posts the patient's body towards a different route of adaptation. In short, helping the body to improve itself.
In general, I would say that Osteopathy can "treat" or help with dysfunctions of the body :
"Dysfunction" could be described as a state between health and disease.
Untreated dysfunctions can lead the body toward uneconomical way to adapt a certain pattern. Uneconomical through a mechanical, physical, physiological, energetic (calories) point of view. It is a bit like driving around with a Porsche forgetting to remove your handbrake ! You can expect a poor acceleration, overuse of the brakes and high fuel consumption.
On the long term the body will be more exhausted and this can lead to potential illnesses (eg : infections) or premature ageing (eg : osteoarthritis).
While Osteopathy focusses mostly on the dysfunctions of the body certain pathologies can also be helped or improved (to a certain extent) ; certain types of asthma, gastritis, endomitriosis, Crohn's... Even if A.T. Still reported to treat cases of dysentery, it is unreasonable nowadays to prefer Osteopathy to an allopathic approach for the treatment of any types of infections, diseases or cancers.
"Osteopathy has no limit, only Osteopaths have some" this is a sentence from Idon'trememberwho, and I find it particularly true.
I have met a few people telling me about there symptoms during casual conversations and they say that Osteopathy can't help it because they saw an Osteopath and their problem didn't get any better. I would say that this Osteopath couldn't help you, how many have you tried ? Because you know there are as many different Osteopath(ies) than there are different Osteopaths. That's right, no Osteopath will practice the same way another one does !
The following list includes a series of patients' complaints or symptoms that I could help with :
Common complaints :
-neck, shoulder pain/sprain
-Thoracic outlet syndrome, carpal tunnel syndrome
-Temporo-mendibular joint pain
-hip, knee, ankle, foot pain/sprain
-complaints due to wear and tear (osteoarthritis)
-Repetitive strain injury
Less common complaints :
-Crohn's disease (decrease reoccurence of crisis, improve digestion and stress)
-endomitriosis (in certain cases helped with pain and associated symptoms eg : lowback pain/headaches)
-asthma (mostly with stress or effort induced asthma decrease of frequency and seriousness of attacks)
-Bell's palsy (helped to recover but need more patients to say how much the treatments help)
-hemiplegia (might help the recovery after the attack, but mostly decrease the aches and pain caused by spastic muscles and body imbalances)
-paralytic syndromes (see above)
These are cases I have treated over the years where I believe my osteopathic treatments have been helpful in the recovery.
Of course not all complaints are "treatable" and when there are not, it is important to check the reasons that could interfere with the improvements. These maintening factors can be due to daily activities, diet, intoxications, lack of sport, poor posture, psychological barriers or underlying pathologies. In this case your Osteopath is able to refer you to the appropriate consultant or to another Osteopath who may have another method of treatment.
Tuesday, July 10, 2007
Surgeries are not always useful or needed but they do save millions of lives every year.
While allopathic medecine "saves" your life, it brings little attention to the consequence of such a procedure. I don't talk here about the risk inherent to a surgery but about the "post traumatic adaptation" of your body.
My first clinical experience with such a case was when I was an Osteopathic student at the ESO teaching clinic. I was treating Mr G., 67yrs old, for some chronic low back pain. Mr G. couldn't stand for more than 30 minutes without experiencing pain in both thighs. This was a good excuse to avoid the boring food shopping with his wife. He was playing golf twice a week, while the walking and the swing were more supportable than standing still, at the end of the game and for the following few days his back was particularly stiff.
The treatment that I was providing were mostly based on deep massages, mobilisation of the spine, hips, knees... Mr G. was feeling some relief from it and was coming back every 3 weeks for a maintenance treatment.
One day, my Osteopathic tutor (Miss Celine Meneteau) entered the treatment room and asked me : "What is the scar your patient does have on the front ? Did you ever stretch it ?" Effectively the patient had a peritonitis 20 years ago and a subsequent 20 cm scar on his abdominal wall, and "no" I never worked on it, and never thought that it could be of any significance regarding my patient symptoms.
I did indeed stretch this scar as well as providing the usual treatment.
3 weeks later, Mr G. reported that he could not escape any more the shopping with his wife because he could stand more than 2hrs and half without any pain. His swing improved of 60 yards (obviously with the same club !).
"Post traumatic adaptation" :
Obviously an open wound is an experience a bit painful. The following weeks after the surgery, the patients will tend to protect their scar adopting an antalgic posture. The aim of this antalgic posture is to decrease the tension around the painful area.
In the case of a Csection, for example, the patient will bend forward and avoid to straighten up or to arch backward. Slowly the patient recovers from her surgery and can sraighten up a bit more, but compare to her initial posture she is now leaning forward. Why is this ? because there are some scar adhesions !
When an abdomen is cut open, you cut different layers of skin, muscles, fasciae... when the healing process takes place, scarring tissues create adherences between these different layers. What was once upon the time smooth, sliding, elastic healthy tissues are now fix, congested, non-elastic ones. This is the beginning of a long chain of problems...
Let's continue with our new mother who just had a Csection :
The first symptoms will be a sensation of heavyness on the lower abdomen, increase frequency of urination, bloating sensation.
Few months later low back pain starts being an issue and can be associated with pain/cramps in the calves. Of course carrying a child is not helping, but the tension of the scar obliges the mother to constantly lean forward. To compensate this imbalance, the extensors muscles of the spine constantly contract to prevent her from falling forward. At the same time when she leans forward, her gravity centre moves forward as well. This increases the pressure at the distal end of her feet. More tension by the calves muscles is needed to bring back the gravity centre. Guess what ! it gives pain/cramp/stiffness in the calves !
Exercise Time, let's have a try :
Please stand up, flat feet on the floor, bend forward a bit then grab an inch of skin underneath your belly button. Now straighten up (gently) stop as soon as you feel uncomfortable in your lower abdomen. As you cannot straighten up completely, you should be able to feel some contraction in your low back muscles. Slowly you will feel your posture shifting forward, and an urge to push down with your toes, now you feel more tension in your calves . Well done ! if you are a man you just discover the post traumatic adaptation of a Csection!
If you continue this little exercise, You will notice that if you want to look straight you have to extend a bit more your neck. On the long term it increases the compression on the facets of the cervical spine which leads to neck pain, spondylosis, headaches...
In this case, if you just manipulate the spine or massage the back you cannot expect any improvement but a symptomatic short term relief. As soon as you will start working on this scar as well as opening the anterior fascial chain, the change in the posture will be tremendous and this will lead to a great improvement of the symtoms.
Patients who had a masectomy and suffer from shoulder pain on the same side few years later, Patients who had an appendicectomy as a child and now you suffer from some sacro-iliac pain on the right side, patients who had a Csection or a hysteretomy and complain from low back pain or neck pain, did you ever think it could come from this old scar ? If it sounds familiar don't hesitate to contact your nearest osteopath or another competent therapist.
Friday, July 6, 2007
In this post I'll try to explain different modalities of Osteopathic treatment.
The two extreme ways of treatment are the minimalist approach and the other one is the maximalist approach. The minimalists will tend to push the diagnosis at the extreme and the treatment at its minimum, while the maximalists will tend to treat and diagnose at the same. The ratio in % I give is purely indicative.
Mechanical link (95% diagnosis, 5% treatment) :
Paul Chauffour and Eric Prat developed this approach in which they are looking for the Primary lesion and treat it, hoping for a decompensation of all Secondary restrictions.
They divide the body in 8 different unities :
-the spine and pelvis
-the anterior thorax
-the limbs (arms and legs)
-the viscerae (organs)
-the cardio-vascular system
-the intra-osseus lines of force
Each of these unities will reveal one or two major restrictions. So which one is the one to treat ? Paul and Eric use the "inhibitory balance" to find out : if you apply a gentle pressure on two dominant restrictions the adaptation will soften under your fingers while the predominant lesion will still be dense. After finding the major restriction, the "Primary Lesion", you treat it with a "recoil" technique ( a swift flick of your thumb). The major restrictions found earlier should have soften, if not, then treat again the most dominant one. Each treatment comprises of around 350 to 400 tests and only 1 to 3 recoils !!!
This example of treatment has been reported to me by 3 of my colleagues who where watching a "mechanical link" demonstration :
The patient was having some pain in the right shoulder if he abducted his shoulder to more than 90 degrees. The Primary lesion was a spasm of the right femoral artery ! After correction of this spasm with a recoil, the patient could lift his shoulder without any pain or restriction.
This sounds incredible ? this is just one example. Even chronic cases seem to respond as well from this type of treatment.
This approach fits perfectly with A.T. Still statement : "find it, fix it, leave it alone..."
Gilette's approach (80% diagnosis, 20% treatment) :
This protocol of treatment has been developed by a Chiropractor (Gilette) but been presented to us during our osteopathic course by an Osteopath Mr Desjardins. Even if I am not so keen on chiropractic in general, I must say that I find this approach quite interesting.
The "philosophy" of this approach is that the pelvis is the major area of compensation between the descending forces of the upper body and the ascending forces coming from the legs. Therefore if the pelvis is not able to compensate then problems occur.
The diagnosis is fairly straight forward :
specific diagnosis of the pelvis pattern
-gross mobility testing of the thoracic spine
-testing of the occiput-atlas joint
The treatment is fairly straight forward :
-specific stretches of the pelvic ligaments
-mobilisation of the major group in restriction of the thoracic spine (HVT/Staircase)
-the occiput-atlas is seen as a barometer of the spine ; if after the previous corrections it is still restricted then manipulation of this level will be needed.
The pelvis and the thoracic spine is then reassessed.
With this methods you can treat a patient in less than 20 minutes. Mr Desjardins told us that it was the most effective type of treatment he ever practiced. Some of my colleagues use it and are convinced of its effectiveness.
Personally I still hope that I am a bit more than just a pelvis and a spine... But if you want to keep your practice simple and be able to see more than 80 patients a week this is certainly the way !
The Three Unities (75% diagnosis, 25% treatment) :
I have learned this approach from David McGinn at the CIDO. But I am still confused about who was the original author of this approach (dear colleagues please help me out with this one).
The aim of this method of diagnosis is to divide the body in three unities :
-Unity 1 : this is the locomotion unity, involving the lumbar spine from L3, the pelvis and the legs
-Unity 2 : this is the action and balance unity, involving the arms, the head and the cervical spine down to T4
-Unity 3 : this is the vital unity as well as the junction between the two other unities. It comprises the thoracic spine, upper lumbars as well as all the ribs.
Global tests permit to know quickly if a unity is involved or not. If a unity is involved then specific testing will reveal the predominant Osteopathic lesions.
As a general rule the Primary lesion should be found in all positions (standing, sitting, prone, supine, sidelying) and its correction should result in an increase of mobility of the other secondary restrictions.
I find this method of diagnosis really interesting and relatively minimalist. From your findings you can use the type of treatment you want. The major reproach I can think of is that the visceral and the cranial systems are not really integrated. A few other tests are needed for the diagnosis to be a bit more precise.
My Osteopathic Approach (40% diagnosis, 60% treatment):
I generally spend a good 15 min of the treatment (out of 40 mins) to test and diagnose a chain of tension to work on. The method of practice will change according to the body morphology. The fitter the patient is, the more precise the diagnosis will be and the more minimalist the treatment will be. If the patient is not as fit as he could be, the treatment will tend towards a maximalist approach (GOT approach, see below).
My assessment is based on the "Three Unities" (see above) while integrating fully the visceral system.
The treatment will generally be focused first on the visceral system, which removes the major part of the musculo-skeletal restrictions. After a reassessment I treat the remaining Osteopathic lesions from bottom to top.
I generally keep the cranial approach towards the end of the treatment unless I have found that area to be the main focus of my treatment (eg :TMJ, stressed patient, emotional trauma...).
The General Osteopathic Treatment (10% diagnosis, 90% treatment) :
Also known as Total Body Adjustment, the GOT, as practiced in the UK, has been introduced by John Martin Littlejohn and his student John Wernham. GOT is the British classical Osteopathy.
It is a routine of treatment based on 10 different principles :
- articular integrity
- mechanical law
The aim of the treatment is to literally "shake" your body by mobilizing every one of your joints from head to toe. It may be associated with some HVT ("cracking" techniques) through the spine. By mobilizing the whole body, an harmonization of all structures takes place. It improves the plasticity and elasticity of the tissues therefore enhances the adaptability of the body to its surrounding environment.
One may argue that the diagnosis is 100% part of the treatment, as the GOT practitioner diagnoses and treats at the same time. This is true, but this is the case for any type of techniques, because 90% of the treatment is spent in treating the patient, GOT is the most maximalist Osteopathic approach.
Of course these are not the only way to treat a patient, but the most well-known, or interesting that I have met during my Osteopathic Journey. Every Osteopathic practitioners evolve between a more minimalist or maximalist approach depending on the patient they treat.
Monday, June 25, 2007
The risk is about 1/1.5million. It seems quite a lot but in fact you have more chances to die being struck by lightning !
Taking pills (NSAID) may seem safer, but in fact 16000 deaths a year in the US alone are attributed to the use of these painkillers. This gives a ratio of 500/1m people dying from gastric bleeding from taking anti-inflammatories. I won't even start to talk about liver intoxication associated with paracetamol.
So what is dangerous about it ?
in fact the danger comes from the rupture of the cervical artery or from a migration of atherothrombosis during the cervical manipulation which leads to a CVA or death.
Caution must be taken with :
- patients suffering from High Blood Pressure (walls of arteries are more rigid and/or presence of cholesterol)
- patients suffering from high cholesterol
- patients suffering from hyperlaxity or connective tissue disorder (eg: Marfan syndrome)
- patients suffering from vertebral atery occlusion syndrome
The cause of your neck pain may not come from your neck !
This little test can be performed on yourself or on your patient. The patient sits on the table and you ask him to look over the right and left shoulder, check the rotation and ask the patients to notice when they feel the pain. Now, place your hands underneath the diaphragm and gently lift it up (liver, stomach...) and ask your patient to rotate his head again. Any change in the rotation or in the pain indicate that there is probably no need to manipulate the Cspine, the problem is coming from somewhere else. Yes this may sound odd but a gastritis, an anterior tilt of the liver, a Csection scar... can create neck pain.
Is it a problem if I "crack" my neck myself ?
It is not such a problem if you manage to do it at the right spot ! Often we tend to manipulate the part which is painful and this is not necessarly the right vertebrae or part of the body to manipulate. By moving the vertebral joint you will make it looser, if you manipulate it too often this joint will become hypermobile. To stabilize it, muscles will contract, this is painful and you feel the urge to crack it again... a splendid vicious circle. In other words, if you keep "cracking" the same vertebrae I seriously doubt that this is the right one to move and this will cause you other problem on the long run.
Sunday, June 24, 2007
Physiotherapy : the physiotherapist is a specialist in rehabilitation. After an injury (fracture, surgery, CVA...) the physio will rehabilitate the patient with massages, mobilisations, ultra-sound, exercises or even teach a patient to use crunches. His approach is generally symptomatic and his recommendations are often statisticly based (eg : in chronic low back pain a series of 3 push ups, 5 sit ups and 7 pulls of the right ear lobe improve the symptom by 47% over a period of 7 weeks. Please don't try this at home, this is just an illustrative example !!!).
Why is this ? I believe that physiotherapists are the right hand of the medical field and have been formed to fit the medical way of thinking. Therefore anything they do must be proven effective and safe, even merely effective is fine as long as it is safe.
The problem is that proving something is hardwork, time consuming, money consuming, and often another study will few months later proves the opposite to be true. A study is often too specific or too global to be constructive.
This approach avoid to talk about the "Unicity" of the patient. It does mean that if two patients complain from the "same" areas or symptoms they will be given the same treatment regardless the root of the problem which is not necessarly the same. The outcome of the treatment is therefore not as effective as it could be : it does not address the root of the problem but the treatment is as safe as it can be.
Chiropractic : Here is a joke for you ... what is the difference between a chiropractor and an osteopath ? 60 000 $ a year.
Chiropractic has been developed in the US at the end of the 19th century by Dr Palmer. Chiropractors claims that the source of our problems comes from the nervous system. Therefore corrections of "subluxed" vertebrae tend to lead us towards balance and recovery. Chiropractors will use spinal manipulations, ultra-sounds, massages, TENS, or other "high-tech" equipments. Often the massage, US, TENS(...) is given by a PA (physician assistant), then here comes the Chiropractor who will manipulate the spine. The chiropractor may need to see you up to 3 times the first week then will decrease the frequency of the treatments.
Personnally I am far from convinced that a back pain necessarly comes from a "subluxed" vertebrae but if you believe that the key of your problem comes from your spine, well then go for it. If you are not getting any better then make your next stop the Osteopath ;)
Osteopathy : Any traumas, injuries, sugeries, infections you had in the past are affecting your body in some way today by creating some restrictions and series of compensations. After a while your body cannot compensate any more, you bend forward to pick up a pen and "click", a vertebrae moved a bit too much and you just suffer from an acute facet lock. Now, is it just a vertebrae or a whole pattern of compensations, interactions, fascial connections, visceral dysfunctions, nutritions(...) that is responsible for your agony ? I would like to believe that we just need to correct a vertebrae, as it would make the work a bit easier, but the human is a little bit more complicated.
Generally an Osteopath will spend between 30 and 40 min with you and only you. During that time at least 40% of the treatment is spent in diagnosis in order to understand where the problem is coming from, this allows a more accurate treatment.
Osteopaths only use their hands, as machines tend to be imprecise and often scare the patient.
Personally I will never see a patient more than once a week and rarely more than 3 times the first month. Some Osteopaths are even reluctant to do more than one treatment every other week. (for some more details about the treatment content please check the other posts !)
What ever therapist you see do no hesitate to try different ones and stick with the one you feel the most appropriate. If you do not feel any improvement after 2-3 sessions, look for another approach or opinion.
Saturday, April 28, 2007
It is a sensitive thing to divide Osteopathy in different systems as any of these systems are inter-related. Some Osteopaths will even say that no such thing exist as "Structural Osteopathy", "Visceral Osteopathy" or "Cranial Osteopathy". I never really understood why. Maybe because from this notion comes the notion of "Cranial, Structural or Visceral" Osteopath and this can't be, because an Osteopath is not supposed to be specialised but to be holistic.
I do believe that we are all coming from different background and graduated from different schools which may differ from there lectures' content. Therefore we all practice differently and may have more affinities for one technique or another, for one field or another... Some Osteopaths may get a Master from the OCC, UK (Osteopathic Children Clinic) and I will certainly describe them as more "specialist" than I am in treating babies and children.
At the same time if I meet an Osteopath describing himself as a Cranial Osteopath, I would immediatly feel irritated/intrigued.
In the UK a great majority of osteopaths (from what I believe) are more focussed on the "structural and cranial field". In France maybe more on the "visceral and cranial field".
"Structural Osteopathy" :
is aiming at restoring movement through the Musculo-skeletal system (joints, muscles, fasciae, ligaments, capsules ...) by a combination of techniques. It may involve some "HVT/LVT" of the spine (the famous "cracking techniques"), articulation of joints, deep massage, trigger point inhibition, stretch, fascial unwinding...
"Visceral Osteopathy" :
is aiming at restoring the mobility and motility through the different organs of your body. This may sound strange but an organ can easily be the cause of a lowback, neck, shoulder (...) pain. It will do so by changing the posture of the patient (adoption of an antalgic posture) or by directly referring pain to an area of the body (liver/right shoulder, kidney/lowback pain...). The Osteopath will then mobilise, stretch, inhibit, unwind(...) the concerned group of organs. I do believe that at least 60% of the patients ' complaints do have a deep visceral cause. This means that if left untreated their symptoms are more than likely to reoccur.
"Cranial Osteopathy" :
is aiming at restoring the mobility and rythm through the bones of the cranium, spine and sacrum. This cranial rythm pulses between 10 to 12 cycles per minute and is believed to be the core mechanism of all the body functions. This is the approach of choice to treat babies (colic, reflux...), stress, anxiety, headaches(...). Cranial Osteopathy is still quite controversial even amongst osteopaths but is fast becoming a therapy in its own right.
Seeing, feeling, understanding and treating the body through these three fields make Osteopathy an effective holistic therapy.
Tuesday, April 10, 2007
Osteopathy is a manual therapy which was developed at the end of the nineteenth century by Dr Andrew Taylor Still in the US. Dr Still based his discipline on 4 main principles :
- "Life is movement" : therefore any structures that are not moving in your body, are deteriorating or "dying".
- "The Structure governs the function" : and vice versa. If the structure of your body is affected so will be its function (a broken elbow results in a poor elbow motion for example). The opposite is also true : if you spend your life time lifting bricks, you will develope strong, fibrotic back muscles and probably degenerative discs and spondylosis in your lumbar vertebrae.
-"The rule of the artery is supreme" : blood flow is essential to our body and if any structures (muscles, joints, fasciae...) are stiff, rigid these will impair a good vascularisation which will lead to further deterioration.
-A.T. Still believed as well in the "self-healing mechanism of the human body", and that the Osteopath was not treating the patient, but was in fact sign-posting the patient's body towards a better way to "self-heal".
For an Osteopath, the aim of the treatment is to find the "restrictions" of your body and to mobilise them : "Find it, fix it and leave it alone".
"Restrictions" have many different names such as : "Osteopathic lesions", "Hypomobilities", "Somatic dysfunctions" (pseudo-medical term), "subluxations" (chiropractic term). They result from any micro/macro-traumas, environmental factors, diet, pathologies or simple adaptations.
The most important ones are called primary lesions and they will be responsible for a series of compensations called secondary lesions. Very often, the patients' complaints are secondary lesions. This is why a symptomatic approach is rarely effective on the long term ; because the primary lesion is still there and will recreate the same series of adaptations and therefore the same symptoms !
The Osteopath will tend to focus his treatment on finding and treating the primary lesion. By doing so, he's treating the cause of the symptom rather than the symptom itself.
OK, by re-reading myself it looks a bit confusing, let's give an example : A patient comes complaining of a low back pain, the case history reveals a fractured ankle 10 years ago. The patient had an Xray revealing some wear and tear at L5S1. He has been advised to have some physio (ultrasound, massage ...) on his back and to take some painkillers. Few month later the back pain is still pesistent with some gastritis (thanks to the NSAID). The Osteopath will test all the body and find some major restriction on his ankle. For 10 years the patient has been walking with a slight limp which developed an excessive compensation pattern through his pelvis and lumbar spine. As long as nothing is done to improve the mobility of his ankle no improvement can be expected for his back. His ankle restriction is his "Primary lesion", and the L5S1 joint the "Secondary lesion". The Osteopath will then mobilise his ankle as well as probably, knee, hip then low back and within few treatments we can expect a long term improvement.
Thursday, April 5, 2007
Everything started in December 2005 when my girlfriend and I went to do some volunteer work in Thailand, Surin (thanks to Starfish ventures ). There I worked within the rehabilitation department of Surin Public Hospital, directed by Dr Noi, and Dr Lee. The language barrier was a real challenge. By the end I succeeded to communicate on a basic level with the patient ( lie on your back : "none niai", lie on your tummy : "none kwam ") but of course my tone and accent were rarely precise enough and often instead of saying : "sit down" ("nang") I was actually saying : "cinema". You can imagine that certain patients were a bit confused... Dr Noi and Dr Lee had a lot of patience with me and were helped me out when going through the case history of each patient.
Too often in Europe we practice osteopathy in a private practice having no or very little indirect communication with any doctors or specialists, and working there really allowed me to be in contact with physiotherapists, acupuncturists, radiologists, orthopaedists as well as seeing more "challenging patients' complaints"
Once Dr Noi told me : "you know here, in thailand, in public hospital we are paid really little, we do our job with passion , whereas in private hospital they do the job for money, do it quickly and by quantity..." I know that in France it is definively the opposite, but i found that this statement was true at least in their department.
So a few months later we went to renew our visa in Kuala Lumpur, Malaysia . I visited the KLCC and discovered a medical center. I came in looking like a typical tourist (shorts, converse, camera, sunglasses) and got my first interview !