Career Advice For Osteopaths

As we approach the end of the 2018 academic year in Australia, a new cohort of student osteopaths are about to graduate and enter the next stage of their journey as an osteopath.

With this in mind I have reached out to a number of osteopaths, from new graduates to experienced practice owners, academics and entrepreneurs, to share with you some career advice in the form of a tweet (280 characters or less, although some couldn’t help themselves, and went a little longer).

The aim of this post is to help start you thinking about what you want from your career, and what you might have to do (or not do) to achieve that. I hope it will also save you some of the frustrations I (and many others) have gone through in the early stages of our careers.

A successful professional life looks different to everyone.

For some, it means making a lot of money. For others, it’s about having time flexibility. Others still want to have a big reputation and sphere of influence. Many want to be anonymous instead.

There is no one way to define success, however there are some common practices between all who have achieved success in their own way:

  • Self awareness
  • Patience
  • Flexibility
  • Discipline
  • Reflection
  • Mentorship

Whether you are a student, a recent graduate or an experienced professional, there is always potential upside in hearing from others what they believe to be important to achieving professional success.

If I have seen further it is by standing on the shoulders of giants. – Isaac Newton

Absorb What Is Useful

When it comes to receiving advice, it’s important to take what is relevant to you on board, and not get too caught up in the rest. I’ve tried to reach out to a variety of practitioners, with different professional skills and experience, to give a broad perspective on osteopathy.

Absorb what is useful. Reject what is useless. Add what is essentially your own. – Bruce Lee

So, without further ado, posted in the order I received them, the advice for new osteopaths:

Giles Gyer

Giles is an osteopath (2012 graduate of College of Osteopaths, London), medical acupuncturist and sports/remedial massage therapist and is the co-found of OMT Training, a teaching organisation for manual and physical therapists. I don’t know Giles personally, but apparently we look similar enough for a colleague to use his image (from Google Images) on a PowerPoint slide when introducing me, so he had to be part of this piece. His advice is:

“YOU are the most important person in the treatment room” the key to longevity within osteopathy is to look after your body and your hands.. Don’t use techniques that compromise your joints especially your thumbs and back.. Be opened minded to other professions, they’ve got some great skills and techniques you can steal!!

Follow Giles on Twitter and OMT Training on Instagram.

Aaron Anderson

Aaron is an Australian trained Osteopath. He completed his studies in Australia – Osteopathy with Distinction (RMIT), Sport Science (University of Ballarat). Aaron treats both adults and children. Aaron operates Movement Squared, both in Melbourne and Hong Kong locations (definitely a long commute), and additionally has been an onsite practitioner in both the corporate and sports performance world. He is currently completing a Masters in High Performance Sport through ACU. His advice is:

I recommended to my Associate try to excel in Anatomy and HVLA. These fields can easily put you in the top 10%. Be out and about in person. That’s when people will enquire directly about making an appointment. Still better than running an awesome social media campaign in my experience.

Find out more about Aaron and his business Movement Squared or follow Aaron on Twitter.

Jena Chang

Jena is an osteopath who graduated from RMIT in 2013. She works in private practice at Box Hill Osteopathy and Complete Health Osteopathy and Pilates. Her advice to new osteopaths is:

RE: job hunting
If they are interviewing you, you have a right to interview them back. Finding the right workplace is essential in your growth and development as your as your emotional well-being! Never settle for less.

Follow Jena on Instagram (side note: I love Jena’s content, it’s so positive) and Facebook.

Bruce Duncan

In over twenty five years as an Osteopath, Bruce has treated people from all walks of life. He has been Osteopath to the Australian Open Tennis Tournament since 2004, and at the Hawthorn Football Club since 2015. A graduate of RMIT, class of 1992, Bruce founded North Carlton Osteopathy in 1998. His advice is:

Interpersonal skills maketh the osteopath. Diagnostic & hands-on skills are a given, but connecting with warmth, understanding & empathy will take you next level. Build trust and take ownership of their management together.

Follow Bruce via North Carlton Osteo on Instagram and Facebook.

Alison Sim

Alison is an osteopath and pain management specialist. She graduated from Victoria University in 2001 and went on to complete her Masters in Pain Management from Sydney University Medical School and Royal North Shore Pain Management Research Institute. Alison works in private practice at Brighton Spinal and Sports Clinic and Pain Matrix in Geelong, treating people with chronic pain, and runs an education company for allied health professionals, Beyond Mechanical Pain.

Stay flexible in your thinking and humble about your role. Listen and learn from your patients. Keep a strong focus on life outside of work. Keep learning and evolving for your whole career.

Follow Alison’s work via Beyond Mechanical Pain on Twitter and Facebook.

Claire Reed

Claire is in her first year of practice as an osteopath, after graduating from RMIT with the class of 2017. Claire primarily works at Coburg Osteopathy & Health Services, and earlier this year organised the #3058Workout, a massive charity exercise day that raised over $11,000 for cancer council. She has had a great start to her career, no doubt with more to come. Her advice is:

Keep reading and asking questions. Your colleagues are your greatest resource and supporters so use them, ask them questions and observe them as often as you can.

Follow Claire on Instagram.

Nathan Kelly

Nathan, The Surfing Osteopath, a graduate of the class of 2013 from Southern Cross University, owns and operates Universal Health & Performance on the Gold Coast. He practices in an evidence informed manner, utilising traditional osteopathic techniques, dry needling and strength and conditioning principles to help people with injury management and rehab as well as performance enhancement. His advice is:

You’ve spent the last 5 years learning everyone else’s version of osteopathy, it’s now time to spend the next few years exploring how you want yours to look. Osteopathy is a framework which you can build from, and that’s the brilliant part of this job; the exterior is yours to create. The heart of osteopathy is inherently punk, it was born out of rebellion and questioning of the status quo. So keep asking questions, keep studying the human condition and keep osteopathy punk.

You can follow Nathan on his popular Instagram page.

Jacqueline Shergold

Jacquieline (Jacqui) graduated with me from Victoria University in the class of 2011, and since graduating has worked in private practice in Ireland, studied a Diploma in Paediatric Osteopathy at the Osteopathic Centre for Children (OCC) in London and now works as part of a multi-disciplinary team at a specialist baby treatment centre. Her advice is:

Listen. Listen to your instincts. Listen to your peers and mentors. Listen to your patients and listen to what their bodies need and want. Listen to podcasts and go to conferences/workshops/lectures. Take time to listen and you’ll be amazed at what you hear.

For more information, check out her practice website or connect with her on LinkedIn.

Jade Scott

Jade is a graduate of Victoria University, in the class of 2001. She is the owner and director of Western Region Health, one of Australia’s largest osteopathic practices. Jade has been involved in clinical education for a number of years and has an extensive graduate mentorship program in place in her practice and was involved in the development of the 5th year student internship program. Recently Jade has been presenting to osteopathic and allied health business owners on employment models in healthcare. Jade still practices and has a particular interest in maternal and paediatric health. Her advice is:

Don’t confuse confidence with conviction

Never underestimate the need to ‘fake it till you make it’

Social recognition is the key to filling your books

A patient’s financial situation should never cloud your ability to deliver their best treatment plan
Always go above and beyond

‘See how you go’ is not an option

‘Find, it fix it, leave it alone’ should be replaced with ‘find it, fix it, address the predisposing factors and maintain health’

Money is a wonderful byproduct of loving what you do

Core values make us the best at what we do (professionalism, integrity, respect, care and innovation)

If you surround yourself with brilliant people, remarkable things happen…

You can find out more about Jade via Western Region Health and follow them on Facebook for the latest updates.

Shane Buntman

Shane is a graduate of the Victoria University program, class of 2004. He currently operates a large practice across two locations in Melbourne’s CBD – Melbourne Osteopathy Sports Injury Centre. Shane has previously worked in the UK, and before osteopathy studied biology and genetics, as well as worked as  remedial massage therapist. Shane is passionate about developing the profession of osteopathy, and writes for Osteopathy Australia in their quarterly magazine on the topic of business in healthcare/osteopathy. Shane’s advice is:

Every time you step into the consulting room think ‘I’m representing the entire profession Osteopathy’.

It’s not about how interesting you can be, it about how interested you can be in others.

You can find out more about Shane via the MOSIC website and follow them on Facebook and Instagram.

Jon Marshall

Jon, owner of Back in Health Osteo is an osteopath and acupuncturist with clinic locations in Melbourne and Singapore, where he is currently based. Jon graduated from the program at RMIT in the class of 2008, and in 2011 he completed his Masters of Acupuncture, having previously studied a diploma prior to osteopathy. He is a master of the Japanese martial art Aikido and he founded the Melbourne Budo Academy in 2010, which teaches Aikido, Brazilian Jiu Jitsu, Shinkendo (Japanese swordsmanship),  Japanese Jujutsu, and Judo. He also teaches dry needling and cupping courses through his education company, Manual Medicine Australia. His advice is:The greatest thing that I would like to impress on you is that your learning NEVER stops.

Keep all your textbooks and don’t burn your notes. You will refer to them and keep learning from them over your entire working life; they have been written by some real giants in the Osteopathic world and we are lucky to be able to stand on their shoulders.

Don’t be overwhelmed, everything you have learnt in the course takes years to sink in, just keep learning and studying.

Be a generalist before a specialist. Be a Manual Medicine Master.

Work on yourself professionally and personally.

Don’t put down similar professions as it is unprofessional and it makes you sound like a knob. Everyone has something to teach us and never stop honing your craft.

Get together with colleagues, attend seminars and maximise your potential and be the very best Osteopath you can be.

Don’t get lazy or complacent, go out and chase your dreams.

Leaving Melbourne, while hard may be the best decision you ever make professionally…..

You have one of the best jobs for work life balance.

Keep healthy, take regular breaks and taste those sweet fruits!

The future is bright!

You can follow Jon’s clinics on Instagram and Facebook.

Tina Maio

Tina is a highly experienced osteopath who graduated from the osteopathy program at Victoria University in 1999, having also completed a Physical Education degree there previously. Tina owns and consults at Coburg Osteopathy and Health Services, where she treats people from all walks of life, but has established a reputation for her work with athletes, from the junior level all the way through to elites. Tina is particularly known for her work with golfers, with her current stable of players on the US PGA Tour, Nationwide Tour, European Tour, One Asia Tour, Japanese Tour and PGA and LPGA. Tina has presented locally and internationally in sports osteopathy and sports medicine. She is on the leadership committee for the Clinical Practice Group in Sports Osteopathy through Osteopathy Australia and is a clinical advisor for EMS Swiss Dolorclast. Her advice is:

Allocate time to professional development that excites you, it will create lightbulb 💡 moments that will fuel your passion for wanting to help others. Be committed to you career, but don’t abandon your personal life. Remember that working with people in pain is exhausting so take steps to look after yourself.

You can follow Tina through the Coburg Osteopathy Instagram and Facebook pages.

Nigel Roff

Nigel graduated from RMIT in the class of 1993. He practiced in Sydney for 6 years before establishing Willsmere Health Osteopaths in Kew, Victoria in 2000.  He practises patient-centred care with an emphasis on current evidence-based practice. He has a special interest in distance running and the treatment of injuries associated with running, and can also provide training advice. Nigel describes himself as having “No specialisations, I just treat people and their nervous systems”, but he also describes himself as a “hack runner”, so he is definitely modest (he recently competed the Chicago marathon, which is fairly far from “hack”). Nigel is an example of a practitioner who has built a successful career in osteopathy without having a high profile, except with his patients, where it counts most. His advice is:

Assume nothing, actively listen to your patients, they will tell you what’s wrong. You may not be able to help but that’s ok. And finally you are not responsible for your patients problems.

You can follow Nigel on Twitter or Facebook.

Anne Cooper

Anne is a former nurse and a 1989 graduate of the International College of Osteopaths, making her the most experienced practitioner on this list. She founded what is now Central Sydney Osteopathy in 1990 and has had a huge influence on the profession over the years. She has been president of Osteopathy Australia, and is now a life member, she is currently president of the NSW Osteopathic Council and has previously sat on the Osteopathy Board of Australia. Anne calls herself a dinosaur, but dinosaurs are extinct, while she is still overseeing a busy practice and seeing patients. Her advice is:

A new business is like any newborn; feed it when it asks to be fortified, nurture it, love it and help it grow strong and robust. That means 100% attention. Meet your patients needs, and very soon they will meet yours.

Osteopathy is medicine, not sports science. The human form, and what ails it, is not a predictable equation. Our job is simply to assist homeostasis. Treat what you find in that one unique patient, not what you’ve been told you should find.

If you think your patients should reflect your own image, then you’ll struggle. Appeal to ALL types. Old, young, fat, normal and thin, non/sporty, sick, well, straight, gay, black coffee and white, mums, overworked, unemployed.

When you graduate you don’t chat about technique at conferences and reunions. You talk business. So get it right from the start. This is a physical job, output exactly matches input, and if you get it right from the start you’ll enjoy a comfortable lifestyle and a deeply satisfying career.

You can follow Anne via the Central Sydney Osteopathy Facebook page.

 

Della Buttigieg

Della is a graduate of the Victoria University program, class of 2003. She is the founder of Melbourne Osteohealth, and a lecturer at Victoria University. She is a caring and passionate osteopath with particular interest in pain and rehabilitation for long term health and function. She firmly believes that the key to preventing many health problems from developing and recurring lies in educating our patients; arming them with an understanding of the their pain and teaching them how to reduce or eliminate it. Recently she has been involved in presenting on both the theory and application of pain science to clinical practice for allied health professionals. Her advice is:

What most patients want is someone who can help them feel good again and while better movement, more sleep and a balanced diet are a good start, humans never feel better than when they are having fun… prescribe fun!

You can follow Della via Melbourne Osteohealth on Instagram and Facebook.

Heath Williams

Heath is the founder of Principle Four Osteopathy, Corporate Work Health Australia and Ergawell. He is a graduate of Victoria University, class of 2003, and currently lectures there along with Southern Cross University, primarily in rehabilitation. Heath previously has worked in the UK and Sweden, and is currently a member of the Osteopathy Australian Clinical Practice Group for Occupational Health and Safety. Heath has a big focus on continuing education, and has undertaken numerous courses, workshops and seminars covering topics as diverse as manual therapy and exercise rehabilitation all the way through to communication. His advice is:

Be curious and open to opportunities! Learn from your own experiences, your clients and your colleagues and say yes to opportunities. Life will never be dull and work will always be fun and engaging.

You can follow Heath on his popular Instagram or Facebook pages.

Josh Lamaro

Josh is a graduate of the Victoria University osteopathy program. He owns Paleo Osteo in Bendigo and Torquay in Victoria, which is an “evolutionary medicine and nutrition clinic”. He has a special interest in the treatment of chronic conditions such as fibromyalgia, chronic fatigue syndrome, and auto-immnune diseases using the modern and traditional principles employed by Osteopaths. Certified in anti-ageing medicine through the Australasian Academy of Anti-Ageing Medicine, Josh uses functional medicine principles to help address his patients’ health in a wholistic manner. His advice is:

There is an alarming trend in osteopathic education at the moment that is tending away from what osteopathy really is.

There is a tendency to look for the “tissue causing the symptoms” and eradicate or palliate the symptoms. The ancient wisdom of the body is that it is always seeking balance, and will find it irrespective of the minds influence on what is “normal.”

A metaphor might be something like a boat sinking due to a hole in the bow of the hull. The passengers on the boat necessarily have to run to the rear of the boat to counterbalance it away from the sinking end. This could be seen as an “abnormal” distribution of human weight on a vessel (analogous to abnormal lab tests, abnormal tissue tonus etc,) but without this shift having occurred, the result would be far more disastrous. It is therefore of little use to usher the passengers back down the front (medicate/palliate/undo local “restriction,”) rather, what must be done is to seek the true reason the body is needing to find balance in this way.

Asking “why?” til one can no longer ask it anymore lands you somewhere in the realm of where to begin.

You can follow Josh on Facebook and Twitter.

Stephen King

Stephen is dual qualified as an osteopath and physiotherapist. He graduated from the Victoria University osteopathy program in the class of 2010, and the University of South Australia physiotherapy program in 2013. He is the director of Movement Assessment Technologies (MAT), which teaches allied health professionals about movement assessment and functional rehabilitation, The Injury Rehab Centre, a practice in Cheltenham, Melbourne which integrates the concepts taught through MAT and the host of the 21st Century Physio podcast, where he interviews industry leaders about the future of physiotherapy and allied health. Prior to working as a clinician he was a personal trainer and strength and conditioning coach, which is where his interest in movement started, and nowadays he spends his time helping professionals get better outcomes for their clients and patients. His advice is:

My top 3 things that I wish I knew as a new grad.

  1. Do not take everything from Uni as fact – a lot of what you learnt is out of date (it’s not 1898).
  2. Osteopathy is more than a 3x3m room. Think outside the box, set goals and work hard.
  3. Be the change you want to see.

You can follow Stephen via MAT on Facebook, Instagram and YouTube and through The Injury Rehab Centre on Facebook and Instagram.

Dr Nic Lucas, PhD

Nic is an osteopath, medical researcher, lecturer turned entrepreneur. Having completed his osteopathic studies at Victoria University in 1999, he went on to further studies at the University of Newcastle in epidemiology and pain medicine, before completing his PhD in diagnostic medicine at The University of Sydney. While at uni, Nic founded the International Journal of Osteopathic Medicine (IJOM) and served as an executive editor for 19 years and sold to Elsevier, the world’s largest medical publisher. He also started the Student Osteopathic Medicine Association (SOMA), helped develop the osteopathic course at The University of Western Sydney, where he went on to lecture for almost 9 years, and sat on numerous osteopathic committees and registration boards. After selling his two osteopathic practices, he has moved into coaching online entrepeneurs with his company X10 Entrepreneur.

Are you an Osteopath, or are you qualified as an Osteopath? Big difference. Don’t lose sight of yourself in a Title. Your identity is greater than your qualification. You can go anywhere, do anything. There’s never been more opportunity. Don’t ask for permission to go be awesome AF.

You can follow Nic on Facebook, Instagram or check out his website.

Summary

You probably started to sense a trend with the advice given.

While a few of the quotes mentioned technique, the majority talked about attitude, and the big picture.

Common themes were personal growth, education, self-care and listening/communication. This might not make sense now, but when you see such diversity in methods, all with similar results, then you have to look deeper at what is being done.

At the end of the day, this is just a milestone in your life journey. Graduating may feel like “everything” right now, but over time, you will grow and it will become “something”.

You have the opportunity to make an impact on people’s lives, which is an amazing privilege.  I wish you every success in your future, both personally and professionally, and hope that this blog helps you in some way.

Finally, start building your network. The internet makes this easier than ever before, and will strengthen your professional life immensely.

Good luck!

Class of 2011 at Victoria University (phone cameras have come a LONG way since then).

 

Nick Efthimiou Osteopath

This blog post was written by Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

You can follow Nick on Facebook, Instagram, Twitter and connect with him on LinkedIn and Snapchat.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 


 

 

11 Important Things To Know About Pain

As someone who spends his life thinking about how to better understand pain, I have reached the point where I have amassed a great deal of knowledge on the topic.

The problem with knowing a lot about a topic is, it is easy to fall victim to the curse of knowledge.

The curse of knowledge is best explained by this example:

In 1990, a Stanford University graduate student in psychology named Elizabeth Newton illustrated the curse of knowledge by studying a simple game in which she assigned people to one of two roles: “tapper” or “listener.” Each tapper was asked to pick a well-known song, such as “Happy Birthday,” and tap out the rhythm on a table. The listener’s job was to guess the song.

Over the course of Newton’s experiment, 120 songs were tapped out. Listeners guessed only three of the songs correctly: a success ratio of 2.5%. But before they guessed, Newton asked the tappers to predict the probability that listeners would guess correctly. They predicted 50%. The tappers got their message across one time in 40, but they thought they would get it across one time in two. Why?

When a tapper taps, it is impossible for her to avoid hearing the tune playing along to her taps. Meanwhile, all the listener can hear is a kind of bizarre Morse code. Yet the tappers were flabbergasted by how hard the listeners had to work to pick up the tune.

The problem is that once we know something—say, the melody of a song—we find it hard to imagine not knowing it. Our knowledge has “cursed” us. We have difficulty sharing it with others, because we can’t readily re-create their state of mind.

I, like many health professionals (and experts in every area) often struggle to convey our knowledge to our patients. This is a huge problem, as education (transferring knowledge), is one of the key strategies we can use to help people.

We say one thing, and with it we are thinking of many other things implicitly, based on our years of accumulated knowledge and experience. Unfortunately, patients only hear what we say, and not everything else that we are thinking of when we say it. To make matters worse, patients will often hear all of what we say, but truly understand even less.

So what’s the solution? How do I make this information as clear as possible?

Simple:

  • Use concrete, not abstract, language.
  • Use examples that relate to you.
  • Repeat the key concepts, over and over, until they stick.

With this in mind, here are 11 important things to know about pain.

1) Pain does not equal tissue damage

This is the most important thing to understand about pain.

Pain is not a marker of tissue damage.

Yes, it does occur with injuries that involve tissue damage. That is not in dispute. However, there are countless examples of people experiencing tissue damage and not feeling any pain. There are also many examples of people experiencing very minor or no actual tissue damage and a lot of pain.

Think about stubbing your toe. Often there is no discernible tissue damage, yet stubbing your toe hurts, a lot. However, after you look down and examine it, often the pain quickly subsides.

Or what about the examples of people who have been shot and don’t realise this until later!

Additionally, the intensity of pain we experience is not a direct measure of the severity of what is wrong. A paper cut hurts immensely, at least at first, but it is hardly a serious injury. On the other hand, many people with life-threatening cancers feel little no pain, especially in the early stages of the disease.

So if pain is not a measure of tissue damage, what is it?

2) Pain is protective

Pain is a protective “feeling” we experience with our conscious awareness.

Huh?

Well you can’t be unconscious and experience pain, by definition. That’s how anaesthetics work.

I’m going off on a tangent here, back to the point. Pain is protective.

Whether it is protective of an injured body part or protective of a threat to our brain’s concept of self pain is a biological process that is meant to keep us safe.

 

Imagine if, instead of being told that her sore knee is because of wear and tear, a doctor tells her patient that her knee pain is because her NERVOUS SYSTEM is being PROTECTIVE of it. ~ Imagine this doctor then tells her patient that to deal with the pain she needs to become more ADAPTABLE and RESILIENT, and that she can do this by improving her flexibility, strength and endurance with EXERCISE and ACTIVITY. ~ Imagine if this doctor also told her patient that STRESS and FEAR makes her PAIN WORSE, and that she not only needs to become more physically adaptable and resilient, but more MENTALLY as well, and that this is possible because even into older age, the BRAIN and nervous system CAN LEARN and CHANGE for the better! ~ #integrativeosteopathy #osteopathy #osteo #pain #neuroscience #exerciseismedicine #positivevibes

A post shared by Nick Efthimiou (@integrativeosteopathyau) on

That sentence is complicated, so read it again, and then I’ll break it down.

Pain can be protective of an injured body part. Most of us would have experienced this, but as I said above, it doesn’t measure damage. Pain can protect a previously injured body part too, often way before it is at any risk of being injured again. This is what happens when people talk about having a bad ____ (insert body part here).

Pain can also be predicatively protective. That is, we feel pain in anticipation of something happening to us. I see this lots with people who have low back pain – before they even move they feel pain, even though nothing has happened except a thought!

Finally, pain can also be protective of our concept of self. Our concept of self is the idea of “I”. It is who we think of when we think in the first person. The concept of self has been discussed anddebated in religious and philosophical circles for millennia.

The self is an individual person as the object of his or her own reflective consciousness – Wikipedia

When you understand this, you can see how pain that comes on for “no reason” can be explained as being protective of the self.

If you experience pain after intense periods of stress, then this is an example of your brain (we’ll get to that) deeming that stress as “threatening”, and along with the corresponding changes in a biochemistry during periods of stress, producing pain to get you to change your behaviours

3) Pain is produced by the brain and localised to the body

You don’t see with your eyes.

Your eyes have cells in them that respond to stimulation by light. Once stimulated, these cells send the information signal, via the optic nerve, to the brain. It is the brain which composes the “image” that we see. Interestingly, our brain doesn’t always produce an objectively accurate image. Unless we are really paying attention, it will often give us a generalised image, that is predictive, based on previous experiences. This is why eye-witness testimony is not considered reliable enough to convict as a stand alone evidence. It is thought this is to save energy.

The same goes for all our sensory experiences. Our brains produce a conscious experience based on input from the sensory nerves.

 

Most people are familiar with taste, touch, smell and hearing, which along with sight make up the “5 senses”. However, our brain is also receiving sensory information from many other nerves throughout the body. This gives us interoception (our sense of our internal body) and proprioception (our sense of our body’s position).

Along with the sensory stimuli mentioned, we also have sensory stimuli we are unaware of.

Nociception.

Nociception is “noise” from the body. Sensory nerves that respond to thermal, mechanical or chemical stimulation are constantly sending signals to the spinal cord. Most of this is blocked, because it is just that – noise. However, when when those nerves are stimulated to a greater degree – think an injury, or contacting a hot surface – then your brain becomes aware of the change to the noise levels.

Think about how you can hear your name spoken at a noisy party.

Your brain, not knowing exactly what is going on, will respond by producing pain, and will decide to protect the area where the increased nociception is coming from.

How does it do that?

With pain of course!

To make matters even more complex, we can have pain in the absence of nociception – think of amputees with phantom limb pain – but the majority of pain people experience is either the result of increased nociception or decreased inhibition of nociception.

More on that later.

4) Chronic pain is different to acute pain

Acute pain is usually a response to either a tissue injury or other immediate threat, it subsides as the injury or threat does.

Chronic pain is the result of changes to the nervous system which make it more sensitive. This means the nervous system and brain become “hyper protective”, generating pain with little or no provoking stimulus.

Whether you or someone you know has chronic back pain, arthritis, headaches or some other chronic pain condition (like fibromyalgia), it is important to know that in cases like this, the problem is pain, and it is the same mechanisms that are involved across the board.

How can this be? How can low back pain be the same as a headache or arthritis?

The changes that take place in the nervous system, predominantly take place in the central nervous system (brain and spinal cord). This is like the central control room for our nervous system. Thus if something is wrong with the central control room, then everything linked to it (which is everything), can be affected.

Of course, there are local (or peripheral) factors involved, which contribute to the pain being localised, but there is often a large central nervous system component to chronic pain.

As a result, chronic pain needs to be addressed as a problem in its own right, and not treated like acute pain.

5) Recurrent pain and multisite pain are both forms of chronic pain

Some people experience recurrent pain. That is pain that “comes and goes”.  They will often think that each episode is a discrete event, that is, it is the same problem happening over and over again. It gets better for a while, then it happens again.

Others experience pain in multiple body regions. They might all be one sided, or they cross midline and are above and below the waist. There may or may not be a pattern (often this pattern is explained in biomechanical terms by well meaning practitioners, but that’s another issue altogether).

This is not the case.

Both recurrent pain and multisite pain are forms of chronic pain, and need to be managed as such.

Often multisite pain starts as a single site, and progresses to multisite, chronic pain. In these cases it can be considered a progression of the same condition. It is important to understand the distinction between these presentations of pain, because chronic pain requires different management to acute pain (see no. 4).

6) Pain is never simple, even when it seems so

It may seem like some pain is simple.

You twist your ankle and it hurts.

Or, you drink lift too much and end up in pain.

We think like this because our brains like linear “cause and effect” relationships.

However, pain is not linear. It is emergent.

A linear process is when one thing progresses to another. In simple terms, it is when A + B = C.

An emergent process is when two or more things combine to form something that doesn’t share the properties of the things that make it up.

Because of this, and all the invisible and unconscious factors that contribute to us experiencing pain, we can never say that pain is simple.

When you twist an ankle, all the associations with twisted ankles you have ever experienced that are buried in your brain are activated. The meaning and context of the ankle twist comes into play (a soccer player who will miss the final will experience different feelings to someone who gets out of duties they didn’t want to do because of the injury). Sometimes the nociception doesn’t represent tissue damage at all, but spikes due to a sudden increase in load.

Why does this even matter?

Because chronic pain starts as acute pain, and in some cases, it was considered “simple”.

7) Pain is not caused by “poor posture”, weak muscles or being “out of alignment”

 


If you have understood everything up until now, this should make sense.

However, many people still think of pain being caused by these things, because we observe these things when people are in pain.

It is the common error of attribution: correlation is not causation.

When you experience pain, you might be weak, or stand/sit differently or even look and feel like you are twisted or bent. There is no disputing this.

But it doesn’t cause pain.

More likely, these things are caused by pain.

They are defensive, or protective behaviours.

8) Osteopaths (and other practitioners) don’t “fix” pain

You might think this is a strange statement to make.

Why else would you pay to see an osteopath then?

Well, there are lots of reasons, but when it comes to pain, the resolution can only come from within your own body and brain.

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A good osteopath will do everything in their power to help remove the barriers to recovery, and facilitate the physiological and psychological processes that need to take place, but no one can change you on the inside from the outside.

Even pain relieving drugs can only work if you are in the right context – morphine doesn’t always help, while sometimes a placebo pill works better than the real thing.

So if you are looking to be “fixed”, it is unlikely to happen as you want. This is probably the hardest thing to accept as both a patient and a practitioner.

9) Everything can “work”

There are claims from therapists, doctors and other kinds of healers about all kinds of treatments for all kinds of pain.

It’s likely all of these people have numerous success stories to confirm that what they do works.

But just as an osteopath can’t fix someone (see no. 8), everything can work for pain.

This is because the brain has the ability to produce pain relieving chemicals, in the right circumstances.

These pain relieving chemicals are extremely powerful, and when the context is right – belief, expectation and ritual all come into play – then the brain, in anticipation of what’s to come and in response to what has happened sends out all these amazing substances to help you deal with pain. This process is called descending modulation (or inhibition).

This is not a bad thing at all. It is actually the goal of many therapies, including osteopathy and exercise rehabilitation.

The problem comes, when interventions are sold in misleading ways, i.e. they are sold as doing something unrealistic or impossible.

In simple terms, if something sounds too good to be true (amazing success rate, top secret, revolutionary) or can only be done by a particular person, it is unlikely that the intervention is really doing what is claimed.

That’s not to say it doesn’t work, only that is doesn’t work because of what is claimed.

10) Inflammation is a good thing

Many people take anti-inflammatory medications for pain without a prescription. They don’t work (at least for low back pain).

Many others use ice after sustaining injuries.

The majority of people doing this don’t know why they are doing it. If you asked them, they might mention something about stopping inflammation.

If you asked them why they want to do this, they might say it helps with pain and recovery.

Now what is more likely?

Our bodies have, over thousands of years, evolved highly effective mechanisms for dealing with injury, part of which is the inflammatory process, or this process is an error of biology and must be stopped?

Inflammation is the body’s way of healing.

Yes, it can be painful, but pain is a protective response. And you know what needs protecting? Injured tissues.

That is not to say you need to completely rest an injured tissue by the way. It is simply saying that suppressing inflammation (particularly with drugs) can impair and delay healing.

Finally, chronic inflammation is not a good thing. However, it is usually the result of other issues, and while suppressing it relieves the inflammation, it doesn’t address the reasons why it is happening. Like chronic pain, chronic inflammation needs a different approach to acute inflammation.

Oh and one more thing,

11) How you live is more important than what you do

 

Most people in pain are looking for a fix.

Be it medication, treatments of various kinds, a specific exercise or even surgery.

The issue here, is that for many pain problems, these interventions all have low effect sizes. That means, they work, but not by very much. Hence the cost and risks often outweigh the benefits.

What is most important, particularly for sufferers of chronic pain, is living well, despite your pain.

Healthy lifestyle habits contribute to healthy bodies and brains.

Healthy bodies and brains experience less pain overall, and when they do experience pain, respond better to interventions.

That is not to say all treatments for pain don’t work.

Nor is it to say how you live can solve all types of pain.

It is simply saying, that your lifestyle plays a large role in your likelihood of developing and recovering from pain.

Think about it. If someone leads an unhealthy, high stress lifestyle, barely sleeping and consuming lots of drugs and alcohol, do you think it matters what kind techniques an osteopath uses, or what type of exercise they do?

Do you think it will make any difference in the grand scheme of things?

Conclusions

I consult with people in pain on a daily basis.

I work with them to try and help them feel and live better.

Sometimes, their pain goes away. Sometimes it doesn’t. Sometimes it gets worse. We are not predictable like a machine.

It is a really hard job, and while many practitioners love to talk about their success rate, I think if you take a big picture view, it is unlikely any single practitioner gets results above and beyond what the statistics say they should for the patient base they work with.

I do believe there are practitioners who would do worse, simply because this information about pain is still not common knowledge, even among health professionals, but to do better is unlikely.

Thus, if someone has a long waiting list, it doesn’t necessarily mean they are the best therapist, it simply means they have a lot of people waiting for their services.

When you choose a therapist to help you, it is less about what kind of therapist they are, and more about how they work, and whether that suits you. A good way to know if they are up to date with the research is to ask them about some of the topics above. They don’t have to agree, but if they have no idea, or dismiss things outright, that might be a hint.

Pain is a mystery, but that doesn’t mean you can’t reduce it, or live well with it. After all, it’s not just about the pain.
Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

References

The Curse of Knowledge

Self

 

Why You Should Choose Conservative Health Care

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You can’t cut out pain. – every *good* orthopaedic surgeon ever

Despite what we know about pain, many people are subjected to poor medical management for their pain on a daily basis.

From the recommendations of medications that don’t work for certain conditions (ahem, anti-inflammatory drugs and low back pain), to expensive courses of passive therapies that have extremely low effect sizes.

Not only do these treatments not work very well, they are is an enormous waste of everyone’s resources. To make matters worse, many of these management strategies are not benign, meaning they have the potential for negative side effects.

When it comes to poor medical management, over the counter medications and ineffective passive therapies are the (very small) tip of the iceberg. Many costly, and potentially dangerous drugs, invasive therapies like injections, nerve blocks and the “grand-daddy” of them all, surgery all carry high risk profiles and for very small benefit, especially over the long term.

It’s right about now that I should add some moderation to this post:

I’m not saying these treatments are completely worthless all the time. In fact, I have had many patients who have benefited from the right prescription or surgery over the years.

What I’m saying, is that these treatments often come with big costs and risks that are not fully disclosed when they are recommended (although nearly every surgeon does a better job at explaining the risks of their treatments to patients, many still overplay the benefits or don’t fully explain the alternatives).

With this in mind, the sleeping giant in the treatment of most painful problems, especially those involving the musculoskeletal system is good conservative health care.

I emphasise the good, because there is so much bad out there.

No, I’m not trying to be negative and put down other health professionals. I am simply stating, that based on my experiences with patients (and supported by research), many have not had adequate conservative care to begin with, which is how they’ve ended up with chronic conditions in the first place.

What Is Conservative Health Care?

Conservative health care is based around interventions designed to avoid radical medical therapeutic measures or operative procedures. 

They are typically lower in cost than more aggressive treatments, which a much safer risk profile.

The downside is that some conservative treatments don’t have a large effect size, and many work in general, not specific ways.

Some examples of conservative health care include:

  • Education, advice and reassurance
  • Lifestyle changes
  • Dietary changes, including supplementation
  • Exercise based interventions
  • Physical/manual therapy
  • Certain medications

When Should You Seek Out Conservative Health Care?

Conservative health care is not appropriate for all health problems.

Serious and life threatening conditions typically need more aggressive and/or invasive treatments. Examples of such conditions include major infections, cancer, organ diseases and major trauma (though there are many more).

When conservative health care is most optimal, is when a condition is chronic and stable, or progresses slowly, when the condition is self-limiting (i.e. it will resolve with time, and symptomatic management is all that is required) and when the condition is non-specific (it can’t be attributed to a single cause), like many low back pain presentations.

Usually, a general practitioner will be able to advise you when conservative options are suitable, so that’s often a good place to start.

Conservative Treatment For Pain

Pain is the number one reason people consult their GPs, however, a lot of pain is very poorly managed from the begining, leading to the progression towards chronic and more debilitating pain.

This is where I feel that conservative management can really shine.

Almost every chronic condition will improve to some degree from improving your health generally.

Additionally, many chronic pain presentations will benefit just as much, if not more in the long run, from good conservative management.

Unfortunately, many people miss out on receiving good conservative care when they need it most, leading to them needing/wanting more aggressive treatment options when their condition has progressed.

The Benefits of Conservative Health Care

Conservative health care has a number of benefits for all parties involved: patients, practitioners and 3rd party payers (insurance companies, governments etc).

One of the biggest benefits is economic.

Let’s take chronic low back pain as an example, because it is so prevalent, and so widely researched.

The cost of these conditions to the Australian economy in 2012 was more than $A55 billion. Back pain and osteoarthritis, the most common of musculoskeletal conditions, accounted for 52% and 41% of cost respectively.

When we look at the costs, most people intuitively think of the cost of treatment (consultations, investigations like imaging, medication etc), however, the bigger cost is the indriect cost, that is the cost to society and the individual of lost income, productivity and quality of life as a result of their condition.

While the direct costs of chronic conditions is around A$9 billion annually, the indirect costs are a staggering A$54 billion annually!

With such high costs, you’d think that prioritising excellent conservative care from the outset would be high on the agenda for all involved.

Unfortunately, many clinicians do not follow the clinical care guidelines which are developed by compiling the best evidence from researchers around the world. In fact, only 20% of low back pain patients received care inline with the guidelines.

These guidelines are designed to ensure the best possible management of each condition, yet with only one in five people getting treatment based around them, many are missing out and going on to develop chronic pain, which ends up costing them in time, money and quality of life.

Other benefits of conservative health care include:

  • Safety – by definition, most conservative health care is low risk.
  • Availability – there are typically many more health professionals able to deliver conservative health care than specialists who deliver more invasive treatments.
  • Sustainability – conservative approaches can typically be maintained over the long term, which can help manage chronic conditions.

What stops people getting good conservative treatment?

I believe that most of the time, most people are doing the best they can. As a result, the lack of implementation of clinical guidelines for conservative care is not down to any one factor, but here are a few:

  • Market forces – funding for public health services is always stretched, so GPs cannot spend adequate time educating patients. Private practice clinicians are often limited in the number of times they can see someone due to a patient’s ability to afford treatment.
  • Expectations – patients often want to be “fixed”, not understanding, or wanting to participate in more active management for their conditions.
  • Practitioner knowledge and skill – most health practitioners are skilled in diagnosis and treatment, not in facilitating behavioural change. This makes it hard to create long term, empowered change.

With this in mind, we can see the challenges that need to be overcome to offer the best available conservative care.

What is needed to improve conservative treatment?

  1. Government and insurance companies need to appreciate the long term cost savings conservative care offers, and fund it accordingly. If a surgery costs $20,000 spread across direct and indirect costs, and that surgery could have been prevented by 2 years of physical/exercise therapy, then even at $100 per session, twice per week, you are coming out at break even. However once you add in the rehabilitation costs of surgery, and the costs of the increased risk, the physical therapy option is actually cheaper.
  2. Patients need to take responsibility for their thoughts and actions. Yes, circumstances can affect everyone, which can make life harder and less fair for some, however, taking 100% responsibility for how you respond and act will mean that you are in the best frame of mind to improve your situation and your condition.
  3. Educational institutions need to adapt to the changing demands on healthcare and focus more on communication and behaviour change. Simply increasing the awareness of this important skill will lead to those interested healthcare practitioners pursuing further education.
  4. Health practitioners must accept that they can always improve, and seek out ways to develop their skills to better serve their patients. This includes seeking out appropriate continuing education, but it also means enhancing their networks and their ability to utilise these networks to benefit their patients.

The Big Two

Of all these factors, the two most important are economic and cultural forces.

Money is always an influence on how we make decisions, and many people simply don’t have the financial freedom required to pursue optimal conservative care, especially privately.

While there are always those who are living on the edge, and literally have no room in their household budgets for anything about the essentials of living (housing, food, transport and utilities), there are many more who claim that health care is too expensive. Yet these people walk around with the latest iPhone on a high monthly plan, or drink/smoke/gamble regularly. For these people, who may be on average incomes, it is simply a matter of choice and priorities*.

This is where culture becomes important.

Our culture in Australian is heavily influenced by commercial interests.

Unfortunately, there is a lot of money to be made in selling treatments for conditions that offer a simple solution to a person’s health problem.

Whilst they appeal to our emotions, simple solutions are usually inadequate for complex problems.

So when you propose a long term course of conservative care, which involves active participation by patients, it is often a tough sell.

It is made even tougher by the massive marketing budgets pharmaceutical companies and medical device companies have. They use these to influence our culture.  Every night on TV there are commercials for different types of pain medications. Ironically, if most people spent just 30 minutes less watching TV, and decided to go for a walk instead, they probably wouldn’t need them anywhere near as much.

A Different Perspective

If instead of thinking in terms of expense (cost and time/energy), you changed focus to investment, then immediately you have changed your perspective on health.

When you invest in a term deposit, at the end of the term you have more money than when you started.

Conservative health care, done properly, is an investment.

Yes, you are spending time, money and energy to change your health, which has an initial up front cost. But, by the end of the treatment program, you should have improved health, reduced pain, better function and an overall better quality of life.

Get more years out of your life, and get more life out of your years.

These improvements can be thought of as your return on investment. Like a term deposit, conservative treatment is mostly safe, offers fairly predictable outcomes and is overall, low risk.

Once you have restored your health, the idea is to maintain it (just like you would with wealth). Usually this means you need to continue your healthy habits which you established during treatment.

A final word on perspective; if you are in debt, you must pay back your debt before you can invest. The bigger your debt, the more work and time it takes to repay. The same school of thought applies to health. While things can change quickly, true healing from chronic conditions, or even severe acute conditions, takes time.

If that puts you off, think about it like this: time will pass, regardless of what you do or don’t do. If you do nothing, you will be in the same, if not worse situation in a year or ten.

Conclusions

Conservative care is extremely important from both a public health and individual perspective. Delivered optimally, it saves money, improves outcomes and reduces the need for interventions with higher side effect or risk profiles.

There are some barriers to delivering good conservative health care at the population level. On an individual level, the two most important variables can usually be overcome.

If you are a patient: when you are seeking out a health care provider, discuss long term strategies and look for providers who will incorporate an active management plan.

If you are a practitioner, you should look to improve your communication and behavioural change skills. Telling someone what to do isn’t good healthcare. Guiding them through the process of how to do it is.

 

Nick Efthimiou Osteopath

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

 

Notes

*For those who are truly struggling, most universities with allied health programs have student teaching clinics. These allow students to provide supervised care at reduced costs. In special circumstances, the fees can even be waived. Bottom line, no matter your circumstances, if you are really set on helping yourself, you can find a way.

References

(1) Medibank: Chronic pain costs economy more than $22bn a year

(2) Pain drain: the economic and social costs of chronic pain

(3) The burden of musculoskeletal conditions in Australia: a detailed analysis of the Australian Burden of Disease Study 2011

Osteopathy For Carpal Tunnel Syndrome

Image credit: By DoPhotoShop - http://dophotoshop.com/carpal-tunnel-exercises.php, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=14614865

Image credit: By DoPhotoShop – http://dophotoshop.com/carpal-tunnel-exercises.php, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=14614865

Carpal tunnel syndrome is a common presentation, but is often poorly managed. Osteopathy can provide a conservative option to treat carpal tunnel syndrome.

Carpal tunnel syndrome is a fairly common condition that affects women slightly more than men, with numbers ranging from 1-7% of the population affected. (1)

It is described as “a painful disorder of the hand caused by pressure on nerves that run through the wrist. Symptoms include numbness, pins and needles, and pain (particularly at night).” (2)

It usually presents with the following symptoms (3):

  • paresthesia, dull, aching pain, or discomfort in the hand associated with weakness or clumsiness;
  • fluctuating level of symptoms with exacerbation at night (nocturnal numbness), worsened by strenuous hand use or activities with maintained posture (driving);
  • and partial relief of symptoms by changing hand posture or shaking the hand.

Diagnosis or description?

Generally speaking, any condition that has the word “syndrome” in its name is not a diagnosis, but rather a collection of clinical findings.

In the case of carpal tunnel syndrome, it is considered a clinical diagnosis, but, whilst the symptoms can be similar from person to person, the clinical findings (and thus underlying causes) can be quite different, based on a variety of different factors.

Some of these factors include:

  • Individual anatomical differences (wrist space, nerve length, a cervical rib etc)
  • Lifestyle and occupational activities (assembly line workers tend to have a higher incidence of carpal tunnel syndrome than other occupations – NINDS)
  • Pregnancy – pregnant women have a higher incidence
  • Health status – diabetes, hypothyroidism and obesity are known risk factors (Frontiers)

To diagnose carpal tunnel syndrome a clinical examination is sufficient, though in more severe cases, nerve conduction tests are recommended.

When you consider that any combination of factors can be present, an individualised approach to management becomes critical.

General Recommendations

The general medical recommendations (1, 4, 5) to treat carpal tunnel are (in order):

  • Rest. Rest is important, but it is often futile if there are other issues involved, because as soon as you stop resting, symptoms flare up again.
  • Splinting, particularly at night. Splinting can be useful, but again, it isn’t because of a “lack of splinting” that you develop the condition in the first place. This means, that without addressing the other factors, splinting is just another form of rest, and symptoms will likely return once splinting has stopped.
  • Physiotherapy. Hand, wrist and arm exercises can be useful in helping reduce symptoms and address causative factors. Exercises targeted at mobilising the nervous tissue, can be particularly helpful here. Whilst different professions, osteopaths can do most of what physiotherapists can do and vice versa, and what matters most is that the professional in question is up to date in their knowledge and provides an individualised treatment approach.
  • Diuretics to reduce fluid. Diuretics can provide a short term reduction in fluid, but again, we need to work out why the fluid was accumulating in the first place. If, for example, there is lymphatic congestion, the diuretics will only have a short term effect, often with the risk of side effects. Another common cause of congestion is hypothyroidism, which needs to be medicated properly, so identifying the cause of the congestion is as important as reducing the fluid with diuretics.
  • Cortisone. Cortisone can reduce inflammation locally, with the potential risk of nerve injury resulting in worse pain. The benefits do not outweigh the risks, in my opinion, considering the alternatives available. If you do decide to have a cortisone injection, it’s best to have it performed by a surgeon who performs it often, as their skills will be higher, reducing the risk of adverse effects.
  • Surgery. Surgery is indicated in severe cases, but is not always successful (like any treatment). It has the risk of nerve and/or artery damage, with the benefit of increasing the space under the transverse carpal ligament, which is often a cause of symptoms. The success rate of surgery for carpal tunnel is generally higher at 12 months than conservative approaches, when considering nerve conduction studies, but due to the risks involved, the recommendation is to initially treat conservatively, and only explore surgery if there is not the desired improvement.

(My) Osteopathic Approach

To understand my osteopathic approach to treating carpal tunnel syndrome (and any condition really), you have to have a grasp of complex systems and emergent properties.

Put as simply as possible:

This means that something like pain, or symptoms arising from the nervous system are not predictable based on statistical or experiential averages, and any linear causality we deduce, is false logic.

So, when it comes to treatment, we have to have an understanding of normal physiology, then use our clinical skills to find the “abnormal” or “dysfunctional” or “disturbances to normal”.

We can then apply an intervention that results in a change (remember, this change is unpredictable), monitor the change (see if the abnormal has become normal) and then reevaluate the approach.

In essence, it is a trial and error approach, but an educated one.

Measure Twice, Don’t Cut

It’s important to measure the effects of treatments somehow, but, this can be hard, because clinical findings vary for the same condition, and the same clinical findings will not always result in symptoms, even in the same patient.

Because of this difficulty in measuring clinical findings and symptoms, I try to use objective outcome measures. These are simple, validated (by research) questionnaires, like the Boston Carpal Tunnel Syndrome Questionnaire, which provide a measure of the disability associated with a certain condition; and they can be very helpful to use at the beginning, mid-point and end of treatment process to gauge efficacy.

As mentioned earlier, nerve conduction tests are valuable in certain cases, but are invasive and costly from an economic point of view, so they are not always practical.

Treat The Whole, Not The Cause

As I described in Osteopathy For Low Back Pain, there are general, or systemic effects from osteopathic treatment, as well as local.

When treating a person with carpal tunnel syndrome, as opposed to treating carpal tunnel syndrome as a condition, these general effects can be important in improving overall sense of wellbeing as well as positively affecting the body’s physiological functioning.

Sense of wellbeing is often overlooked in outcomes based medicine, but, with outcomes being equal, the process that produces a more pleasant/less unpleasant experience for the patient is superior.

nerves_of_the_left_upper_extremityIn addition to the general aspects of an osteopathic manual treatment, with carpal tunnel syndrome, a focus on the structures related to the median nerve starting from it’s origin in the brachial plexus as it arises from the C5-T1 nerve roots, all the way to it’s end point in the hand.

It is surprising how many people I see who have consulted with their GP and perhaps a rehabilitation professional (occupational therapist, physiotherapist, hand therapist) who have only had interventions directed at the wrist and hand.

Simple anatomy suggests that this will not be adequate.

Given the nature of nerves, symptoms will appear distal to (below) any site of adverse tension/compression. Considering the hand is the site of carpal tunnel syndrome symptoms, my preference is to work up from the hand and wrist towards the neck and thorax.

Common areas of dysfunction include:

  • Transverse carpal ligament (this is what surgeons cut)
  • Carpal (wrist) bones
  • Radius and ulna (forearm bones and their joints)
  • Interosseus membrane of forearm (connection between radius and ulna)
  • Elbow flexor muscles and associated connective tissues
  • Pectoralis minor
  • Upper ribs (especially the 1st rib) and clavicle
  • Scalenes (and other neck muscles)
  • Cervical spine (neck) and thoracic spine and rib cage

Unless all these areas are considered and any dysfunction addressed, I wouldn’t consider the examination process thorough enough.

Neurodynamics must be considered

One of the issues with traditional approach to carpal tunnel syndrome, is that the median nerve itself is not considered as a primary cause of the symptoms, but rather a secondary “victim” to other changes.

Neurodynamics considers 3 aspects (Shacklock):

  1. The mechanical interface of the nerve and body tissue (joint, ligament, muscle etc)
  2. The neural tissue itself
  3. The innervated tissues

Abnormal changes at any of these aspects can alter neurodynamics (the function of nerves), leading to symptoms.

Techniques Are Secondary

Lot’s of people want to know what technique will work best, whether it is a manual technique delivered by an osteopath, or an exercise to self manage. The technique doesn’t matter as much as the reasoning behind the technique and how the technique is executed.

So if someone reasons that muscular tension in the neck muscles is affecting the median nerve, a range of techniques to reduce said tension will be helpful. These can be active or passive and are guided by patient and practitioner experience and preference, as well as a risk to benefit analysis (when known).

This technique needs to be delivered or performed in a mindful manner, with attention being paid to the experience of the technique, as well as the response, by all parties involved (patient and practitioner).

By engaging patients in the process, the treatment automatically becomes more “active”, which we know produces superior results to passive treatments in the long term (BMP).

Conclusions: Putting It Altogether

 

Carpal tunnel syndrome has two components – the symptoms experienced (pain, numbness and tingling etc) and the reduced nerve conduction, which is not always perceptible.

Osteopaths have a role to play in reducing the symptoms (6), and research performed on other manual therapies supports this (7).

However, it must be considered that there is no set formula for a condition like carpal tunnel syndrome, and that each person will have their own “physical story” explaining their condition, and it is this story that a practitioner must somehow read, understand and interact with.

So when you are seeking treatment for carpal tunnel syndrome, you want to find a practitioner who considers everything, not just what is happening at the wrist, not just what is happening “in your body”, but everything.

It sounds cliche, but that is what a truly holistic approach entails.

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

References

(1) Primary Care Management of Carpal Tunnel Syndrome

(2) Better Health Channel – Carpal Tunnel Syndrome

(3) Carpal Tunnel Syndrome – Primary Care and Occupational Factors

(4) Conservative Interventions for Carpal Tunnel Syndrome

(5) Is surgical intervention more effective than non-surgical treatment for carpal tunnel syndrome: a systematic review

(6) Effectiveness of Osteopathic Manipulative Treatment for Carpal Tunnel Syndrome: A Pilot Project

(7) A Pilot Study Comparing Two Manual Therapy Interventions for Carpal Tunnel Syndrome

(8) Median Nerve Image

Rethink Pain: Posture

Xray bronze Vitruvian man isolated on white

I’d say that almost every practitioner who deals with people in pain would have heard a variation on the following a million and one times:

I have terrible posture.

The implication is that this “terrible” posture is:

  1. A problem, in and of itself.
  2. The cause of their pain.

Previously in this series I discussed moving towards a model of pain that focuses on the nervous system, rather than muscles and bones (and other tissues) and osteoarthritis.

This post is going to look at posture and it’s link, or lack thereof, to pain as well as strategies to improve your posture, including the role of osteopathy.

What is posture?

The position of the body with respect to the surrounding space. A posture is determined and maintained by coordination of the various muscles that move the limbs, by proprioception, and by the sense of balance. (1)

What influences posture?

A commonly held view is that posture is purely structural.

Unfortunately, while this would be great, as it would make things simple, it’s not accurate.

Posture, like pain, is an output of the nervous system, which is influenced by (in no particular order):

  • Skeletal structure
  • Psychological factors – mood, emotions etc
  • Physical activities
  • Postural reflexes

Does posture cause pain?

No.

There are people with all kinds of posture who have pain, and there are people with all kinds of posture who don’t have pain.

If posture caused pain, then all people with the same posture would experience pain, or all people with the same pain would exhibit the same posture.

When you understand pain is a protective output of the brain, you can extrapolate that when you have pain, and your posture is altered, these postural changes are protective.

By the same token, changes in posture that occur after treatment for pain, be it hands on or movement based (or anything else really), occur because your brain is no longer needing to protect the affected region, because the perception of threat or danger has decreased.

Do You Need To Improve Your Posture?

Whilst there is a very low correlation between posture and pain, there are at least a couple of reasons why you may want to improve your posture:

  • Improved movement efficiency
  • Improved aesthetics
  • To improve some musculoskeletal conditions (this is a separate issue, because it is specific to the individual and condition)

So unless these are a priority, then you have to ask yourself if you really want to (or need to) improve (or change) your posture.

If you do want to improve your posture, then there are things you can address:

  1. Your mood, emotions and mindset.
  2. You habitual activities and positions.
  3. Improving postural reflexes.

Sorry, but you can’t change your skeletal structure.

So now you know what to change, but how exactly do you do it?

Let me show you.

Change Your Mood, Change Your Posture, Change Your Mood

You can pretty much tell how someone is feeling by observing how they are holding themselves.

What is interesting, is that whilst mood affects posture, posture also affects mood. So if you are in a bad mood, simply changing your posture can change your mood.

Your mood is simply an emotion, a feeling, and according to the theories surround Rational Emotive Behaviour Therapy (REBT) “humans do not get emotionally disturbed by unfortunate circumstances, but by how they construct their views of these circumstances through their language, evaluative beliefs, meanings and philosophies about the world, themselves and others”. (2)

So really, to change your mood, you have to change your emotions by changing the language you use (to yourself and others), examine your beliefs and philosophies about the world. This will then have a flow on effect to your posture.

This is way beyond my scope of expertise, but if you find you are constantly experiencing negative mood and emotions, you could benefit from speaking with a psychologist trained in REBT or Cognitive Behavioural Therapy (CBT).

What You Do, You Become

Most of our day is made up of habitual tasks and activities. From the way you brush your teeth, to the way you pour yourself a glass of water, all the way through to your regular sitting positions and favourite activities (or lack thereof).

As our bodies crave efficiency, they will adapt to accommodate our habitual postures and positions. Some of this adaptation is structural (bone, muscle and ligament remodelling) and some is functional (loss of stability, range of motion, neural tension).

The way to change this is to increase your awareness of what you are doing throughout the day, and pay attention to how things feel while you are doing them. Then modify.

For example, if you always lean up against the left arm of the couch when watching TV, you are habitually shortening one side of your body and lengthening the other. If this was causing you problems, you could practice alternating sides of the couch, which might feel weird at first, demonstrating both the mental and physical adaptations that have taken place.

What You Really Came For – Reflexive Exercises

When we are babies, we have primitive reflexes. Part of our development sees these reflexes “going away”, however, in a way, they remain as our postural reflexes.

For an example, sit tall or stand, close your eyes and let your body sway. Once you hit a certain point, your righting reflex will kick in so you don’t fall over.

Sedentary lives devoid of rich tactile and movement based sensory stimuli can lead to diminished postural reflexes.

One way to “get these back” is to perform reflexive exercises.

These exercises aren’t like traditional exercises which focus on strength, power or endurance. These develop the qualities that underpin movement, which allow us to express and developed strength, power and endurance.

These are performed in a sequence, from most stable to least stable, and from least complex to most complex.

The positions we can use are:

    • Lying.
    • Quadruped (hands and knees).

  • Kneeling and 1/2 kneeling
  • Standing – bilateral stance, split stance and single leg stance

In terms of complexity, we can progress by:

    • Single joint movement

    • Multiple joint movement
    • Contra-lateral arm/leg movement
    • Contral-lateral arm/leg movement that crosses the midline of the body

 

Reflexive exercises are usually rhythmic and self-limiting (you can only perform them correctly, or not at all), which make them fantastic for not only improving posture specifically, but fundamental movement ability in general.*

Can Osteopathy Improve Posture?

Yes, but not in the way you probably think.

Most people assume that if they walk into an osteopath’s office, and come out after a series of treatments standing taller and feeling “lighter”, that the osteopath has somehow “straightened them up” as you would a stack of blocks.

In reality, osteopathy will affect the 3 aspects of posture described earlier:

  1. Interacting with a personable and affable practitioner can help improve your mood, emotions and mindset.
  2. An osteopath can help you identify your habitual activities and positions, as well as help ease some of the strains that these induce using manual techniques.
  3. Finally, an osteopath can help “re-ignite” your postural reflexes, both by using manual techniques to help improve body awareness and help address any issues that might be negatively affecting them, as well as through exercises as described above.

Conclusions

Posture is very poorly correlated with pain, which goes against much of the information you may have read online or heard from health practitioners.

Most of the time, things that are helpful for treating pain, like manual therapy, exercise and cognitive/emotional therapies will also have a positive effect on posture.

In most cases though, treating pain does not require a specific focus on posture, at least in the traditional sense.

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

 

References

*I will post up some examples of reflexive exercises on my Instagram and Facebook pages over the next few weeks, so connect with me on those channels to make sure you don’t miss them.

(1) Harris, P., Nagy, S., Vardaxis, N., Mosby’s Dictionary of Medicine, Nursing and Health Professions

(2) Rational Emotive Behaviour Therapy