Osteopath Dr Phil's Tips

Sense and Nonsense in Manual Therapy

Manual therapy is permeated throughout with myths, fads, frauds and self deceptions on a grand scale. The author, himself an· osteopath and vigorous sceptic, presents here some personal opinions of some of the obvious nonsense that he has encountered.

It is wrong to think that any non-orthodox health worker must agree with any of the others. Nor is there necessarily any consistency of agreement within each denomination. Internal disagreements may be at least as wide and intense as their disagreement with orthodoxy. The author thinks it is far more important to show questioning, debate and academic ferment leading to testing of hypotheses, than it is to pretend that there is any real cohesion within each form of therapy. Collusion with ideas that are unsound, naive and generally insupportable is almost universal throughout health care.

In the hands of a good manual therapist you should experience a careful and perceptive analysis of the structural tensions and torsional patterns of the body that are giving you trouble. Where appropriate this exploration leads to the use of slow and relatively pain-free unknotting and unwinding, aiming to re establish smoother and more integrated function.All of this must be preceded by a full and broad ranging case his torr taken by the manual therapist (not just a checklist to fill in). When any medical complication is suspected, referral is mandatory.There must also be full discussion of the diagnostic pattern, with some sensible exploration of the reasons for the problems. Prognosis, treatment plan, management and prevention of recurrence also need thorough discussion before treatment can start.

Where the problems are long-standing, quite severe and complex, the initial exploratory stage may be quite long, before some agreement about treatment and management is arrived at.

Snares And pitfalls.

You must have a strong personal recommendation. Picking from an advertisement, list, register, yellowpages, shop front or brass plate is asking for trouble. High odds!

  • If you don’t know who to see, perhaps ask the local ballet school or dance company. If their person can finetune bodies with very exacting and precise needs, their manual skills are at least likefy to be better than basic.
  • If you are female and at all uneasy about seeing a male therapist, ask if a companion can come and sit quietly during your session. Good ethical therapists welcome this with apprehensive patients.
  • Always ask how long they spend with you, and whether all of the treatment is done by them - with their undivided attention. Anything much less than half an hour is pretty useless. They haven’t much to offer. If they are using “assistants” or associates to do part of the treatment, they are working pro bono walleto et ego rather than doing their personal best for your problem. Here the clinical relationship I rapport never reaches a full focus where they can really help you to resolve things properly.
  • Addiction. A nice massage, a rub and a crack, and some special stretches can be highly addictive. The repeated popping of spirial joints is “not helpful toward sturdy stable structure; they only wear a rut from the ‘in’ position to the subluxated position, making it easier and easier for the malposition to reassert itself”. (Mye!s, 1998 This is the Macdonald’s of manipulative therapy. Is your treatment really resolving problems so that you don’t have to keep going back? Or is it just a nice (or nasty) temporary relief of tensions that becomes less effective over time? Regular supportive treatment may be unavoidable for some, but it means that your body is not doing it’s own. work
  • Remember that doctors and therapists may seem very nice and kind; even charmingly winsome. But most are also very tough bullies, either direct or indirect subtly; and you don’t want to have more to do with them than is absolutely necessary. Many are also extremely arrogant, thoughtless, greedy and lazy- and some are entirely unscrupulous, with an almost sociopathic lack of real ethics.
  • If there is the slightest whiff of a publicity machine, an overblown or “public” reputation, “charisma’’ and followers, run fast. Sceptics know that any requirement to believe is always a lie: others don’t. They delude themselves and others they come into contact with .
  • Latest and greatest, then, is usually not the best; just the most puffed up.

The symmetry myth

Apart from where New Zealanders bury their dead, symmetry does not exist in most organic life forms. All of us are “handed’\ with dominant arm, eye and leg preferences. Virtually all of our activities, work, sport and preferred positions of rest are asymmetrical. “Which side do you dress sir?” Bone growth 1tself is asymmetrical: one is foot larger than the other; legs, knees and pelvis, generally round 2% to 5% differences in length, breadth, size and shape. A 10% difference in one shoe size is not unusual. So the spinal and general posture is never perfectly straight - nor should it be. The body functions in complex oppositional spirals and doesn’t need bilateral symmetry at all. Within (perhaps) up to 30 degrees of displacement, we can all do well.

So:

  • You don’t need X-rays to show that your spine wanders sideways from the vertical; we all do. Unless, of course, there is some major anomaly, structural damage or medical bone/joint problem to be eliminated.
  • You don’t need someone to tell you one leg is longer than the other, or one hip or shoulder higher; they all are. Naturally, if we strain a joint in our neck or back we will temporarily lean to one side (like limping); but it resolves itself. This certainly doesn’t need a bully to “thrust it straight”, especially when a disc is injured or bulging. Very dangerous.

Spinal joint magic

The myth that minor disturbances of spinal joints of themselves cause illnesses elsewhere in the body is total nonsense. The mixed stiffness, laxity, crookedness, even over-straightness that we all have, do not link to any particular general pathologies at all.

The magic pop

Many people “crack” their knuckles by pulling the fingers. This doesn’t seem to do much good; nor does it seem to do much harm.

The little joints at the back of the vertebrae are much the same size as finger joints; and the same therapeutic irrelevance applies to popping them, with some modifications and caveats.

Of course it is impressive when someone pops the spinal joints for you, especially if they don’t frighten or hurt. Sometimes there is an immediate release of tensions and extra freedom of movement. But, on its own, this will not resolve any difficult chronic problem; and can often be dangerous. It’s never good for it to be retreated too often, as it may wear a groove of recurrence (Myers, above). Some pain relief from forceful manipulations may be due to shock and impact to the tissues triggering an endorphin release -which might last anything from five minutes to five days.

Specific diagnoses

Any diagnosis must make good sense in line with our ordinary knowledge of anatomy, physiology and conventional pathology. Anything efse is likely to be rubbish, however plausible. .

Osteopathic spinal lesions and chiropractic “subluxations” do not exist as discrete significant entities nor as stopping points in diagnosis. If a joint seems restricted there may be hundreds of different pathologies and patterns of somatic dysfunction that would make it so. And why is this happening?

In the spine, for example, we must consider:

  • Schuermann’s disease (osteochondrosis: very common).
  • Vertebral architecture collapsing from osteoporosis.

Or

  • Secondary carcinoma (from, say, breast or prostate).
  • Disc damage or degeneration.
  • Foramina! nerve-root compression and neurology.
  • Degenerative joint disease.
  • Seizure of a hypermobile joint.
  • Ankylosing spondylitis; rheumatoid, Pagets, and other less common medical problems.

In all of these examples the “thrust and pop” approach could be disastrous. There is no excuse for ignorance of basic orthopaedics, rheumatology and neurology in manual therapy.

Healing energy

Good manual treatment is surrounded by a morass of esoteric flim-flam about “healing energies”. You will run into all sorts of chacras, chi, auras, meridians, acupressure points and fanciful pseudoscientific research tosh. These are grandiose explanations for effects that themselves have been very poorly studied. Apart from heat transfer and physical contact/ movement it’s a safe bet that there is nothing more happening than the effects of human intersubjective realities. These are complex, but the feelings of comfort, contact, containment and care; the handing over of control of movement with reassurance and release of specific tensions/torsional patterns account for most of these quite easily.

Claims for the effective use of very subtle body movement patterns clearly do have s e basis in the complexity of this intersubjectivity. But they are not realistically described by their proponents. It is only when we realise that these “enhanced placebo effects don’t work with most chronic long-term problems that life starts to get interesting.

Vague conditions

Many diagnostic labels are dumping grounds for patients and stubborn symptom clusters that don’t really belong together.

Chronic fatigue syndrome, post-myalgic encephalitis, post-viral fatigue syndrome, reflex sympathetic dystrophy, post-traumatic shock syndrome, repetitive strain injury, and fibromyalgia are some of these grab-bag diagnoses.’

While there is usually no doubt that the patient was in a ghastly state at some time, and still may be well below par, they’ve usually become stuck in patterns of illness behaviour. Like the unemployed in a poverty trap, this can be nearly impossible to get out of. Among the characteristics of this are “multiple faddism”, hypochondriacal self-preoccupation and simultaneous engagement with several therapeutic resources.

Many seem trapped between “won’t” and “can’t” get on with building a life. And, unless we are able to help them face up to what they might really be furious and resentful about, and perhaps such difficult things as laziness, cowardice, self-indulgence, failure and embarrassment, manual therapy has nothing to offer beyond temporary or illusory relief.

Therapists claiming to offer remedies for these “conditions” are fibbing. The honest opinion must be that “a few will do well- but it’s a long hard struggle”.

Spurious links

Links between specific muscle-group function and particular food sensitivities/allergies and so forth are claimed by many. Don’t believe it. It is no more likely than that your bowels are traced out on the sole of your foot (ugh: squishy), your liver palpable in the pulse at your wrist, or your premolars precipitating pancreatitis. Pure nonsense: but easy to fake phony testing procedures.

In conclusion

Good manual therapy feels right to the patient and makes sense to them. It can be helpful for a surprisingly large range of human ills, but is often very time consuming, hard work and tiring both to the therapist and to the patient. The common-sense warnings and dismissals outlined here should help you to avoid the 98% of peripheral and mainstream manual therapists who, in the author’s opinion, can’t really help resolve difficult problems.


References

Myers T.W. 1998. Journal of Bodywork and Movement Therapy. Vol 2 1101. “The wounded healer” P. 18. Churchill Livingstone. New York. Edinburgh. USA/UK.