Welcome

I do hope this blog will be a useful resource for students, colleagues and those with an interest in osteopathy and manual medicine. I will update the blog from time to time with additional resources and observations which are either noteworthy or curious in themselves or contribute to the promotion of health, the scope of practice and the osteopath’s role in the wider healthcare context.
You will also find information relating to student workshops and CPD courses, based on small groups with PBL and practical content.
Kind regards
Laurence Kirk



Top Blogs

Jul 22 / admin

Mind My Mood

The author Norman Cousin has documented his personal experiences of illness and the positive effect of laughter and comedy(Anatomy of an Illness; Bantam USA Reissue:1998,). If we are attempting to work within the biopsychosocial model of healthcare should we also be looking to encourage fun and laughter when appropriate?

The biopsychosocial model of healthcare is not a new concept, and many osteopaths will be familiar with the work of Wadell and Main and their  ‘yellow flags’,  and the potential effect of adverse ‘mood’ on patient recovery and prognosis. This contrasts with the effects described by Norman Cousins in his classic account of the ‘healing power of comedy’

Indeed, as long ago as 1911 one of the original osteopathic pioneers: Louisa Burns,  was keen to research the physiological relationship between the mind and body. She carried out a number of experimental studies  and published the results. An excerpt is shown below, which although very much of its time, still poses some interesting questions.

Nearly a 100 years later in 2010 Davis et al have published the results of a study looking at the effects of Botox injection on the emotional experience. Participants were given positive and negative video clips to view (rather than the ‘gloomy words’ used in Burns’ day) Those subjects who had received Botox were more affected by the negative video and more likely therefore, to be a little ‘gloomy’ as a consequence. So, an inability to engage facial muscles fully in response to external stimuli may have a direct effect on mood and potentially also on well being.

Louisa Burns

Effects of Gloomy Ideas

The blood pressure, pulse, respiratory movements, reaction time and dynamometer tests were taken, then words from one of the “gloomy” lists were pronounced, and the subject asked to give a synonym or related word in answer. Fifty words are usually about as much as the average person wishes to endure in such a test  The results of these experiments may be grouped as follows:

Blood pressure decreased, sometimes by thirty or forty mm., but usually ten or fifteen mm. of mercury.

Pulse decreased, with occasional irregularities.

Respiratory movements become irregular, sometimes with frequent sighings.

Reaction time increased, sometimes almost doubled, for gloomy words; the usual increase is about .5 sec. per word.

Dynamometer tests show decrease of strength of both hands, but especially the right, during and after the pronunciation and replies of the “gloomy” list.

The gloomy lists are about as follows:

  • dark
  • forlorn
  • worry
  • pity
  • sorrow
  • labor
  • falter
  • hard
  • dull
  • silent
  • dying
  • moody
  • ill
  • stupid
  • sickness
  • failure
  • weak
  • fatal
  • peevish
  • restless
  • weight
  • shroud
  • torn
  • sleepy
  • dark
  • grave
  • worry
  • silly
  • mean
  • weeping
  • hopeless
  • false
  • blue
  • aches
  • heavy
  • frozen
  • sad
  • weary
  • broken
  • tomb
  • alone
  • poor
  • sorry
  • decay
  • faded
  • old
  • grief
  • timid

A few people who were subject to slight hypochondria were employed as subjects. The gloomy list had not the least effect upon their physiological activities. Apparently the gloomy trend of thought is usual with them

Louisa Burns, M.S., D.O., D.Sc.O. 1911 Studies in the Osteopathic Sciences: The Physiology of Consciousness: Volume 3

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Jul 14 / admin

Influencing Tissue Repair

Traditionally, the tissue repair process is broken down into four distinct stages. In the example below tissue damage has resulted in bleeding peaking quickly, and only lasting for a few hours, followed by the three remaining stages of inflammation, proliferation and remodelling. As can be seen from the diagram, the process begins almost immediately following injury and may still be ongoing months afterwards. The stages are not completely distinct, they tend to blend into each other, with bridges between. Each stage of the process depends on, and is linked to, the previous stage*

A variety of neurological, bioelectrical, mechanical and biochemical triggers initiate and facilitate the progression of each stage. There are exciting advances in our understanding of the role of these messages and the various specialised cells involved in repair** and remodelling, from macrophages to myofibroblasts***. Our knowledge is still incomplete, but fortunately, the design specification is good and  in most cases it is a highly efficient and effective process. As practitioners we only need to intervene if the process has gone awry, and our intervention is geared to ‘restore normal function’; in other words to ‘reboot’ the process so it can proceed to a normal conclusion.

It is important to remember that the inflammatory process is normal and absolutely vital to repair and recovery. When the process works correctly, that individual may not attend for treatment. It is only when the process goes astray that a patient may present with an unresolved injury.  At this stage, we may tell our patient that we are ‘reducing inflammation’ after injury. In fact, what we may actually be doing is stimulating a normal inflammatory/repair process in order that the damaged tissue can then progress through the stages of recovery as it is meant to.

Manual treatment can assist this process,  as can, for example,  anything from acupuncture  through to low level laser and shockwave treatment but ultimately these methods all achieve the same end result i.e. a ‘rebooting’ of the normal and correct repair process.

Later blogs will look into this in more detail and explore the best windows of opportunity for influencing tissue repair with manual treatment.

*Smith C, Kruger MJ, Smith RM, Myburgh KH: The inflammatory response to skeletal muscle injury: illuminating complexities; Sports Med. 2008;38(11):947-69.

**Butterfield T,  Best T, Merrick M: The Dual Roles of Neutrophils and Macrophages in Inflammation: A Critical Balance Between Tissue Damage and Repair; J Athl Train. 2006 Oct–Dec; 41(4): 457–465.

***Hinz B: Formation and Function of the Myofibroblast during Tissue Repair; Journal of Investigative Dermatology (2007) 127, 526–537.

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Jun 30 / admin

Evidence informed Practice

As clinicians, we are expected and indeed required to be up to date with the evidence relating to our practice. However, in common with many other areas of medicine, the current evidence base for osteopathy is limited. Due to this, we must allow the evidence to inform our existing practice, rather than base our practice exclusively on the small number of techniques/approaches for which 'acceptable' evidence is currently available.

A recent review of the effectiveness of UK manual therapy has received wide coverage,  partly as a result of the advertising standards agency’s drive to prevent unsubstantiated claims being made by manual therapists for the treatment of specific conditions.

The original paper may be viewed here with valuable additional commentary by Scott Haldeman and Martin Underwood available here.

As osteopaths we are required to keep abreast of the changes in evidence relating to our clinical practice, including the techniques we carry out. Many of us have our own view on what constitutes ‘evidence’ but this does not always constitute the robust randomised, double blind, clinical trial (RCT) which is acceptable to a research or academic audience.  An important distinction has to be made between a  ‘lack of evidence of  effectiveness’ (which not only applies to many of our techniques but also to a significant number  of e.g. surgical procedures*) and outright evidence of ineffectiveness. In the latter case we would be disinclined to use that particular approach, but in the former, we should cautiously continue until research clearly either condones or condemns! This is also the case for surgeons as well as osteopaths, with the same difficulty in constructing appropriate and relevant RCTs**

A useful table summarising the results of the review can be found here: evidence review table

In the meantime Scott Haldeman in the Bronfort commentary has summarised his approach to keeping up to date, although this may not be appropriate for all:

1. Ensure attendance at  those scientific meetings where the latest clinical studies are presented and discussed.

2. Ensure that I keep up to date with the latest research in order to be confident that I am as knowledgeable about my field of practice as any other clinician.

3. Ensure that when I advertise my practice or talk to prospective patients that I only make claims that I can support by quoting the scientific evidence.

4. Discuss with patients the scientific rationale of any treatment I am considering to address their problems and why I am suggesting a certain course of care.

5. Avoid suggesting a treatment approach to a patient without discussing the expected benefits, the possible adverse reactions and the options that are available either through my office or by referral to another clinician.

6. Determine the preferences of my patient for the different treatment options when the likely outcomes are similar and empower him or her with the knowledge to make an educated decision on his or her care.

7. When a treatment option is decided on, I attempt to closely monitor the patient’s positive and negative response to the treatment and make adjustments to the type of care offered depending on the response.

As a complete counterpoint you may enjoy reading this article, with a provocative spin on the ‘evidence based establishment’

*Ubbink D, Legemate D: Evidence-Based Surgery: British Journal of Surgery,Volume 91 Issue 9, Pages 1091 - 1092

**Abraham N: Will the dilemma of evidence-based surgery ever be resolved?; ANZ J Surg. 2006 Sep;76(9):855-60.

**Boswell et al:  Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain; Pain Physician. 2007 Jan;10(1):7-111.



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Jun 25 / admin

Still Relevant

I rather like this quotation. Osteopathy is often referred to as both a science and an art. To continue the analogy; Students may start with 'painting by numbers' but they should be encouraged to become 'artists in their own right' as they progress. Can those with a structural bias be likened to figurative painters, and those with a cranial bias abstract or impressionist?
No matter the difference it's all art!

‘THE OSTEOPATH AN ARTIST.
I believe you are taught anatomy in our school more thoroughly than any other school to date, because we want you to carry a living picture of all or any part of the body in your mind as a ready painter carries the picture of the face, scenery, beast or any thing he wishes to represent by his brush. He would only be a waster of time and paint and make a daub that would disgust any one who would employ him. We teach you anatomy in all its branches, that you may be able to have and keep a living picture before your mind all the time, so you can see all joints, ligaments, muscles, glands, arteries, veins, lymphatics, fascia superficial and deep, all organs, how they are fed, what they must do, and why they are expected to do a part, and what would follow in case that part was not done well and on time.
I feel free to say to my students, keep your minds full of pictures of the normal body all the time, while treating the afflicted.’

Philosophy of Osteopathy  A. T. STILL, KIRKSVILLE, MO. 1899.  p13

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May 22 / admin

Fryette’s Laws?

In many institutions, and particularly in the USA, there seems to be tacit acceptance of the idea that the physiological motion of the spine can be reliably predicted and explained by reference to 'Fryette's Laws'. Given that nearly 100 years have elapsed since the ideas were originally formulated, why are they still being used?

Harrison M Fryette(1876-1960) was an early ‘pioneer’ osteopath who researched spinal motion over a number of years, with a seminal paper on the principles of spinal motion delivered to the American Osteopathic Association in 1918. However, it was some time before his ideas gained ground, until they were eventually revisited and relabelled as ‘laws’ as late as 1956 by T Edward Hall in the yearbook of the Osteopathic Institute of Applied Technique. The original principles were:

Principle I: When the spine is in neutral, sidebending to one side will be accompanied by horizontal rotation to the opposite side.
Principle II: When the spine is flexed or extended (non-neutral), sidebending to one side will be accompanied by rotation to the same side.

a third principle was added in the 1940s by CR Nelson

Principle III: When motion is introduced in one plane it will modify (reduce) motion in the other two planes.

Since the 1950s the osteopathic and chiropractic community have been enthusiastic in their adoption of these principles to the extent that they even appear in the Glossary of Osteopathic Terminology published by the American Osteopathic association (AOA) and questions based on these principles appear in state board examinations, set as current biomechanical theory and not as historical footnotes. Interestingly, the ‘laws’  as now published specifically exclude the cervical spine, as a result of a conflict  between the original principles and the weight of current research findings.

On what basis were these ideas formulated?

Fryette drew heavily on earlier work conducted by Lovett in 1905* The research methodology consisted of cadaveric study and in vivo research via the application of gummed paper stickers to the spinous processes of a small number of student volunteers. The results were obtained by observing relative motion of these gummed paper stickers, and inferring as a consequence, the nature of the underlying spinal motion which had occurred.

Over the last century kinematic research has progressed from direct observation, cadaveric study, radiological analysis, cineradiology, CT, MRI, Steinman pins, implanted Gallium balls, to computer modelling. The more we are able to visualise and research living spinal motion, the more complex and unpredictable is the precise combination of individual joint rotation and translation for each region and segment. Rather than definitive ‘laws’ it appears that there are substantial individual and regional variations with, as yet, no accurate model for predicting all of the motion behaviour. With all this uncertainty why do some of us still persist in promoting a model for physiological motion based on work conducted over 100 years ago?

The work of Fryette must be applauded for it’s longevity and insight, and celebrated as part of our osteopathic heritage and history, but the ‘laws’ can no longer be viewed as such, nor do they serve as a viable explanation of physiological motion behaviour.

Time to move on, and as Fryette** himself emphasised:

‘No intelligent scientific spinal technic can be developed that is not based on an accurate understanding of the physiological movements of the spine’

* Lovett RW (1905) The mechanism of the normal spine and its relation to scoliosis. Boston Med Surg J 13:349–358

** Fryette H H; Principles of Osteopathic Technic, The Academy of Applied Osteopathy 1954 p.16

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May 1 / admin

What’s the Crack?

Many people will be familiar with the sound of joints 'cracking' or 'popping' when they visit an osteopath. The "crack" associated with a joint manipulation is thought to be caused by a 'cavitation' process:

Cavitation is thought to occur when the joint surfaces are suddenly gapped and the pressure inside the joint has to decrease in order to compensate. As a result dissolved gasses in the joint(synovial) fluid are released into the joint cavity.  These gasses make up about 15% of the joint volume and  mostly consist of carbon dioxide.  The crask or pop is thought to be generated by an ‘ elastic recoil’ of the synovial capsule as it “snaps back” from the capsule/synovial fluid interface.

Once a joint undergoes cavitation,  following manipulation, the range of motion of the joint increases. The sudden joint stretch or distraction during a manipulation occurs in a shorter time period than that required to complete the protective stretch reflexes of the muscles around the joint.  There are specialised sensors or receptors in and around the joint and it is the stimulation of these receptors which may be the reason behind the many observed beneficial results of manipulation. It is possible that without the cavitation process  it would be difficult to generate the forces in the joint without causing muscular damage.

Current evidence suggests that some or all of the following mechanisms may be responsible for the observed effects of joint manipulation:

  • Changes in group Ia and group II mechanoreceptor discharge,
  • Altered sensory processing facilitation in the spinal cord
  • Altered control of deep skeletal muscle reflexes.
  • Activation of descending inhibitory pathways from the brain

Useful References


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Apr 26 / admin

More on Wolff’s Law

Julius Wolff (1836-1902) was a German surgeon, regarded by many as one of the founding figures of modern orthopaedics. In 1892 he published ‘The Law of Bone Remodeling’* . His theories, although somewhat flawed, were remarkable given the limited knowledge of physiological processes available at the time.

In general terms his theory emphasised that the structure of bone will adapt to super-imposed forces by becoming stronger (or weaker) as necessary. More specifically, he devised a mathematical model to predict how the internal architecture of bone would respond to these forces. It is the assumptions implicit in the specific theory which have been challenged. The general premise of the original theory does however, still hold true.

Over a 40 year period in the late 20th century, an American researcher, Harold Frost, began to add further insight and worked to refine Wolff’s original ideas into what he termed the ‘Mechanostat Theory’ (The Utah Paradigm of Skeletal Physiology)

This refinement states that bone growth and bone loss is stimulated by the dynamic mechano-elastic deformation of bone and not simply by static loading.  There appears to be a relationship between muscle cross sectional area and bone cross sectional area. The mechanostat theory seeks to integrate the tissue-level organisation and  physiology of bone including. e.g.  the dynamic aspects of  both osteoblasts and osteoclasts, and their associated feedback loops, with Wolff’s 19th century concept.

The original premise of the Utah Paradigm emphasised the inherent economy of  human tissue growth and design:

“The design of healthy, mammalian load-bearing bones would provide only enough strength to keep postnatal voluntary loads from causing spontaneous fractures, whether those loads are chronically small, normal or huge in size”**

However,  it should be remembered that our  skeletal function is  not solely mechanical, and that skeletal structure represents an adaptive compromise between a number of often differing needs. Mechanical integrity is just one part of a set of  competing physiological influences  including e.g. diet, hormones, pregnancy, bone marrow storage, and absorption of nutrients***.


*Wolff J. “The Law of Bone Remodeling”. Berlin Heidelberg New York: Springer, 1986 (translation of the German 1892 edition)

**Frost HM. A 2003 update of bone physiology and Wolff’s Law for clinicians. Angle Orthodont 2004; 74:3-15.
***Ruff C,  Holt B, Trinkaus E. Who’s Afraid of the Big Bad Wolff?: ‘‘Wolff’s Law’’and Bone Functional Adaptation; American Journal of Physical Anthropology 129:484–498 (2006)

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Apr 21 / admin

Does Size Matter?

A new study* has looked into the impact of bodyweight on disc degeneration in the lumbar spine. It had previously been assumed that extra body weight may lead to additional stresses and demands on both the bony structures of the spine and the shock absorbing intervertebral discs. In turn this had been assumed to lead to a greater likelihood of degeneration and eventual failure.

This new study suggests that these assumptions may not be consistant. It appears that moderately increased body mass leads not only to an increase in the vertebral bone density, but also to delayed disc degeneration. The subjects of the study were 44 identical twins. One twin was heavier, by on average 13kg, than the lighter twin. The authors suggest that the increased ‘bodyweight loading’ may have a protective and strengthening effect.

This finding will not be news to many osteopaths who will be familiar with the old and sometimes disputed concept of Wolff’s Law** dating from the 19th century, which essentially indicates that, over a period of time, a structure will adapt to additional imposed forces by becoming stronger (or indeed weaker if the forces are reduced).

Many larger individuals may be tempted to assume that, within limits, their own body mass may have equipped them with denser and stronger spinal structures. This may be true if the weight had been adapted to over a period of years, but not necessarily for sudden weight gain, particularly in adulthood. However, it could be that regular well controlled weight lifting or weight bearing activity generates the same response over a number of years.

As osteopaths should we therefore be advocating regular controlled weight lifting to reduce future susceptibility to disc mediated low back pain, rather than suggesting avoidance of lifting?

*Challenging the cumulative injury model: positive effects of greater body mass on disc degeneration The Spine Journal, Volume 10, Issue 1, January 2010, Pages 26-31 Tapio Videman, Laura E. Gibbons, Jaakko Kaprio, Michele C. Battié

**Wolff J. “The Law of Bone Remodeling”. Berlin Heidelberg New York: Springer, 1986 (translation of the German 1892 edition)

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Apr 16 / admin

Pelvis discussion MCQ

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Title: Greenhill
Description: Practice Osteopathy Student Workshops
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Mar 24 / admin

Manipulation and Pelvic Floor Muscle Tone

A Brazilian study* has recently shown some very interesting results after treating women with manipulation(HVT) and measuring pelvic muscle contraction strength before and after applying the technique to the sacrum.

This was an experimental study with no controls or randomisation. A significant number of the 40 women recruited to the study were able to generate substantially more pressure using pelvic floor muscle contraction immediately post HVT of the sacrum. Particularly noteworthy was the fact that the participants were all ‘healthy’ young women with no history of vaginal delivery or pelvic floor trauma.

Sadly, many women do suffer reduced pelvic muscle tone post pregnancy and in later years. This often leads to a number of functional problems including stress incontinence. Should further research on the effects of manipulation show equal or possibly even greater benefit in symptomatic subjects, HVT applied by osteopaths may become a useful addition to usual care, including pelvic floor exercises and electrotherapy.

* http://www.jmptonline.org/article/S0161-4754%2809%2900319-4/abstract

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