There were some lovely lightbulb moments when studying to become an osteopath, none more so than when we talked about A.T. Still's (the founder of osteopathy) assertion that structure governs function and vice versa. This is one of the basic tenets of osteopathy and is such a simple idea and yet so elegant and indeed really powerful. Modern architects, and industrial designers talk about form following function...but in the body it is so much more. You may think a baby is like a mini adult, if you were to see a baby's skeleton it would just be that of a small person. Not so. Much of the intricate structure of the skeleton is laid down as done in response to the forces that pass through it. The size of muscle attachments depend on the forces they are required to cope with, as do the overall shape density and internal geometry of long bones. Our activities carry on changing our body's structure all the way through out life. Too much time staring at a badly positioned screen and you can end up with a head forward posture, work out a lot and you'll get bigger muscles and muscle attachments.
The structure of the your body and the elements within it also dictate the limits of its function. You can't bend your elbow far in the extended direction because the olecranon hits the base of the olecranon fossa. If it didn't then you'd almost certainly damage soft tissues, blood vessels and nerves, so it's a good job all in all! As we get older we can become more and more limited as our structure becomes further and further from the ideal.
A really good example of this is the head forward rounded shoulder posture of the typical office worker. The head is heavy, so once it sits anteriorly gravity tries to pull it further so. As it comes forward and the upper back starts to round, so the shoulders start to move so they sit more forward. Shoulders are not designed to sit protracted like this. Like every other joint they have compromised range of movement for stability, protection and to provide muscle attachments. If your shoulders are sat where they should be there is no bony encumbrance to raising your arms out to the side and nearly to pointing vertically (actually this is a slight simplification because your arm does a little trick to avoid one but to all intents and purposes...). If the shoulder is tipped forward then so are all the structures. You want to reach straight up but to the shoulder that is reaching up and back...try it now, you can only get to about 80'. Rounded shoulders also internally rotate the arms meaning if you want us the hands in the neutral position you have to externally rotate the forearms which can lead to tight muscles and repetitive strain injury and can also alter cause both blood and nerve supply to become restricted leading to pain, numbness, tingling and even loss of function. As usch the change in structure can have a very profound effect on function both directly and perhaps indirectly.
If the back is curved like that for long enough the vertebrae will start to wedge and it will not be easily reversed and in some elderly patients osteoporotic crush fractures have caused the vertebrae to wedge significantly. For many of us though it is still early enough days to correct our rounded shoulders and our head forward some relatively easy exercise and stretches, a well adjusted workstation and some mindfulness about posture can all help significantly...oh and some help from your osteopath might not go a miss.
As osteopaths we believe that it is important that joints are meant to move and that they require movement to remain healthy. Much of the treatment I give is about getting joints moving that aren't, and rebalancing the tone of tissues such as muscles around the joint so that impediments to full and free movement of the joint are reduced. The 'cure' comes from the movement and the body's response to that movement, recalibrating its neutral position, pumping away waste and replenishing nutrients.
Rome wasn't built in a day but today is as good a day as any to start thinking about the small changes to the structure of your body which limit function and asking yourself how you might reverse them
Paracetamol is not the panacea
Those in the medical professions have long known that actually paracetamol is not an anti-inflammatory and therefore of less use than non-steroidal anti-inflammatory drugs (NSAIDs) but it has continued to be propounded for pain by, amongst others, NICE, especially for those patients with stomach problems or other reasons to avoid NSAIDS. Cochrane are a great organisation who specialise in systematic reviews, looking at all of the available evidence, sifting, grading and weighting it and producing a definitive synthesis with a grading for how strong the evidence is. Recently they conducted a systematic review on how effective paracetamol is for acute low back pain...it isn't...at all and the evidence is strong, read the review here. A blog Cochrane have published by a major contributor goes further (here)...it appears that there is evidence for very little pain relief from paracetamol. There is some good news though (here), as I posted in an earlier blog, Cochrane studied topical NSAID gels of Diclofenac, Ibuprofen and Ketaprofen, and some Diclofenac patches provide effective pain relief...and of course won't irritate the stomach. So! If you have a bad back you might want to reach for the gel rather than a pill and if that doesn't work, of course, call for your osteopath.
Osteopathy is not a risky business, whatever some professional sceptics may have you believe. A comprehensive study of available literature, conducted in 2009 found that serious adverse events did occur that were associated with osteopathic treatment but they were very rare. The most serious of these were strokes associated with damage to the arteries of the neck following an upper neck manipulation.
Risks of major adverse events, such as stroke with neck manipulation, are very low. Estimates suggest around 1 per 100,000 to 1,000,000 manipulations or 1 per 50,000 to 100,000 patients. To put this in perspective, the risk of having a stroke without a manipulation is around 100 strokes per 100,000 (or 1 per 1,000 people) in the general population in the UK over a one year period. you can read the study here if you wish.
But that doesn't tell the full story. Those are serious adverse events associated with neck manipulations but that could be like saying going to the shops makes you fat because you notice that the more often you go to the shops the fatter you get. Of course it is not shopping that makes you fat, it is eating the chocolate bars you buy at the shop that makes you fat but there is a correlation because if you go out to buy chocolate bars more often and then eat them you both visit the shop more often and get fatter.
So appears to be the case with neck manipulations and artery damage leading to stroke. A new review of the literature, read it here finds evidence that the linking variable is likely to be neck pain or headache and that some patients with a dissecting artery present at the therapist with neck pain or headache and are treated but that the neck pain/headache is the true symptom of the dissecting artery and the manipulation has no effect on it. There is a lovely table at the end of the paper showing Hills criteria for causality which clearly shows on how many counts cervical manipulations fail to qualify as causal for dissecting arteries.
This is good news but is unlikely to change how I practice in the short term. I will still take a detailed case history so I am aware of the likelihood of any conditions pertinent to my treatment of you and I will still exercise caution in the treatment of anyone at risk of cardiovascular disease or connective tissue disorders or indeed with any anticipated bone weakness.
Damian is the principal osteopath at Vauxhall Village Osteopathy and Oval Osteopathy