Last week The Guardian (hardly the UK's most sensationalist newspaper) ran a couple of articles 
here  and here based on this paper 

Analgesic effects of non-surgical and non-interventional treatments for low back pain: a systematic review and meta-analysis of placebo-controlled randomised trials

Here's a link, click on the PDF symbol to download

The Guardian take-home, and indeed  the headline of one of the articles is 'only  10% of non-surgical  interventions provide pain-relief', but is this what  the  research paper says?  Spoiler, no it doesn't

The paper is a systematic review of randomised controlled trials comparing individual treatments with a sham or placebo (a sham treatment is not quite the same as a placebo but the idea is  that it mimics the treatment being tested but tries to exclude the supposed active element).  The group had previously undertaken this activity in 2008 and this was an update so the paper aimed to find and add all of the published research since 2008  that met its inclusion and quality criteria.  Papers that didn't quite meet the gold standard would be included but marked down.

Providing sham treatments for manual therapies is difficult  and double blinding (ensuring that neither the practitioner nor patient know whether they are in the active or sham group) is very difficult and so out of the c6500  new studies since this group's previous  version of this paper only c170  met the grade for inclusion 

These papers tended to cluster around interventions  for which a sham or placebo can more easily be contrived such as analgesic drugs and  meridian point acupuncture

There was enough evidence to say that 5  interventions were likely beneficial (they include  spinal manipulation and  massage)  ​

And so, despite  16 years having elapsed since the last systematic review , actually the take home was that there was still  not enough evidence to say how effective  most interventions were

In the UK, osteopaths hold a distinctive position in the healthcare system. As primary care practitioners, they are expected to have the medical knowledge necessary to identify serious health conditions that may present as simple musculoskeletal issues. This responsibility requires a deep understanding of human anatomy, physiology, and biomechanics, ensuring that diagnoses are credible and that referrals are made appropriately. This level of expertise sets osteopaths apart from bodyworkers like massage therapists, whose scope typically does not involve diagnostic responsibilities.
Osteopaths also stand out because of their hands-on approach to treatment, which they share with chiropractors but contrasts with the often exercise-focused methods of many UK physiotherapists. However, unlike many chiropractors, osteopaths heavily rely on touch not only for treatment but also as a key part of their assessment process. They constantly evaluate tissue health with their hands, allowing for an iterative treatment approach that adapts to the body's responses. In this way, osteopaths blend diagnostic precision with a tactile, responsive style of care, positioning them uniquely between the medical and manual therapy worlds.

Osteopathy is a holistic healthcare approach, focusing on the musculoskeletal system and its relationship with overall health and using touch to assess tissue health and function and usually also to provide treatment.  By addressing structural imbalances and improving movement, osteopaths aim to enhance the body's natural ability to heal.  Within those parameters though diagnosis and treatment approaches can vary widely  and it is important that you choose an osteopath who will give you the care you are expecting .  

​Below, we highlight the various types of osteopathy, with the emphasis on   structural osteopathy, currently the cornerstone of care at our practice.

1. Structural Osteopathy Structural osteopathy is central to what we do. This approach targets the body’s structural components, including muscles, bones, and joints, to alleviate pain and improve mobility. Techniques we use include:

• Soft tissue work: Releasing tension in muscles and fascia.  Techniques may include    stretching, massage, medical acupuncture or inhibition to trigger points and muscle energy techniques
• Joint articulation    and manipulation: Restoring range of motion and reducing discomfort.  Articulation techniques are repetitive, aiming to gradually increase range of motion, manipulations are usually fast movements  delivered with an impulse that  override inappropriate muscular guarding and are often accompanied by an audible pop or click.  Other techniques may include functional technique or balance ligamentous tension where the aim is to find and support a position  where the joint can unlock itself
• Exercise prescription:   We will ask you about your exercise regime and where relevant will  provide you with exercises to  help your recovery
  
• Lifestyle advice: Exercise  for your whole body and as part of your usual routine is more important than rehabilitation exercises and we will try and advise on what would suit you and adaptations you can make .    We're not here to nag you about smoking, drinking or diet are here to support you  with small nudges!
  
• Posture:  This is a tricky one.  Significant postural change is usually a very long term objective and requires a 7 day a week commitment but we can support you as you  make those changes yourself and can advise on such issues as desk/work setup and provide some linited advice on orthotics, wrist splints etc 
  

Structural osteopathy is particularly effective for resolving and managing conditions such as:

• Back and neck pain.
• Joint injuries, including sprains.
• Sports-related injuries and performance optimization.

At our practice, we prioritize individualized care, tailoring treatment plans to each patient’s unique needs.

2. Cranial Osteopathy Cranial osteopathy is a gentle technique focusing on the subtle movements of the skull and its influence on the central nervous system. It is often used for:

• Chronic headaches or migraines.
• Stress-related tension.
• Pediatric care

We don't curently offer cranial osteopathy

3. Visceral Osteopathy Visceral osteopathy addresses the body’s internal organs and their connections to the musculoskeletal system. 
We don't currently offer visceral osteopathy

4. Classical Osteopathy Classical osteopathy builds on the foundational principles of osteopathy as developed by its founder, Andrew Taylor Still. It emphasizes treating the whole body as a connected unit, focusing on balance and harmony. Practitioners use a combination of structural techniques and rhythmic movements to:

• Encourage the body’s self-healing mechanisms.
• Address a wide range of systemic issues.
• Enhance overall vitality and wellness.

This approach is holistic and comprehensive.  Although we don't  currently have any  classically trained osteopaths we do tend towards a very holistic approach in our treatment and we may treat more boradly than some other osteopaths

5. Paediatric Osteopathy   Paediatric osteopathy is designed for infants, children, and adolescents, addressing their unique developmental needs. 
We don't currently offer paediatric osteopathy

Why Structural Osteopathy is key at our clinic,
structural osteopathy is our primary focus because it offers practical, effective solutions for a wide range of musculoskeletal conditions. By restoring the body’s structural balance, we help patients reduce pain, improve movement, and enjoy a better quality of life.

So how do we justify our approach as cost effective?  

a drug may contain multiple ingredients and  testing those ingredients in isolation may not give you many clues regarding the drug's effectiveness, moreover, if the drug has been designed specifically for that patient, it may not tell you how well that combination will work for another patient, in addition there is the placebo effect

Is it time to recognise that the placebo as a reference against which to measure non-chemical interventions is nonsense?  When we try and break down a complex and unique intervention into individual elements so that they can be tested against someone having ostensibly a similar experience minus that intervention that becomes so artificial it is pseudoscience and importantly disregards the nature of osteopathy.  Osteopathy is not defined by 'cracking' joints or by craniosacral therapy or by any particular technique.  It is not the same thing to everyone...which makes things very difficult...but it is not about the techniques used, at least not at a granular level.

Without looking up the latest agreed definition (which probably comes from the US where they do both more..and less... as osteopaths than the UK tradition)  I would say that at its heart osteopathy is about using non-pharmaceutical techniques to treat people with dysfunctions that are  largely (but not exclusively) musculoskeletal.    A T Still the originator of osteopathy created it in response to the deaths of three of his children from meninigitis and saw it as a full system of medicine in opposition to the brutal heroic medicine practiced at the time and believed that a body free of osteopathic lesions would be a body that could resist disease in all its forms.  There are many possible applications for osteopathy and the boundaries of what it is appropriate to say we treat are contentious...so lets start with the basics...musculoskeletal issues.

Whilst I said that osteopathy is not the sum of the techniques used I think it is useful to think about they might constitute:

• soft-tissue techniques (to work on muscles etc, perhaps massage, MET, stretches)
• articulation (repeated and gently increasing movements through a joint's range of motion)
• techniques applied to joints and muscles (functional, strain-counterstrain, Still techniques perhaps medical acupuncture)
• exercise prescription
• lifestyle advice
• referal to other specialists
• retraining concious  thinking about health beliefs (it is safe to move, I am not my pain)
• retraining the nervous system to allow movement (subconcious it is safe to move)
• manipulations/high velocity thrusts ('cracking' joints to overide inappropriate guarding)
• cranial osteopathy / involuntary motion / craniosacral
• pharmaceutical intervention  - only applicable to osteopaths who are also medcal doctors, few in the UK, nearly all in the US

All bar the last three are fairly uncontentious within our community and would to a greater or lesser extent be part of the armoury of most osteopaths.   There are; however, schisms about the last three, such that I would argue adherents to each provide a subtantially different service to those who don't, so whilst I don't believe in testing different techniques separately I do think there is some mileage in testing the major types of osteopath separately .

I want to separate out pharmaceutical intervention.  It doesn't form much of UK practice whereas it is almost ubiquitous in the US.  It is not part of the uniqueness of osteopathy even if at some time it would be useful to understand how effective co-treatment could be.

Cranial osteopaths and those who use lots of manipulations are almost mutually exclusive, both eyeing the other with a degree of suspicion and in the middle there are osteopaths who may use little or none of either and can sometimes be quite sniffy about both

Where I am heading with this is that it would be useful to classify osteopaths into different cohorts, in order to assess their effectiveness for patients with particular and that perhaps the faultlines broadly fall into three categories

1. Those who often use manipulations and rarely use cranial osteopathy
2. Those who often use cranial osteopathy and rarely use manipulations
3. Those who rarely use either

These could be worked up into statements about the type osteopathy we practice and osteopaths could be encouraged to choose the statement that best suits them.

Then, part two,  we need to work out what they are treating, and in this we should avoid over medicalisation.  Luckily this is already happening.  Diagaoses such as non-specific low back pain are more honest than trying to pin the cause on a particular structure or tissue, at least when there has been no trauma 

Thirdly there are different cohorts of patients, do we split them by age, lifestyle factors, health beliefs, chronicity, co-morbitities etc

It's a pretty complicated matrix but in my opinion if we want to truly test how effective an osteopathic approach to treatment is then that is what we need to work towards , in the meantime my fear is that a less granular approach risks throwing the baby out with the bathwater and that would be a terrible shame...and not evidence based medicine

Osteopathy, when performed at least moderately competently is reactive, not prescriptive.  The osteopath is constantly monitoring the structure, the tissue on whch they are working feeling for a return to normality, or the sense that no further change will be forthcoming, the technique, used by the practitioner to achieve the change may well be constantly changing fractionally in response to the perceived needs of the patient's body.

Moreover osteopathy tends to treat very widely, both physically, 'the knee may have a strain of the medial collateral ligament but is that because there is a problem with foot and ankle mechanics and that is causing a gait pattern thatcauses that or is preventing it from healing...is that also then causing an assymetry in the back which may be leading to other problems?'...and beyond, 'is this patient cycling and reinforcing this bad pattern, have they recently split up with their partner and sleeping on the sofa and the poor sleep is affecting their recovery?' (note I am not saying we do the work of counsellors but we do provide a listening ear).

This creates a problem.  How do we measure the effectiveness of interventions so that we can compare and understand what works and what doesn't?  Our interventions are complex and multifaceted.  What is the active ingredient in osteopathy and what is placebo?  How do we determine which part of our treatment is effective and which part is a waste of our time and the patient's, insurance company or NHS's money?

It is made all the more complicated by the fact that osteopathy is a broad church.   There are some osteopaths who only use very gentle techniques such as functional techiques and cranial osteopathy, others including me prefer, where it is safe to put some force through a joint or work on it persistantly until it starts moving.  I've had effective treatments from both modalities but I've also had patients who have had multiple 'gentle' treatments to no effect and have improved massively from one treatment using more direct techniques.  Is that down to the previous osteopath's personal competence, the general effectveness of those 'gentle' techniques or just a mismatch between that patient's need and the type of treatment they got...That may include some element of 'placebo' as they felt like I was doing something, whereas they were not convinced the other treatment did.   (I do treat more gently when the patient doesn't want or isn't appropriate for a direct approach...and sometimes refer when I tihnk they would be better suited elsewhere).

So how do we measure osteopathy?   More on that next time

Every now and then a patient comes in and when I ask what they want from treatment they answer some variant of "I've got bad posture" "I've got a hump" "fix my text neck" etc, or worse, "I've seen this video online, where they take this boy and straighten him out".  I am going to confess now.  I think I came to osteopathy based on a false belief.  The mother of a boy in my year at school, who lived in the same road as me, walked with a terrible stoop and one day that stoop was gone.  I think I asked my mother what had happened and my Mum said thought she had been to the osteopath.  I was impressed...but with hindsight, I think my Mum was guessing (they weren't particularly friends).  I suspect she had surgery and a rod put in to correct a very severe kyphosis.  The thing is that a deformity (I tried to think of another word, but this was an extreme variation from the norm and will have drastically affected her quality of life) like that held for years will have changed the shape of the structures - caused the vertebrae to become wedge shaped, shortened muscles ligaments etc at the front and lengthened them at the back - even if the initial injury was reversable at the time.  That is why the surgery is not just a release but a rod is needed to hold the back in position.  

By the same token, even if we can release tight tissues, stuck joints etc holding something in a sub-optimal position without surgery, the stretched ligaments and lengthened muscles on the outside of the curve aren't going to ping back with magical elasticity.   Something that has built up over years will take time and concerted effort to correct and indeed it may only be reasonable to manage it rather than completely reverse it.

If this all sounds very negative, it isn't!  We can usually correct things that have happened recently and we can often improve older injuries to improve function and reduce pain.  Osteopathy can also play a part in significant postural change but as a part of a wider program, over time.  I keep banging on about Pilates because it helps you to strengthen your postural muscles, including reinvigorating tone that has been lost by being stretched over time.  I am still slowly correcting my own assymetries and imbalances, using osteopathy to periodically release tightened and stuck tissues and joints and to integrate change, as well as Pilates, swimming and strength training to build new tone

Oh and by the way, if you've seen those videos, no I don't do the osteopathy with a plank and hammer, or one yank on a chin strap

I'm a great believer that regular exercise and movement will mean fewer visits to the osteopath.  Not only will you suffer fewer injuries but they are likely to resolve more easily.

One of my favourite ways of achieving this is Pilates.  What I especially like about Pilates is that a good class will see you stretching most parts of your body and conditioning many of the smaller postural muscles as well as the abdominal core.  It is also very adaptable with classes available at all levels and your teacher can also give you variations on exercises to suit your own abilities and stage of development.  I also enjoy the classes

The Pilates method was developed by a German, Joseph Pilates, during the first half of the 20th century, initially whilst interred at Knockaloe internment camp during the first world war, where he practiced his ideas with his fellow internees.  As well as mat work, often using small apparatus such as rings, balls, bands and rollers Joseph Pilates also developed a range of apparatus designed to accelerate the process of stretching and strenghtening.  The most popular of these is the Reformer...but there are a range of others, including the Cadilllac...which really does look like an instrument of torture!

Pilates's father was a gymnast and I think this shows in the practice that now bears his name.  There is more similarity than difference with yoga...but the emphasis is more directed to core strength and there is no spiritual element....although it can be quite meditative.  Pilates wanted his method to feel like a workout and I have been to some classes that burned like leg day with an evil PT at the gym...but not all classes are the same.  The accepted description for Pilates is "a mind-body exercise that requires core stability, strength and flexibility, and attention to muscle control, posture and breathing", that's quite a remit and different classes and instructors will have different areas of emphasis.  

I thought it might be useful to talk about the different classes I have attended, so that you can get an idea about what is on offer and what might be suitable for you.   I am lucky in that my Vauxhall practice is situated in Embody Wellness and I can organise my patients so that I can attend a couple of classes a week, sometimes three. All of the classes at Embody Wellness are mat based, although they do have a reformer available for 1-1 sessions. 

I started out with bodycare pilates, which is taught by John Hobbs and fits nicely with the days I work at Embody Wellness, being Tuesday and Thursday at 10:00 (he also does level 1-2 pilates on other days which is similar).  This class is aimed at anyone and has attendees in their 70s and 80s as well as beginners and those who just want a class that is about maintaining movement and flexibility and is perhaps less focused on strength.  There is not a great deal of standing work in this class although there is usually a balance, most of the work is lying down either on the mat or using the equipment to enhance the stretch or provide a balance challenge during strength work.  John likes to use all of the small equipment and we usually start with quite a pile of bits and bobs beside us.  If you haven't done pilates before I would suggest something like this or some 1-1 sessions before joining a more advanced class.   Just because I have said it is lying down doesn't make this a rest.  I struggled to start with but picked it up pretty quickly.

​Suzie Lovelock teaches at Saturday lunchtime and I have challenged myself by attending her 'dynamic pilates' class on a number of occassions.  This is of a completely different order of difficulty.  This is where I really feel the burn, usually in my legs and glutes.  Lots more standing work, poses held for longer, more demands on core strength.  This class makes me sweat, and stumble, and exposes my weaknesses both in terms of coordination and strength.  Just because I could leg press half a metric ton didn't mean I could hold a lunge whilst rotating and moving my arms!  This class has changed title to 'strength and flexibility', when I get the chance I look forward to seeing what's changed.

Kelly Balmer also teaches strength and flexibility and I have started swapping my Tuesday class to this.  The level is pitched somewhere between the other two.  Kelly's class possibly focuses on core strength most of the three and Kelly is all about form.  I'll be honest here.  I can't do a proper roll-up or roll-down yet (like a situp but a controlled movement spinal segment by spinal segment) but I'm enjoying gradually getting better.

If this reads like an advert for Embody Wellness please know I get a staff discount of 20% but do pay for classes and am not paid commission or to promote them.  I am writing this because I genuinely think Pilates is an excellent adjunct to osteopathy in maintaining body function.  That said I going to give them one last plug because they do offer a discount rate of £45 for your first 5 classes, click here.  I hope to see you there.

I was flicking through old articles and I came across this one, suggesting that we were not far off finding ways to slow down, pause, or even reverse some of the significant processes of ageing.  The article is looking at ageing at a cellular level and is from the perspective of a biologist who is looking drugs that reduce the cellular effects of ageing.  Don't get me wrong.  I am excited by that but it is only half of the equation.  We have it in our hands to do the best with what we've got .  Three of the four key osteopathic principles are valid here. 

1. The body is it's own medicine chest
2. Structure and function are reciprocally related
3. The rule of the artery is supreme

Don't take the first too literally but the body is pretty good at resolving most problems given a fair chance.  To give it that fair chance we need to:

1. Give it the nutrients it needs - Nutrition is such a loaded area.   It's true that there is much conflicting advice out there.  One of the reasons for that appears to be that different diets suit different people, another is that there is growing opinion that the combinations of foods can be as important as the component parts (so a Mediterranean high in deep fried food may not be as harmful because there are protective effects in the salads that are typically eaten alongside), so it is complicated and I am not going to offer my pet opinions here.  What does seem a fairly safe bet though is that you do need to eat a balance of foods and that vegetables should form a significant part of that and if you are not eating meat at all then you will need to find alternative sources for some of the substances we need that are generally found in that part of our diet
2. Don't poison it - tobacco, alcohol and excess sugar, amongst others, disrupt our body's normal processes, reducing healing, prolonging inflammation and causing direct damage at a cellular level.  I don't want to be a killjoy but if you want to live a long and healthy life quit smoking and moderate your drinking and your intake of sweet things (many artificial sweeteners seem to cause issues by fooling the body into thinking its getting a hit of sugar). 
3. Fix what you can at a macro level - Your cells need energy, nutrients and the removal of metabolites to stay healthy, your tissues need to be able to be serviced by the systems that repair damage, remove debris, challenge and destroy foreign or displaced material.  That means keeping the body's communication network operating freely and without impediment.  The 'rule of artery is supreme' was once taken to imply supremacy over venus drainage.  Now we talk about the role of osteopathy in improving fluid dynamics in the arterial, venous and indeed the lymphatic system.  The role of the artery may (or may not) be supreme, but it is the lower pressure venous and lymphatic systems which may be more interrupted by inappropriate muscle tone and which rely on body movement to generate the pumping action which drives them and that leads me to
4. Maintain movement - 'structure and function are reciprocally related' - use it or lose it.  Your body is designed to be used.  That which isn't used doesn't then receive the care it needs to maintain its integrity.  If you don't move a joint then the synovial fluid won't be wiped or pumped over the articular surfaces properly and the cartilage may become diseased, if you don't move so that surfaces between layers of fascia slide across each other as they are designed to, eventually they lose that ability to slide.   Muscles weaken and bones lose density without being subjected to load.  

So really you already have so many tools to prevent ageing.  Eat a balanced diet, don't poison your body (too much :)), keep moving with some weight bearing exercise like walking or running and something that stretches you like pilates or yoga and get small problems that don't resolve  quickly on their own looked at.  You may not live to 150 but you will have done what you can to make the life you have as healthy and therefore enjoyable as possible

So many people are working from home right now and, if we are to believe what we are told, it will be the new normal for many, at least part-time.  In some ways, that is great.  Most people won't miss the commute and in theory, at least, that is time you can repurpose to do what you want...and apparently cosmetic and deodorant sales are down, so that suggests you are repurposing some of that wash and brush-up time too.  The down side is that for most of us, at least here in London, space is at a premium...we don't have a room set up as an office...so we have to work in our living space and that might involve some compromises.  How can you make that work?

1. You need a desk or table, don't spend all day working on your lap...or from bed...at least not often.  If you are short of space think about investing.  How about a coffee table that is also a dining table/desk like this or a cheaper option is a wall mounted drop leaf table like this - make sure you don't mount the drop leaf table too high (see 2.1 below)
2. Don't compromise on the chair.  You really do need a proper office chair 
   1. One that adjusts for height so that you can find a height where you can type or use a mouse with your shoulder relaxed, your elbows at 90', or just a little more open than that, and your hands slightly dropping onto the keyboard at the wrist
   2. One that swivels so that if you are looking at a screen and at paperwork you can twist the chair not your body
   3. One that rolls freely so you can get up and down without having to do that back-twinging scooch to get tucked in under the desk and vice versa.  It has been a year now, if the rug has to go...it has to go, and stop dropping your clothes on the floor, this is important
   4. If you have shorter legs or the table you are working at is high (tables are often higher than proper desks) you may want to get a footrest, they are not expensive
3. If you use a laptop either get a separate screen or a separate keyboard and laptop stand.  The former is probably better, the latter probably easier to stow away when you are not working...either is a godsend.  The distance between the keyboard and screen on a laptop is insufficient to find a posturally decent position for working.  They're fine for short bursts but if it is all day you are going to be sat with your neck and back bent and that will cause problems.  Likewise a separate mouse is probably a good idea, using the tracker pad on the laptop with the laptop directly in the right place for the keyboard puts your arm in quite an unnatural position
4. Get your eyes tested and try to avoid glare on the screen (that might mean investing on some blinds and/or using lamps rather than overhead lighting), we don't want you getting headaches
5. Take regular breaks.  At work you'd get up and move around the office to talk to people.  Do the same at home.  Set an alarm, if needs be,. to remind you once an hour to get up and stretch your legs, make a cuppa etc
6. Go home from work.  Few people work set hours these days but the commute time should be your bonus for the inconvenience of working from home, don't feel that 'should' be work time.  If you can, pack away the work stuff at the end of the day, or at least at the weekend, so your home feels like a home again.

Coronovirus, what can you do?
 
I don’t propose to repeat the advice you are getting elsewhere but I do think there are a couple of points from the osteopathic perspective that bear consideration
 
If you have a mild dose of Coronovirus and can potter around, do so, your body relies on movement to maximise the efficacy of your immune system but the important caveat here is, without exhausting yourself, remember you are not replenishing your oxygen as efficiently so don’t use up everything you’ve got

What can you do before widespread infection hits?
Try and get your rib cage working as well as possible.   Fibrosis will restrict your lung capacity so you want to get your thoracic capacity as good as possible beforehand and make breathing as easy as possible (if you are asthmatic or have other longstanding lung conditions speak to your GP before doing anything that affects your lungs).  I suggest yoga or pilates for movement or just some daily stretches at home, open book, cat camel , or an exercise that makes you take deep breaths like running (try couch to 5k) this will also improve your stamina, which is the ability of your blood to carry oxygen.

MORE THAN ANYTHING ELSE WASH YOUR HANDS THOROUGHLY AND REGULARLY AND STAY HOME IF YOU ARE AT ALL UNWELL!