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.
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?
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!
It’s January and many of us have made promises to shift the Xmas pounds (maybe from more than one Xmas!). I am coming round to the idea of ‘couch to 5k’. I haven’t run yet, but I’m thinking about it albeit still on the couch.
For those of you who are taking up running this January, I have a few thoughts for you to try and help you do it without injury.
Some of you may have been to multiple osteopaths and may have been surprised by how different your treatment has been. It would be fair to say that osteopathy is a broad church! If you had asked me, before I trained as an osteopath, what defined osteopaths I would probably have said, the type of treatment they offer and would probably have said specifically the use of high velocity thrusts, or, manipulations…because that was the kind of treatment I had from the osteopaths I had visited and I felt that was what was different from massage or physiotherapy.
But there are plenty of osteopaths who don’t use manipulations and, of course, Chiropractors use ‘adjustments’, which amount to the same thing…in fact they have probably been using them longer.
What makes an osteopath, is more about how we think than any individual technique, or protocol and it is the philosophy that sets us apart from chiropractors, physiotherapists and other bodyworkers.
There are 4 key principles of osteopathy
During the first year of training to be an osteopath I spent a lot of time learning anatomy from textbooks. These books describe structures and tell you the names, locations, relations (what is around it), blood supply and nervous supply, amongst other useful information and we (try to) learn these by rote so we can pass our anatomy exams.
Some time later…it was the third year of training for me…I suddenly realised that I could differentiate between two structures at different depths by reference to my anatomical knowledge and comparing the shape and, particularly in the case of muscles, lines of force. My particular road to Damascus moment occurred when I felt something pulling up towards the neck from the angle of the scapula (part of the shoulderblade). The trapezius muscle is the most superficial muscle here but I realised the fibres don’t run in that direction, whereas underneath it is levator scapulae and this line of tightness corresponded exactly with where that muscle should run. Over time I became more and more able to differentiate between different structures using this method and I rarely think about the textbook anatomy.
Today a patient came in with a pain in his buttock (we joked that I should entitle this, ‘the pain in the bum patient’). On examination the tender bit was in the lower part of gluteus maximus, just above the ischial tuberosity (sitting or sitz bone) but the area affected didn’t run in the same direction as the fibres of that muscle, nor indeed the small internal rotator muscles that lie underneath (and provoking those muscles didn’t recreate the pain), it was also a bit too high to be ischiogluteal bursitis. I was stymied for a moment…and then I remembered that I had read a paper highlighting that a significant minority of people had an anatomical variation whereby their biceps femoris (the outer hamstring) either additionally or often alternatively attached to the transverse ligaments of the sacroiliac joint rather than the ischial tuberosity and realised that this explained the symptoms in this location.
There are many anatomical variations, extra ribs at the top or bottom of the ribcage, extra or fewer vertebrae (actually just more or less of them that are not fused; kidneys and nipples often appear in greater number than is standard and sesamoid bones are non-standard parts in more than one place in the body.
Understanding how ‘the body’ works is a wonderful thing, understanding how the body underneath my hands is put together is even more exciting
People ask me what I most often treat. The glib and osteopathic answer is 'people'. If I'm going to be reductionist and nominate a body part then ribs are surprisingly high up there. Why surprising? Well? How often do you think about your ribs? The amount of patients who say 'I have ribs at the back too?' or 'that far up/down'. You break them or bruise them but rib dysfunction with no traumatic onset?
I'm being a little disingenuous here, because, most often it is not the rib itself that is the problem but the joint or joints attaching it to the spine and to the sternum (breastbone).
Most people have 12 pairs of ribs.
The top pair are the 1st ribs, uniquely they only have one joint at the rear with the spine
Ribs 2-7 have two joints at the rear, all of ribs 1-7 are true ribs and have a joint at the front with the breastbone
Ribs 8-10 are false ribs, they don't come all the way to the front but join to cartilage which then combines and joins to the 7th rib
Ribs 11 and 12 are floating ribs, they only have the two joints to the spine and the front end 'floats' but not very freely as t is held in place by muscles.
So what can go wrong? Well the ribs are subject to loads of forces in different directions. Obviously they move when you breathe...you may never have thought of that..and when you move your thoracic spine they have to move to accommodate that and then there are the shoulder movements that basically require your ribcage to deform to accommodate those too. Each time a healthy rib moves all of the joints between it and your spine and sternum should move a little too, but like every other joint, they can get irritated, inflamed, restricted, stuck and the whole rib can end up out of synch with the spine and with the other ribs around it. Which can cause the joints to get very inflamed and painful.
and can cause the muscle overlying the rib to be held on stretch for long periods, which then makes the muscle sore and or tight. So many of those 'knots' you get in your upper back between the shoulderblades are not knots at all but instead some muscle stretched over a prominent and unyielding rib below. Then there are the muscles between the ribs, you know, the tasty bit in spare ribs, they are intercostal muscles and can become too tight and feed into the dysfunction by pulling the ribs together unevenly like badly ruched curtains and then there are muscles attaching to the top and bottom ribs, at the top, particularly the scalenes, these are the muscles that run up the side of your neck and they attach to the first and second ribs, poor rib function there can lead to the scalenes becoming tight resulting a stiff and painful neck, not to mention the effect it can have on the nerve and blood supply to the arm. At the other end the 12th rib attaches to quadratus lumborum and psoas, as well as the diaphragm and dysfunction here can lead to low back pain, even hip problems and problems with the nerve supply into the leg.
I rarely treat ribs in isolation but, I treat them with most patients and they deserve to have more attention paid to them in general
Leg and yes, the gluteal region too. Sciatica is one of those terms thrown around with varying degrees of accuracy, so I thought it might be time to talk about what it is..and isn't...and of course what osteopathy may be able to do to help.
The idea behind sciatica is irritation of the sciatic nerve causing pain in the leg. Let's get the annoying 'know it all' stuff out of the way first...
1. There is no sciatic nerve...Really! What we call the sciatic nerve is actually a sheath containing 2 completely separate nerves, the tibial and fibular (or peroneal) nerves.
2. A slipped disc, disc protrusion, herniation etc cannot press on the sciatic (or fibular or tibial) nerve, these nerves are what are called peripheral nerves and are formed outside the spinal column (hence in the peripheral, not central, nervous system). What can get irritated in the spinal column, by a slipped disc etc, is a nerve root. These exit in pairs at each spinal level and then send branches which join in plexuses (plexi?) to form peripheral nerves
OK, so lets assume we are talking about nerve pain, numbness or weakness in the buttock, maybe down the outside or back of the thigh and sometimes into the calf and foot.
Where are the main places that the nerve can be irritated?
The first place is in the spinal column. A disc bulge can press on the nerve root and cause pain down the leg. Typically L45 or LS discs are particularly prone to herniation and can bulge and press on l5 or S1 nerve roots which cause symptoms in these areas
Overtight buttock muscles, especially piriformis can compress the sciatic bundle and irritate the nerves contained within. Typically this is felt as pain along the route of the nerve in the thigh and often doesn't extend beyond the knee although it can go all the way to the foot.
The common fibular nerve is prone to injury and entrapment where it winds around the fibular head (the bony lump on the outside just below the knee). Relatively minor knocks here can stop the nerve gliding smoothly meaning that it can get stretched and harder bumps (hit by a car bumper etc) may lead to loss of power from the muscles it supplies, and foot drop.
The tibial nerve can get trapped behind the knee, under soleus muscle and in the foot, in a structure called the tarsal tunnel, which can become congested due to poor foot mechanics.
How do we know where the problem is?
Sometimes it is very obvious from the history, where the injury took place and what kind or injury it was, sometimes examination and basic orthopaedic testing will find an obvious derangement and treatment of that will reduce or eliminate the symptoms. An MRI would be required to confirm a disc bulge and/or nerve conduction testing can show whereabouts a nerve is damaged. Beware though 80% of 40 year olds with no back problems or sciatica will have disc bulges on an MRI. So you may have a disc bulge and sciatica but it may not be the cause, or may be part of the cause and resolving an issue elsewhere may be enough to eliminate the symptoms
What can an osteopath do?
It depends...as always. If you have herniated a disc, nature may have to take its course, most disc herniations become asymptomatic within 12 weeks (sadly, not all). That said, sometimes even sciatica due to an apparent disc bulge may respond to treatment, either the treatment reduces local muscle spasming, postural issues or fluid congestion around the nerve root thus decreasing compression and irritation, or working elsewhere along the root of the nerve increases it's capacity sufficiently to reduce symptoms. If the problem is due to tight muscles in the buttock we can work to loosen those and, more importantly work out why they have overtightened and work on those factors also. Problems in the foot and further down the leg are often very amenable to osteopathic treatment. Finally, if you are suffering from sciatica it is probably affecting how you sit, walk etc and that will have a knock on effect on other tissues in your back and possibly in your other leg. We can work to minimise those disruptions, so that when your sciatica does go, you aren't left with a whole pile of other problems
Damian is the principal osteopath at Vauxhall Village Osteopathy and Oval Osteopathy