Living on an island

No man is an island entire of itself; every man
is a piece of the continent, a part of the main;
if a clod be washed away by the sea, Europe
is the less, as well as if a promontory were, as
well as any manner of thy friends or of thine
own were; any man's death diminishes me,
because I am involved in mankind.
And therefore never send to know for whom
the bell tolls; it tolls for thee.
(John Donne)

Living on an island, as I do, diminishes one's world in a physical sense and, after many years of uninterrupted island life, possibly in a mental sense, too.
However, it is good for the osteopath, whose essential skill is to see patterns and connections in complex systems. This is nurtured by the island life. In regard to ecology, for instance. Living on an island the problems become as clear and immediate as the obvious limitations of space and other resources. Questions such as "Where does the rubbish go?", "Is there enough water?", "How should we manage the land?" assume the real dimension that is their right, but which may become misted in larger territories where the limits are less obvious. I might think about these things differently if I lived in Siberia.

Last spring I wrote about our small "river" which, to my surprise, was flowing happily with clear water. It is usually dry or just damp, as it has been this spring. This little river is an enigma, because its flow seems unrelated to local weather patterns. Last spring there was little rain, this spring quite a lot. One can only conclude that it must be part of a bigger picture, as we all are. Indeed it is said that this island's water table depends on an aquifer which extends deep under the sea bed from the mountains of the mainland nearly 400 km away. So a local water situation is not just a local situation, but part of a much wider one. This of course should be obvious if one thinks about it, and island life puts a focus on these things.

It should also be obvious that the same phenomenon happens in the human body. But it is not:  conventional medicine still tends to think in terms of a headache being a head problem, back pain being a back problem, gastritis being a stomach problem, and so on. To the osteopath, particularly (and paradoxically) if he lives on an island, this seems ludicrous. All of these things are global problems in that they have widespread, multifaceted causes and consequences.

It is pleasing for the osteopath to extend the analogy with water flow, and I think credible too. Human health and ill-health depends on flow in various forms, real and metaphorical, such as the appropriate and well-coordinated flow of blood, lymph, axoplasm (the cytoplasm of nerve cells), nerve impulses, soft-tissue and articular movement, mechanical forces through the body, thoughts, emotions, and so on.

The osteopath is primarily concerned with such "flow".

Jane's Magical Rubber Band Trick

When Justine talks about the stressful situations in her life, she pulls her head back on her neck and down into her raised shoulders. I have been treating her for pain: left neck, shoulder, upper chest, arm, and both sides of her lower jaw. We have established that an important influence on her pain is emotional, mediated by muscle tension. The muscles in question, of the shoulder, neck and jaw, are metaphorical "barometers" of stress.

I make Justine aware of her stereotypical postural response to stress so that she can recognise it when it occurs. I instruct her to be aware of her posture and how her emotional state affects it. I also teach her what a normal posture feels like, and how to let go of the stress pattern at will. Then I give her an elastic band and tell her to put it around her left wrist. I tell her to give it a good twang every time she notices that she has reproduced her negative postural response to stress.

The elastic band trick was passed on to me by a very nice lady called Jane (hello Jane) and it works like magic. Actually it isn't magic, it works on the basis of what we know about how behaviour is learned and unlearned. Behavioural responses to stress (e.g. a postural pattern) can persist even when they serve no purpose, or even when they are harmful, because they become habits. But habits can be unlearned by reward and punishment. 

In Justine's case, the punishment is the twang of the elastic band. The reward in the short term is the sense of satisfaction at succeeding in recognising and reversing a response. In the long term it is the reduction in pain and discomfort that she suffered, and the experience of a new, more confident "me" in her daily dealings with the people and situations in her life.

Since you should ask, I can supply excellent rubber bands eminently suited to the task, each one individually anointed and potentized according to a special ritual (a family secret of one generation), at £25 (incl. VAT) each plus postage and packing. Apply within.

We are not rational beings

Daniela puts tissue paper on the floor to avoid contact with her bare feet. She's afraid of being infected by some contagion.

"People worry too much about germs", I opine. The TV ads for household detergents latch onto collective germ phobia. As if you will die horribly if a single germ is alive in your kitchen. But, in fact, most common germs are as innocuous to you as your family pet. You live together with them in harmony.

"Once", Daniela says, "When I was in severe pain with my back, a friend told me about a friend of hers who was in pain for some time, and it turned out she had bone cancer. I couldn't sleep that night for worry!"

Daniela has an exaggerated fear of illness, and of death.

Anything can happen in life and we all have to die. But thinking about these things to an inordinate degree does not change these facts. Most pain, by a long long way, is benign: it is not caused by serious illness. Contact with germs is inevitable, useful (it keeps our immune system primed), and mostly benign. I tell these things to Daniela.

Then I think of something. Daniela hasn't been eating properly since her husband died two years ago. "I just don't feel like cooking", she says. And she doesn't do the stretching exercises I have prescribed for her. She is not looking after herself.

"But Daniela", I say, "Isn't it a kind of contradiction for you to tell me you're so afraid of illness, while at the same time you are not willing to take steps to prevent it?"

We humans are full of contradictions, we are not rational beings. But Daniela goes away with something to think about.

How to be an effective patient

I have been looking through patient files from 10 years ago, trying to find factors which might explain the difference between satisfactory and unsatisfactory outcomes of treatment, and one factor stands out among all others: compliance.

Compliance means attending all treatment sessions when and for as long as is prescribed, correctly carrying out exercise and other prescriptions, and adequately attending to lifestyle advice that is given. Patients who do these things mostly get better, patients who do not, frequently do not. Simple, one might think. Except that it is not that simple. It is not that simple because various wider factors come into play here, notably fashion, personality and the practitioner-patient relationship.

It is a political correctness today that medical care must be "patient-centred". This buzz-word can be interpreted in different ways. A correct, realistic, and beneficial interpretation is that medicine should be personalised, not standardised. An erroneous, unrealistic, deleterious, and extreme interpretation would be that the customer (i.e. the client/patient) always knows best.

Clearly here there is an issue of control, that is, who controls the treatment and management of you, patient or practitioner? One can look at ill health from the point of view of a problem to be solved. Research into coping with psychosocial stress suggests that those who adopt active, positive, problem-focused coping strategies rather than passive, negative, emotion-focused ones suffer less impact from potentially stressful situations. A key component which brings this benefit is the higher sense of personal control that derives from going out and doing positive things in the attempt to solve a problem. What kind of strategies one adopts to cope with challenges depends on personality, which is ultimately the product of innate and acquired traits, and learning through experience.

So an active, positive, problem-focused attitude is good, right? To an extent. The other side of this coin is when one sees a patient who has so much faith in and reliance on their own sense of control that it becomes an obstacle to healing. How does this happen? A learned, experienced, and conscientious practitioner knows how to deal with certain kinds of problems. He or she has organically developed a way of addressing these problems that transcends by light-years the fragmented information that one might amass from visits to a few websites, even if that information is academically sound. It also transcends the fragmented information that one might derive from single visits to numerous different "experts". Yet this is exactly what a certain kind of self-reliant patient will do: consult websites and visit numerous experts, but they will never give any of them the time or the trust to carry through a coherent and cohesive treatment plan to the end.

To be an effective patient, you do need the will to go and something about your problem, and that may involve seeking out an expert practitioner who you feel you can trust. But then, once you have decided that, it is never going to be an effective strategy to believe you can cherry-pick which of his/her advice you want to consider, nor to try to rearrange the amount, duration, or distribution of your treatment according to your own ideas. You do not know better. You are going to have to relinquish a little control, and trust your practitioner to the end of what you have agreed would be a fair trial. Otherwise you stand a great risk of wasting your own money, as well as your practitioner's time and dedication.

Effective medicine is patient-centred, practitioner-directed.

Sport can be a pain

"You can always tell an older athlete by their injuries",

says ex Olympic swimming silver medalist and Commonwealth champion Sharron Davies (50), adding,

"Hobbling around makes me feel really old." (Daily Mail, Thursday 7 February, 2013).

Professional sports are one thing. The athletes have access to teams of doctors and therapists daily. They also know that on the balance sheet of life is written: "Chronic consequences of strain and injury". Some of them get paid sufficiently to make up for that, perhaps.

Amateurs are another matter. They and worse, their trainers, believe they can copy the professionals with punishing training regimes. When minors are involved, this is nothing less than child abuse.

I do not like treating amateur sports people. In fact, in many cases I refuse, as it frequently becomes clear that the person is not willing to follow my instructions to take a rest from their sport. "Why can't you get me better by Saturday?" they say.

Sorry, you can't bend the laws of biology to suit your own ego.

Moderate sport is good for people. But if sport is ego-led or obsession-led it is a real pain.

Mind, magic, and reality

I have heard it said that we create our own reality and to a certain extent I think that is true. If we actively strive to achieve, intelligently and with a positive attitude, we improve our chances of shaping our lives according to our wishes and goals. But there is no guarantee that we will succeed, it is merely a question of probabilities.

In some people's eyes, the idea that we create our reality takes on mystical, magical significance. I think this mode of thought probably became popular in the West I think thanks to the thought experiments, chemically enhanced or otherwise, of the late 60s and 70s. According to this, everything you know in the world is an illusion. You think the illusion is real because through a process of learning your mind has developed to conform to the norms and expectations of your family, peers, culture and society. If you could only free your mind, it is said, you could perceive and make manifest any of an infinite number of alternative realities.

I am not convinced by these ideas. I believe there to be, for all practical purposes that concern us in our lifetime, one objective reality and an infinite number of subjective ones. If you don't believe in objective reality, try this simple experiment. Go into town, find a busy pedestrianised area or street, plug your mp3 player in your ears with the volume turned up, then close your eyes tight and start to walk at a brisk pace. I'd wager you'll come up against concrete reality soon enough.

This is not to denigrate subjective reality, it can be very powerful. But it is not the same thing. I am constantly struck by how people are attracted to mystique and love to believe in magic things, whilst at the same time ignoring the truly amazing, scientifically explorable and verifiable abilities of the human mind to affect the material world. Physical health, for example, is profoundly affected by the workings of the mind and we know some of the mechanisms involved. To consciously intervene in this requires proper knowledge, effort and time. I suspect that is why it is preferable to believe in magic. I have written previously on magical beliefs here and mystical explanations here.

I do also wonder why believers in magic and mystical powers end up coming to me to help them resolve their unresolved pain. I do not believe in magic or any kind of mysterious vital "energy", I believe in physiology and psychology, and my technical approach is quite concrete and mechanical. I do not "do" magic, but a lot of therapist do, so I wonder why these believers are in need my help. Could somebody explain that to me?

How valid is your opinion?

There are some matters that almost everybody seems able to express opinions about, things such as what constitutes a healthy diet, the best way to treat a cold, global warming, what should be done about the economy, etc. It is interesting when people are airing opinions at dinner parties to consider whether the opinion holders are enabled to hold an opinion on the matter they are discussing. What is enabling is actually to know something substantive about what you are talking about. Which I think is not the case in most conversational exchanges of opinion. It is amazingly easy to form strongly held opinions that lack any validity at all, opinions of the sort whose degree of approximation to reality is more a question of chance than of judgment.

Dinner party conversations are one thing, but in many life and death questions, professional opinions do matter very much. Mark Lynas, one of the initiators of the protest movement against GM foods, has recently caused a furore in green circles by changing his mind and publicly backing GM foods (1). In a speech to the Oxford Farming Conference, Lynas apologised for having spent years fighting GM crops, saying, "As an environmentalist ... I could not have chosen a more counterproductive path. I now regret ir completely." Why did he change his mind? Conspiracy theorists say he has been bought or otherwise got at. He says, and I believe him, that he changed his mind after he examined the science seriously and in depth. He now knows that his previous stance was not just misinformed but also wholly insufficiently informed. That is not to say that I agree with him, necessarily. But I am honest enough to say that his opinion is more valid than mine, because I simply do not have the knowledge to develop a sufficiently well informed opinion. I would hazard a guess that most of those people who hold strong opinions on the matter are equally ill informed.

To come to a well informed opinion, say, about the potential damage to human health from eating GM foods, you would need, firstly, quite detailed knowledge of physiology, metabolic biochemistry and molecular biology, both of humans and the genetically modified organisms (both animals and plants), as well as about genetics and the genetic engineering procedures involved. This would allow you to judge the plausibility (or likelihood, given what it known about biological mechanisms) of harm being done. Further, you would need to be able to judge whether harm has been shown to be done to living creatures fed GM foods (whether in experiments or in real life) and how relevant those results are to the real world. For this you would need a good understanding of research trials and their interpretation, and an equally good understanding of epidemiological research and its interpretation. The "interpretation" bit in turn requires mathematical and statistical knowledge. And you would need the time to seek out and read all the studies (i.e. the original material) rather than basing your judgment on other people's reporting of them. I would be willing to bet (if it were possible to have an answer) that most of the people who are reading this who have an opinion about the matter find themselves in the same boat as me, deficient in one or more of these areas. So we have to rely on second hand reports, reviews and authority opinion. And along the way things can so very easily become skewed by people's personal attentional biases and preferences.  And along the way things can so very easily become skewed by people's personal attentional biases, cognitive biases and preferences.

It is a pity so many professional opinions actually lack good validity. The validity problem is not solved by being an "expert". Although it is ameliorated, it is still present at dangerous levels. There are some questions which my patients ask me about again and again, about which they suppose I might hold a valid opinion. Topics which come up with a certain frequency, for example, are vaccinations and statins (cholesterol lowering drugs), questions about which I have more than lay knowledge, but lie outside what I would define as my areas of expertise. I am sure other doctors and health professionals are asked the same questions, and amongst them there will be individuals with greatly differing degrees of real knowledge about these things. These are questions with many facets and about which the science is neither simple nor cut and dried. So that "standard care" is provided, doctors typically follow "guidelines" produced by their governing organisations, which are supposed to be the interpretations of the science that pose the best relationship between benefits and risks. But often to produce those guidelines it will not have been easy to produce a consensus document because, for a variety of reasons, the questions are so difficult to answer. And how many doctors will have reviewed the original science themselves? I can tell you: a very very very low percentage of them.

I think that given the difficulty involved in forming valid opinions, one has to develop an overarching strategy. My own involves an attitude and a couple of principles. The attitude is that of caution. The first principle is that it is wiser to suspect that a technological innovation may potentially be harmful unless there is good reason not to, rather than the current standard which is to consider it harmless unless proved otherwise. "Good reason not to" is either because it would be highly implausible, or because it has been convincingly shown not to. The second principle is never to base an important decision on one "expert"'s advice. Seek wider and dig deeper.

If a patient asks me whether I think they should have a certain vaccination, I reply that I cannot tell them what they should do, because it is a complex question about which I am not sufficiently expert to give professional advice, but that if they like I can tell them what I would do (or have done) for myself and my loved ones, and then where and how they should seek further information. That is the only honest and ethical response I can give.

Finally Dear Reader, the next time any professional so called "expert" advises you to do this or to do that, it may be an interesting exercise to try to gauge just how valid is your adviser's opinion on the matter, just how substantive is their learning and authority. You can do this by reading up some basic information and any issues surrounding your particular problem, and then by asking them a few difficult questions. If you receive dogmatic or rote answers, if your professional responds with irritation at being questioned, if he/she shows no inkling of actually having thought about it, or if he/she is not ever ready to admit even partial ignorance, go and ask somebody else instead. That's my advice, for what it is worth.

(1) Turncoat hails GM food a world saviour. The Sunday Times, 13.01.2013, page 6.