Pages

Welcome to my blog

Hello. I am iciclehunter and this is my diary. My job title is "osteopath", and my work is hunting for clues, detective work, problem-solving. These things involve reason and science, but are not limited by them. They also involve the eye of experience, and "hunches". Thus, some would regard my activities as those of a quack, a title I assume here with irony. I am writing this blog because I like writing. I am quite opinionated, and perhaps I suffer from a repressed need for expression. I have no particular prior "agenda"; if I have any bees in my bonnet, no doubt they will make themselves apparent by their buzzing. All names and identifying details of any people featuring in these anecdotes have been changed. Thank you for reading.

Monday, 17 April 2017

The Old Doctor

Doctor Still was a man with many skills. As a teenager growing up in Virginia in the 1830s and 40s, he was an avid and able hunter, his catch providing not only dinner for the family but also dissecting material to satisfy his growing curiosity about the body and its workings. Rural life was for the self-reliant and Still learned about farming and building early on. Later qualifying in medicine, he was enlisted as a surgeon during the American civil war.

Unsatisfied with the efforts of his students to convey the meaning of his new science in the written word, Still became an author. Although not a sophisticated writer, Still had a way with words, and a bluff, droll turn of phrase. His observations on osteopathy and learning liberally employ hunting, agricultural, engineering and military metaphors. In his writing he was a philosopher, a humorist, an eccentric. He devotes an entire chapter of one of his works to ear wax, as he was convinced that it had hitherto unrecognised and important physiological significance – it was produced by the brain to lubricate the nerves, he supposed.

In life Still was an original, and a man with a mission. His mind focussed by the failure of chemical drugs to save his children, he aimed single-mindedly and single-handedly to establish a new and better medical system. His hatred of drugs was matched only by his firm faith in the wisdom of nature. He “unfurled the banner of osteopathy to the wind” in 1874, and founded the first school of osteopathy in Kirksville, Missouri, in 1892. Interspersed were years of itinerant practice, experimenting and developing his method and his ideas.

Still’s idea was simple, intuitive and profound. He had found out for himself as a youngster that mechanical effects could cure physical symptoms (in that case resting the back of his neck against a swing seat to ease a headache). He had marvelled at the intricate machine-like make up of the musculo-skeletal system in the animals he dissected, and observed how each part seemed designed perfectly for its role. (Structure governs function, he was later to state). He had come to the conclusion from medical experience that the body possessed an inherent healing mechanism. He reasoned that this might become compromised by mechanical derangements and that manipulation could restore the anatomy to its functional state.

But Still was an absolutist. He did not just say mechanical derangement was a possible cause of pathology, but the underlying cause of all pathology. He believed that a detailed knowledge of anatomy and “the knife of reason” were the fundamental tools needed to cure any ill.

“The osteopath must learn that his first lesson is anatomy, his last lesson is anatomy, and all his lessons are anatomy” 

In Still’s world the existence and the ultimate wisdom of the Creator were fundamental. Often, he refers to the “master mechanic”. Often he invokes the wisdom of nature, and one wonders whether God and nature were not intimately intertwined in Still’s mind. Often he reasons that disease would not exist in a perfect body – perfect from a mechanical point of view that is – nature would not have been so foolish. Still, evidently, new or thought little of his contemporaries Mendel and Darwin.

Still’s world also was dominated by mechanistic thought, and a fascination with advances in technology, which was of course largely mechanical in those days – the Victorian age back in Britain. Thought processes were linear, with a desire to search for and find one clean and clear cut line between one cause and one effect, like a rod connecting a piston to a crank.

Engineering is guided by physics, in which Newtonian variety the workings of the universe were described by laws. This requirement to seek and find natural laws expanded to other fields, such was their success in physics and such was the success of physics. Thus was the need expressed again and again by Still, to regard the human machine in terms of immutable “natural laws”, and illness in terms of their not having been observed.

Still was driven to build a scientific medical system, but his idea of science was very different from our modern way of science. He used the word to countermand the empiricism of the medicine of the day, which he abhored. To the Old Doctor, “science” meant the rigorous use of rational thought. He often stated that we must reason from the given facts, by which he largely meant the anatomy before us.

But his reason depended upon something which he thought were facts, but were actually articles of faith – his osteopathic principle that the deep cause of all illness was to be found in abnormal anatomy. In fact Still’s relationship with factual reality often tended to be of the kind, I think, therefore it is (apologies to Descartes). In one paragraph, for example, he muses on the cause of “bilious fever”:

Science does not yet know the cause. What if the diaphragm blocked venous return to the thorax? Surely the liver would suffer. Since my osteopathic principles are absolute, and they must be right in all cases, the case is proved! Bilious fever is caused by a disorder of the diaphragm. (Apologies to Still).

The aetiology of all disease was expressed in one of Still’s best known aphorisms: The rule of the artery is supreme. Health depended upon the arterial blood supply as well as unimpeded venous drainage, lymph flow, nerve activity, and cerebrospinal fluid flow. If any of these were impeded by a “dislocated” bone or muscle, illness would soon follow. Still was about 100 years ahead of his time in the importance he placed on the fascia, the “hunting ground” where to find the origin of disease as well as its cure.

A brilliant anatomist, Still’s knowledge physiology was less solid, but spiced up with wild guesswork: the lymph vessels were filled by lymph directly from the cerebrospinal fluid; fever was produced by heat from nerve electricity, and served to transform wastes into gas; food was transformed into gas in order to be digested and assimilated by the body, the lungs (“the clouds of the body”) were the body’s major source of water. Very soon at Kirksville, Still installed a physiology teacher by the name of Littlejohn.

There is little record of the technique of Still, as he never described it. By the available accounts it was simple. Many treatments were effected with the patient seated or on foot, and he invented his technique on the spot according to necessity and circumstances. He made use of articulation, leverages and combined indirect-direct technique ("Still technique"). He often spent much time on soft tissue work, even several sessions, before attempting bony adjustment. He states in one of his works that the osteopath is “no lightening bone setter”, yet one of his original business cards recently came to light claiming to be just that! He scorned general non-specific massage (“engine wiping”) and believed in the least necessary treatment: “Find it, fix it, then leave it alone”.

What balance can we draw? On the positive side we can say that Still insisted that his medicine must be based on reason, that he recognised the importance of the somatic component of disease, that he would accept no dogma nor adhere to any orthodoxy, that he abounded in original thought, that he recognised no limits, that he was an enthusiast.

"The explorer for truth must first declare his independence of all obligations or brotherhoods of any kind whatsoever". (A.T. Still)

Against this must be set the clear fact that his reasoning was limited by the paradigms of his time: mechanistic thought, absolutism, unifactorialism, and that his vision was at times tunnelled by the sheer force of his belief.

However Dr Still's basic premise, that the body's macro-structure and it's dynamic relations are fundamental to the deep workings of physiology, was ahead of it's time and is supported by recent findings in modern science. Still recognised that his new system was in its infancy and would develop enormously in the years after his death, and so it has scientifically and technically. But despite the relative simplicity of the original idea and methods, they have provided the main contribution to many manipulators’ work, with quite remarkable success.

My favourite of his aphorisms is the one I believe expresses best the essence of the success of manipulation as a treatment. The saying is his simplest: “Movement is life”.

Dear Doctor

Dear Doctor,

You not very good with chronic ill health, are you? I'll tell you why. It's because it is complex, and your concepts and treatments are simplistic, most of the time. Moreover, you haven't the time or the inclination to go the extra mile. Also, you are afraid of sanction if you step outside the boundaries of your official guidelines. The result is bad medicine.

I have chronic Lyme symptoms and all of the above is clear from my contacts with you. Granted, chronic Lyme is the motherf**** of all chronic diseases, but even so, I think I am on safe ground generalising from there. Furthermore, there is no reasonable doubt that chronic Lyme is a major and increasingly prevalent problem in the world today. Doctor, do you know anything about it that's worth knowing? Not in my experience or the experience of thousands of others.

It is obvious from people's comments on the forums that people with Chronic Lyme disease / Post-treatment Lyme Disease Syndrome (call it what you will, Doctor) respond differently to different treatments. These are people who have been failed by official guidelines and orthodox antibiotic protocols, and for whom conventional medicine offers nothing more. Naturally enough, they are willing to try anything which will afford them some hope. You, Doctor, will consider that they make irrational choices. You may also be one of those who denies the existence of chronicity in Lyme disease. One of those who thinks it is in our heads, that we are all neurotic, depressed, or a bunch of nutters.

But time and time again on the forums I read of people who, having tried this, tried that, maybe appearing to enjoy some short-term benefit which later proves to be illusory, and having fallen back into disappointment or desperation, then try one more thing, and for no apparent reason, they start to get better and their improvement is sustained. It may be something that you Doctor, dismiss as Hocus Pocus, an effective placebo at best, but they have tried lots of other Hocus Pocus before. Hocus Pocus that didn't work. But suddenly this Hocus Pocus does.

The fact is, Doctor, placebo or no, the catalyst for one is not an effective catalyst for another. You, with you attachment to protocols, objectivity, and rationality do not understand this. What this does show is this. With chronic Lyme, "killing the bugs" is futile without also finding the effective personal catalyst. And it shows another thing, too. The disease is not just described by the bug, but in equal measure by the person's own capacity to respond to it. So look at the soil, Doctor, not just the weeds. Take another look at those outliers, those heart-sinks, those crazies, who do not respond to your protocols. Come on, don't be afraid, it will not kill you.

Yours,

Icicle Hunter


Other posts on Lyme disease

Saturday, 8 April 2017

Manifesto

This is the manifesto I operate under at my osteopathic practice. When you read it, bear in mind that I am mostly involved in treating more chronic conditions.

I believe in:

  1. Trusting your body's intelligence. Your body is much more intelligent than my conscious mind. Your body arranges its internal economy to best accommodate a lifetime's accumulation of trauma and stresses. I cannot tell it how to do that, in what time frame or in what order. I can only help to remove the strain and ensure that your body's basic needs are met. This is sufficient and complete treatment. The body's resources are then freed to heal rather than diverted to fight the strain. 
  2. Slow, gentle treatment. The body, even under optimal conditions, responds in its own time. You cannot with impunity bend the laws governing biological processes. The best, longest lasting changes are the ones which happen so naturally they are often largely unconscious. They do not take place immediately, but in the days or weeks after treatment. 
  3. Supporting the bodies efforts to heal. Stiffness, pain and inflammation are some of the body's healing responses. Only medicine gone mad would want to smother them completely. A rational system of medicine, on the other hand, works to make them unnecessary by modifying the conditions in which they have developed. 
  4. The unity of the organism. A headache isn't only a head problem, a painful hip isn't a only hip problem, a gastric ulcer isn't only a stomach problem. The head, the hip, the stomach are not floating in space divorced from all else. Everything is a global problem. 
  5. The only antidote to health problems is health. Also known as vitality. A vital organism responds quickly and efficiently to its health problems. If you have a lingering elbow pain, it is not (usually) just because something is “wrong” with your elbow. Either you are working it too hard for your body reasonably to endure, or your body is insufficiently vital to respond to the injury. The answer is not to treat the elbow, (then the knee, then the shoulder, etc.) but to rest the injured part and work to improve the body's vital responses. 

I do not believe in:

  1. Symptomatic treatment. Symptoms arise in areas of greatest strain. Strain accumulates in these areas because of distortions throughout the body. Treating only the symptomatic area may make it feel better temporarily, but only temporarily. And the overall strain will soon manifest elsewhere, too. So it is better not to treat the bits, but the whole. 
  2. Heroic treatment. Things should not be forced with heavy clicks and crunches. A stiff area might be stiff for a good reason (see “Trusting the body's intelligence” above). In any case, if something needs forcing, it is not ready for release. If and when it becomes ready, based on the body's own priorities and time-scale, it will not need forcing. 
  3. Single treatment cures. See “Slow, gentle treatment" above. 
  4. Compartmentalisation and micromanagement. As I have mentioned, your body is intelligent (see “Trusting the body's intelligence” above). To attempt to manage its every part and function would be presumptuous and ineffectual. It is far preferable to give general treatments rather than treating the minutiae of each painful part. 

In conclusion, for those seeking a quick fix in one or two sessions, my place is the wrong place to come. The approach I propose may take longer than you might have envisaged. On the other hand it will be low risk, and it will produce deeper, longer-lasting results to your whole health.

23 April 2013.

Friday, 7 April 2017

Lessons in Osteopathy

This series of "lessons" appeared recently on my Facebook Page, in order to let people know that there is more to osteopathy than manipulation. There is actually quite a lot of thought behind it!

1. Fluid Flow

The first essential thing is flow, a word that will come up again. In this lesson I use it about the movement of bodily fluids. Blood (not bones!) has always been central to osteopathy. Blood brings life, that's why there is the term "life blood". It brings oxygen and nutrients, and carries away wastes and dead matter. If blood flow is compromised, the stage is set for illness. If blood flow is restored, we have the conditions for healing. Osteopaths call that "the rule of the artery". But there are other important bodily fluids that have to flow or move normally for health to be maintained, such as the lymph, the cytosol (liquid inside cells) of nerve cells, and the synovial fluid (the lubricant of joints). Osteopaths reason that the proper flow of bodily fluids may be compromised by such things as tights muscles, stiff joints, poor posture, and poor breathing. Therefore osteopaths work to improve these things.

2. The Healer Within

Osteopaths believe that it is never the physician or therapist that heals the patient, it is the patient who heals by their own innate intelligence and energies. The therapist simply facilitates or catalyses the process, by helping to create a context for health rather than illness. In the case of osteopathy, this is seen to be done by removing obstacles to health. In particular, we attempt to reduce physical barriers to free flow, especially of body fluids (as explained in Lesson 1), nerve impulses, and indeed all of the body's tissues (more of this in another lesson). There are other things involved, too, but this concept of improving body mechanics and hydraulics is fundamental to osteopathic thinking. That the body can organise and regulate itself is not a revolutionary concept. In science it is called "homoeostasis", literally "staying the same". But the phenomenon was observed by people for millennia before it was given a highfalutin name.

3. Vitality

In the first two lessons I touched upon the ideas of "life blood", "flow", and our inner "healer". These are all aspects of what I will call "vitality". Vitalism is an essential part of osteopathic thought, one at which sciency people scoff. They scoff at it because it is intangible and cannot be measured. And yet it is very simple really: vitality is the capacity for life (and by implication health). Of course it is an abstract idea, but if we consider vitality as a quality, then it is determined by many things; that is, it is a composite quality. That does not make it any less useful as an idea. Osteopaths will argue about this (they argue about many things), but personally I will say that I can feel good vitality in bodily tissues which are pleasingly elastic and responsive to my touch, neither too resistant nor too yielding; tissues through which the movement I solicit in them flows naturally without let or hindrance. There's that word again: flow. Good flow is a prerequisite and an indicator of vitality.

4. Movement is Life

My favourite artist is without doubt Van Gogh. Have you noticed how everything in his pictures seems alive? Why? It's the movement in them. In previous lessons I have connected the idea of "flow" to that of "vitality". In a phrase, what I have said is "movement is life". Obviously that cannot be taken as a literal truth. Many things move which are not conventionally considered to be alive: the air moves as a breeze or wind, and there are currents in bodies of water, to give just two examples. Yet if we turn it around, and take the movement out of a living organism, it would die. So movement of some kind is essential to all life. You might say, a tree doesn't move, except when moved by an outside force such as the wind, yet it lives. But for one thing, yes, it does move - it grows! Secondly, if you looked inside its living tissues with a powerful microscope, you would see many things moving about to sustain the life of the tree, things to do with the transport of nutrients and metabolism. To qualify our simple and inexact aphorism that movement is life, I would say that all life depends upon intelligently directed movement. If this is diminished, impeded or distorted, the organism will lack vitality, and ill health will ensue. For this reason the osteopath's work is to maintain, so far as possible, the free movement of the body's tissues and fluids.

5. Congruence and integration

Have you ever seen a flock (technically a "murmuration") of starlings? Did you see how they group and fly together in coordinated, coherent, integrated dances? I have written in previous lessons about flow in the body's tissues and what that feels like. Here I'd like to expand upon that as a little. Let's say you are lying face down, head turned to one side, and I gently and repeatedly push on the side of your hips and release. Your body will rock gently from side to side with a certain rhythm, a rhythm determined by your own individual conformation. My other hand contacts your spine and with its fingers or the heel of the hand works up and down your spine, resting briefly between each vertebra and the next. What does my hand want to feel? It wants to feel each vertebra moving as predicted from years of experience, in an integrated way with the rest of the spine. That gives a sense of flow. Some things may prevent or upset this, things such as tight muscles large and small, shortened ligaments, damaged joints, even things you might not expect like internal problems and anxiety. My job is to restore flow, by whatever safe means. Let me analyse a little what makes "flow". It is these things, applied to the feeling of movement through the body's tissues:

  • Correlation: a mutual relationship between things.
  • Coordination: the organization of separate things into a complex process.
  • Coherence: logically or aesthetically ordered.
  • Congruence: being in agreement or harmony.
  • Integration: forming into a unified whole.

More generally speaking, these things are (literally) vital for life and health.

6. Making the Body Work Better

There is a rather opaque tenet of osteopathic thought, originally stated as "structure governs function". That means basically that the shape of the physical structures of the body (the anatomy) determines what they do and how they work. Any disorder of anatomy causes things to work less well. While this sounds reasonable enough on the face of it, it is in fact one of the most argued about thoughts in osteopathy! I won't go into the ins-and-outs of that argument, I will just tell you my interpretation. It is very simple. Tight muscles or other tissues, stiff joints and poor posture make the body work less well. Osteopaths work on the physical tissues of the body in order to improve their function, with a mind, in doing so, to improve the way the whole body works, too. In effect, we work on the physical structure of the body in order to affect change in the organism's great control systems - the nervous system, the endocrine system, and the immune system - all under the overarching command of the mind.

7. An Alternative View

Federico Fellini said, "A different language is a different vision of life." It is often difficult for people to understand that osteopathy is not about treating medical conditions... a herniated disk, for example, or arthritis. Osteopathy has limited use for such diagnoses. The thing to understand is this... knowing you do or don't have a herniated disk or arthritis does not tell me much about what I need to do in treatment. In that regard your medical "diagnosis" is next to useless. What tells me how to treat you is observing how movement flows through your body. There's that word again... flow... it is so important. So osteopathy is absolutely not an alternative way of dealing with your medical diagnosis; it is a completely different way of looking at health and illness, which has its own terms of reference coherent with what we are trying to achieve.

8. Tools Do Not a Craftsman Make

When I used to teach osteopathy, I noticed how my students were obsessed with collecting techniques. They thought the more techniques they knew, the better they would be as osteopaths. I used to tell them that knowing 200 techniques without attention to osteopathic thought was next to useless, while knowing ten techniques and and having a good appreciation of osteopathic thought could make a very good osteopath.

So the first thing I would like you to understand is that doing "osteopathic techniques" does not mean "doing osteopathy". Doing osteopathy means paying attention to things such as those I have brought up in previous lessons, all the while developing the sensitivity to be able to apply them through technique. The technique without the thought behind it is nothing, or at most a hopeful shot in the dark. One technique performed for the right reasons (which doesn't necessarily mean cracking your back where it hurts) is more valuable than fifty techniques performed without any good reason.
My students also used to look forward to learning those techniques that make cracking noises, thinking they were the "best" techniques. I used to tell them that the best technique is the one which gives the greatest benefit with the least risk. Clicks and cracks mean nothing. So the second thing I want you to understand is that osteopathic technique does not mean making the joints go "crack". Osteopathy has a very large toolkit of manipulation techniques. The wise osteopath uses the less invasive techniques first and foremost.

And thirdly, many people need to reframe their idea of what our techniques are supposed to do. We are not knocking bones into line. We are moulding, reshaping, reworking the body into a more balanced, more harmoniously coordinated, working system. Let me repeat: WE ARE MOULDING, RESHAPING, REWORKING THE BODY INTO A MORE BALANCED, MORE HARMONIOUSLY COORDINATED, WORKING SYSTEM.

9. So What Do Osteopaths Treat?

If you remember your lessons, you will remember I said in Lesson 7 that osteopathy is not an alternative treatment for medical conditions. Do you remember what I meant by that? Did I mean that if you come to me with a "disease", say degenerative joint disease (aka osteoarthritis, aka arthrosis) or degenerative disk disease (aka "a slipped disk"), I can't help you? No, of course I didn't mean that. But I will not be treating your "disease". "Diseases" are the invention of modern medicine and treated by doctors. They consist of a more or less well defined description of the bodily changes involved in their development, and a name. Osteopaths think that in many cases the doctors are barking up the wrong tree. Why? Because a disease does not exist in isolation. It exists as one with a person, who lives in an physical environment and a society. Therefore, it seems to us, to give one person's problem the same name as that of another person and to regard and treat it equally is nonsense. So, if we don't treat diseases, do we then treat symptoms? A sore shoulder, dizziness, period pains? Not exactly. There is no one standard kind of treatment for each kind of symptom. So, what do osteopaths treat? We treat people. The people we treat obviously have symptoms, and may have diseases, and we intend that through our treatment these things should give them less trouble. But we do not treat the symptoms or the diseases, we treat the person who has them. That is, what we do in treatment depends on a series of factors unique to the person, and only in a minor way on the disease or symptom they have.

10. The Rate of Change

People naturally want to get better quickly, and that is normally possible to achieve if their problem is recent and uncomplicated. But if it has been developing for a long time, it is not realistic to hope for a complete cure in a few treatment sessions. Does that sound reasonable? Yet people often do expect that. Why? Sometimes the reason is this: that what appears to be a recent problem (because the symptoms have appeared recently) is actually something that has been developing for years. Another reason? Well, humanity is not renowned for its reasonableness. In any case, with problems that have been developing or producing symptoms for a long time, the beneficial effects of treatment accrue gradually, sometimes over many months, or even years. There will be ups and downs to get through, and change will not necessarily occur entirely as predicted. New symptoms may temporarily appear then subside. That is because the body has its own agenda. We can free the way for a healing, but only the body can dictate by what exact course and time scale. One thing is certain: healing and recovery are quicker and more certain if a person can eliminate from their life the things that have predisposed to, triggered, or are maintaining their condition.

11. Moving Pictures in Our Minds

In the late 1890s / early 1900s our founder Andrew Still got angry with one of the teachers in his school, who had been a pupil of his, for teaching physiology. "Anatomy, anatomy, anatomy!", he shouted. Anatomy is the bits and pieces, physiology is how they work. Arguably we realise today that, while a visionary, sometimes Still was a little unreasonable in his fundamentalism. So today we are taught physiology. But his point was two-fold. Firstly, if you know your anatomy and how to work with it manually, it is a large part of what you need to get people better (he would probably have said "all you need"). Which, so far as manual treatment is concerned, is largely true. Secondly, I think he was saying that if you know your anatomy well, you should also be able to deduce all the physiology that actually matters in practice. After all, physiology has another name: "functional anatomy". That means, why things are shaped the way they are in order to carry out their functions. Whatever, osteopaths are very well drilled in anatomy. When we handle your body, we have little moving pictures in our minds depicting what is happening inside. This is, we are watching your anatomy working, seeing physiology in action in our mind's eye.

12. But You Haven't Mentioned Back Pain!

You're right. This is the twelfth lesson on osteopathy and I haven't mentioned backs once, until now. How so? Back pain forms a large proportion of any doctor's case load. All the more so for osteopaths as a lot of back pain seems to have an important mechanical component, and osteopathy is, on the face of it, a mechanical treatment. We also see lots of problems with necks, chests, shoulders, hips, knees, ankles and feet, elbows, wrists and hands, nerve pain like sciatica, and "muscle pain" (in inverted commas because frequently it isn't actually muscle pain). All these are often perceived by people in the same way, as being in some way mechanical, so the osteopath seems a good choice. On the other hand guts, wombs, lungs, eyes, and things, or immunity, hormones, energy levels, general health, and things, are not perceived as "mechanical" and so not many people would think of going to an osteopath about them. But if you have taken away anything from this series of lessons, I hope it is that osteopathy is not just mechanical, it is also physiological, and that the aim of the osteopath is to improve physiology, vitality and health as a whole. Now, as a colleague of mine has said, the only cure for ill health is health. Paradoxically, as we focus more on health than illness, many experienced osteopaths are very good "problem-solvers" with ill health in general, particularly with those chronic (long term) conditions for which conventional medicine often seems to have little to offer. So it makes sense to see if an osteopath might contribute to your state of health, whatever your specific complaints.

13. And Finally

In the preceding lessons I have told you about MY osteopathy. That is, how I personally have interpreted and taken ownership of this discipline. Other osteopaths would say different things about it. In fact, if you have been to different osteopaths, you might have noticed how they can have different visions of what needs to be done, or they may have given you very different treatments. A wag said that the collective noun for osteopaths is a "disagreement". But I think I am right in saying there are certain things which are common to most, if not all, of those using the title "osteopath". What are they?

  1. Manual treatment.
  2. An appreciation of how the workings of the structural tissues of the body influence health.
  3. A tendency to look wider than the immediate area of pain or symptoms.
  4. An appreciation of, and trust in, the self-healing tendency of the body.
  5. An understanding that the health of an area is only as good as its fluid circulation (blood and lymph) and nerve supply.

This is my last "Lesson". Is this all I have to say? No! But I think what I have said in this series of lessons has given the reader an all round idea of what osteopathy is all about, at least through my eyes.

Wednesday, 22 March 2017

What are experts good for?

I was going to call this article "What is the point of experts?" but I thought better of it. That would be too facetious even for me. The point of experts is quite obvious, but the point I want to discuss here is how well they live up to their raison d'ĂȘtre.

It has long been my observation that in many fields "the experts" are commonly nowhere near as expert as you or I would like to believe, or indeed as they would like us to believe. In fact, of the "professions", the only one I can think of in which the expert is truly an expert more often than not is engineering. That is probably because it is based on the "hard" sciences of mathematics and physics (of the old school, Newtonian variety), which, I am told, are not opinions. And because if they were not, bridges would collapse (sometimes they do) and aeroplanes would drop out of the sky (sometimes they do). But think of the others... accountancy, architecture, business management, dentistry, information technology, law, psychology, economics (most of all economics!), you name it. My own profession, too. Is the expert really all that expert? Too often for comfort, no!

One reason is that most professions, particularly those concerned with human sciences, are dealing with a lot of unknowns, and so opinions and interpretations take the place of facts. Two other important reasons are the way in which "knowledge" is regulated by committee, and sheer laziness.

Take medicine, which is no exception to the general rule (to state it kindly). It is not a pure science, it is an applied science and an art, at the centre of which is the human being. Now, (s)he who says (s)he knows more than a fraction about the human being is a fool. That would be true even if only the physical workings of the body were concerned. But there is a whole area of the human being which is routinely ignored by doctors: the mind. Now, the wise know how to navigate in uncertain waters, knowing that in order to do so one needs to consider all areas of relevant knowledge. These individuals may rightly be called experts, even though of course they do not "know everything". But if one ignores a whole vast field of pertinent knowledge, one doesn't stand a chance.

Another thing one needs to do when attempting to navigate uncertain waters, is to feel comfortable in trusting one's own experience and hunches, something that doctors are increasingly discouraged from doing in favour of applying "knowledge by committee". And a third thing one needs is humility and honesty, in the open admission that one's knowledge is limited. Because without humility, sooner or later you are going to come a cropper. Humility is sometimes in short supply in medicine, particularly in the upper reaches of so-called expertise, where in truth one should be more aware than ever about one's limitations.

Knowledge by committee is a major problem with modern medicine. That means that scientific evidence is reviewed by official bodies, who then publish guidelines for the treatment and management of this or that condition. Increasingly, so-called guidelines are taking on the character of orders, and woe betide the doctor who strays from them. The consequence is that doctors are increasingly disempowered from professional decision making. This is the ugly face of Evidence Based Medicine. It has a pretty face too. It's proponents say that it guarantees that only safe, effective treatments are offered. But it's critics point to the fact that standardised treatment protocols by definition limit individualising treatment, that it favours treatments for which large scale gold-standard research protocols are feasible, that it excludes potentially effective treatments, and that it denies patients choice. But in the context of this post, my main criticism here is that it diminishes medical professionals, turning them into bureaucrats, "experts" in learning and delivering protocols devised by other people. Painting by numbers. This inevitably leads to laziness. Why should I read that research paper? Already from the title I can see that it contradicts the guidelines. Therefore it is of little use to me or anybody else. You see the reasoning? Believe me, this happens.

So, as our example of "experts", what are doctors good for? Based purely on my own impression (which I do not hold to be "the truth"), and offered as such, my assessment is this. 10% of them are good or very good, 20% of them are bad or very bad, and the rest wallow in a wide swamp of mediocrity. In general they are better with acute complaints than with chronic ones. Their worth reaches its peak in A&E and Intensive Care. (There's something about the really critical that focuses the mind, and options become more basic.) It reaches its lowest ebb with some of the loafers working in outpatient specialist care. General practitioners (family doctors) are not what they were. They are comfortable with a restricted range of drugs for a restricted range of conditions. Surgeons range from greedy butchers to exquisitely skilled, highly professional craftspeople, so be careful.

Is this a broadside against doctors? No, it is a general comment about "experts", taking the profession of medicine as a typical example. It is a criticism of the diminishment of true professionalism perpetrated by professional establishments themselves. And it certainly is a broadside against the many loafers and incompetents who coast along in most professions. If you take home one message from this, take this one: don't necessarily trust the "expert".

Tuesday, 21 March 2017

Why do Lyme symptoms become chronic?

A significant number of people with Lyme disease who have been treated with antibiotics according to standard guidelines go on to suffer from chronic symptoms. Why is this? Stephen Harrod Buhner, in his book Healing Lyme (2nd edition, 2015), suggests there are four different potential reasons, all of which may explain persistent symptoms in different patients:
  1. Antibiotic treatment has successfully eliminated the organism that caused the disease (primarily spirochaete bacteria of the genus Borrelia), but damage to organic structures that was caused by the bacteria persists. 
  2. Some people are still infected even after antibiotic therapy. 
  3. The immune response to the initial infection becomes an auto-immune response, that is, the immune system begins to attack the body's own tissues.
  4. Fragments of non-viable ("dead") bacteria remain in the body after antibiotic treatment, maintaining an inflammatory respons from the immune system.
One finds different terminology in the scientific literature. If it is envisaged that chronic symptoms are caused by persistent infection, the term "Chronic Lyme Disease" is often used. If, on the other hand, the view is that continued symptoms are not due to continued infection, one will see "Post Lyme Disease Syndrome (PLDS) or "Post-Treatment Lyme Disease Syndrome" (PTLDS), or some such, instead. If the doctor ignorantly denies the existence of either, he or she will often come up with "depression", "delusion", or some other half-baked psychiatric diagnosis.

Buhner is not just guessing. There are research papers supporting each of these mechanisms. I shall quote some of his remarks verbatim below, and I hope some doctors will read them. If you are a doctor, mark this. Buhner is not a doctor but he is not a quack either: he has done his homework about Lyme, probably to a greater breadth and depth than you have about your special subject, and is possibly one of the most knowledgeable people in the world about Lyme disease.

"I want to be clear here about my own orientation. We have had contact with over twenty-five thousand people with Lyme in the decade from 2005-2015. I have, additionally, reviewed upward of ten thousand peer-reviewed journal papers on Lyme disease, its coinfections, their treatment, and overall outcomes. There is no question in my mind, and none in the literature, that both post-Lyme disease syndrome and chronic Lyme exist. The journal papers, by themselves, leave no doubt for any reader who relies on evidence-based (rather than faith-based) material. The numbers of people who experience either (or both) of these conditions may be a legitimate point for discussion but that they exist is not. I personally find the position of many in the conservative medical community on these conditions (i.e., that they do not exist) to be malpractice of the most egregious sort."

Amen.


Tuesday, 14 March 2017

I've had it with those monkeys - They don't know what they're doing

I've had it with those monkeys. They don't know what they're doing. From now on I'll deal with this my own way. I've just come up against the kind of thing many people with Lyme disease know only too well: the sheer boneheaded stupidity and stubbornness of standardised medical guidelines and (bog) standard medical thinking.

The doctor assigned to my case is a pleasant young lady specialist in internal medicine at the local hospital. I saw her the first time 6 months ago and she was nice enough and seemed competent enough in the little she had to do. At the time my symptoms were improving after antibiotic treatment, so all she wished to do, rightly, was to book a follow up, which was today.

Unfortunately, recently I have had a relapse of my unpleasant neurological symptoms. Doctor was puzzled. I don't blame her. It's a weird, poorly understood disease, not many cases are seen on the island where I live (I have been told I am one of two known cases), and she is young. I don't hold that against her. I prefer the young ones - they're usually less complacent and set in their ways.

I gave her some clues. I told her that the persistence of symptoms after antibiotic treatment of Lyme disease is a major problem; that there are two theories: (a) that Borrelia bacteria persist in the system even after antibiotic treatment - proponents of this theory refer to "chronic Lyme disease", and (b) that Borrelia does not persist after antibiotic treatment, and the persisting symptoms must be explained by other mechanisms - proponents of this theory refer to "post-treatment Lyme disease syndrome" or PTLDS for short.

I told her that Borrelia burgdoferi is known to exist in different morphological forms: free spirochetes, round bodies (cysts) and biofilm colonies, that these different forms have different responses to different antibiotics, and that this may explain why the symptoms of Lyme disease recur after antibiotic treatment. I told her what Sapi et al. (2011)* found in their in vitro experiments: that doxycycline reduces spirochetes by 90% but increases the number of round bodies by 200+%; that amoxillin, metronidazole, tigecycline, tinidazole reduce both spirochetes and round bodies; that tinidazole is the most effective, reducing spirochetes and round bodies by 90%; that only tinidazole is reasonably effective against viable biofilm organisms; that furthermore, their results suggest that Borrelia spirochetes transform into round bodies when treated with antibiotics and transform back into spirochetes when antibiotic treatment is stopped; and that this effect is greater when doxycycline is used. I noted that I had been treated with doxycycline.

I told her that of the many species of Borrelia that can infect humans and cause disease, B. burgdoferi, B. afzelii and B. garinii are the most important, that while B. burgdoferi is more common in the United States, the other two are more common in Europe and Asia. I noted that I probably became infected in Asia, but had only been tested for B. burgdoferi.

I told her that in people infected with Borrelia, coinfections are common, the most common of which are Bartonella, Chlamydia, Mycoplasma and Babesia. I noted that I have not been tested for any of these.

She said how interesting. I apologised for my lecture but pointed out that most doctors were unaware of these things. As an aside, even though some of the information might be arguable in the light of other research, most doctors are also unaware that there is something to argue about. I am very much afraid I blinded Doctor with science. Also, I miscalculated. I had forgotten that national health service doctors are not paid to think, but to follow standard protocols.

Anyway, Doctor said she had to confer with her superior, the head of department, and asked me to wait. I waited for half an hour. She called me back. She told me she had spoken to her boss and read some stuff on the computer (I am assuming she meant the relevant health service guidelines on their Intranet). On that basis she told me that I had received the right treatment and therefore I must be free of Borrelia. My symptoms were left-over neuropathic symptoms, and needed to be treated with specific drugs for neuropathic pain.

I tried to reason with her, noting that what she was telling me was not an open and shut case, and there were strong scientific reasons for believing that doxycycline alone may not be adequate treatment for Lyme disease. But her face was set firm, and she flatly said she was not going to prescribe antibiotics and there was no need for further tests.

I saw the lay of the land, so I told her I didn't want drugs for neuropathic pain, got up and left. I was a bit short with her (not to my credit). What got me in this instance (and there have been others), was not being refused antibiotics - I can understand that choice, if it has been properly reasoned through on an individuial basis - but the complete disregard for the pertinent information provided, which might have made a doctor think, "Hang on a minute. This doesn't fit in with what the guidelines say. Hmmm... let's have a think about this", and the unwillingness to have engage in a reasoned discussion based on science. So that's what they call "Evidence Based Medicine". More like Asinine Based Medicine.

But I do not blame the doctor. She is young, could not go against her superiors, and could possibly be disciplined if she went beyond official guidelines. In time I hope she learns that to make a good doctor she is going to have to learn critical thinking, a healthy dose of scepticism towards "standard protocols", to appreciate that where science is incomplete one has to be prepared to move outside the box, and where personal knowledge is lacking, to do some in depth reading in the interests of one's patient, and to use her capacity for reason.

But I do blame a system - both educational and of health care provision - which in its bovine stupidity trains these positive traits out of young doctors. And I point the finger at her superior - and all like him - who should know better; who in either arrogant stupidity or laziness (I know not which), despite evidently not having had to deal much with Lyme disease, believes that what he learned about Lyme at school, and what he thinks he knows about infectious diseases in general, is complete and sufficient.

Anyway, I'm shot of it. I'll deal with this in my own way from now on.


* Sapi et al. Evaluation of antibiotic susceptibility in vitro of different morphological forms of Borrelia burgdorferi. Infection and Drug Resistance 2011: 4 97-113.


More of my posts on Lyme disease