Welcome to my blog

Hello. I am Sherlock and this is my diary. My job title is "osteopath", and my work is problem-solving. This involves detective work, hence my name. Detective work involves reason and science, but is not limited by them. It also involves 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.

Friday, 2 October 2015

Are my teeth causing my back pain?

There are two kinds of theories about this:
  1. If your jaws or teeth are not well aligned, this can over time result in changes in your posture, which in turn can be a factor in the onset or maintenance of pain. This kind of relationship is explained here. This theory is perfectly plausible and there is a lot of clinical data to support it.
  2. Each tooth "corresponds" to a different vertebra or part of the body. Excessive pressure on a tooth can cause pain in the corresponding part of the body. An example of this kind of relationship is described here. In my opinion this theory is nonsense.
Why is it nonsense?
  1. Meridians and chi are myths.
  2. It is too simplistic. The body does not work in terms of simple correspondences of this kind. Connections in the body are much more sophisticated and nuanced. There are no nerves directly connecting the jaws with the spine. Any neural pathway between the jaws and the spine would have to pass first through the incomprehensibly complex computer that is the brain. It is not credible that the brain should assign a single vertebra to each tooth in a nice regular order. Why would it? There is no evolutionary or functional reason why it should. Interconnectedness in the body is about function, not about pointless pretty patterns, however randomly pleasing to the observer. 
  3. It is implausible. That is, it is an idea incompatible with what centuries of scientific study tell us about the way human biology works.
  4. Its proponents have never bothered to test it properly.

In fact, it is typical of those over-simplistic, implausible and unsubstantiated theories which suggest simple solutions with minimal effort, i.e. magic. I have written about this here, here, and here.

This is what happens. It is known that people manage to see meaningful patterns even where there is only randomness, a phenomenon called pareidolia. So, a person dreams up a half-baked idea based on some impression of this kind, or by reworking somebody else's fancy theory in a new guise. The person likes the idea and so invests their belief in it. Vainly, they like to think they have "discovered" some hitherto unknown phenomenon. They never bother to test the idea properly. Instead they write a book. Other people mistakenly think people who write books must be more knowledgeable or intelligent than people who don't. So they believe the books. Some of them begin to foist it on their patients or teach it in schools, without ever having questioned it, let alone tested it. Believe me, I have worked in non-conventional medicine for over 20 years, I know how this works.

A recent question from a patient concerned this tooth-vertebra theory. "Of course you know this", she said. I replied that I was familiar with the idea, and I didn't believe it. "I believe it", she said. Why? Because she had read it in a book, and she found it convincing because her daughter had a problem with such and such a tooth and also a pain in the "corresponding" part of the body. (Her daughter had pain in various parts of her body).

But people tend to give of their belief very readily. You need much stronger reasons than that for investing your belief in something. Ideas should earn your belief to make your belief worthy. Not just because you like the sound of it! I have written about this here.

Friday, 25 September 2015

Why am I so sensitive to pain?

From time to time patients tell me they are very sensitive, by which they usually mean that when something is slightly wrong with their bodies, their bodies immediately let them know. Or they may say something like, "I know my body", by which they mean they are very in tune with the physical sensations coming from their bodies. What the patient says next will often be an interpretation of their symptoms ("there must be something wrong with that part of my body"), according to their beliefs about their body. And this interpretation will in the course of the consultation beg the question: Do I agree, and if not, what is my interpretation? Often, that interpretation is not the one the patient expects.

If you are unusually sensitive to sensations coming from your own body, your perception of small deviations from the norm is amplified. And - this is the key - you may habitually interpret them as being bad, as "something wrong". Moreover, since they worry you, you are more alert to them, and since you are on high alert, you are more perceptive to them. And since you are wary of them, you focus on them and worry about them, they cause you more discomfort. It is a perpetual, self-maintaining cycle.

This leads to the person being continually troubled, and worried about, a succession of varied symptoms. Doctors can never find anything wrong with them, so they go to other doctors, who can't find anything wrong with them either. This is extremely frustrating both for the patient and the doctors.

It is not just about what you think. This cycle between your interpretations, your perceptions and your behaviour produces another change, a concrete physiological one. The parts of your brain and spinal cord concerned with processing pain signals become sensitised, so it takes less stimulus to produce pain. Happily though, the process is reversible.

Highly sensitive people may believe their sensitivity is advantageous to them, and to an extent that might be true, inasmuch as it induces them to look after themselves and so reduce the risk of serious disease. Some even look on it as a sort of virtue. But the self-focus and health-focus can become an obsession. There is a thin line between a general attitude and a mild obsession, between habitual self-care and compulsive health-oriented behaviour. It is a question of balance. Too much self-focus, even about health, is just as unbalanced as too little.

Let me tell you what I think is a better solution than either worrying or obsessing. If you could only break the cycle, by not interpreting sensations from your body as something bad happening, you would worry less and you would actually begin to feel less unpleasant sensations. So, stop thinking what you think you know about your body and consider this:

  1. The workings of your body reflect your expectations. Quite a lot of science supports this statement. That means that if you think a sensation means something bad is happening in your body, bad things are more likely to happen in your body as a result. Conversely, if you do not attach a negative belief to a sensation, the chances are you will experience the sensation much less because you are not attaching inordinate importance to it.
  2. Bodily sensations, even pain, are not necessarily related to any disease, injury or other physical problem. The sensation of pain is produced by the brain. The brain is continually being bombarded with what we call "noxious" nerve signals coming from the body - these are pieces of information that tell the brain that there is some low level potential for harm due to small physical, biochemical or biological changes. If our brain caused us to feel pain in response to all of these, we would be in constant pain. But the brain will only respond with pain once a certain threshold is reached. That is so pain should only be experienced if the alarm is real and significant. That is, in a normally functioning, balanced organism. But in some people, this threshold is very low, so they feel pain or other bodily sensations for insignificant reasons.
  3. The sensitivity of the brain to these signals depends on many things:
    • Your genes.
    • Your attitude.
    • Your emotions.
    • The "remembered" effect of past illnesses and physical injuries.
    • Past emotional trauma.

    So if you are hyper-sensitive, your new physical symptom probably has a lot to do with some of the above and correspondingly little (or nothing) to do with any new injury or disease.   
  4. If you do not focus your attention on your symptoms and you stop equating them with damage or disease, you will worry less and feel less discomfort.   
  5. Knowing these things will empower you to free yourself from the tyranny of your bodily sensations.
By the way, I know some of these things not only from science and observing my patients, but from personal experience.

Monday, 21 September 2015

Henri and the stone

On my desk there is a flat stone taken from a river in the south of France, a piece of slate with a golden sheen. I took it from the river because I liked its shape, texture and colour, and thought it would make a nice paperweight. Which it does. Henri takes it in his hands and announces, "This stone has a lot of energy". He means he likes it. Henri attributes the agency for his attraction to the stone, to him it has some intrinsic power which draws him. I think the stone is pretty, but it is just a stone. Henri's affirmation suggests he believes feelings are imparted to us (if we are sensitive) by the world around us and can be taken as facts. He obviously believes too that he is sufficiently sensitive. I do not believe this. I believe he just likes the stone. The rest is fantasy, his attraction is purely subjective: a product of Henri's mind in which emotions are confused with reason. The golden sheen in the stone is pyrite, "fool's gold".

Wednesday, 5 August 2015

Thinking outside the box but still stuck with a straight line

I have considerable sympathy for the point of view of Dr. John Sarno, a statement which might be deemed odd coming from an osteopath. Osteopathy was founded on the principle that health and illness depend on the mechanical integrity of the body, a very different proposition to the one that has been proposed by Sarno.

Sarno has written a series of books in which he sets out his theory. Sarno believes that most back pain stems from emotional factors. Not only back pain in fact, but also most common presentations of pain in general, as well as a range of other symptoms and disorders. According to his theory, the brain produces symptoms "to keep one's attention focused on one's body" in order to protect the person from psychological distress. He attributes the potential for such distress mainly to a "reservoir of rage" left over from childhood: "There's a leftover child in all of us that doesn't want to be put under pressure, and indeed it can get very, very angry." This anger can spill out years later in adulthood because "the unconscious has no sense of time". The risk is all the greater if one has suffered a traumatic childhood. Self-demanding personalities (e.g. perfectionist) are particularly susceptible due to the self-imposed pressures they place on one. A third factor is ordinary everyday stress. Sarno has a somewhat outdated name for his "diagnosis" - Tension Myositis Syndrome - and a hypothesis about the mechanism of pain production: tissue oxygen deprivation from altered blood flow to an area.

The postulated pathophysiological mechanism is of some osteopathic interest, because it is exactly this which the latter also postulated as the main pathophysiological initiator of disease processes. Nevertheless, Sarno is at pains to emphasise that the actual physical mechanism involved is not the fundamental part of his theory: the important thing is that, however the pain symptom is physically produced, the primary cause is not physical, but emotional.

I have said I have considerable sympathy for Sarno's view. This is because my clinical observations, my studies, and my reasoning all point to a significant psychological component to a lot of the pain patients present with at my practice. Moreover, Sarno is dead right when he says that while patients' pain is usually attributed to any pathological phenomena found on x-rays and scans, in actual fact such findings are often just coincidental rather than being of any great clinical significance. He is also right when he states that conventional medical treatments perform poorly with most kinds of musculoskeletal pain.

Yet, while thinking outside the orthodox box, Sarno is ensnared by the same important fallacy that also ensnares much of orthodox medicine, and which ensnared early osteopathic thought, too. This is the fallacy that identifies a single kind of cause and draws straight lines between that cause and all ailments:
  • Orthodox medicine looks for "the cause" of all symptoms in identifiable physical pathology.
  • Early osteopathy looks for "the cause" of all symptoms in mechanical disorder of the body.
  • Sarno looks for "the cause" of all symptoms in his reservoir of rage.
All of these viewpoints are wrong because such reductionism is too simplistic: real life is not like that. It is becoming increasingly evident scientifically that the central nervous system is of the most fundamental importance in determining states of health and disease. But it is also evident that its plasticity is not modelled by any one kind of input alone, but by a multitude of inputs. The production of pain, say, in your low back, is the work of the central nervous system, of that their is no doubt. But it is the work of a central nervous system responding to this multitude of inputs. A substrate of repressed rage may be not enough to produce pain. A disc hernia may not be enough. A bad day at work may not be enough. A row with your partner or spouse may not be enough. Smoking may not be enough. Dehydration may not be enough. An awkward movement or an excessive effort may not be enough. Postural strain may not be enough. Poor nutrition may not be enough. A sudden bout of cool damp weather may not be enough. Catching a cold may not be enough. But put several of these together, and it might well be enough to produce pain.

In those circumstances, to take any one of those factors and then to say, "That is the cause of your pain", and further, "That thing must be the cause of all pain" seems to me to be a rather unrealistic and unsophisticated style of thought. The more one attempts to describe complexity in straight lines the more one's understanding becomes boxed in.

  • An Expert Interview With Dr. John Sarno, Part I: Back Pain Is a State of Mind. www.medscape.com 7 June 2004
  • An Expert Interview With Dr. John Sarno, Part II: Pain Management Prophet or Pariah? www.medscape.com 14 June 2004

Monday, 15 June 2015

Keeping faith with the doctor, or not

There are those patients who cross you off for ever for failing to meet their expectations once, after exceeding them many times before; and there are those others who come back to you for help despite your previous efforts failing to achieve their hopes, because they know you tried harder and did more on their behalf than anybody else had done.

I am wondering which behaviour is the most rational. I know which is at the same time the most humbling and the most gratifying to the doctor or therapist.

Saturday, 30 May 2015

The importance of magic

Harry David Thoreau wrote that "the mass of men lead lives of quiet desperation." We misplace value, feel a void, and attempt to fill it with superficially gratifying things. Daily I see people with voids in their lives, people for whom the world seen through the window of every day life has lost its fascination, its promise, its mystery.

One of the ways in which people try to recreate the sense of fascination, promise and mystery is by belief in magic. I am not talking necessarily about witches and magic potions, but more about magical beliefs. What is a magical belief? In the form in which I commonly witness it, it is a belief that good can be achieved without effort by the application of some esoteric principle unknown to science. In short, people want magic because it provides simple explanations, easy solutions and appeals to a spiritual void.

A psychological reliance on pills to cure ailments, whether those pills are chemical or homoeopathic, is one modern magical belief. The trust people invest in pharmaceutical medicines is wholly disproportionate to the general ability of these medicines to achieve their stated aims. And the power people afford to homoeopathic remedies through that trust would be entirely misplaced were it not for the catalyst to healing provided by their own minds.

Classical homoeopathy is today's alchemy. Nobody today would believe anybody who claimed to be able to turn lead into gold. But a lot of people believe in homoeopathy, which is based on similarly suspect premises. In the days of alchemists, more enlightened philosophers understood the effort to achieve the transformation "of lead into gold" as a spiritual metaphor, not a viable material process. I would expect that in five hundred years' time today's classical homoeopathy, in common with other current "magical" practices, will be regarded much as today we regard our ancestors' efforts to physically transform lead into gold.

But to take a pill in faith and hope is easier than making the effort to create a healthy lifestyle, in which health rather than illness can flourish. Diet, activity and exercise, rest and sleep, relationships, making time for relaxation and interests, achieving a healthy mindset: these are the basics. If they are not right it takes time and effort to get them right, and it is not plain sailing. No pill or magic can do it, and no pill or magic will work if these factors are creating an unhealthy environment.

Having read this far, you may be surprised now to learn that I believe I have transformed my own life with the help of alchemy. I adopted a motto of the medieval alchemists: "Work, love, patience". I have found it a powerful message to myself and it has transformed my behaviour and my relationships with people and with the world. But that was not a mechanistic process, and it was not magic. It was brought about by the power of the mind. That is what I mean.

My premise above is that people want magic because the world has lost its fascination, its promise, its mystery. The irony is that the greatest and most wondrous things are occurring all around us and within us. Look at the wonders of nature. Contemplate the power and mystery of the human mind. Why on Earth would we really need any more magic than that!?

Quod est ante pedes nemo spectat: coeli Scrutantur plagas. What is before one's feet no one looks at; they gaze at the regions of heaven.
(Ennius quoted by Cicero)

Tuesday, 26 May 2015

The folk belief in "blocked energy" as a cause of pain

My patients mostly come to me with musculoskeletal symptoms, many of which are not related, or only partially related, to any identifiable disease process. A majority come with spinal pain.

People have often formed their own ideas of what might be causing their pain, and two common notions are:
  1. Something is "out of place".
  2. Something is "blocked".
We could call these "folk" theories. They are formed from an interpretation of the sensation that the person feels, based on the person's beliefs about how the world works. It is the second of these notions, the idea that something is blocked, that interests me today.

I have a culturally diverse patient base, but within it this idea seems to be quite widely and diffusely prevalent. It is the notion of what is blocked that differs. Among my patients the difference lies along the cultural divide between:
  1. Those who are significantly influenced by what are called "New Age" ideas.
  2. Those not significantly influenced by the above.
New Age ideas draw on Eastern traditions, shamanism, and the esoteric knowledge of ancient cultures. With respect to the idea of a blockage causing symptoms, those who are significantly influenced by New Age ideas, tend to think in terms of "energy". Those who are not, think in terms of something concrete and mechanical, a bone for example.

It is the energetic "folk" explanation which I want to examine. In particular, I want to consider how it compares with (i) an influential branch of oriental medicine, that is, Traditional Chinese Medicine (TCM), and (ii) Western scientific concepts.

The folk explanation, so far as I understand it, is that energy flows through the body, and areas of muscle or joint pain indicate places where the energy is not able to flow through; it is "blocked" and so it accumulates.

Two questions arise. Firstly, is this a realistic description? Secondly, is it a fundamental cause of our ailments?

In TCM, according to Royston Low*, the Bi syndrome signifies "a blockage and inteference with the circulation of Qi and blood in the meridians, giving rise to pains, aching and stiffness in the muscles, joints, bones and tendons". It is seen to cover "more than purely rheumatic or arthritic conditions, for the pains of sprains and similar traumatic conditions are also due to a blockage in the flow of qi and Blood, and these also will come into this category". If not of frankly traumatic origin, Bi is said to be caused by the invasion of an external influence, specifically wind, cold or damp. Any of these can be transformed in the body into heat, hence inflammation.

In Western medicine, the most common benign forms of musculoskeletal pain are often explained in terms of:
  • Sprains and strains: where there is some actual lesioning, gross or microscopic, to soft tissues.
  • Inflammation: a consequence of the above, where chemicals are released from damaged tissues to enhance local blood flow and attract white blood cells which scavenge damaged cells.
  • Hypertonus: an excessive state of muscle tone. In simple terms, the muscle is more contracted than it should be at rest.
  • Neural sensitisation: where nerves conveying pain signals become more sensitive. There does not necessarily have to be actual tissue damage for this to happen, it is enough that the nervous system perceives the potential for damage.
Some strains or other injuries may store energy. If there has been an injury whereby there has been some deformation of elastic tissues - e.g. impaction of bone, stretching of soft tissues - some energy may be stored within those tissues as strain energy. That means that if they could be released from what were holding them in deformity, they would spring back to their previous (normal) state. This would only happen if the deformation had been within the threshold of those tissues' elasticity. (Beyond that, there would have been permanent deformity i.e. loss of elasticity). But at the same time, with soft tissues like muscles and ligaments, there would be some constant on-going energy expenditure by the surrounding muscles that were maintaining the state of strain. So we see a multi-faceted alteration of energy transformation, rather than a simple "blockage".
In the case of inflammation resulting from sprains or strains, in energetic terms there is a local accumulation of matter (fluid and blood cells), and an increased local rate of energy transformation and transfer (heat production, heat loss). At the same time there is a breakdown of matter, involving energy expenditure. There is also obstruction to normal fluid flow.

With muscle hypertonus, the muscle tissue becomes locally denser (more mass per unit volume), but on the other hand to keep it that way there is an increased local transformation of energy and its loss to the body as heat. The area of hypertonic muscle does constitute an area of altered mobility, where the transformation of chemical energy to kinetic energy is not well integrated with what is happening in its functionally related parts.

In the above situations, there are various processes going on. It would be simplistic to say, in Western terms, that there is an "energy blockage". Rather, there is a locus of altered energetic transformation.

Neural sensitisation, conversely, is not necessarily confined to the area that is painful. It may concern the length of the nerve supplying that area, or the whole of that region of the body, or the central nervous system (brain and spinal cord). In the affected neural tracts, there is not a "blockage" of information flow but, if anything, the opposite: there is a facilitation of flow of information about pain.

So while the folk explanation of an "energy blockage" concurs partially with TCM theory, in the terms of Western science it is inexact and simplistic. On the other hand, a simple and exact explanation which fits with both TCM and Western science is that pain indicates either a locus or domain of altered function.

The second question was, can this alteration be considered a cause? All parents will know that children learn early on that the "Why?" question can go on endlessly. There is always another cause up-stream or another level of understanding. Locally altered function may be a distal link in the chain of pain causation. But it is part of a wide space-time network of influential factors that have set it up. If we were to accept the explanation of an "energy blockage", the same would be true. So, not a cause, just a local "blip" in a wide context.

In conclusion, the folk use of the word "energy" provides an illusion of understanding, but it is at odds with physical reality. Moreover, I would argue that, as a concept, it affords little practical therapeutic value.

* Low, R., The Acupuncture Treatment of Musculo-skeletal Conditions: A Practical Handbook for the Practitioner. Harper Collins, 1987.