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.

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.

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.
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.

In conclusion, 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 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.

Friday, 8 May 2015

Words, calamitous words

Sometimes people tell me on the phone that they are in "agony" with back pain, and then I see them walk quite happily and sprightly through my door a few hours later.

How often do you hear people (or yourself) describing things as "terrible" or "dreadful" or "an absolute disaster" or "a complete nightmare" or "horrific", when they are nothing of the kind? A war is a disaster. Losing a football match is not. Burning the food is not. Making less profits than last year is not.

Of course, we may use exaggerated negative words for comical effect. There is no harm in that. But sometimes we can get into the habit of using them to draw attention to ourselves and our unhappiness. This is called "catastrophising". 

If we get into this habit, we risk two undesirable side-effects. Firstly, the words will become devalued, people will realise this and pay them less attention. (This is, in effect, what is said to happen if you "cry wolf" too often.) We will have to think of ever-more catastrophic language to produce the same effect. It's a sort of linguistic inflation.

Secondly, every time we use an exaggerated word or expression, we reinforce our own belief about how bad our life is. In short, the catastrophic use of words helps to maintain a negative attitude to the world.

If this is you I am talking about, you need to be aware of the words you use, catch yourself before uttering in a disproportionately negative one, and replace it with something more measured.

And get a sense of proportion. Resetting one's sense of proportion can quickly mitigate stress. The Sunday Times of 1st March 2015 carried an article about an RAF nurse and paramedic called Charlotte Thompson-Edgar. Squadron Leader Thompson-Edgar was awarded a Victoria Cross in recognition not only of her “exceptional performance” in six tours to Afghanistan, but also the “great skill, courage and determination” she showed in saving a badly injured soldier. She had used a pioneering medical technique in an ingenious and unconventional way to save the soldier, who had lost 75% of his blood. Thompson-Edgar said of her experiences in Afghanistan: “You see injuries like that and then you come home and you hear people in Tesco whingeing about this, that and the other. You just want to say, 'Oh my God, have you any idea?'”

Her observation needs no further comment.

Tuesday, 21 April 2015

A clever snake

My son and I were on a hike in the mountains in north-eastern Italy. We were walking along a mountain stream, looking for pools to fish or bathe in. We came to a beautiful pool by a low waterfall. We spotted a grass snake swimming on the surface of the water by the near bank, and at the same moment the snake spotted us. It turned and fled, swimming gracefully across the pool straight towards the far side of the waterfall. It seemed to know where it wanted to go. The bank on the far side of the pool was high, rocky and vertical but the snake was clearly taking a habitual route. It began to slither up the narrow steps in the rock over which water was tumbling. The water washed it back down into the pool. It tried again in the same way and the same thing happened. It tried once more, twice more, but it couldn't get up the waterfall. Lying back in the pool, it raised its head and looked around. Trailing in the water were the branches of a willow. It swam to the nearest one and, winding its body up and around the slender hanging branch, it climbed up, through the tree and over to the top of the bank above the waterfall – the point it had been trying unsuccessfully to reach a moment before! This was no mean feet as the animal was under stress and yet it still managed to think clearly.

I like this story because it is a lesson in problem solving from an unlikely source. A part of effective stress management is the ability to solve problems effectively. Some people lack effective problem-solving strategies and as a result are more prone to stress. The snake in this story wanted to get from where it was in the pool to a point above the waterfall on the far bank, but it found that it couldn't by its first choice of route. What did the snake do to solve its problem? It analysed the situation. It stopped. It looked for and found a potential alternative method. It tried the alternative method. It succeeded! Snakes are not supposed to be possessed of intelligence and they have tiny brains, so much tinier than ours. But if a grass snake can so ably solve problems, we surely can! What the snake did – analysis, search for ideas, trying a new idea – was, in a rudimentary way, the same procedure for problem-solving that can be taught to people as a part of stress management training.

A mysterious bout of tinnitus

Yesterday while reading the newspaper after lunch, one moment there was nothing wrong with me and the next I had tinnitus. It started as a vague sound in my right ear like water running from a tap but by the late afternoon had changed to a constant high pitched metallic ringing quality. I was not aware of it while talking to people or watching the television, but in a quiet room it was very noticeable and not very pleasant. When I woke up this morning it had largely disappeared, which was a relief. I have had patients with tinnitus (not that I have treated them "for" tinnitus), and some of them have suffered with it constantly for years. It is a distressing condition, and people can descend into depression because of it. But why it occurs is often a mystery.

I tried to think what, in my case, had triggered mine so suddenly and unexpectedly. The only unusual or different thing that happened to me yesterday was that, on rising in the morning and stumbling around, I hit my left inner elbow (specifically for the anatomically minded, the medial humeral epicondyle) hard against a wooden door frame. It hurt like hell for a couple of minutes, then subsided into a bruised feeling. Could this be significant? Could it be a reflex effect?

Being unable to find any evidence of such a reflex effect or any nervous pathway to explain it, I looked to traditional Chinese medicine. And I realise immediately that both the medial elbow and the ear are on the path of what is known as the Small Intestine Channel (or Meridian). Point 8 of this meridian is just behind the medial humeral epicondyle, while point 19 (the last point) is just in front of the ear. Moreover, point 8 is sometimes listed as being treated for deafness!

But, assuming my tinnitus could be explained by reference to the course of the Small Intestine Channel, why would it be on the opposite side to the side of my traumatised elbow? And here, I have to invoke neuroanatomical knowledge. The nerves that carry sensation to the brain cross over in the brain stem, so that the nerve impulses from one side of the body end up on the opposite side of the brain. (This is also true of the motor nerves - those which cause muscles to contract). However, this crossing over does not occur with most cranial nerves (nerves connecting the brain to the sense organs, skin, muscles and glands in the head and face), such as the vestibulocochlear nerve. The latter goes to the inner parts of the ear and is concerned with hearing and balance. So it is conceivable that a reflex originating in an arm or leg, for example, could cause effects on the opposite side of the head or face.

It may be that the traditional Channels (Meridians) of Chinese medicine are functional representations of neural pathways which Western neuroanatomists have not yet mapped.

On fundamentalists

I practise both osteopathy and acupuncture and within both of those disciplines there is a vocal fundamentalist minority. When I observe the behaviour of fundamentalists in both disciplines, I see some common characteristics:

First, fundamentalists tend to think in black and white. Either something is right or it's wrong. Either it fits the preconceived model, in which case it must be right, or it doesn't, in which case it must be wrong. This one characteristic of fundamentalist thinking gives rise to some absurd claims.

Second, as far as osteopathy and acupuncture are concerned, old is good and right, new is bad and wrong. This view of course, requires black and white thinking, but it stands out as an idiosyncrasy in its own right. In particular, new is bad and wrong if it conflicts with what is traditional.

Third, these fundamentalist claim special knowledge. The structure and content of this knowledge are quite rigid: stable in time, afforded consensus within a restricted group, and exclusive in terms of what is considered valid. Only people who have served their time within this group can claim to have valid knowledge in their disciplines. They do not question their special knowledge. One has gone on record as saying: "Do not question this. It works."

Fourth, they tend to claim the widest scope for their disciplines and improbable results for themselves. I know of one osteopathic fundamentalist who used to claim a 100% success rate treating all manner of complaints and conditions including chronic systemic illnesses. If you should questions their results, they attribute your this to your own shortcomings, as you do not possess the right special knowledge.

Fifth, they flatly reject scientific validation of their claims. I confess to believing that their are legitimate concerns about the methods usually proposed scientifically to investigate disciplines like osteopathy and acupuncture. Yet the rejection of the fundamentalists makes no attempt to overcome such concerns. This rejection, however, does not stop them cherry picking any scientific evidence which could possibly be interpreted as corroborating the theoretical basis of their treatments. In those cases, of course, they "already knew it", and are inclined to ridicule science for being so slow to catch up.

Sixth, fundamentalists also reject outright any alternative explanations for their claimed effects. Not only are they sure that those effects are real, they are also sure that their sometimes quite detailed mechanistic explanations for them are correct. (Fundamentalist acupuncturists reference the concepts of traditional Chinese theory, fundamentalist osteopaths reference conventional physiological concepts. Note that a reference to conventional concepts is not validation. The number 2 and the number 5 are conventional concepts. But 2 + 2 = 5 is not conventional, or valid arithmetic.) Yet despite lack of solid evidence for their theories, they heap contempt on any suggestion that they may be wrong. To the fundamentalist, the word "placebo" is anathema.

Seventh, they tend to be unreasonable. As such, having reasonable conversation with them is not a possibility. This derives from the extreme and rigid biases implicit in points 1-6 above.

I reject fundamentalist thinking. I am open to old ideas and new, I try to think critically, and I like to have a reasonable conversation.

Anybody who has found this interesting should read, for balance, this related post.

Saturday, 18 April 2015

The reality of the hill

There is a place near the top where the going is tougher than it looked from the bottom. I like to get to the top, and the bottom of things. Now I am not speaking metaphorically, I mean concrete, physical things, in particular hills (top of), valleys and water (bottom of). Although I think there is a metaphorical truth there too. But it has nothing to do with ambition, and everything to do with exploration. Here I want to talk about hills.

There is a place near the top where the going is tougher than it looked from the bottom. That is, in the area where I live. We could almost call it a rule. From the bottom, climbing to the top looked, if not straightforward, at least not very difficult. But then you find, three-quarters of the way up, that it is a little more difficult than it looked. It is steeper, and rougher, and more prone to sliding away underfoot, and there are steep rocky bits that require actual climbing. When you look up, distance seems to have lengthened, so you still have much further to go than you would have imagined when you had looked up at this spot and its relationship to the top from down below. When you look down also, the distance to the bottom has telescoped out, and the ground drops away more steeply than it seemed to on the way up.

There is a place near the top where the going is tougher than it was before and it is here where anxiety first nags, then attacks. Anxiety says to you: Isn't this is getting a little risky? It is steep and rough and unsure, and it is a long way down. Should you be doing this? So you stop and you breathe and you look out over the flat horizon of the sea, which has a steadying influence, and then you take stock. Is this really steeper than it was further down? Is it really rougher? Is the ground really less sure underfoot? Am I really less capable of negotiating this bit of ground than the preceding ones? How much is my anxiety facilitated by the physical discomfort of the hard, sustained uphill climb? How much by my wish that I were nearer the top? How much by my impression of height?

There is a place near the top where the going is tougher than it was before. And having taken stock, you say to yourself the following. Yes, this is objectively steeper, and rougher, and less sure than it was further down. But equally, my physical discomfort, and my impression of height, and my wish that I were nearer to the top, are all skewing and exaggerating my perception of the steepness and roughness and instability of the going. So while it is objectively steeper and rougher and unstable, this is not by a great degree, and I am well capable of negotiating this until the I get to the top.

There is a place near the top where the going is tougher, and you wonder: Is it real that which exists regardless of my presence, or is it real that which I perceive and feel as real? And you answer, one is objective and the other subjective, and both have equal realness. The latter though is only real momentarily, to you personally, at a certain place and a certain time. And while you cannot substantially change the concrete, objective reality of the hill, you can change your real experience of it.

There is a place near the top where the going is tougher than it looked from the bottom. Now I am speaking metaphorically as well as concretely. The hills (and valleys) of life, bring us places on our paths where the going gets steeper and rougher and less sure, but you can change your experience of them, making them less steep, gentler and surer. It is not always easy. Anxiety lurks, and has a persistent nagging habit. But neither is it impossible. With practice, you can do it effectively at will.

Thursday, 5 March 2015

Stress: it's just life

Many of my patients ask me, when they are suffering from a new health symptom, “Why has this happened?” Usually the broad answer is, in part, that it is the impact of stress, in one form or another. One of my answers to this question is, “It's just life”.

Modern life is intrinsically prone to generate stress. For example, the human frame and the human mind were not designed to work 8+ hours a day, day after day, year after year. Anthropological studies of pre-agricultural societies (small groups of extended families living by hunting and gathering in a natural environment) show that activities that can be classed as “work” - hunting, gathering, building, preparing food, making clothes, weapons, tools and implements, and such like – occupy them for four or five hours a day on average. The rest of their time is spent resting, sleeping, talking, singing, dancing, story-telling, partying and having a generally relaxed and good time.

Another major source of stress in modern societies – relationship troubles – is attenuated in small pre-agricultural societies because these societies usually have strict rules of behaviour that govern relationships. Stress counsellors use the adage, “Accept what cannot be changed”, and in small scale societies, the rules of relationships being inviolable, the anxiety of a potential choice against convention was not a factor. There was no choice!

Of course, abundance of choice now affects all areas of modern life, not only in the relationship stakes. It is most obvious in our role as “consumers”. There are so many different things we can “consume”, and so many different varieties of each. There is marketing and peer pressure upon us to “consume” all of them, which generates in us not only the anxiety of the choice, but the potential for fault lines of an economic nature to weigh upon us, too. Simpler societies do not have to live with this.

A fourth major source of stress is change, and more particularly the pace of change, which is accelerating in an almost exponential way, to the point now where many people, particularly those over the age of 50, are finding it difficult to manage. New technology can do more things faster, and humanity, because of some facet of idiocy innate within its psyche, feels obliged to use all of that new capacity for the promise of increased wealth and/or status. So you have to be “connected” “24/7” and “upgrade” promptly for fear of poverty or ridicule and social exclusion. And suffer the consequences of the stress of keeping up with it all.

This is not an advertisement for the caveman way of life: it is no bed of roses, either! Pre-agricultural societies had to cope with difficulties of their own, without our technological advantages – bad weather, wild animals, danger and disease. However, they had millions of years to evolve organic ways to deal with these. We have had only a few decades to adapt to the stresses of modern relationship dynamics, consumerism, and the pace of change, and only a few thousand years to adapt to the hard work of ploughing the fields and scattering.

For these reasons, modern societies are much more vulnerable to stress than pre-agricultural ones. That being the case, we have to learn and hone a much larger and more sophisticated repertoire of protective measures against these forms of stress than they need to.

Pre-agricultural societies had their witch doctors (shamans, medicine men, wise women, etc.), versed in special knowledge including how to ward off misfortune, illness, and the evil eye; and how to engender courage in the hunt or in battle. Today we have doctors, clerics and psychologists, who arguably, despite their merits, might not always deliver us from evil with quite the panache of the witch doctor.

But I think the most effective way in which we can ward off the effects of the modern evil, stress, and to live peaceful, happy and fulfilling lives is to be our own witch doctors. We all need a repertoire of procedures and incantations, different for each one of us and each to his or her own, but always adhering to a few basic principles.