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.

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 Sarno has a somewhat outdated name for his "diagnosis" - Tension Myositis Syndrome - and a hypothesis about the mechanism of pain production: tissue oxygen deprivation from altered blood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.

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.