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.

Monday, 21 March 2016

How to download any scientific article for free

A major bug for searchers of knowledge is the conflict of interest inherent in the relationship between the world of science and that of publishing: unhindered flow of information vs. the profit motive. I am not alone in thinking the current dynamic is weighed too heavily on the side of profits for large companies.

With the usual fee for journal access at €30 per article and upwards, without institutional access to a wide range of journals, your efforts as a student, independent researcher or author are severely or even terminally hampered.

So I hail researcher Alexandra Elbakyan from Kazakhstan, who has created a website that bypasses journal paywalls, providing immediate and free access to "nearly every scientific paper ever published". You can read more about it here.

I would just like to clarify a couple of points about how to use the site. It can be used in two different ways:

You can go to the site at http://sci-hub.io/ and enter the title of the article you want to see, its URL or its PMID or DOI identifier, then click "Open".

Or you can go to the URL of your article, then in the browser search bar insert ".sci-hub.io" (without quotation marks, and don't forget the initial full stop) in the URL immediately after the ".com", ".org", "net", (etc.) part and before all the rest of the URL. Then click go or press enter.

In both cases you will be taken to a page in Russian. Don't panic: it is a CAPTCHA challenge. Just type in the box the letters shown above it and click on the button below it. In a few seconds your article will be shown on the screen as a downloadable PDF.

Saturday, 19 March 2016

Should I take an anti-inflammatory?

This is a question patients suffering from pain frequently ask me.

First of all let me say here what I first tell everyone who asks this question. Whilst I can tell you what is my general attitude to anti-inflammatory and pain medication, and I can tell you what I would probably do in general terms if I were in your situation, I cannot give you specific advice about medical drugs: this does not form part of my professional competence or my role.

So, what is my general attitude to anti-inflammatory and pain medication? This derives from four simple facts:
  1.     It is a biological fact that the inflammatory response is a necessary healing mechanism for tissue damage.
  2.     However, it is a human fact that it can be very painful.
  3.     Moreover, uncontrolled chronic (long-term) inflammation can do more harm than good.
  4.     On the other hand, taking anti-inflammatory drugs long-term can produce serious side-effects and can also be absurdly counter-productive (some of them actually increase joint damage in the long-term).
Therefore, my general attitude is to avoid this kind of medication unless either the pain is unbearable, or it is affecting the body negatively in the long-term (e.g. mood, walking, sleeping). In these cases, if it were me I'd take the minimum dose necessary to reduce the pain to a tolerable level.*

Otherwise, why would I want to suppress a healing reaction?

This, in my opinion, is a major reason for recurrent ill-health: the masking of symptoms and the suppression of the body's own medicine chest have meant the original complaint did not heal normally or completely.

Far better to attempt to eliminate the underlying reasons for the inflammation and/or pain. That is what osteopathy is all about.


* There is no guarantee of course that anti-inflammatory or pain medication would have any effect. See here.

Friday, 4 March 2016

The power of procedures

Summary in simple language: If when I am treating a patient, I find and work on "abnormalities" that others do not see and no machine can detect, it does not matter. Those abnormalities fit into a personal scheme of things which I have learned about and learned to deal with over many years. In this context, actions have effective power.

When a doctor writes a prescription for a medical drug, the prescription has power - a certain power to heal - quite apart from the physiological changes brought about by the drug. This is usually regarded as a placebo effect, that is, an effect produced by the mind of the patient, triggered by his or her interaction with the doctor.

But could it be that the power of words and actions derives not only from the workings of the patient's mind? Could directed intelligence and concentrated intent be able to change things by actually acting directly on living matter? In the case of a doctor writing a prescription, any such power must be relatively weak, because there is usually not a great deal of concentration of intention in that act. Other modalities, like acupuncture and osteopathy, being procedure-rich, would have greater potency in this regard.

In osteopathy, each procedure requires focused attention and is carried out with intent. Each individual act of intent fits coherently into an encounter where the overarching intent is to heal. This is a context in which acts might acquire power - the power to act upon physiology in ways directed or influenced by the intent itself. Mind over matter, if you like, and if you think that is mumbo-jumbo, fair play to you. But it is a possibility I am advised by my experience to allow.

Much has been written recently of what are seen as weaknesses in the osteopathic model: the lack of statistical association between structural abnormalities and illness or symptoms, the lack of inter-rater reliability of diagnostic palpation, the non-existence in science of some of our constructs, the variability of method and approach used by different osteopaths. But if the ideas in the previous paragraphs were possible, none of this would matter very much.

These things are problems only if I believe that what I feel and what I work on should be taken as objectively verifiable phenomena; and that the plausibility of my working explanation should be supported by established science. They would cease to become problems if I believed the following:
  • Subjective phenomena are equally important as objective ones.
  • Phenomena specific to my interaction with my patient here and now are equally important as context-independent ones.
  • Focussed intent is a powerful therapeutic agent in its own right.
Well, I am at ease with subjectivity; I am at ease with the idea of patient-therapist as a time-limited, context-specific system; and I am happy to allow the possibility that the power of attention can change the attended-to.

In this regard, to the osteopath, intra-rater reliability - that one can reliably tell the difference between normality and abnormality within one's own frame of reference - is more important than inter-rater reliability. The rhetorical question will arise as to what use it is pick out, even with 100% reliability, "abnormalities" that do not exist (that cannot be detected objectively)! But in my mind it is probably an error of thought to equate "reality" (i.e. what "exists" and what does not) with objectivity.

So perhaps it is enough that what I do is coherent within my model and within my own perceptual and conceptual frame of reference. Each of my actions then could become a catalyst and a conduit for my focussed attention and my intention.

By the way, and importantly, I am by no means saying it is all like this. There is plenty that is easily observable by anybody, which we work on day by day.

Thursday, 11 February 2016

Why didn't the pills my doctor prescribed work?

It is a very reasonable question that was put to me by a patient with mechanical back pain. He could not understand why neither of the two medicines his doctor had prescribed to him (one after the other, not together) had not done for him what they say they do in the packet, that is, what they are sold to do, i.e. reduce pain. The two medicines in question are the usually preferred drug treatments for simple muscle pain and mechanical joint pain because they are considered generally to carry less risk of side effects than some other medicines used for the same purposes. They are called paracetamol and ibuprofen.

So, why didn't they work? Why didn't they do what they say they do in the packet and on the advertisements? Why didn't they do what they are sold to do?

Gentle enquirer, what to you is the meaning of the phrase “it works” is not the same meaning as that used by the drug companies. To you the meaning is, “it will reduce my pain”, and you think that is a reasonable interpretation, because that is what the drug is marketed and prescribed to do. But the drug companies do not think it is reasonable for you to expect a drug actually to do what it is marketed to do. Eh? How's that?

Well, the drug companies consider it reasonable to put a drug on the market (and so, incidentally, do the national and international organisations which govern these things) if it produces the right effect (pain reduction in this case) in a proportion of the people treated with it. And when you think about it, that too is a reasonable position. You would have to be very naïve to expect a drug to work 100% of the time.

But here is the rub. What would you consider to be reasonable, in terms of the proportion of the people taking the drug who benefit from its intended effects, in order for the drug to be said to “work”? I'd go out on a limb here and bet that the percentage you are thinking of is quite a bit higher than the expectations the drugs industry has of their products.

Let me explain further. There are two kinds of numbers that are important:
  1. The probability that the effect of a drug is significantly better than that of a placebo in statistical terms. That does not have to mean that its effects are much better than placebo, just that they are better and that the difference is unlikely to have happened by pure chance. The actual difference in effect may be quite small. (*)
  2. The “number needed to treat” (NNT). This is a technical term which means the number of patients you need to treat with the drug in order for one of them to experience the expected beneficial effect. The number for a 1000 mg dose of paracetamol is 3.8. For 400 mg of Ibuprofen it is 2.5. (**)
What?! (I can feel a eureka moment coming in the person who asked the question.) You mean to say my doctor prescribed paracetamol to me on the basis that 1 out of 4 patients benefit, on the off chance that I might be one of the lucky ones? And then the same with Ibuprofen on the basis that I might be the lucky one out of two and a half? And she didn't tell me about that? And the drugs companies do not tell you that in their advertising? And that's quite OK?!

I'll let you decide.


Notes

* But in fact, a recent study suggests that paracetamol is no better than placebo for low back pain. (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60805-9/abstract).


** NNT for 50% pain relief in 4 to 6 hours in cases of post-operative pain.

Saturday, 19 December 2015

Book Review: The Upside of Stress - by Kelly McGonigal

"Stress is harmful, except when it's not", Kelly McGonigal considers at the end of her book. The Upside of Stress is about what makes the difference, our mindset, especially with regard to stress itself. That McGonigal is a highly knowledgeable expert in her field is obvious. The big idea that makes up McGonigal's "new science of stress" is interesting but tricky. That idea is that a positive view of stress not only protects against its negative effects, but further, is life-enhancing. She cites numerous scientific studies which appear to be consistent with this hypothesis. However, there are three problematic areas: definitions, fluidity of concept, and causality.

"Stress is what arises when something you care about is at stake." Although she calls it a "conception" rather than a "definition", effectively this becomes her working definition of stress, and it is problematic. As a conception or a definition, it is so broad as to be almost meaningless, covering as it does every conceivable situation which solicits some kind of response, from a making a routine effort, through small demands, bigger challenges, adversity, to major threats and mortal danger. If something dear to me were not at stake, I wouldn't get out of bed in the morning. I do not call that a stress, although some people in some circumstances would. In a sense, McGonigal is telling us to mentally shift more of our life from the "threat" side of the continuum to the "challenge" side. That is a commonly used strategy already in stress management.

But the point is, the definition covers most of what most of us do every day: living our lives. In that context, it is relatively uncontroversial to assert that a positive mindset is likely to have positive effects. On the other hand, the popular conception of stress is a distressing feeling of being under pressure. One could assert, and I do, that this idea constitutes a sort of folk definition, and it defines stress as a distressing experience. Lazarus' (1966) explanation of stress is more in line with the this folk definition: "Stress arises when individuals perceive that they cannot adequately cope with the demands being made on them or with threats to their well-being."


While there may be opportunities to be derived from any adversity, clearly if we change our definition to have it include the the whole range of human experiences involved in living, we are dealing with a very different kettle of fish, in which all the upsides are much more easily appreciable. McGonigal has exploited a semantic paradox. But, paradox resolved, I am not sure that there is a great deal there that is new.

There is a problem also with McGonigal's assumptions about how people view the relationship of stress and stressor, which is rather ambiguous and fluid. A stressor is an event or situation which triggers stress. Stress is the process within the person by which a stressor results in certain kinds of physiological, cognitive, emotional and behavioural responses. The range of responses considered "stress responses" is wide, and again, subject to the limits imposed by our definitions. McGonigal herself sometimes appears to use the words stress and stressor interchangeably, which does not help to make her case. Stress is a difficult concept in the abstract. We associate it with the contexts which trigger it or with the feelings triggered by it. The lay public does not generally use the word "stressor": most people use "stress" to mean both the perceived outward source of their stress, and the feelings triggered by that outward source. Now, when we suggest to a person that they begin view stress positively, it is most likely that they will be conceptualising their stress not as stress itself, but as the stressors that trigger it or the feelings it produces. Does it matter? In practice, probably not, but it may weaken McGonigal's claim that this is a new science of stress. Engendering a positive view of challenges is standard in cognitive approaches to stress.

Thirdly, it is basic science that a correlation does not imply causation. Correlations may be legitimately presented along with other kinds of evidence to imply causation, and this McGonigal does. Yet one has the impression that she relies a little too heavily on the former. Further, on occasion she ignores the aforementioned principle of logic, in order to present a correlation as implication of causation with little supporting evidence.

This book claims to present a "new science of stress", and to be fair a lot of the science cited is recent. Yet I'm not convinced that many of the ideas are actually new. For example, we are told that stress responses other than "flight and flight" have been largely ignored by psychologists, and we are introduced to two other, more sophisticated ones: "challenge" and "tend and befriend". But it is a false argument. It is already widely recognised that there are many ways of responding to stress within the human range. Problems occur (i.e. we stress) when we inappropriately rely on our primitive responses.

It is unclear to me exactly how great the effect of stress mindset is. According to McGonigal it is surprisingly large, consistent and long-lasting. Yet in one of their studies Crum and Salovey (2013) - one group of workers whom McGonigal cites extensively - found that compared to traditional "stress influencing variables" (amount of stress, appraisal, coping strategies) stress mindset accounted for only an additional 2 to 3% of the variance in measures of health and life satisfaction, and did not account for any significant additional variance in work performance.

In summary, McGonigal's manoeuvre is to bend our definition of stress into one which we can regard positively, and then suggest that we do so. But most of us cannot regard stress in the abstract, we regard it in terms of the context that triggers it or the feelings it engenders. Viewing these things positively is not a new proposal. The relative size of effect of the stress mindset is unclear, and in one study has been shown to be small.

However, for me there are two important take-homes from McGonigal's book. Firstly, it may be counter-productive for me as a health care practitioner to emphasise to my patients the negative effects of stress. This may provoke anxiety that in turn can feed stress. I know that this is a valuable observation that I have probably underestimated in the past. Secondly, that single, simple mindset interventions can help people avoid the negative effects of stress and indeed, thrive in the face of adversity. I had not previously considered that a single intervention might produce long-lasting effects. Although academically weightier and more substantial than popular self-help guides, The Upside of Stress will be valuable to the stressed lay person as well as to workers at the coalface.


References

McGonigal K.  The Upside of Stress: Why Stress Is Good for You and How to Get Good at It  2015, Avery.

Crum A. J. & Salovey P.  Rethinking Stress: The Role of Mindsets in Determining the Stress Response  J Pers Soc Psychol. 2013 , Apr; 104(4), 716-33.


Lazarus, R.S.  Psychological stress and the coping process.  1966, McGraw-Hill.

Saturday, 7 November 2015

A dose of reality

It was pointed out to me as I was privately despairing at how, by nature, human beings habitually abuse their bodies and then expect magical cures, that actually there has never been so much public interest in health. It is true - you only have to flip through a few magazines and newspapers to realise that. However, it seems to me that it is mostly a superficial and slanted interest. People are interested in the kind of health that is sold in a bottle labelled "natural", rather than the kind you have to make an effort to achieve. But since much ill health is generated by unhealthy habits, changing habits is not easy, and most people cannot find sufficient motivation to make the required effort, then they will have to make do with poor health no matter how many supplements they take.

A man came to see me, a visitor from France, 65 years old, a stressed businessman with high blood pressure and an unspecified heart complaint. He came for an attack of neck pain, an exacerbation of a recurrent problem, treated once every few weeks by his osteopath in France. “He is not only an osteopath”, he told me, “He also massages pressure points on my feet to send energy to my internal organs. I like to eat all the foods I shouldn't eat, so my liver is not so good, but with his work on my feet he puts my liver in order.” Brilliant! Instead of treating your body well, just get a foot massage once in a while so you can eat rubbish with impunity. Do people really believe this hocus pocus? Yes, they do. Including, apparently, one of my colleagues.

A fifty-something year old lady came with complaints of chronic back pain, gastrointestinal disturbances and psychological “tension”. Asked about her medical history, she told me that she had had fibromyalgia. Now, fibromyalgia is not something one usually recovers from so completely as to use the past tense about. So, too clarify, I asked her, “Do you mean you no longer have it?” Then she told me that her “intense work” with a shaman had helped her overcome it. (I'm sure there are more shamans in the few square miles of my catchment area than in the whole of Siberia). I was just marvelling at the power of the unconscious mind when we got to her drug history. She had been taking pregabalin for some time, a drug with a few specific indications, one of which is pain from fibromyalgia. Yet she attributed her improvement to the attentions of a shaman. People are more inclined to believe in magic than chemistry.

I don't know which helped her most (how could I?), but we must accept that an alternative reality to her preferred one is that the drug is masking the symptoms. This same very overweight lady was looking for a mechanical solution to her back pain, something to be adjusted. I suggested a mechanical solution: “You're too heavy”. We'll see if she takes it seriously.

There is something called reality and something called fantasy. Fantasy suggests easy, mysterious or magical solutions. Reality suggests concrete ones which usually require some kind of sustained effort. Reality is a brutal beast. Many people are disinclined to take it by the horns and grapple with it. The best medicine then is a dose of reality.

Mandolin Man

A couple of years ago I took up playing the mandolin and it struck me how much like a person a stringed instrument is!

How so? To tune a string on any stringed instrument you have to adjust the tension of the string little by little until the tone is true. Then you do the next string, and the next string, and so on. When you have done that you find that the tone of the first string is no longer true, because by changing the tensions of the other strings, you have ever so slightly bent the wood on which the strings are set, and in so doing you have changed the tension of the first string, too. In fact, every time you tune one string, you change the shape of the whole instrument and the tone of all the other strings. This phenomenon is accentuated with the mandolin in comparison to some other stringed instruments, like the guitar, because the mandolin is by nature a relatively highly tensioned instrument.* So, what you have to do is to go through the whole procedure - tuning each string - two or three times, to approximate by gradual steps a well-tuned instrument in which each string performs its proper role making good harmony with the others.

Now, this is exactly what happens when one treats a person with osteopathy. I am pained by a common expectation among prospective patients - that one can "click something into place" and everything will be all right. And I am even more pained that often such expectations have been engendered and reinforced by colleagues and chiropractors. People are not made of lego bricks! They are more like mandolins.

If you change a tension anywhere in the body, the rest of the body will change to adapt to it. Just like a mandolin. If one then acts to change those adaptations, the original tension change will be modified - reduced or augmented. Like the mandolin, the body is an integrated thing that has to be dealt with as a whole, so far as possible. And like the mandolin, that process of adjustment and balancing takes place by repeated trials and gradual increments.

Then, inducing any lasting change in the body is not so easy. One lay person I spoke to understood this immediately. "I work a lot with wood", he said, "And I know that if a piece of wood is warped you can't just quickly bend it back into shape and expect it to stay there." That is very true, and bodily tissues (and indeed the bodily system) are like wood in this way - they are resistant to change, but they will adapt slowly, a little at a time, to the physical forces placed upon them. It is a process which takes time. A warped mandolin will not play well and needs careful restoration by a skilled luthier.

I don't "click things into place" on my mandolin and I don't do it on my patients either - the idea is absurd.



* Here is another interesting analogy. As I mentioned above, the mandolin is a high tension instrument compared to say, a guitar or a harp. In just the same way, people come in more or less highly strung variants. There are those who are extremely sensitive to small changes in tension, and others who tolerate gross changes well enough.