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.

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.


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.

Sunday, 11 October 2015

Live blood analysis and belief bought cheaply

Speaking of belief, a patient I saw recently told me excitedly about a doctor she had seen that morning. This doctor had been invited to the area by the patient's acupuncturist, who had been studying under him and was now taking up his method. She told me this doctor (a "proper doctor" she assured me) had a special microscope with which, by examining a drop of one's blood, he could pick up all sorts of prepathological states which conventional methods could not. What kind of conditions? Toxicity states such as heavy metal load, food and other sensitivities, electromagnetic stress, genetic predispositions, infection by obscure parasites, to mention just a few. My patient had had the test done and had been told that she had 60 odd of the 800 odd diagnosable conditions. She was quite pleased with this result.

I cannot be certain, but it is probable that she was referring to is a method called live blood analysis by dark field microscopy. Most scientists think the above mentioned uses of this method by alternative medicine practitioners ("proper doctors" or not) are nonsense. You can read a critical account of the method here. Just one quote from the linked article should suffice:  

"With live blood analysis, practitioners take the seed of truth that the evaluation of the blood constituents can give valuable information and grow a forest of fantasy and magic. It is something to behold."

What interests me though is the process by which an intelligent perseon invests their belief in something so unquestioningly and acritically. I can think of several contributory factors in the particular case of my patient:
  1. A distrust of conventional medicine which is seen as being toxic and in unholy alliance with the pharmaceutical industry. (To an extent I would have to agree).
  2. Ignorance of and possibly (though I don't know) disdain for science.
  3. A choice of trust in the practitioner who in turn has chosen to invest trust in the doctor concerned. 
  4. An attitude of awe of prestige (a "proper doctor") and fancy sciency looking equipment.
Is this a good basis for belief? I don't think so. It seems to me have been a belief bought very cheaply.

Thursday, 8 October 2015


Some people say I am close minded because I am sceptical about a lot of stuff...

Classical homoeopathy
Vibrational medicine
Crystal healing
Applied kinesiology
Quantum healing
Vega testing
Healing energy
Meridians (energy channels)
Polarity therapy
Soul healing
Much of craniosacral therapy theory
Much of reflexology theory
Evil spirits

These are some of the things that, because I don't believe them, some people think make me close minded.

But I say this: If you went gathering food in the forest, would you gather of every plant you found? Of course not, you would only gather the ones which were most likely to be edible and nourishing. If you did otherwise, at best you would eat some plants with little food value, worse you would get ill, worst you would poison yourself and even die. So you would need some means to discern which plants could be eaten and which were the most valuable sources of nutrients. You would use two different methods. Firstly, you would choose those plant foods which, by the very existence of your people, had proven themselves non-harmful and nourishing through decades and centuries of use. Secondly, in poor years you might decide to experiment with small quantities of unknown plants, but you would be very wary about it. You would avoid very bitter tasting plants and you would trust sweet tasting ones more. These rules of thumb, too, would have proved themselves more or less reliable to your people over time.

The main thing is, you would be discerning in your choices of what to take in. And you need some reliable criteria to go by. The same is true of beliefs. Because while beliefs in things which are not true can at best be effective placebos and harmless diversions, they can also be limiting to your personal fulfilment, they can increase your stress levels, they can make you ill, they can poison your mind, and worse. That is why I say beliefs must be measured against some reasonably reliable criteria.

I have written about the criteria I use elsewhere. Here is a summary:
  • I do not believe something just because somebody tells me it is true.
  • I do not believe something just because it fits in with my lifestyle or sense of identity or because it gives me comfort to do so. 
  • I am inclined to be more open to a proposition the more it seems plausible. I do understand limitations of plausibility. 
  • I am inclined to believe a proposition more readily the greater the supporting evidence from well planned and conducted systematic studies. 
  • Notwithstanding the above, I am well disposed towards the collective experience of many generations of many people, so long as their interpretations are not convincingly refuted.
I am very interested in how people form beliefs. I think a belief afforded to some idea simply because it sounds nice is not a worthy belief. It must earn your belief in some proper way to be any good to you!

So, what do I believe in? I believe in the workings of nature, the marvel that is the human mind, and the prism of science and the power of love. That is, I believe, pretty much all you need.

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. I have written about this here, and will take it up again in my next post.

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.