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Osteopathic principles in the modern world
International Journal of Osteopathic Medicine (2013) 16, 17e24
www.elsevier.com/ijos
Osteopathic principles in the modern world Andrew Cotton 769 Fulham Road, London SW6 5HA, United Kingdom Received 24 February 2012; revised 8 October 2012; accepted 10 October 2012
KEYWORDS History of osteopathy; Manipulation; Osteopathic; Osteopathy; Osteopathic medicine; Osteopathic philosophy; Osteopathic principles
Abstract The value of osteopathic principles has been called into question in modern clinical practice. It is argued that osteopathic principles define osteopathy, with a refutation of some criticisms of principles based osteopathy. An example of the generic form of principles based practice is described. Without osteopathic principles, a tendency towards loss of identity and distinctive osteopathic practice follows. This is closely associated with modern themes of progress and evidence based practice. Loss of identity breaks the continuity needed for expert craft practice, and a shrinking of the clinical remit of manual osteopathy. It is argued that osteopathic principles represent a means to prevent contraction and drift of remit and methods. Without principles, osteopathy ceases to exist as a distinctive form of healthcare. This loss is questionable if osteopathy has particular utility in the relief of human suffering. ª 2012 Elsevier Ltd. All rights reserved.
Introduction
Implications for clinical practice
As the years pass and the memory of the early days of osteopathy fades, modern osteopathic practitioners from all parts of the globe seem to be united in their differences. For some, osteopathy has become a kind of super physiotherapy, with the focus determinedly on musculoskeletal pain syndromes. For others, osteopathy is indistinguishable from modern medicine, with manual treatment E-mail address: [email protected]. 1746-0689/$ - see front matter ª 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijosm.2012.10.002
Osteopathic practice declines to anonymity and irrelevance as it loses core beliefs. Osteopathic principles represent a tool for preventing the decline of manual osteopathic practice. Osteopathic principles driven practice gives shared identity, community, and depth of practice within a self-delimited field.
18 considered adjunctive and indeed optional.1 It is as if osteopathy is almost entirely a moveable feast, with no clear identity or modus operandi.2 If osteopathy has some utility for humanity, the question may be asked what is an osteopath for? What is it that osteopaths offer that justifies any wider recognition of value? These are not simply abstract questions, for it may be, that as the founder (A. T. Still) claimed, osteopathy has a unique character and is vitally important3 in the relief of human suffering. If this claim is true, it behoves us as osteopaths to question the nature of our practice, to try finding and doing what we do best, what is most needed, that which without us would remain undone. The author argues for a revolution in our thinking, in the sense that we are losing our raisond’e ˆtre, and must return to our principles to find osteopathic “best practice”.
The history and development of osteopathic principles The term “osteopathic principles” is evocative of something steady, something to rely on, to fall back on when needed. But looking back at osteopathic principles leaves the student of osteopathic history uneasy, for something steady is not to be found. On studying Still’s writings, he does not make explicit reference to a single set of principles, rather various principles and rules variably important and applicable. Indeed one gets the impression that his views evolved over the years. For critics of osteopathic principles, this gives justification for saying that since the views of the founder were not fixed, perhaps anything goes. Indeed, one often hears about widely different approaches to the practice of osteopathy being justified by statements to the effect that “if Still were alive today, this approach is what he would be using”. Still probably faced great difficulty trying to teach something as complex as osteopathy. How could he convey a lifetime’s understanding, and subsequent conviction, to others in a simple and understandable form? How could he prevent misinterpretation? Still’s principles Still comes across from his writings as a practical man, a man fascinated with machinery. He was an inventor, and applied himself to the human body and its diseases as an engineer would. He lived at a time when industrialisation and “better machinery” were the zeitgeist of the age, but by contrast modern medicine was in its infancy. Without effective
A. Cotton pharmaceutical agents, Still had the chance to practice his radical treatments with patients who had little alternative. In this sense he lived in a unique time, and it is doubtful whether osteopathy could have been founded at any other point. Still’s promotion of mechanical principles comes across clearly from records of the time. He would go into the classroom at Kirksville and proclaim “the lever, the screw and the wedge!”4 or “no physiology!” Hulett tells of a culture where knowledge of physiology was considered inversely proportional to one’s skill as an “operator”.5 This use of the term “operator” is interesting, suggesting a tacit view that the human “machine” was in need of adjustment by an operator, like any other machinery. Still said “then the engine goes into the hands of the engineer... as osteopathic machinists we go no further than to adjust the abnormal conditions back to the normal, and let nature do the rest”.3 The principles he espoused were practical rather than philosophical in nature, a how-to guide for those trying to practice later. However, Still had by this time lived many years as a mechanic and surgeon, and brought a depth of understanding to his subject that could not be quickly taught. One would have needed to live his life to see as he saw. There were those who tried to follow Still’s teachings faithfully, and others who modified his practice as their understanding changed. This parallels other schools of thought, where there is often a schism into purists and pragmatists, each claiming justification from some part of the founder’s writings, from folk memory or common sense. Osteopathic principles represent a solution for this problem of drift. How to reduce osteopathy down to a core, without which the practice is not as Still conceived it. This reducing to a core can be seen, for example, in his phrase “The rule of the artery must be absolute, universal and unobstructed, or disease will be the result.”6 Semantically analysed, this term has little meaning unless one knows what Still meant by “rule”. This can lead to a sense that since his principles cannot be fully understood, they must be of limited value. One must try to see Still’s principles in the context of his time to understand what he meant. For example, he also said “the rule of artery and veins is universal in all living beings, and the osteopath must know that and abide by its rulings, or he will not succeed as healer”.3 A “rule” here seems akin to a natural law (hence ruling), which is axiomatic or self-evident. Still, as an engineer, was partly concerned with the free and appropriate delivery and removal of
Osteopathic principles in the modern world the body’s constituent fluids for the maintenance of health. The exact design of the fluid had been taken care of by God and nature. This explains Still’s continual entreaties to pay particular attention to the framework, to the minutest degree, as this was the conduit for the free passage of vital fluids. In this context, the rule of the artery could be thought of as; of all nature’s rules regarding supply of various fluids to the tissues of the body, the need for the timely and free passage of arterial blood and all it contains is the most important imperative to consider as an osteopath when treating disease. “Structure governs function” is similarly a guide for a human mechanic. This phrase does not seem hard to interpret for an engineer, being self evident, and does not benefit from retrospective overanalysis. It is, similarly to the rule of the artery, an abbreviated idea that suggests again the axiomatic importance to an osteopath of form and mechanism. If an articulation has congruent surfaces, when off axis it will not articulate and integrate freely. That freedom creates function at many levels, and a local and remote sensory awareness of that function. This does not preclude the inverse, function governing structure; rather it is a practical guide for an osteopath embarking on human analysis and treatment. Things were sufficiently clear for Still to say “this is the way to do it”. Principles delimit a field of interest, as after all the whole point of a principle is to prevent endless re-examination, and instead suggests the use of self evident maxims which form the basis of a tried and tested method. From these beginnings, osteopathic principles have had a history of their own, notable for their increase in number and abstraction as time passes.7 Hence “structure governs function” becomes “structure and function are reciprocally related” or “the rule of the artery reigns supreme” becomes “fluids have an important role in the maintenance of health”. The four Kirksville principles8 often used do not refer to fluids at all (Fig. 1). This sense of drift over time is a very important issue facing osteopathy, for it goes to (1) the body is a unit (2) the body possesses self-regulatory mechanisms (3) structure and function are reciprocally inter- related (4) rational therapy is based on an understanding of body unity, self-regulatory mechanisms, and the interrelationship of structure and function.
Figure 1 A modern interpretation of osteopathic principles.
19 the heart of osteopathic identity, and how an osteopath is best to proceed in the field of human suffering.
The functions of osteopathic principles Osteopathic principles as a fixed point of reference Any “principle” has more functions than the obvious one, as a guide to action. The first to consider here is a principle as a fixed point of reference. As previously noted, osteopathy seemed for Still akin to the maintenance of complex machinery. In Still’s osteopathy the actual practice of that physical maintenance is a manual craft, the physical application of theory. Any craft-based speciality generally involves learning from the teachings of those that came before, and/or pursuing trial and error. In “The decline of the skills society” Sennett9 notes that, no matter what the enterprise, for medium level skills in a physical activity one needs to study and act out that skill for at least 10,000 h. That is 3e4 h a day for 5e7 years. As we know from studies of neural plasticity10 our brain and spinal cord can change to be better at the task we set them, enabling us to sublimate that task and free our mind, as Sennett says, to “engrain the facility in the body” and move to deeper and more subtle understanding and competences. The development of skill cannot be rushed. It requires constant attention, where circumstances change all the time, building a repertoire of skills to apply and adapt. Confidence then builds from successful results, a psychological bulwark in a sea of complexity. It is important to realise that using principles as axioms enables the deliberate narrowing of focus, such that one can then deepen understanding to an unlimited extent within that narrowed field. As Still said, “Our therapeutic house is just large enough for osteopathy and when other methods are brought in just that much osteopathy moves out.”4 Certain conclusions follow from this interpretation. The author has argued that Still’s conception of osteopathy was primarily structural. If it necessarily takes many years to gain mastery in manual osteopathy, the adjustment of that structure which derives from principles, then one needs direction about what and how to practice. Otherwise one experiments, looking for the best approach but perhaps never practicing one thing. Osteopathic
20 principles may be thought of as a way of bypassing interesting, even helpful but “not-osteopathy” diversions, and suggests that although it may not be evident at first, the application of these principles will be worth it in the end. This “appeal to experience” has been criticised by the proponents of evidence-based practice, and I would like to examine this criticism as it undermines the idea that one can rely on the now seemingly archaic principles of a charismatic founder. Osteopathic principles and the modern world The idea that it is obvious that the new should supplant the old is closely associated with great themes of the age, science and capitalism. In a technological society, a rational person “moves on” from the old to the new, and if he/she does not keep up is left behind, old fashioned, out of touch and unrealistic. Along with this move to prioritising the modern and leaving behind old technologies, comes the erosion of associated social and memetic structures. This includes values, associations, strategies and principles. The wisdom of the old becomes largely irrelevant, outdated skills gained in a bygone age for a task long redundant. As Berman quoted, “All that is solid melts into air”.11 These scientific, medical and consumer driven changes have had immense consequences for the practice of osteopathy. In the field of osteopathic education, for example, change has been positively valued as a way of meeting educational norms. This has contributed to a deliberate rejection of the old12 with steady reinvention, modernisation and contextualisation. In the United States, these changes, (rather than using osteopathic principles as a reference point), have led to the modern practice of osteopathy being virtually unrecognisable from the early days. Hands on osteopathic manual therapy (OMT) is optional, if considered at all in patient management.2 Still’s vision of osteopathy as a virtually universally applicable, drugless manual therapy (the body reliably, and necessarily, “producing its own medicines”) is easily dismissed by a modern generation never exposed to the idea that all physiology is form in motion. Freeing form is one of the keys to freeing physiology to act since form and physiology are the same thing. The argument proposed in this essay is that osteopathy is most valuable when deliberately constrained in scope by its principles, which allows for the fullest development of principlesdependent analysis and management. Pharmacological intervention, for example, is not dismissed but is considered not within the remit of osteopathic management. Once expansion into other
A. Cotton therapeutic methods begins, manual skills fail to progress to expert level, and of course the extent of non-osteopathic management is infinite. As Nietzsche puts it, “there shows itself, juxtaposed and often entangled with one another, a magnificent, manifold, jungle-like growing and striving, a sort of tropical tempo in rivalry of development, and an enormous destruction and self-destruction, thanks to egoisms opposed to one another, exploding, battling each other for sun and light, unable to find any limitation, any check, any considerateness within the morality at their disposal.13 As technology has progressed, it is easy for a modern practitioner to believe that their understanding of human function surpasses that of the early osteopaths. This understanding is however only from a medical/technological perspective. The belief system and manual skills for an osteopath to manage and positively value, for example, an acute fever without medication are now virtually non-existent. This cedes care of the ill patient to the medical doctor, and the osteopathic view of the body being able and better off caring for itself, if free to do so, is progressively lost. Medically (i.e. pharmaceutically) based practice may then consider the principles of the early osteopaths irrational or dangerous, but with no evidence for that opinion other than the assumption of progress. Osteopathic principles and science Some modern osteopaths go so far as to say that they try to base their practice on evidence from scientific trials. This approach will inevitably lead to a shrinking of the scope of osteopathic practice to those conditions where there is “good quality evidence” of positive therapeutic outcomes. An example of this might be the standardised treatment by manipulation of non-specific low back pain syndrome. This is a form of modernity, reducing individuated, arcane complexity to simplified “best practice” as defined by scientific evidence. By way of contrast, when reading accounts of the early days of osteopathy, the focus was entirely on osteopathy as a broad reform of medicine, treating manually and expertly all acute and chronic diseases. Still considered osteopathy as scientific, in the sense that it was rational and based on empirical evidence. The validation came from universally applicable self-evident axioms, rather than evidence from the treatment of named conditions. The structure (and hence the physiology) was being adjusted, not the condition per-se.
Osteopathic principles in the modern world Scientific evidence To date it has proved very difficult14 to generate what is now called “good quality”15 scientific evidence from a slowly developed, personally engrained craft based on principles. Osteopaths examine unique and changing individual circumstances, and work using often unique and evolving approaches. Still, indeed, warned against the learning and application of standardised techniques. There are few easily measurable quantities involved, which one needs for the scientific method. Outcomes can be measured, but not the manual evaluation, beliefs and interventions used. From this point of view, for the purposes of any statistical analysis, osteopathy must be altered to be something measurable or classifiable (i.e. other than itself), making it impossible to generalise back from osteopathy-as-measurable/classifiable to the practice of manual osteopathy-actual. As an example of how research is not generalisable, from a study of otitis media treatment using “adjuvant” manual osteopathy; “The pediatrician was blinded to patient group and study outcomes, and the osteopathic physician was blinded to patient clinical course”16 (authors italics). No osteopath could ignore clinical course and be practicing osteopathy, so it is not osteopathy that is being tested, rather a procedure. This will generate false positives and negatives. Because research like this examines situations that are artificial, results from their study cannot be used with any generalisability e exactly the opposite of what is intended. The same criticism is true of any study claiming to offer guidance for future approaches to a given condition. Evidence based practice is logically misconceived. Sennett17 considers the move to evidence based medicine (EBM) as an insidious form of deskilling, for the purposes of bureaucratic/scientific categorisation and measurability. Rather than the bipolar “traditional treatment or evidence-based practice”, a mixed “third way” has been suggested18 as the answer, using best available evidence. It is the suggestion of the author that any evidence based practice is incompatible with manual osteopathy, as evidence from previous approaches has logically no bearing on the structural findings (which are then treated) and principles of treatment in a patient, and may instead bias the examination. Manual osteopathy contends that mastery of practice, in the therapeutic context of osteopathic principles, confers such benefits for health that the codification of practice is vital, indeed it defines osteopathy. Practice evidence is stronger as a guide for action the less it is abstracted, so by inverting the
21 “hierarchy of evidence”,19 osteopaths are capable of generating useful evidence. RCTs, meta-analysis etc. represent the least useful evidence as they are most removed from practice-actual. Further, relying on unrepresentative and weak studies to claim scientific validity is to invite criticism as pseudoscience. Again, this is the opposite of what is intended. Case studies, personal observation, one to one teaching etc. represent the most useful form of evidence for guiding practice as abstraction is minimised. The problem of confirmation bias remains, but is balanced by visual and palpatory evidence which is to some extent objective. Denigrating personal experience can be a form of solipsism, in the sense that the personal experience of others is doubted or feared. It may be that claims of scientific validity represent a defensive posture of rationality, as if practice is either conventionally scientific or dubious. This dichotomy fails to recognise the richness of science, and is unhelpful since it drives regulation, education etc., and allows steady drift away from principles-centred practice. Modernity and the valuing of change is of limited value when the tools to hand, the structure of the body and the human skills to understand and manually treat it, are limited. Principles in this sense represent a realm of interest. A lifetime is all one has to gain mastery. If human health requires good function, and structure governs function, then mastery of the adjustment of the form/function couplet is critical to human health. It follows, then, that if it is critical, somebody has to do it. If it is left undone, people will stay untreated, literally forever ill. Louisa Burns’ now probably unrepeatable groundbreaking research on the effects of spinal injury on local and remote tissue pathology is a compelling reminder of the reality of the relationship between form and illness.20 This all leads to the central dilemma of modern osteopathic practice. Conceived as a broad approach to marshalling the body’s resources, early osteopaths could practice their approach in heroic fashion, not limited by modern constraints of evidence or medico-legal threat. Ideas like the complex osteopathic lesion, vitality, the constitution and healing crisis are alien to most modern practitioners. Osteopathic manual medicine is facing extinction, with little access to teaching of the old methods. How far can the practice be taken? Does the body produce it’s own medicines? Does structure really govern function? And if so, what to do with the thousands of osteopaths that do not believe these ideas to be central to osteopathy? Either it works, but hardly anybody
22 practices it, or it doesn’t work and has no logical basis for it’s continued existence. Principles to osteopathy are rather like DNA is to a cell. If an osteocyte loses its DNA, it still looks the same and for a while nothing looks different. If cartilage DNA is inserted into the osteocyte and the cell produces cartilage proteins, one day the bone bends instead of staying straight under load. At this point it is realised that something is missing, that something was needed to hold up the head, but the bone forming DNA is gone. By analogy, there are osteopathy surface markers on many osteopaths, but no osteopathy is produced. This has led in the United States to osteopathy as a recognisable system of healthcare being virtually unknown to the public, what Gevitz memorably called “osteopathic invisibility syndrome”.14 Osteopathic principles have evolved, as previously noted. In the sense that one needs constancy to achieve depth in an endeavour of known worth, limited extent and an unchanging nature (i.e. the physical dynamics of the body, and the capacity of osteopaths to bring about integrated manual change), this evolution is not necessarily an advantage, as it gives the impression that the thoughts of early osteopaths can be routinely gainsaid in the light of modern discovery, simply because of progress. Modernising the language, semantic deconstruction (what is “supreme” or “governs” anyway?), constant revisitation, and elaboration. These are all relativism; saying that all points of view are potentially equally valid. This is justified as a balanced defence against absolutism, as in, for example, Still being infallible. This is an obvious fallacy, as a rational approach using principles as a basis for practice uses the gaining of craft mastery to vouchsafe safety and effectiveness, and is not absolute but rather a reasoned judgement of relative utility. Change is positively valued in a technological society. However, one could not say that osteopathy seems richer for change, as modern manual osteopathy seems to address a smaller and smaller range of conditions as the indicated therapy. This may be compared to the original Stillian remit of osteopathy being the indicated treatment for virtually all acute and chronic diseases. Anybody wondering whether claims of efficacy like this are credible could investigate the interesting example of the American flu pandemic of 1918e19, where some studies show that traditional manual osteopathic management achieved remarkable reductions in mortality. This has been reviewed by McKone.21 There are still practitioners of illnesstreating osteopathy, and the interested reader
A. Cotton might research the survival of schools of “classical osteopathy” in the UK. It is of course possible to endlessly deconstruct and find inconsistencies in any limited statement, to justify not making the attempt to apply it because of other imperatives. This is however to focus on downside, contradictions and limited value, rather than any upside. Contradictions in limited statements (i.e. principles) are inevitable. Further, one can only ever act without full understanding, because you cannot speed up mastery. You must judge matters prospectively, in action, and retrospectively as the situation plays out. This is the nature of craftsmanship. In the context of this essay, this means applying osteopathic principles and noting the results, rather than diagnosing by category and applying standardised “best practice” treatments. Best practice cannot ever be applied, since the structure being addressed may not require the manual intervention “best practice” determines. As Hayek points out, “In some fields [science] has developed important theories which give us much insight into the general character of some phenomena, but will never produce predictions of particular events or a full explanation, simply because we can never know all of the particular facts which according to these theories we would have to know in order to arrive at such concrete conclusions.”22
Osteopathic principles as an agent for the bonding of osteopaths No human endeavour exists in a technical vacuum, and osteopathy is no different. As has been described, relativising has led to a wilful forgetting of the past. But, like in a family, there may be a relationship cost. Where do I come from? What do I believe in? What should I do? Who are my brothers and sisters? Can I trust them? Are they like me? Studies have shown the importance of stable emotional and social structures for human health. Health of a profession, as a social structure, is dependent to some extent on similar cohesion. If some osteopaths believe osteopathic principles to be redundant, who presently is to say any different? Beliefs have become values, established approaches have become models, and principles become concepts, with anything solid steadily “evaporating”. In many ways this state represents modern osteopathy, with very little worldwide sense of shared identity or trust, shared philosophy or
Osteopathic principles in the modern world
23
method. One is largely free to practice as one wishes, and to claim the right to do so. Nobody is in charge. By contrast, formally shared principles encourages community, helping to foster the perpetration of expert practice toward known, valued ends.
Osteopathic principles as a guide to action So how does one use osteopathic principles in practice? If structure governs function, one’s job is to expertly “adjust” structure to adjust its counterpart, function. This will happen at a strategic and local scale as appropriate. Environmental and psychosocial interactions are “adjunctive”. The principles driven approach requires evidence from personal experience of clinical outcomes, since one cannot ever find “good quality evidence”. This is to suggest a better quality of evidence, not no evidence. In a reflective craft effectiveness, confidence and safety develops with experience, and experience comes from observation and practice. Clinically applying osteopathic principles in the physical realm, leads to the observation of complex interactions between form, exo- and endogenous strains, and responses over time. This leads on to personal ownership of the theoretical and practical basis of osteopathy when treating disease processes. Osteopathic principles are essential for optimum human healing and health.
This was summarised by Barber, an early osteopathy definition from 1898: “Osteopathy is veritably a common-sense method of treating diseased conditions of the body, either structural or functional - without knife or drugs, by means of strictly scientific manipulations. It makes no demands upon the vitality of the patient, but enlists the curative powers contained within the body, which readily respond when properly appealed to. Its method is purely mechanical, and its cardinal principles might be classified as follows: Skeleton Adjustment, Glandular Activity, Free Circulation of Blood, and Coordination of Nerve-Force”.23 These “cardinal principles” lead on to a rational, manual, treatment approach. Full analysis of the principles-based management of illness is beyond the scope of this essay, but is summarised in Fig. 2. Here is a simplified generic example; Early osteopaths describe a tendency for the structure to collapse over time into “lesion”, the focal buckling and condensation of spinal inflection points in a non-uniform stress and strain field over time. Local, reflex and global sympathetic efferents, driven by strain (lesion) induced error signal afferents, downrate vegetative function (liver, guttube peristalsis, secretomotor, elimination etc.)
patient health
Healing and health can be improved by self-generated means, since the body produces its own medicines.
Osteopathic principles were developed to represent a code-drift sheet anchor.
The delivery of those medicines is by mechanical agency, coordination depending on sensory information and mechanical effectors. The means of delivery is disturbed by amount, quality and timing, if structure moves away from the structure governing function.
prevent drift of that code.
because the application of principles is intrinsic to the method, it cannot
The unitary physical body acquires entropic disorder over time, as does any organised structure.
decades of learning and practice in a
This disturbs globally the delivery and coordination of those medicines, delivery being mechanical.
The arts of triage and management of the constitution have been
Osteopathy has been developed as a rational therapy for this reorganisation, because lifetimes of study have led to the processes being recognised, understood and remedial skills developed.
Figure 2
Osteopathic manual reorganisation Healing and repair is optimised, as uprated mechanical performance delivers the chosen function, and resistance is maximised.
Justifying osteopathic principles.
the body has by eliminating delivery bottlenecks or re-establishing them.
24
A. Cotton
leading to systemic effects. Illness and eventually the chronic state follow, as sympathicotonia plays out in tissue and gland exhaustion. As the body is structurally (and hence physiologically) adjusted, the sympathetic drive (humoral and neural) from afferents is downrated, central vegetative suppression goes sub-threshold, so that organs and glands recover. Tissues and systems move to the anabolic state. The structure is stabilised so the system does not simply oscillate and weaken. “Vitality” expresses itself in a now achievable “healing crisis”, the body producing it’s own medicines as and when free to do so. As Hollis stated, “osteopathy is nature’s method of curing disease.”24
Conclusion Osteopathy has made progress in some areas in the last 75 years, with expertise gained in musculoskeletal management, the cranial field, and an accepted place on the healthcare map in many societies. What has been almost lost is a connection to the aspirations and skills of the early generations of osteopathy. Many modern osteopaths subsequently have no conception of osteopathy as the indicated and routine therapy in the treatment of illness. It is quite understandable that many will be sceptical of the seemingly unlikely claims of the old osteopaths. With virtually no living memory of manual osteopathic medicine practice, and a culture of increasingly evidence-based medical disease management, it is easy to be dismissive. But what if it works, indeed it is vital? And if it is not practiced, it is lost? The case can be made for adherence to our principles. It gives us a firm place to stand.
Conflicts of interest I am the sole author of this submission, and I have no affiliations or conflicts of interest.
References 1. Johnson SM, Kurtz ME. Diminished use of osteopathic manipulative treatment and its impact on the uniqueness of the osteopathic profession. Acad Med: J Assoc Am Med College 2001;76:821e8.
2. Gevitz N. Center or periphery? the future of osteopathic principles and practices. J Am Osteopat Assoc 2006;106: 121e9. 3. Still AT. The philosophy and mechanical principles of osteopathy. Kansas City, Mo: Hudson-Kimberly pub. co; 1902. 4. Still AT. Osteopathy, research and practice. Kirksville, Mo: The author; 1910. 5. Hulett GD. A text book of the principles of osteopathy. 5th ed. Los Angeles,: Printed by Fletcher Ford co.; 1922. 6. Still AT. Autobiography of Andrew T. Still, with a history of the discovery and development of the science of osteopathy. New York,: Arno Press; 1972. 7. Rogers FJ, D’Alonzo Jr GE, Glover JC, Korr IM, Osborn GG, Patterson MM, et al. Proposed tenets of osteopathic medicine and principles for patient care. J Am Osteopat Assoc 2002; 102:63e5. 8. Chila AG. American osteopathic association. Foundations of osteopathic medicine. 3rd ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011. 9. Sennett R. The decline of the skills society. Townsend Center for the Humanities; 2009. 10. Doidge N. The brain that changes itself: stories of personal triumph from the frontiers of brain science. New York: Viking; 2007. 11. Berman M. All that is solid melts into air: the experience of modernity. New York: Simon and Schuster; 1982. 12. Ross-Lee B, Kiss LE, Weiser MA. Transforming osteopathic medical education. J Am Osteopat Assoc 1996; 96:473e8. 13. Nietzsche FW, Zimmern H. Beyond good and evil. London & Edinburgh: T. N. Foulis; 1914. 14. Gevitz N. Researched and demonstrated: inquiry and infrastructure at osteopathic institutions. J Am Osteopat Assoc 2001;101:174e9. 15. Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, et al. Grading quality of evidence and strength of recommendations. BMJ 2004;328(7454):1490. 16. Mills MV, Henley CE, Barnes LL, Carreiro JE, Degenhardt BF. The use of osteopathic manipulative treatment as adjuvant therapy in children with recurrent acute otitis media. Arch Pediatr Adolesc Med 2003;157:861e6. 17. Sennett R. The craftsman. New Haven: Yale University Press; 2008. 18. Fryer G. Teaching critical thinking in osteopathy e intecraft knowledge and evidence-informed grating approaches. Int J Osteopat Med 2008;11:56e61. 19. Straus SE. Evidence-based medicine: how to practice and teach EBM. 3rd ed. Edinburgh ; New York: Elsevier/ Churchill Livingstone; 2005. 20. Burns L. Pathogenesis of visceral disease following vertebral lesions. Chicago 1948. 21. McKone WL. Osteopathic medicine: philosophy, principles, and practice. Oxford ; Malden, MA: Blackwell Science; 2001. 22. FAv Hayek. Rules and order: a new statement of the liberal principles of justice and political economy. London: Routledge & K. Paul; 1973. 23. Barber ED. Osteopathy complete. Kansas City, Mo: Press of Hudson-Kimberly publishing co; 1898. 24. Hollis A. The principles of osteopathic technique 1914.
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Osteopathic principles in the modern world Andrew Cotton 769 Fulham Road, London SW6 5HA, United Kingdom Received 24 February 2012; revised 8 October 2012; accepted 10 October 2012
KEYWORDS History of osteopathy; Manipulation; Osteopathic; Osteopathy; Osteopathic medicine; Osteopathic philosophy; Osteopathic principles
Abstract The value of osteopathic principles has been called into question in modern clinical practice. It is argued that osteopathic principles define osteopathy, with a refutation of some criticisms of principles based osteopathy. An example of the generic form of principles based practice is described. Without osteopathic principles, a tendency towards loss of identity and distinctive osteopathic practice follows. This is closely associated with modern themes of progress and evidence based practice. Loss of identity breaks the continuity needed for expert craft practice, and a shrinking of the clinical remit of manual osteopathy. It is argued that osteopathic principles represent a means to prevent contraction and drift of remit and methods. Without principles, osteopathy ceases to exist as a distinctive form of healthcare. This loss is questionable if osteopathy has particular utility in the relief of human suffering. ª 2012 Elsevier Ltd. All rights reserved.
Introduction
Implications for clinical practice
As the years pass and the memory of the early days of osteopathy fades, modern osteopathic practitioners from all parts of the globe seem to be united in their differences. For some, osteopathy has become a kind of super physiotherapy, with the focus determinedly on musculoskeletal pain syndromes. For others, osteopathy is indistinguishable from modern medicine, with manual treatment E-mail address: [email protected]. 1746-0689/$ - see front matter ª 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijosm.2012.10.002
Osteopathic practice declines to anonymity and irrelevance as it loses core beliefs. Osteopathic principles represent a tool for preventing the decline of manual osteopathic practice. Osteopathic principles driven practice gives shared identity, community, and depth of practice within a self-delimited field.
18 considered adjunctive and indeed optional.1 It is as if osteopathy is almost entirely a moveable feast, with no clear identity or modus operandi.2 If osteopathy has some utility for humanity, the question may be asked what is an osteopath for? What is it that osteopaths offer that justifies any wider recognition of value? These are not simply abstract questions, for it may be, that as the founder (A. T. Still) claimed, osteopathy has a unique character and is vitally important3 in the relief of human suffering. If this claim is true, it behoves us as osteopaths to question the nature of our practice, to try finding and doing what we do best, what is most needed, that which without us would remain undone. The author argues for a revolution in our thinking, in the sense that we are losing our raisond’e ˆtre, and must return to our principles to find osteopathic “best practice”.
The history and development of osteopathic principles The term “osteopathic principles” is evocative of something steady, something to rely on, to fall back on when needed. But looking back at osteopathic principles leaves the student of osteopathic history uneasy, for something steady is not to be found. On studying Still’s writings, he does not make explicit reference to a single set of principles, rather various principles and rules variably important and applicable. Indeed one gets the impression that his views evolved over the years. For critics of osteopathic principles, this gives justification for saying that since the views of the founder were not fixed, perhaps anything goes. Indeed, one often hears about widely different approaches to the practice of osteopathy being justified by statements to the effect that “if Still were alive today, this approach is what he would be using”. Still probably faced great difficulty trying to teach something as complex as osteopathy. How could he convey a lifetime’s understanding, and subsequent conviction, to others in a simple and understandable form? How could he prevent misinterpretation? Still’s principles Still comes across from his writings as a practical man, a man fascinated with machinery. He was an inventor, and applied himself to the human body and its diseases as an engineer would. He lived at a time when industrialisation and “better machinery” were the zeitgeist of the age, but by contrast modern medicine was in its infancy. Without effective
A. Cotton pharmaceutical agents, Still had the chance to practice his radical treatments with patients who had little alternative. In this sense he lived in a unique time, and it is doubtful whether osteopathy could have been founded at any other point. Still’s promotion of mechanical principles comes across clearly from records of the time. He would go into the classroom at Kirksville and proclaim “the lever, the screw and the wedge!”4 or “no physiology!” Hulett tells of a culture where knowledge of physiology was considered inversely proportional to one’s skill as an “operator”.5 This use of the term “operator” is interesting, suggesting a tacit view that the human “machine” was in need of adjustment by an operator, like any other machinery. Still said “then the engine goes into the hands of the engineer... as osteopathic machinists we go no further than to adjust the abnormal conditions back to the normal, and let nature do the rest”.3 The principles he espoused were practical rather than philosophical in nature, a how-to guide for those trying to practice later. However, Still had by this time lived many years as a mechanic and surgeon, and brought a depth of understanding to his subject that could not be quickly taught. One would have needed to live his life to see as he saw. There were those who tried to follow Still’s teachings faithfully, and others who modified his practice as their understanding changed. This parallels other schools of thought, where there is often a schism into purists and pragmatists, each claiming justification from some part of the founder’s writings, from folk memory or common sense. Osteopathic principles represent a solution for this problem of drift. How to reduce osteopathy down to a core, without which the practice is not as Still conceived it. This reducing to a core can be seen, for example, in his phrase “The rule of the artery must be absolute, universal and unobstructed, or disease will be the result.”6 Semantically analysed, this term has little meaning unless one knows what Still meant by “rule”. This can lead to a sense that since his principles cannot be fully understood, they must be of limited value. One must try to see Still’s principles in the context of his time to understand what he meant. For example, he also said “the rule of artery and veins is universal in all living beings, and the osteopath must know that and abide by its rulings, or he will not succeed as healer”.3 A “rule” here seems akin to a natural law (hence ruling), which is axiomatic or self-evident. Still, as an engineer, was partly concerned with the free and appropriate delivery and removal of
Osteopathic principles in the modern world the body’s constituent fluids for the maintenance of health. The exact design of the fluid had been taken care of by God and nature. This explains Still’s continual entreaties to pay particular attention to the framework, to the minutest degree, as this was the conduit for the free passage of vital fluids. In this context, the rule of the artery could be thought of as; of all nature’s rules regarding supply of various fluids to the tissues of the body, the need for the timely and free passage of arterial blood and all it contains is the most important imperative to consider as an osteopath when treating disease. “Structure governs function” is similarly a guide for a human mechanic. This phrase does not seem hard to interpret for an engineer, being self evident, and does not benefit from retrospective overanalysis. It is, similarly to the rule of the artery, an abbreviated idea that suggests again the axiomatic importance to an osteopath of form and mechanism. If an articulation has congruent surfaces, when off axis it will not articulate and integrate freely. That freedom creates function at many levels, and a local and remote sensory awareness of that function. This does not preclude the inverse, function governing structure; rather it is a practical guide for an osteopath embarking on human analysis and treatment. Things were sufficiently clear for Still to say “this is the way to do it”. Principles delimit a field of interest, as after all the whole point of a principle is to prevent endless re-examination, and instead suggests the use of self evident maxims which form the basis of a tried and tested method. From these beginnings, osteopathic principles have had a history of their own, notable for their increase in number and abstraction as time passes.7 Hence “structure governs function” becomes “structure and function are reciprocally related” or “the rule of the artery reigns supreme” becomes “fluids have an important role in the maintenance of health”. The four Kirksville principles8 often used do not refer to fluids at all (Fig. 1). This sense of drift over time is a very important issue facing osteopathy, for it goes to (1) the body is a unit (2) the body possesses self-regulatory mechanisms (3) structure and function are reciprocally inter- related (4) rational therapy is based on an understanding of body unity, self-regulatory mechanisms, and the interrelationship of structure and function.
Figure 1 A modern interpretation of osteopathic principles.
19 the heart of osteopathic identity, and how an osteopath is best to proceed in the field of human suffering.
The functions of osteopathic principles Osteopathic principles as a fixed point of reference Any “principle” has more functions than the obvious one, as a guide to action. The first to consider here is a principle as a fixed point of reference. As previously noted, osteopathy seemed for Still akin to the maintenance of complex machinery. In Still’s osteopathy the actual practice of that physical maintenance is a manual craft, the physical application of theory. Any craft-based speciality generally involves learning from the teachings of those that came before, and/or pursuing trial and error. In “The decline of the skills society” Sennett9 notes that, no matter what the enterprise, for medium level skills in a physical activity one needs to study and act out that skill for at least 10,000 h. That is 3e4 h a day for 5e7 years. As we know from studies of neural plasticity10 our brain and spinal cord can change to be better at the task we set them, enabling us to sublimate that task and free our mind, as Sennett says, to “engrain the facility in the body” and move to deeper and more subtle understanding and competences. The development of skill cannot be rushed. It requires constant attention, where circumstances change all the time, building a repertoire of skills to apply and adapt. Confidence then builds from successful results, a psychological bulwark in a sea of complexity. It is important to realise that using principles as axioms enables the deliberate narrowing of focus, such that one can then deepen understanding to an unlimited extent within that narrowed field. As Still said, “Our therapeutic house is just large enough for osteopathy and when other methods are brought in just that much osteopathy moves out.”4 Certain conclusions follow from this interpretation. The author has argued that Still’s conception of osteopathy was primarily structural. If it necessarily takes many years to gain mastery in manual osteopathy, the adjustment of that structure which derives from principles, then one needs direction about what and how to practice. Otherwise one experiments, looking for the best approach but perhaps never practicing one thing. Osteopathic
20 principles may be thought of as a way of bypassing interesting, even helpful but “not-osteopathy” diversions, and suggests that although it may not be evident at first, the application of these principles will be worth it in the end. This “appeal to experience” has been criticised by the proponents of evidence-based practice, and I would like to examine this criticism as it undermines the idea that one can rely on the now seemingly archaic principles of a charismatic founder. Osteopathic principles and the modern world The idea that it is obvious that the new should supplant the old is closely associated with great themes of the age, science and capitalism. In a technological society, a rational person “moves on” from the old to the new, and if he/she does not keep up is left behind, old fashioned, out of touch and unrealistic. Along with this move to prioritising the modern and leaving behind old technologies, comes the erosion of associated social and memetic structures. This includes values, associations, strategies and principles. The wisdom of the old becomes largely irrelevant, outdated skills gained in a bygone age for a task long redundant. As Berman quoted, “All that is solid melts into air”.11 These scientific, medical and consumer driven changes have had immense consequences for the practice of osteopathy. In the field of osteopathic education, for example, change has been positively valued as a way of meeting educational norms. This has contributed to a deliberate rejection of the old12 with steady reinvention, modernisation and contextualisation. In the United States, these changes, (rather than using osteopathic principles as a reference point), have led to the modern practice of osteopathy being virtually unrecognisable from the early days. Hands on osteopathic manual therapy (OMT) is optional, if considered at all in patient management.2 Still’s vision of osteopathy as a virtually universally applicable, drugless manual therapy (the body reliably, and necessarily, “producing its own medicines”) is easily dismissed by a modern generation never exposed to the idea that all physiology is form in motion. Freeing form is one of the keys to freeing physiology to act since form and physiology are the same thing. The argument proposed in this essay is that osteopathy is most valuable when deliberately constrained in scope by its principles, which allows for the fullest development of principlesdependent analysis and management. Pharmacological intervention, for example, is not dismissed but is considered not within the remit of osteopathic management. Once expansion into other
A. Cotton therapeutic methods begins, manual skills fail to progress to expert level, and of course the extent of non-osteopathic management is infinite. As Nietzsche puts it, “there shows itself, juxtaposed and often entangled with one another, a magnificent, manifold, jungle-like growing and striving, a sort of tropical tempo in rivalry of development, and an enormous destruction and self-destruction, thanks to egoisms opposed to one another, exploding, battling each other for sun and light, unable to find any limitation, any check, any considerateness within the morality at their disposal.13 As technology has progressed, it is easy for a modern practitioner to believe that their understanding of human function surpasses that of the early osteopaths. This understanding is however only from a medical/technological perspective. The belief system and manual skills for an osteopath to manage and positively value, for example, an acute fever without medication are now virtually non-existent. This cedes care of the ill patient to the medical doctor, and the osteopathic view of the body being able and better off caring for itself, if free to do so, is progressively lost. Medically (i.e. pharmaceutically) based practice may then consider the principles of the early osteopaths irrational or dangerous, but with no evidence for that opinion other than the assumption of progress. Osteopathic principles and science Some modern osteopaths go so far as to say that they try to base their practice on evidence from scientific trials. This approach will inevitably lead to a shrinking of the scope of osteopathic practice to those conditions where there is “good quality evidence” of positive therapeutic outcomes. An example of this might be the standardised treatment by manipulation of non-specific low back pain syndrome. This is a form of modernity, reducing individuated, arcane complexity to simplified “best practice” as defined by scientific evidence. By way of contrast, when reading accounts of the early days of osteopathy, the focus was entirely on osteopathy as a broad reform of medicine, treating manually and expertly all acute and chronic diseases. Still considered osteopathy as scientific, in the sense that it was rational and based on empirical evidence. The validation came from universally applicable self-evident axioms, rather than evidence from the treatment of named conditions. The structure (and hence the physiology) was being adjusted, not the condition per-se.
Osteopathic principles in the modern world Scientific evidence To date it has proved very difficult14 to generate what is now called “good quality”15 scientific evidence from a slowly developed, personally engrained craft based on principles. Osteopaths examine unique and changing individual circumstances, and work using often unique and evolving approaches. Still, indeed, warned against the learning and application of standardised techniques. There are few easily measurable quantities involved, which one needs for the scientific method. Outcomes can be measured, but not the manual evaluation, beliefs and interventions used. From this point of view, for the purposes of any statistical analysis, osteopathy must be altered to be something measurable or classifiable (i.e. other than itself), making it impossible to generalise back from osteopathy-as-measurable/classifiable to the practice of manual osteopathy-actual. As an example of how research is not generalisable, from a study of otitis media treatment using “adjuvant” manual osteopathy; “The pediatrician was blinded to patient group and study outcomes, and the osteopathic physician was blinded to patient clinical course”16 (authors italics). No osteopath could ignore clinical course and be practicing osteopathy, so it is not osteopathy that is being tested, rather a procedure. This will generate false positives and negatives. Because research like this examines situations that are artificial, results from their study cannot be used with any generalisability e exactly the opposite of what is intended. The same criticism is true of any study claiming to offer guidance for future approaches to a given condition. Evidence based practice is logically misconceived. Sennett17 considers the move to evidence based medicine (EBM) as an insidious form of deskilling, for the purposes of bureaucratic/scientific categorisation and measurability. Rather than the bipolar “traditional treatment or evidence-based practice”, a mixed “third way” has been suggested18 as the answer, using best available evidence. It is the suggestion of the author that any evidence based practice is incompatible with manual osteopathy, as evidence from previous approaches has logically no bearing on the structural findings (which are then treated) and principles of treatment in a patient, and may instead bias the examination. Manual osteopathy contends that mastery of practice, in the therapeutic context of osteopathic principles, confers such benefits for health that the codification of practice is vital, indeed it defines osteopathy. Practice evidence is stronger as a guide for action the less it is abstracted, so by inverting the
21 “hierarchy of evidence”,19 osteopaths are capable of generating useful evidence. RCTs, meta-analysis etc. represent the least useful evidence as they are most removed from practice-actual. Further, relying on unrepresentative and weak studies to claim scientific validity is to invite criticism as pseudoscience. Again, this is the opposite of what is intended. Case studies, personal observation, one to one teaching etc. represent the most useful form of evidence for guiding practice as abstraction is minimised. The problem of confirmation bias remains, but is balanced by visual and palpatory evidence which is to some extent objective. Denigrating personal experience can be a form of solipsism, in the sense that the personal experience of others is doubted or feared. It may be that claims of scientific validity represent a defensive posture of rationality, as if practice is either conventionally scientific or dubious. This dichotomy fails to recognise the richness of science, and is unhelpful since it drives regulation, education etc., and allows steady drift away from principles-centred practice. Modernity and the valuing of change is of limited value when the tools to hand, the structure of the body and the human skills to understand and manually treat it, are limited. Principles in this sense represent a realm of interest. A lifetime is all one has to gain mastery. If human health requires good function, and structure governs function, then mastery of the adjustment of the form/function couplet is critical to human health. It follows, then, that if it is critical, somebody has to do it. If it is left undone, people will stay untreated, literally forever ill. Louisa Burns’ now probably unrepeatable groundbreaking research on the effects of spinal injury on local and remote tissue pathology is a compelling reminder of the reality of the relationship between form and illness.20 This all leads to the central dilemma of modern osteopathic practice. Conceived as a broad approach to marshalling the body’s resources, early osteopaths could practice their approach in heroic fashion, not limited by modern constraints of evidence or medico-legal threat. Ideas like the complex osteopathic lesion, vitality, the constitution and healing crisis are alien to most modern practitioners. Osteopathic manual medicine is facing extinction, with little access to teaching of the old methods. How far can the practice be taken? Does the body produce it’s own medicines? Does structure really govern function? And if so, what to do with the thousands of osteopaths that do not believe these ideas to be central to osteopathy? Either it works, but hardly anybody
22 practices it, or it doesn’t work and has no logical basis for it’s continued existence. Principles to osteopathy are rather like DNA is to a cell. If an osteocyte loses its DNA, it still looks the same and for a while nothing looks different. If cartilage DNA is inserted into the osteocyte and the cell produces cartilage proteins, one day the bone bends instead of staying straight under load. At this point it is realised that something is missing, that something was needed to hold up the head, but the bone forming DNA is gone. By analogy, there are osteopathy surface markers on many osteopaths, but no osteopathy is produced. This has led in the United States to osteopathy as a recognisable system of healthcare being virtually unknown to the public, what Gevitz memorably called “osteopathic invisibility syndrome”.14 Osteopathic principles have evolved, as previously noted. In the sense that one needs constancy to achieve depth in an endeavour of known worth, limited extent and an unchanging nature (i.e. the physical dynamics of the body, and the capacity of osteopaths to bring about integrated manual change), this evolution is not necessarily an advantage, as it gives the impression that the thoughts of early osteopaths can be routinely gainsaid in the light of modern discovery, simply because of progress. Modernising the language, semantic deconstruction (what is “supreme” or “governs” anyway?), constant revisitation, and elaboration. These are all relativism; saying that all points of view are potentially equally valid. This is justified as a balanced defence against absolutism, as in, for example, Still being infallible. This is an obvious fallacy, as a rational approach using principles as a basis for practice uses the gaining of craft mastery to vouchsafe safety and effectiveness, and is not absolute but rather a reasoned judgement of relative utility. Change is positively valued in a technological society. However, one could not say that osteopathy seems richer for change, as modern manual osteopathy seems to address a smaller and smaller range of conditions as the indicated therapy. This may be compared to the original Stillian remit of osteopathy being the indicated treatment for virtually all acute and chronic diseases. Anybody wondering whether claims of efficacy like this are credible could investigate the interesting example of the American flu pandemic of 1918e19, where some studies show that traditional manual osteopathic management achieved remarkable reductions in mortality. This has been reviewed by McKone.21 There are still practitioners of illnesstreating osteopathy, and the interested reader
A. Cotton might research the survival of schools of “classical osteopathy” in the UK. It is of course possible to endlessly deconstruct and find inconsistencies in any limited statement, to justify not making the attempt to apply it because of other imperatives. This is however to focus on downside, contradictions and limited value, rather than any upside. Contradictions in limited statements (i.e. principles) are inevitable. Further, one can only ever act without full understanding, because you cannot speed up mastery. You must judge matters prospectively, in action, and retrospectively as the situation plays out. This is the nature of craftsmanship. In the context of this essay, this means applying osteopathic principles and noting the results, rather than diagnosing by category and applying standardised “best practice” treatments. Best practice cannot ever be applied, since the structure being addressed may not require the manual intervention “best practice” determines. As Hayek points out, “In some fields [science] has developed important theories which give us much insight into the general character of some phenomena, but will never produce predictions of particular events or a full explanation, simply because we can never know all of the particular facts which according to these theories we would have to know in order to arrive at such concrete conclusions.”22
Osteopathic principles as an agent for the bonding of osteopaths No human endeavour exists in a technical vacuum, and osteopathy is no different. As has been described, relativising has led to a wilful forgetting of the past. But, like in a family, there may be a relationship cost. Where do I come from? What do I believe in? What should I do? Who are my brothers and sisters? Can I trust them? Are they like me? Studies have shown the importance of stable emotional and social structures for human health. Health of a profession, as a social structure, is dependent to some extent on similar cohesion. If some osteopaths believe osteopathic principles to be redundant, who presently is to say any different? Beliefs have become values, established approaches have become models, and principles become concepts, with anything solid steadily “evaporating”. In many ways this state represents modern osteopathy, with very little worldwide sense of shared identity or trust, shared philosophy or
Osteopathic principles in the modern world
23
method. One is largely free to practice as one wishes, and to claim the right to do so. Nobody is in charge. By contrast, formally shared principles encourages community, helping to foster the perpetration of expert practice toward known, valued ends.
Osteopathic principles as a guide to action So how does one use osteopathic principles in practice? If structure governs function, one’s job is to expertly “adjust” structure to adjust its counterpart, function. This will happen at a strategic and local scale as appropriate. Environmental and psychosocial interactions are “adjunctive”. The principles driven approach requires evidence from personal experience of clinical outcomes, since one cannot ever find “good quality evidence”. This is to suggest a better quality of evidence, not no evidence. In a reflective craft effectiveness, confidence and safety develops with experience, and experience comes from observation and practice. Clinically applying osteopathic principles in the physical realm, leads to the observation of complex interactions between form, exo- and endogenous strains, and responses over time. This leads on to personal ownership of the theoretical and practical basis of osteopathy when treating disease processes. Osteopathic principles are essential for optimum human healing and health.
This was summarised by Barber, an early osteopathy definition from 1898: “Osteopathy is veritably a common-sense method of treating diseased conditions of the body, either structural or functional - without knife or drugs, by means of strictly scientific manipulations. It makes no demands upon the vitality of the patient, but enlists the curative powers contained within the body, which readily respond when properly appealed to. Its method is purely mechanical, and its cardinal principles might be classified as follows: Skeleton Adjustment, Glandular Activity, Free Circulation of Blood, and Coordination of Nerve-Force”.23 These “cardinal principles” lead on to a rational, manual, treatment approach. Full analysis of the principles-based management of illness is beyond the scope of this essay, but is summarised in Fig. 2. Here is a simplified generic example; Early osteopaths describe a tendency for the structure to collapse over time into “lesion”, the focal buckling and condensation of spinal inflection points in a non-uniform stress and strain field over time. Local, reflex and global sympathetic efferents, driven by strain (lesion) induced error signal afferents, downrate vegetative function (liver, guttube peristalsis, secretomotor, elimination etc.)
patient health
Healing and health can be improved by self-generated means, since the body produces its own medicines.
Osteopathic principles were developed to represent a code-drift sheet anchor.
The delivery of those medicines is by mechanical agency, coordination depending on sensory information and mechanical effectors. The means of delivery is disturbed by amount, quality and timing, if structure moves away from the structure governing function.
prevent drift of that code.
because the application of principles is intrinsic to the method, it cannot
The unitary physical body acquires entropic disorder over time, as does any organised structure.
decades of learning and practice in a
This disturbs globally the delivery and coordination of those medicines, delivery being mechanical.
The arts of triage and management of the constitution have been
Osteopathy has been developed as a rational therapy for this reorganisation, because lifetimes of study have led to the processes being recognised, understood and remedial skills developed.
Figure 2
Osteopathic manual reorganisation Healing and repair is optimised, as uprated mechanical performance delivers the chosen function, and resistance is maximised.
Justifying osteopathic principles.
the body has by eliminating delivery bottlenecks or re-establishing them.
24
A. Cotton
leading to systemic effects. Illness and eventually the chronic state follow, as sympathicotonia plays out in tissue and gland exhaustion. As the body is structurally (and hence physiologically) adjusted, the sympathetic drive (humoral and neural) from afferents is downrated, central vegetative suppression goes sub-threshold, so that organs and glands recover. Tissues and systems move to the anabolic state. The structure is stabilised so the system does not simply oscillate and weaken. “Vitality” expresses itself in a now achievable “healing crisis”, the body producing it’s own medicines as and when free to do so. As Hollis stated, “osteopathy is nature’s method of curing disease.”24
Conclusion Osteopathy has made progress in some areas in the last 75 years, with expertise gained in musculoskeletal management, the cranial field, and an accepted place on the healthcare map in many societies. What has been almost lost is a connection to the aspirations and skills of the early generations of osteopathy. Many modern osteopaths subsequently have no conception of osteopathy as the indicated and routine therapy in the treatment of illness. It is quite understandable that many will be sceptical of the seemingly unlikely claims of the old osteopaths. With virtually no living memory of manual osteopathic medicine practice, and a culture of increasingly evidence-based medical disease management, it is easy to be dismissive. But what if it works, indeed it is vital? And if it is not practiced, it is lost? The case can be made for adherence to our principles. It gives us a firm place to stand.
Conflicts of interest I am the sole author of this submission, and I have no affiliations or conflicts of interest.
References 1. Johnson SM, Kurtz ME. Diminished use of osteopathic manipulative treatment and its impact on the uniqueness of the osteopathic profession. Acad Med: J Assoc Am Med College 2001;76:821e8.
2. Gevitz N. Center or periphery? the future of osteopathic principles and practices. J Am Osteopat Assoc 2006;106: 121e9. 3. Still AT. The philosophy and mechanical principles of osteopathy. Kansas City, Mo: Hudson-Kimberly pub. co; 1902. 4. Still AT. Osteopathy, research and practice. Kirksville, Mo: The author; 1910. 5. Hulett GD. A text book of the principles of osteopathy. 5th ed. Los Angeles,: Printed by Fletcher Ford co.; 1922. 6. Still AT. Autobiography of Andrew T. Still, with a history of the discovery and development of the science of osteopathy. New York,: Arno Press; 1972. 7. Rogers FJ, D’Alonzo Jr GE, Glover JC, Korr IM, Osborn GG, Patterson MM, et al. Proposed tenets of osteopathic medicine and principles for patient care. J Am Osteopat Assoc 2002; 102:63e5. 8. Chila AG. American osteopathic association. Foundations of osteopathic medicine. 3rd ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011. 9. Sennett R. The decline of the skills society. Townsend Center for the Humanities; 2009. 10. Doidge N. The brain that changes itself: stories of personal triumph from the frontiers of brain science. New York: Viking; 2007. 11. Berman M. All that is solid melts into air: the experience of modernity. New York: Simon and Schuster; 1982. 12. Ross-Lee B, Kiss LE, Weiser MA. Transforming osteopathic medical education. J Am Osteopat Assoc 1996; 96:473e8. 13. Nietzsche FW, Zimmern H. Beyond good and evil. London & Edinburgh: T. N. Foulis; 1914. 14. Gevitz N. Researched and demonstrated: inquiry and infrastructure at osteopathic institutions. J Am Osteopat Assoc 2001;101:174e9. 15. Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, et al. Grading quality of evidence and strength of recommendations. BMJ 2004;328(7454):1490. 16. Mills MV, Henley CE, Barnes LL, Carreiro JE, Degenhardt BF. The use of osteopathic manipulative treatment as adjuvant therapy in children with recurrent acute otitis media. Arch Pediatr Adolesc Med 2003;157:861e6. 17. Sennett R. The craftsman. New Haven: Yale University Press; 2008. 18. Fryer G. Teaching critical thinking in osteopathy e intecraft knowledge and evidence-informed grating approaches. Int J Osteopat Med 2008;11:56e61. 19. Straus SE. Evidence-based medicine: how to practice and teach EBM. 3rd ed. Edinburgh ; New York: Elsevier/ Churchill Livingstone; 2005. 20. Burns L. Pathogenesis of visceral disease following vertebral lesions. Chicago 1948. 21. McKone WL. Osteopathic medicine: philosophy, principles, and practice. Oxford ; Malden, MA: Blackwell Science; 2001. 22. FAv Hayek. Rules and order: a new statement of the liberal principles of justice and political economy. London: Routledge & K. Paul; 1973. 23. Barber ED. Osteopathy complete. Kansas City, Mo: Press of Hudson-Kimberly publishing co; 1898. 24. Hollis A. The principles of osteopathic technique 1914.
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