Thursday, January 26, 2017

Confessions of an osteopath

After qualifying as an osteopath, my inexperience and idealism led me to believe that osteopathy was the cure for all ills, everything from back-pain to eczema to bed-wetting.  

I felt reasonably confident with orthopaedic conditions but less so with the other stuff. However, I still accepted into my clinic most of what came my way. A part of me felt that to be an osteopath, I had to treat all the conditions that fall under the osteopathic umbrella, anything else would disqualify me. Also, I had unconsciously imbibed the belief that osteopathy is the solution to most medical problems. It was a belief that I had not checked, but had come to believe.

With time I felt disingenuous and worried that it was affecting my reputation. It was even harder to admit defeat once the treatment had started and instead I would carry on treating indefinitely till it petered out.

I am sure that some osteopaths treat eczema and bed-wetting successfully but my omnipotent, hubristic attitude led me to think I was one of them simply by qualifying from an osteopathic college.

The affect of my osteopathic hubris may have been an initial increase in my patient list but ultimately it reflected badly. 

Nowadays I am more honest with myself and my patients.  I am careful on the phone to discuss the condition.  I ask if others have treated them, and how chronic the problem is. If they have been to see other practitioners without relief I put the question to them why they think another manual therapy may help. I discuss a mutually satisfactory approach that meets realistic expectations. From the start I try to set boundaries.

One could argue that it is experience that has helped me to evaluate what I do as an osteopath in more realistic terms. Perhaps it is not possible for educational institutions to teach these skills. However, to self-question and be critical is something the profession must encourage. Helping students and new graduates realize the limitations of osteopathy doesn’t weaken the profession, it strengthens it and it will ultimately help graduates enhance their professional identity and sense of achievement.

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Thursday, January 19, 2017

The 3 boundaries a practitioner must not break.

Why do I get anxious before I see a new patient? If my patient list includes new patients I get more anxious than other days. I arrive at the clinic early, open up my computer and settle down awaiting the appearance of the first patient. New encounters are loaded with a degree of anxiety and I assume patients experience similar feelings especially when in pain.

Therefore, it is important for the osteopath to keep unnecessary anxiety, such as unexpected events or surprises, to a minimum. Anxiety is reduced however, in a safe, therapeutic environment or put another way, when clear boundaries are set.

"Clear boundaries" is a term often used in the adult-child relationship where they are considered important for the child's development. Boundaries help the child know that the parent won't let behavior get out of hand, making the child feel safe, even if they frustrate and inhibit.

Boundaries in the osteopathic/therapeutic sense can be considered factors which define clearly the consultation as... a consultation.

The 3 most important boundaries are:

1) Space. The space is defined as the room in which the consultation takes place. At the risk of stating the obvious, it's a room, not a corridor, not a field nor a person's home. In the patient's mind (and in the osteopath's mind too), it is a room which is dedicated to the osteopathic treatment. Anything inappropriate that permeates the "therapeutic membrane" increases anxiety. Examples might be people walking into the room without proper warning (receptionists, other practitioners, or students), or telephones ringing etc.

2) Time. It should should be made clear before the consultation the start and finish time of the session and how long the session will last. Changes in scheduling can increase a patient's anxiety. Even when the reason for rescheduling may be benign. Regular schedule changes made by the osteopath may elicit the patient's fantasies (other patient's are more important and take preference). Running late for a session also arouses feelings such as anger or jealousy. Similarly, giving patients more time than agreed. This is also considered breaking a boundary as it may arouse feelings of favoritism. 

Which brings me on to my 3rd boundary.

3) Role. The role of an osteopath has many sides to it. We are medical practitioners but we are given permission to touch. Patients offer emotional information about themselves but we are not strictly speaking "talking-therapists". With some patients we may become friendly but they pay us for our services. It is a constant struggle to stay in role. Sometimes we may find ourselves being pulled out of role. In one of the sessions in the series "What is the patient really telling me?" (The Osteopath, Nov 2006, Page 24), an osteopath told the group that she occasionally shopped for one of her elderly patients. This became increasingly tiring for the osteopath.  The group was able to help the osteopath recognize that her behaviour related to the osteopath's feelings of guilt for not helping her own elderly parents who lived far away. The example reflects the way an osteopath can get pulled out of role.

One of the most fascinating aspects of keeping boundaries is the positive therapeutic affect on the patient.  As a parent, as well as taking care of the child's physical needs, maintaining safe boundaries for the child is 90% of the work. Similarly I believe is true of the osteopathic consultation. As osteopaths we need to attend to the patient's medical needs, but maintaining clear boundaries will affect to what extent the patient will internalize the osteopathic therapy.

Tuesday, January 10, 2017

"I'm not well.... JUST DO SOMETHING"

You have come to this blog expecting good content haven't you?  You want me, as an osteopath/blogger to provide value that will satisfy your desire to learn.

By providing good content I hope that you return to my blog and build up my readership.  If the post does not interest you, you'll read a few lines and go elsewhere. If it is good, you might share it.  What a wonderful feeling of success that would be!!

Similar feelings occur in the patient-practitioner encounter.

If I am successful, this patient will return and possibly recommend a friend. That will do wonders for my confidence. However, what if I fail? What will that do to my reputation?  To my business? These are feelings that may be familiar to you.

A patient-practitioner relationship has a giving-receiving dynamic.  The osteopath gives treatment and the patient receives relief. The osteopath is concerned not to disappoint the patient, to meet their expectations. As a result the osteopath manages the consultation in the way he perceives is the wish of the patient. This is understandable, we behave this way socially too, but problems  occur when the patient, consciously or unconsciously, mobilizes the osteopath to behave outside of the patient's best interests. 

An example of this was a patient who, after expressing dissatisfaction with a previous practitioner said she only wanted me to treat her shoulder and not waste time on the rest of the body. Do I stick my clinical judgment and risk losing the patient or do I do as the patient asks and treat ineffectively?

One of the strongest feelings that can be aroused during the consultation is the need to act, by that I mean, to be active, to do something for the patient, even when doing nothing might be the best. The fear is that by not acting, one makes oneself redundant. 

My guess is that many practitioners experience this, not just osteopaths, all practitioners. Physiotherapists, chiropractors, acupuncturists and doctors.  We feel mobilized by the patient to "JUST DO SOMETHING"... and we do!

Understanding this dynamic which I refer to as "mobilized" can be helpful to us.  Next time you are with a patient ask yourself  "How is this patient making me feel?" and thus "How am I acting?". This may help you to stop acting outside the patient's and perhaps your best interests.

So I have reached the end of my blog. I wonder whether you liked it or not.  Will I be criticized for it? Are these feelings mine alone and not experienced by others? On the other-hand, perhaps I'll be regaled and applauded. Still, at least I've satisfied my urge to act.

PALMM - Program for Advanced Learning of Manual Medicine 

Sunday, December 2, 2012

Inverted supinator reflex & its relevance to the manual therapist explained

Osteopaths like many other manual therapists such as chiropractors and physiotherapists have become known as specialists in back pain. For this reason, conditions such as spondylitis and spondylarthrosis are commonly seen by these practitioners, both of which can lead to compressive cervical myelopathy, compression of the spinal cord in the neck. Needless to say, osteopaths, physiotherapists and chiropractors must be familiar with the neurological tests that help differentially diagnose causes of neck and arm pain. In the upper limb it is less the sensory tests and more the motor tests and reflexes that help the osteopath to identify nerve root compression. The inverted supinator reflex is probably the the most important clinical sign that an osteopath, physiotherapist or chiropractor can illicit to decide whether there is spinal cord and spinal root compression. It is pathognomonic of cervical myelopathy at the level of C5/C6. In this article I will try and help the manual therapist; osteopath, physiotherapist and chiropractor the professions that use spinal manipulation, to understand the physiology of the inverted supinator reflex in order to appreciate its significance when treating patients.

One of the most common types of extra-dural cord compression (compression occurring outside of the dura matar) that an osteopath, physiotherapist or chiropractor is likely to come across is caused by spondylotic change, that is, spondylotic compressive myelopathy. Since the majority of movement in the cervical spine is focused between the levels of C5 and C6 vertebrae it is at this level that arthritic changes most frequently occur. At this level, On x-ray it is common to find a cervical bar due to disc degeneration, spondylosis, a posterior longitudinal ligament which is buckled, thickened and calcified and osteophytosis protruding into and narrowing the spinal canal. However, osteophytic changes narrowing the vertebral canal are unlikely to be limited to the spinal canal alone. It is likely that there will also be narrowing of the intervertebral foramen simultaneously due to thinning of the vertebral disc and thickening of the ligamentum flavum. The result of this is both compression of the spinal cord and compression of the nerve roots.

The osteopath must therefore be aware that any patient suffering with nerve root symptoms attributed to degeneration of the cervical spine, such as pain down the arm into the thumb, must be examined in order to exclude any long-track or spinal cord damage. It is for this reason that patients suffering with suspected cervical spine degeneration and nerve root symptoms in the upper limb must always be asked whether they also have leg symptoms such as heaviness, stiffness, difficulty climbing up stairs, tight band-like feelings (dorsal columns), a sensation of standing on a vibrating floor (dorsal columns), a sensation that water is running down the legs (spinothalamic tract) or pins and needles that don't conform to a nerve root pattern.

In addition to questioning the patient, the clearest indication of both nerve root and spinal cord compression in the cervical spine is displayed by the inverted supinator reflex. By tapping the brachioradialis tendon at the styloid process of the radius a force is sent down the bone, irritating the muscle spindles of all muscles at the front and back of the forearm, sending a message to the spinal cord, resulting in the reflex flexion of the forearm and fingers. The nerve roots responsible for elbow and finger flexion are C6 and C8 respectively. C7 however, responsible for elbow extension, is not activated despite its muscle spindles being irritated. This leads us to conclude that in a polysynaptic reflex, when a multitude of nerve roots are activated the reaction is for dominant nerve roots to react whilst others lie dormant.

Spondylosis, thinning of the disc between two vertebra causes compression of the nerve root between two vertebrae, deactivates its axons and gives other nerve roots, unaffected by compression, the opportunity to express themselves. In the event that there is also cord compression, an upper motor neuron lesion, above the level of the unaffected nerve roots, they will not only express themselves, they will be hyper-reactive. This explains the structural changes in the spine that result in an inverted supinator reflex. Bony changes of the intervertebral foramen between the vertebrae C5/C6 of the spinal column cause narrowing of the intervertebral foramen and compress the nerve root of C6 as it exits the spine causing a hypo-reflexive reaction from the nerve root C6. The bony changes in the form of a cervical bar, situated within the spinal canal at C5/C6 vertebrae, result in an upper motor lesion rendering everything below it hyper-reflexive. Therefore, C7, once dormant, now active, becomes hyper-reflexive as does C8. The result is an inverted supinator reflex, inverted because there is an absence of the C6 brachioradialis reflex and C7 is responsible for the elbow extension. One would also find a hyper-reflexive reaction at all reflexes on the same side of the body, that is, the knee jerk and ankle jerk reflex. One would also find clonus of the knee and ankle on the same side as well as an up-going planter response in-line with an upper motor neurons lesion.

This explains the pathophysiology of the the spinal column and the effect that altered structure can have on the nervous system. It should be clear why this sign is an important indicator for the osteopath, physiotherapist and chiropractor and GP as well as manual therapists using spinal manipulation Early identification of spondylotic compressive myelopathy can result in appropriate medical treatment being administered and avoids permanent neurological damage.

Danny Sher
Registered osteopath
Jerusalem: 14 Kaf Tet b'November Street
Modiin: Dimri Medical Center, 37 Yigal Yadin Street

Sunday, November 18, 2012

Sciatica and pregnancy - an osteopathic perspective

Osteopaths are not strangers to patients suffering with sciatica, however, when the patient suffering is pregnant a new set of conditions arise that may affect the sciatic nerve that need to be considered. The most obvious change affecting a pregnant woman is the increase in the size of the uterus.  As it expands the hip, pelvis and low back all have to adjust their position relative to one another in order to accommodate the increase in weight. This affects all the surrounding soft tissues. Since the sciatic nerve exits the lumber spine, enters the pelvis and continues its journey to the hip joint and into the  leg it is not surprising that osteopaths see pregnant women suffering with sciatica.  

The spinal cord and nerve roots are flexible neurological soft tissues and are normally able to stretch and curve around the bony structures of the spine and pelvis.  However, during the last 3 months of pregnancy as weight increases anteriorly for the pregnant woman, the lumber spine is pulled into extension narrowing the intervertebral foramen of the lumber spine and reducing the aperture through which the nerve roots of the sciatic nerve pass. Anyone who has a degree of stress through the sciatic nerve roots to begin with could start to feel leg pain as the pressure on the sciatic nerve increases. 

The glutei muscles are strong postural muscles that attach from the hips to the pelvis and sacrum. One of their functions is to keep the body upright, therefore as the center of gravity shifts anteriorly during pregnancy their workload increases and thus their tone. The sciatic nerve traverses the glutei muscles making it vulnerable to compression as it passes through the glutei muscles.  Once the hypertonia in the glutei muscles reaches a point where it compresses the sciatic nerve, there is hypoxia in the nerve and the pregnant patient may start to experience sciatic pain in the leg.

It is up to the osteopath to find out where along the path of the sciatic nerve, from the back to the leg, the sciatic nerve it is being compressed.  With some conservative osteopathic techniques the osteopath can take the stress off the spine, pelvis and surrounding muscles. The aim of the osteopath is to integrate the function of the muscles of the pelvis, hips and spine to encourage the body to make the transition smoothly.

The osteopathic treatment should be to allow the spine to shift according to changes in the center of gravity thus spreading out the weight equally and efficiently.  Furthermore the osteopath should aim to help the the hips and pelvis to anteriorly and posteriorly rotate dynamically and according to the changes in weight-bearing.

For more information:

Danny Sher B.Sc (Hons) Ost. Is a registered osteopath in the UK and Israel.
He works in his clinics in Jerusalem and Modiin.

Danny Sher
Registered osteopath
Jerusalem: 14 Kaf Tet b'November Street
Modiin: Dimri Medical Center, 37 Yigal Yadin Street

Thursday, November 8, 2012

Low pack, pelvic and pubic-symphysis pain during pregnancy - an osteopathic perspective

An osteopath treating the pregnant patient suffering with pelvic or low back pain must apply physiology and anatomy to a body in flux. Major weight increases, altered spinal curves and unique hormonal make up put a huge stress on the body over a short time. The inability to cope with these changes is often the cause of sacroiliac strains and pubic symphysis diastasis.

Unlike regular back pain, pregnant women have the extra consideration of an enlarged uterus whose strong uterosacral and round ligaments attach onto the sacrum and pubis putting extra stress through these structures.  Combined with the production of a hormone relaxin in preparation for the birth, the pelvis ironicallly has to increase its weight-bearing capabilities whilst accommodating for softer supportive ligaments. This makes the pelvic girdle a more relaxed, vulnerable piece of architecture during pregnancy.

Orthodox medicine tends to classify mechanical back and pelvic pain during pregnancy into roughly 3-5 categories according to the location of symptoms; low back pain due to either joint or disc dysfunction, sacroilliac dysfunction either unilaterally or bilaterally, pubic symphysis pain or pain in all 3 pelvic joints.

From an osteopathic perspective all these conditions are variations on a theme, that is, they are all the result of poor accommodation to the increased physical demands put on the body during pregnancy. Symptoms are likely to occur at the weakest most vulnerable joint in the kinetic chain. The job of the osteopath is to assess the patient and make a structural osteopathic analysis or "diagnosis" to determine why the body is not adapting well to the changes. Furthermore, the osteopath must decide which structures are central to treatment in order for the  body to adjust adequately and compensate during the transition.

Osteopathy does not encourage a protocol treatment and needless to say the osteopath should routinely check and treat each joint in the body, however, there are central structures that require extra attention. The sacrum, hips and perineum are the closest associated structures to the joints of the pelvis and they are expected to accommodate. Any excess tightness in any of these joints reduces their ability to absorb forces and strains the sacroiliac and pelvic joints.

The sacrum for example needs to nutate and counter-nutate (flex and extend) according to the movement of the spinal vertebrae superior to it. If the sacrum is unable to rock back and forth and twist on its vertical axis the illiolumber and pubic symphysis will be strained.  Similarly, any tightness in the hip adductors, external or internal hip rotators mean the femur and ischium tend to function as one unit. Movement of the leg results in traction and stress of the pubic symphysis.

The muscles must also be considered. Any tightness in psoas, abdominal muscles, lumber erector spinae, diaphragm and quadratus lumborum will result in further spinal and pelvic instability.

The osteopath must have an coordinated treatment approach directed at the hips, sacroiliac joints, spinal curves, lumber and abdominal muscles and uterine ligaments in order to treat the pregnant woman affectingly. If the osteopath manages to integrate these structures into a treatment plan the patient is likely to benefit in the long run from a thorough assessment that addresses the root of the problem.

Danny Sher qualified from the British School of Osteopathy (1996) and practices in Jerusalem and Modiin.