Category: Blog

I used to answer this question by saying “we started at different places, but the more that all of us are educated, the closer we tend to get to one another. These days there are probably more differences between practitioners in any of these professions than there are between the professions themselves.” Which is true.

I also used to say “I can’t talk about what they do, but I can tell you what I do”. Which is fair.

I’ve come to realise, though, that each of these professions has made important contributions to the field of manual therapy and, if you are interested enough to read a blog post on the subject, it is worth taking the time to talk about what these are.

None of these disciplines “invented” manual therapy. It has been around for a long, long time. The medicine of most cultures has a form of it. There is a picture of manual therapy on the wall of “the physicians tomb” dating from about 2300BC in Egypt. Hippocrates, the “father of modern medicine” in ancient Greece, described a method for manually treating a back. (One person pulled on the head, a second pulled on the feet, and the third one jumped on the back. Brutal, but probably effective if the jumper new what he or she was doing.) The “Canon of Avicenna” from the Byzantine empire about 1000AD has a number of pictures of manual techniques.

None of these approaches invented “cracking joints”, either. That has been going on for a long, long time, in different parts of the world. There is an unbroken tradition of “bone setting” (as it used to be called) in parts of the world a least as widely spread as Russia, Iran, and Mongolia. AT Still, who “discovered” osteopathy in the late 1800s, was a bonesetter before he started calling himself an osteopath. But each of these disciplines has made important contributions to the field.

Contributions of osteopathy

1) The most important contribution of osteopathy is the way it thinks about health. This sets it apart, I believe, from just about every other approach to medicine, including other manual therapies. I wrote about this in my previous blog post (the short version in in the tagline at the bottom of this post; and in particular, the part about connections throughout the body). Understanding the way that the human body connects with itself in health is, I think, an area where modern medicine has to some extent lost its way, and where osteopathy has a real contribution to make. I’ll write about this more in later posts.

2) Osteopaths have developed a huge range of techniques, from the very subtle and gentle to the quite physical. This makes it useful for all sorts of people. Many of the techniques it has developed have been picked up by other therapists, who find them good enough to use as a modality on their own. Examples of the gentle techniques are osteopathy in the cranial field, which has been picked up by others as “cranio-sacral therapy” and counterstrain (which is becoming increasingly widely used). Examples of more physical techniques are muscle-energy technique, which have been picked up by physiotherapists as “PNF stretches”, (although physiotherapists don’t usually use them in a targeted, precise way to help specific joints to move) and treatment of the lymphatic system, which has been picked up and widely used as “lymphatic drainage massage” (although that is usually used for a narrower range of conditions than osteopaths use it to treat). Again, I will write more about this in later posts.

3) Osteopathy has, in many ways, always been ahead of its time. That’s a big call, but it’s also historically verifiable.

Contributions of chiropractic

While osteopaths have thought about finding the cause of ill health, the genesis of chiropractic, about 10 years after osteopathy (in 1895), was based on the idea that the founder largely knew what the cause of ill health was: the spine and the nervous system. It would be easy to be dismissive of the contribution that chiropractic has made, for this reason. However, chiropractors of various schools have added their own really interesting innovations. At least two areas (and quite possibly more) have, I believe, made a massive contribution, and will probably make bigger ones in the future.

1) Through their emphasise the importance of the nervous system, chiropractors are now leading the way in a hugely exciting field of medicine called (in the US) “functional neurology” (no one is quite sure what to call it in Australia). This approach involves a very indepth understanding of the anatomy of the nervous system, and a range of neurological testing, to work out just what parts of a patient’s central nervous system are struggling. It then uses the “plasticity” of the nervous system to use exercises to improve the functioning of the parts of the brain that are struggling. Chiropractors aren’t the only people doing this work, but they seem to be leading the way.

2) A related but separate area, which has also grown out of chiropractic, is “applied kinesiology“. The scientific basis for this isn’t as clearly understood as the basis for functional neurology, but it is capable of delivering some amazing results. I use two approaches that are derived from it: “Neuro Emotional Technique” (NET) and the “Neurological Integration System” (NIS, or “Neurolink” (which was developed by an osteopath, but largely owes its basis to applied kinesiology).

Chiropractors have come under a lot of criticism over the years. Initially, that largely came from osteopaths, who accused them of using a bastardised form of osteopathy without adequate training. They have, though, done some very cool work, and they deserve the credit for it.

Contributions of Physiotherapy

1) Physiotherapy has always been about exercise, and getting things moving generally. It can trace its origins to the Swedish Gymnastics movement from the early 1800s. This was mostly about trying to generally get the population more physically fit, for military purposes. It included manual therapy, and particularly massage (although European massage is older than this, and “Swedish massage” is actually more of an American concept than a Swedish one). Phystiotherapy was used early in the 1900s with polio victims, the emphasis being simply on getting them moving. By emphasising the activity of the patient within manual therapy, physiotherapy has made a great contribution to the field, and most manual therapists now probably recommend some sort of exercise activity to supplement what happens in the treatment room. (I use all sorts, as appropriate, but two approaches I particularly like are “Dynamic Neuromuscular Stabilisation” (DNS) and “Trauma Release Exercises” (TRE)). I personally believe that the degree of scientific evidence for prescribing specific exercises for specific conditions is much more limited than is often believed (although the evidence for exercise generally is pretty solid); particularly compared to the evidence for osteopathic treatment, and treatments developed by osteopaths. There tends to be an assumption in our society that exercise will always be beneficial, and so the actual science behind it doesn’t always get scrutinised as closely as it probably should. Never-the-less, exercise can be really important, and we have physiotherapists to thank for promoting it.

2) During the late 1800s and early 1900s, physiotherapy was largely adopted by nurses who did some extra training. For this reason it has always been an accepted part of mainstream medicine, whereas osteopathic and chiropractic were started from “outside the tent”, and have a history of being “alternative”. I would argue that, whether by clever design or simply cultural norms, physiotherapists have largely achieved and maintained this position by not trampling on the turf of doctors. So, for example, they have always done work post operatively, but virtually never pre-operatively. They have tended to stay away from anything to do with the abdominal organs, and anything that suggests they could do anything to equip people’s bodies to be better at dealing with pathogens. It is unfortunate that, because this has been their position, and because they are a large and successful profession, others have sometimes believed that the limitations they have placed on themselves have a scientific basis; which they most certainly do not. It is no small achievement, though, for manual therapists to be accepted by mainstream medicine. Hostility from mainstream medicine to manual therapy pre-dates the foundations of osteopathy, and goes back at least to the time of bone setters. The world would definitely be a better place if osteopathy was as well-accepted by mainstream medicine as physiotherapy has managed to be.

After having my interest in manual therapy and massage triggered by a trainee physiotherapist, and being treated for years by a very good chiropractor, I decided to invest five years of my life studying osteopathy. Clearly I personally think that it is the best approach, with the most coherent rationale and the most comprehensive set of techniques. But none of us can afford to be arrogant; there is too much for all of us still to learn. We have learned a lot from one another, and can certainly continue to learn more.

“Let us not be governed today by what we did yesterday, nor tomorrow by what we do today, for day by day we must show progress.” AT Still

To be honest, as a profession, we osteopaths have been pretty poor at explaining what we do. It’s challenging to find a way that:

• really gets it;
• is consistent with what osteopathy has always been about;
• applies to osteopaths generally;
• captures how complex it can be; and
• explains it simply enough for it to actually communicate meaningfully.

One reason it’s challenging is because osteopathy is something of an art form – different practitioners express it differently.

It’s also a way of thinking – or “paradigm” – about human health that is really different from the sort of thinking that dominates medicine.

Moreover, there are other forms of hands-on therapy that have learned some of the techniques developed by osteopaths, without necessarily adopting the same thought processes.

So, I don’t know if I can do better, but here is my take on osteopathy:

1) Osteopathy is a way of THINKING about health, more than a set of techniques

A.T. Still, the ‘discoverer’ (as he put it) of osteopathy said:

“First, Osteopathy is not a system of movements (techniques); second, neither Osteopathy nor its application to the patient is something that can be passed around on a platter. One must delve and dig for it themselves. Third, its application to the patient must be given by reason and not by rule. Osteopathic physicians must be able to give reason for the treatment they give, not so much to the patient, but to themselves. Neither am I operating a school to teach a lot of parrots, or turn out just another doctor. The field is already overcrowded with those who for hundreds of years have treated patients by rule rather than reason.”

This is how osteopaths reason things out.

2) Human bodies are amazingly good at healing themselves. Our self-repair processes are far more sophisticated than any piece of chemistry or technology that we have devised. So, if people aren’t getting better on their own, it’s important to understand the CAUSE.

A.T. Still again:

“When we take up the principles, we get down to Nature. It is ever willing, self-caring, self-feeding and self-protecting.”

“I want it understood that I look upon the treating of effects as being as unwarranted as it would be for the fireman of a city to fight the smoke and pay no attention to the cause that produces it.”

3) Once you start thinking about causes, you realise that everything is CONNECTED.

It is really helpful to think through the ways that different issues and tissues connect, in terms of: anatomical structures and forces; fluid flows; and communication.

Mechanically, how is a neck that is jammed up connected to the fact that the diaphragm (a dome of muscle stretched between the ribs) is really tight, and is pulling down on the connective tissues that go up inside the body and attach to the neck?

In terms of nerves, how might that same jammed up neck be affecting the free-flow of communication through the phrenic nerve, which comes from the neck and supplies the diaphragm?

In terms of fluid flows, how does the fact that the diaphragm doesn’t move very well affect the fact that that it isn’t increasing the pressure in the abdomen when it flattens out; and how is that affecting fluid drainage from the abdomen?

And what does that have to do with the patient’s constantly irritable digestive system? Where is the tension in the smooth muscles of the digestive system? How is that affecting how easily the diaphragm can move? How is that, in turn, affecting the patient’s breathing?

And how is their breathing affecting their neck? And so on.

Osteopathy is, arguably, the only system of health care that thinks this holistically about the whole person, through literally every “system” and tissue of the body (although, of course, there are undoubtedly individual practitioners from other disciplines who think along these lines).

4) We have a wide range of techniques and tools available.

One (but not the only one) of the reasons that people aren’t getting better can be that things are physically tight or CONSTRICTED from moving very freely, at the macroscopic level; and that these restrictions are being held in place by a vicious cycle. This can alter anatomical structures and forces, fluid flows, and communication.

Because we think of things in this way, we start largely (but not exclusively) by thinking about things at a macroscopic level, and allowing these changes to affect the biochemistry, through mechanisms like reducing inflammation, reducing pain and improving fluid flows. There is plenty of scientific evidence that that works.

Osteopaths have, over the years, developed a very wide range of techniques to facilitate ease of movement of, and integration between, all of the tissues of the body: bones, muscles, glands, nerves organs, connective tissues, vessels and more.

The Four C’s

So, I think of osteopathy as being about the three Cs: CAUSES, CONNECTIONS and CONSTRICTIONS. Followed by COMPLEXITY, because we try to unravel what is happening for each person as an individual, rather than just seeing them as the representative of a category.