(Updates have been added since this post was first published a few months ago. Yes, things are moving on at a pace)
Do you know what’s going on in the world of osteopathy? Have you been doing your duty and keeping “up to date” with current trends and research? If you’re feeling out of the loop, I’m not trying to make you feel bad. I just know that the reality of earning a living, along with actually living, doesn’t often leave us a lot of free time. But if you do emerge from the treatment room, and pop your head up into the big wide world, you will realise that change is afoot in the world of osteopathy, physical therapy and healthcare. New ideas, changes and challenges are swirling in the ether. But not to worry. It’s fairly easy to catch up and sound convincingly like you know what you’re talking about, with these key phrases and concepts.
Persistent pain is in, chronic pain is out.
“Chronic” is now seen to be a confusing term for patients. They might think it means really, really bad, redolent of the singsong playground chant. (e.g. “Oh no, double maths today, chro-nic”). PERSISTENT is the new chronic.
Standing is in, sitting is out.
Yes my twitter feed is groaning under the weight of tweets presenting more and more evidence that SITTING IS THE NEW SMOKING. No, it seems that you can’t sit for longer than 20 minutes without suffering a significant increase in your risk of many, many diseases. It has got so bad that if I find myself seated in one place for half an hour I feel I have to jump up to fend off an impending heart attack. We can’t even sit at desks any more. You need a standing desk, or even better, a desk with a treadmill attached.
Weight training is in, static stretching is out
Yes, years of me telling patients that stretching and flexibility were more important than weight and strength training turns out to have been quite a major error. These days weight training is believed to be good for weight control, joint flexibility, cardiorespiratory fitness, building bone, maintaining muscle mass and living longer. You don’t even need to go to a gym. Get your patients doing reps at home of squats, bridges, even pushups if they’re game enough, and it will do them a power of good. And as for doing those tediously long static stretches before exercise, (you sports teams in the park on Sunday mornings looking like a Western version of T’ai Chi), it’s now thought they are not only a waste of time, but they potentially detract from your performance. Warming up is still ok, and some forms of stretching are still OK, but holding a calf stretch for 60 seconds in the hope it will make you lastingly more limber has been shown to be plain wrong.
Optimal movement is in, good posture is out.
This makes life easier. What’s the best way to sit at a desk? It doesn’t matter that much, but what does matter is that you keep adjusting your position. We’d already said goodbye to deportment lessons. But we’ve gone to the other end of the spectrum now, where all manner of of slumping, slouching and fidgeting are lauded as representing “thoughtless, fearless movement” (Louis Gifford). Or try this: “no good or bad movement, just optimal movement”. But most importantly, exercise is getting a good press. We can and should do tons more than most of us are. And the advice about what sort of exercise? In general, advice is to just find something you CAN do and LIKE to do, as you will then be able to maintain it.
And let’s mention Core Stability
Will everyone stop going on about core stability! I know this is a vain plea as core stability has entered the vernacular. Mums talk about the need to strengthen their core on the school run, meaning, I think, that they don’t like their flabby tummies. But why the fuss? It it really anything new, or is it just a rebranding of good old-fashioned sit-ups? I know the very the words sound comforting. If you have a stable core, nothing in life will knock you; a stable core is a kind of self-righting, space-hopper-like defense mechanism against the vagaries of life, and not only that, your tummy will hold you up so your back doesn’t get strained and sore trying to do it all alone. Maybe it is just an excuse for vanity in a world in which every edition of Men’s Health features a six-pack on the cover? Or even a brilliantly successful marketing strategy for the Pilates industry. Whatever the reason, the most progressive thinkers across the physical therapies are doing their best to debunk it. And the paper they refer to over and over again is our very own Eyal Lederman’s the Myth of Core Stabiity. Read it when you have a few minutes to spare. You’ll be able to argue the case against the core with plenty of conviction.
Revalidation is out, Continuing Fitness to Practise is in.
Yes nothing is a moment in time any more. It’s a dynamic age. Everything is a process, not a snapshot. We are all feedback machines, continuously monitoring ourselves and becoming increasingly aware, and making “Right Touch” interventions on the path to perfection. A revalidation pilot by the GOsC proved tedious and unwieldy, (and that’s not just the word “revalidation”.) Continuing Fitness to Practise sounds more chirpy, neat, and “now”, and you can write it like this – CFtP. Looks pretty cool, hey.
Placebo is not a dirty word, but a lively issue for debate
The placebo effect has recently been embraced as a therapeutic tool, not something to be railed against and denied anymore. It doesn’t mean that what we do doesn’t work. It’s something to be explored, understood and used, as an enhancer of the therapeutic effects of our treatment. It is pretty cutting edge, and enormously interesting.
If you really want to up the ante, start talking about the NOCEBO effect. With any luck, the person you’re talking to won’t even have heard of it, and you’ll feel really clever. It basically means, tell someone something will get worse and it will. I have discovered that patients are perversely more impressed by the nocebo effect than the placebo effect. More than once I’ve heard someone proudly tell me “I saw this therapist, he said you’re not going to thank me tomorrow, you’re going to feel sore after this, and so I was, he was absolutely right”. Wow, that therapist must have been some sort of genius.
UPDATE 2016: In a recent development, the shine has been taken off some of this excitement by David Colquhoun amongst others. He suggests that our whole understanding of placebo is distorted by years of trials which compare treatment to placebo, but don’t compare those to people who have no intervention at all, real OR sham. He thinks the success attributed to placebo is merely “regression to the mean”, or people who improve with time i.e it’s not some magical placebo effect, those people just would have got better anyway. Read his post “Placebo effects are weak”. If he’s right, the placebo effect could be vastly overrated, although if the effect is there, it is more likely to work with pain than most other conditions.
“Evidence-Based” is still there, but “Evidence-Informed” is more appropriate, and “Real Evidence-Based” is your trump card. If you want a curve ball, “Values-based” is the brand new kid on the block.
Yes it’s not easy being an osteopath in an evidence-based age. Spend too much time on social media following skeptics and you’ll start to feel like you’re living in Salem. They have a point though. If as a profession we don’t embrace and accept the times we live in, we are in danger of ending up in a box marked “Nineteenth-century curiosities” along with phrenology and Mesmerism. You won’t be able to easily argue osteopathy’s case with a hard-boiled, anti-alternative scientist, (they’re very brainy but their minds are made up), but for others you can quote Trisha Greenhalgh’s campaign for Real Evidence Based Medicine. She’s a solid name in the field of medical research. What she says, goes. I’m slightly hampered in a verbal debate by the fact that I don’t quite know how to pronounce her surname, but her complaints abut EBM include the fact that the volume of evidence has become unmanageable, that the quality mark of EBM is being used by people with their own agenda, and that EBM doesn’t always work that well in practice. Her campaign wants more of a return to a patient-centred approach, with expert judgement rather than mechanical rule-following, and an emphasis on clinician-patient interaction. She’s a great example of someone who is totally committed to the scientific method, but can see its limitations and unintended consequences.
UPDATE 2016: Recently the GOsC has started talking about values-based practice which sounds a bit more rounded. But what is it? According to the Warwick Medical School website it is a “twin framework” to EBP, and is
a clinical skills-based approach for working with complex and conflicting values in healthcare
Biopsychosocial sounds so much more serious than holistic
Still call yourself a holistic practitioner? That’s OK, but it means different things to different people. And it can imply that you’re just a bit of a flake. Now I’m not saying holism is to be mocked, and I am a believer in a holistic approach beyond the usual lipservice, but if you want to be playing in the Premiership this season, you’ve got to have a biopsychosocial approach. Whatever you do, don’t use this word until you’ve practised it extensively, out of earshot of anyone else except a trusted friend. Say it slowly a few times now, one syllable at a time: Bi-o-psy-cho-so-cial. Bio-psycho-social. Once you can do that without any tripping or stumbling, you can alternate between biopsychosocial and psychosocial.
Still think GOsC is the enemy?
Get with the programme! (possibly the leadership programme, or another of their exciting career-development opportunities). GosC is now our friend,… well, OK, maybe not our friend, but in some ways our protector. We might be a hostage to their bureaucratic processes and regulatory powers, but they are our shield of credibility against a clamour of skeptics who are demanding tighter controls and harder evidence. Go and hear Edzard Ernst give a talk, or read Simon Singh’s book Trick or Treatment. They make many good points and are potentially a big help to our profession, if we use them to motivate ourselves to clarifying what we do and getting more evidence. A bit of their brainpower would be useful to us. They’re a small group but because they’re so clever, and so determined, they have a bit of potency. Even chiropractors are not really such a rival any more – they are actually helping us by taking most of the anti-manipulation and anti-snake oil salesman flak.
Signed consent is out, verbal consent is in
Yes there was a time when a signature on a bit of paper would stand you in good stead. Not any more. Consent is a process, not an event, and someone just saying yes you can do that, isn’t always even enough. You have to be certain they understand what they’re saying. And you better make a note of it.
Physiotherapists are getting pretty cool
Still think physios are all tracksuit-wearing gym bunnies who treat everything with ultrasound? Still think we have nothing to learn from them? Get those blinkers off your eyes: pain science is big, it’s growing, it’s being developed by some bright, bright sparks, and they’re mostly physiotherapists. They’re cottoning on to the therapeutic relationship, to the focus on health and not disease, the importance of talking and changing beliefs. They are familiar with the biopsychosocial concept, can probably even say it, and they’ve got the science, the NHS, and the acceptance by the medical world on their side. They go on manipulation courses and craniosacral therapy courses, they even run some visceral courses. What’s even more of a worry, (but probably very welcome to their patients) they’ve realised that lots of the things they used to do were making people worse. They have even started talking about iatrogenic back pain. Yes, osteopathy might have been ahead of its time, but that time might be now and the physios are on the ball.