Is there such thing as a standard protocol for osteopaths?
Unmistakably we are living in a technical dominated society. In the attempt to improve not only the efficiency of a technique but also its application, numerous protocols are developed. Moreover, we can observe that many of these protocols today mainly serve the technique itself and not so much its purpose. The medical term “protocolitis” is here in order. But let there be no doubt about it, in our osteopathic society the patient “osteopathy” is sick in its own bed as well! This raises the question whether it is still possible to find a protocol that does right to the osteopathic philosophy. Studying thoroughly the writings of A.T. Still leads to a conclusion: although not easy, yes it is possible. But only under the condition that we can find the essentials to his philosophy and restore them in their value.
- By Jean-Paul Höppner DO mro
Different times, different meanings – Reading and studying the literature of Andrew Taylor Still is not the easiest task there is, and this for many reasons. For starters there is the difficulty that the language he uses dates from the 19th century. Ever since, not only the style of rhetoric has changed but most importantly it should also be considered that the meaning of the words he chose is not necessarily the same today. All too often the meaning of a word is misunderstood today and consequently the conclusions made from them can and will be incorrect.
Trying to keep it simple – Secondly, Still did not make it any easier as he liked to write in a metaphorical style. His numerous descriptions and examples to illustrate what he wants to pass to future generations are tempting for interpretation. His style made it difficult to access and fully understand his philosophy. Consequently future generations demanded more explanation and this has lead to rather strong simplifications. Simplifications such as for instance the “Kirksville Consensus Declaration of 1953 ”, also known as the “four key principle”. This kind of answers for the ignorant crowds became a warm welcomed guideline in theory and practice for many osteopaths in past present and future – even if there is discussion about what 4 principles originally were meant, and who postulated them, in the end these answers replaced the original version. The simplified versions of Still’s philosophy as well as a matching manual of recipes definitely became best sellers.
Words put into my mouth – Another example of content distortion (a typical symptom of protocolitis) is for instance the use of terms such as “osteopathic lesion” and “dysfunction”. Terms which have become common properties for osteopathic conversations and which have lead to a large variety of practical approaches to treat symptoms in an osteopathic way. These practical concepts were developed to understand osteopathy, but it should be said: these concepts are justified by words that A.T. Still has never used! Today, many if not most of our colleagues swallow and use these words without thinking although Still has asked us more than once to reason. If we would reason, we can only come to the logical conclusion: somehow these simplified conversations do not seem to be quite right, not right at all!
A rhetorical bypass for this inconsistency in reasoning is the use of citations such as for instance “the rule of the artery”. Looking closer into Still’s literature shows that without doubt he spoke these words (Philosophy of Osteopathy, page 153). But, as often in the case of citations, the phrase is incomplete (the rule of the artery and vein are universal) and/or taken out of its context. It is an old strategy in new clothes: take a citation (principle), put it on a banner (concept) and hook it to a stick (technique) … and than wave vigorously with it so everybody will see it. And do not forget: even if it is unimportant for the content, use bright colours because they attract attention.
Essentials in Still’s Philosophy – More than 100 years after Andrew Taylor Still’s death, the interpretation of his philosophy has produced many different concepts. Each and every single one of them is characterized by its own “list-of-things-to-do”. With other words, there exists a whole battery of protocols. Some of them will even tell us when and what we should not do. Applying the latter by planting red flags is often so work intensive and time consuming that in the end our patient looks like a needle cushion and there is no time left for a real osteopathic approach! Looking closer into all of these so-called osteopathic protocols we come to one conclusion: these protocols only serve to present the numerous concepts as warm tempting dishes. These warm tempting dishes however are only watery leftovers that even lack essential ingredients of the original idea! These protocols are warm watery dishes proclaiming to be the modernized version of osteopathy. Welcome to the 21st century!?
Can we please try to get out of the daily rut? Can we please stop for a moment in going along with the contemporary main stream: the assumption that osteopathy has evolved/has to evolve into something modern. Moreover, can we please stop assuming that if we want a modern osteopathy, we need to get rid of the death weight from the past? Does not much of the so-called death weight contain important ingredients to understand and apply Still’s philosophy? Much of the knowledge gathered by A.T. Still contains important pieces of the puzzle to understand what we are doing as osteopaths (and why). Throwing away essential parts of Still’s original philosophy shuts many doors to our possibilities and capabilities – despite what the numerous contemporary protocols want us to believe.
So, can we establish a standard protocol that caters the original roots of osteopathy? Yes it should be possible, presupposed that we respect some of the essentials.
Principles – In “Philosophy of Osteopathy” (preface page 2) A.T. Still clearly states: “It is my objective in this work to teach principles as I understand them, and not rules”. He is clear about the fact that he does not want to instruct the student neither to simply punch nor to simply pull. So he wants exactly the opposite of that what most contemporary protocols make us do! The question therefor is: what principles did he mean? In that very same book he states that osteopathy is only in its infancy but its school is build upon the principle that “the laws that govern life are as old as the hours of all ages” (page 168). As far as we know – since approximately 3,5 billion years, if not older – these laws have not changed and therefor neither that principle. It is even as we speak modern and up-to-date! Being ignorant concerning these laws does not mean that the attempt to bring osteopathy into the 21st century is a legitimate excuse to simply ignore them!! Ignoring them stands for exchanging a by nature proven long-time solid fundament for a short-time quicksand result.
Anatomy – A.T. Still made it very clear that the key to open the door to his philosophy is the knowledge of anatomy. When we look at the human body, an understanding of the laws that govern life will bring us a deeper understanding of his being. “What I mean by anatomy … (philosophy of osteopathy, page 17-18), by putting this paragraph in the context of his philosophy, it becomes clear that the human being has many different forms and being human means having just as much different functions. The laws that govern life however are always the same and apply for all forms & functions! Once more it shows that the principle regarding these laws is not only of all ages but also universal, for all dimensions.
This also applies for the following principle: form is a consequence of its structures and their positional relationships. This is not a citation from Still, but merely a conclusion after thoroughly studying and understanding his writings! So even if these are not his exact words, through and by reasoning it is an essential part for a protocol for osteopaths. A protocol for osteopaths simply cannot lack the presence of profound anatomical knowledge (macroscopically, microscopically, submicroscopically). With other words: no knowledge of anatomy = no protocol.
Normal & Abnormal – A.T. Still wants to teach principles as he has understood them and in order to be able to treat all diseases one requires knowledge of the normal and abnormal as well. A profound knowledge of anatomy in all dimensions seems to be essential in this context! It is essential because it is the reference frame to reason from. Reasoning leads the osteopath to the conclusion whether something is normal or abnormal. And Still is very clear: without knowledge of anatomy you have nothing to reason from (Autobiography, page 162)!
But at what moment can we conclude that we are anatomically dealing with “the abnormal”? Going back to the principle that “form is a consequence of its structures and their positional relationships” we come to the conclusion that we are dealing with “the abnormal” when the form has changed. Going deeper into what is meant by form we can conclude that the abnormal – standing synonym for the changed form – can only mean a change in the positional relationship between the structures of that form. A key role in an osteopathic protocol therefor is the ability to notice a change in positional relationship between structures in a specific dimension – diagnostically as well as therapeutically. It leaves us with the question: how do we do it?
Living pictures – More than once A.T. Still talks about “living pictures” we should have before our mind at all times (for instance: Philosophy of osteopathy, page 13). What he could have meant cannot be explained in two words, neither in two sentences. That these living pictures refer to anatomical knowledge is however clear. But there is more to it and a quick passing through his literature will not be sufficient to understand. Studying thoroughly anatomy in front of his philosophy will shed some light on what he most likely has meant. The living pictures we (should) have are the result of a process of anatomical mind setting, a process of anatomical visualisation. The living picture gives us a clear image of all the anatomical structures that are involved in the changing behaviour of our patient. This picture is like a customized puzzle that is made only by those pieces that indicate a change in positional relationships within our patient’s body. By having this picture before our mind we look at our patient and see the spatial organisation of the involved structures. We are able to see the specific form and function of our patient as a kind of pattern.
In his autobiography (page 148) A.T. Still tells us that every change of the normal is characterized by the presence of a “pattern”. The importance of the term “pattern” once more becomes clear when R.E. Becker quotes Still on the subject of health and disease: “Then Dr. Still says, to make or furnish laws of self without patterns. A healthy state is a state of no pattern. If you’ve got a pattern, you’ve got a strain, a disease, or a problem. If you haven’t got a problem, there’s no pattern. …” (Stillnes of Life, page 3-4). The question now is: what could he have meant by pattern? And, what possible role does the pattern play in a protocol; if any?
Studying anatomy should be more than simply memorizing difficult foreign names. It should be a study of recognizing the spatial organisation of structures. We can do this for bony and muscular structures (a very very very strongly simplified version of this kind of study is the so-called “muscle chain concept”). It can also be done for vascular or nerve structures and in fact, we can do this for any kind of anatomical structure. Macroscopically as well as microscopically. In doing so it becomes interesting to notice that although each of these structures has a different texture (density), they all have one thing in common: the directional characteristic of the structures’ spatial organisation (configuration). This directional characteristic results from the positional relationships that exist between the different involved structures. With other words: within the anatomical form we can recognize a certain pattern by the spatial organisation of its structures. Each pattern is specific and is characterized by its texture (representing the type of structures involved) and its direction (representing the positional relationships). As long as the characteristics of environmental stress comply with the configuration of the form, there will be no strain within that space (the way of ease). However, when this is not the case, whenever one or more positional relationships between anatomical structures become changed (the abnormal), this situation becomes recognizable as a pattern of strain. This pattern of strain is characterized by physical parameters: texture and direction. As osteopathy is a manual approach, these physical parameters should be considered as being essential within each protocol!
Anatomically there are 4 basic textures and 3 basic directions, which brings us to 12 possible patterns. Counting the numerous variations of numbers of involved structures (of same texture!) in such a pattern … the possibilities for one and the same symptom seem to be endless! It looks as we are facing the top of Mount Everest and ask ourselves: how will we get there? A difficult task, certainly when we are only wearing sandals, a T-shirt and Bermuda-short while carrying a walking stick! An increasing cut in the anatomical curriculum has lead to a decreasing amount of anatomical knowledge; the increasing chemical insight of our human being has strangled the physical side of the same story, etc. etc. etc.; we can find more than one explanation or even justification why in the end the philosophy of A.T. Still has been reduced to a soft rolling landscape where we continue our quest for the Holy Grail: the primary dysfunction (also known as “the lesion” or “the osteopathic lesion”). And while we are on our quest, osteopaths are criticizing other field expeditions for poor preparation and even lacking knowledge and experience … o vanitas vanitatum, omnes vanitas.
… It seems that if we do not wish to further contribute to a decaying process, it is time that we face the living dying picture of osteopathy before our mind and draw our conclusions! Here is one of them.
Conclusion – Yes it is it possible to develop and work with a standard protocol for osteopaths. Presupposed that it meets a number of essential conditions. These conditions are the presence of and knowledge about the principles regarding: the meaning of the laws that govern life (physical features), the meaning of form (anatomy) and the meaning of function (positional relationships). The parameters (such as polarity, space-time, change, direction, …) related to these essentials can be defined in a mechanism as a tool for that standard protocol. This protocol can be applied in all dimensions (space) and in all stages (time) of human being. It is a protocol that reflects the true nature of Still’s philosophy. In doing so we will be able to work just as A.T. Still has asked us to do:
“keep it pure boys, keep it pure”.