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The Hands-On Approach of Osteopathy and the Performing Arts Physician

Dr Damon Murgatroyd MB ChB FLCOM, Osteopath, Dip MS Med

This article is intended to enhance the clinician’s understanding of what an osteopath does and the ways that he or she approaches a treatment situation. I myself am a medical doctor who trained at the London College of Osteopathic Medicine (LCOM). Even after thirty years I find it to be hugely exciting to be able to read my patient’s problems in great detail with just my hands. The palpatory skills used flow seamlessly into a physical treatment that is informed by the evidence gained earlier on. Outcomes can at times be both rapid and profound.

What can an osteopath physician offer to Performing Artists? I note that quite a number of highly skilled specialist osteopaths do work in the field of Performing Arts (PA). The BAPAM member’s register contains descriptions of the work undertaken by professionals of different backgrounds. As an osteopath I am intrigued to note that there may be subtle variations in implied approach and ‘intent’. This does not suggest superiority of any profession, but rather helps us to understand the osteopathic mindset.

Doctors list such activities as: work-related problems, overuse, dystonias, hearing and sensory issues, sexual health, and injections. Physiotherapists offer services of (e.g.): injury assessment and rehabilitation, pain management, strains, dance screening, post op rehab, exercise programs. Key descriptors from the osteopaths are: Vocal tensions, Spine and joint injury, Hypermobility, Laryngeal manipulation, Breathing techniques, Functional medical approach, Intrinsic causes, Physical environmental, Psychological and nutritional, Performance optimizing strategies, Jaw issues, Breathing problems, Understanding the needs of the performing artist.

Musculoskeletal medicine can focus greatly on the machine-type nature of the body. Osteopathy is holistically much broader and relies less on protocols. It requires a fluid, more relaxed understanding of what the performer’s body is ‘asking’ of the therapist. Consideration of a myriad of factors allows one to address function beyond pain (Wallden & Chek, 2018). This is immediately understood by the PA clinician, as his or her own performance background allows for a natural, instinctive, reading of the presenting problem. Sort of ‘engaging with the pain of the person’.

Osteopathy, to begin to describe it, is highly integrative. As for any of the BAPAM specialist roles, modern research and the bio-psychosocial approach guides what we offer. A doctor will not be giving up any of the Allopathic musculoskeletal approaches if also working at the same time as an osteopath. Osteopaths and Medics talk the same language.

An osteopath uses his/her hands to read tissues and subtle joint play locally and throughout the body. Reversing the background cause and its effects give one’s patient a route away from pain, stiffness, and deconditioning (Shoup, 2006).

An important baseline concept is the use of ‘a feeling hand’. Part-way through my course at the London College of Osteopathic Medicine I felt that I was developing X-ray hands. Suddenly the black box of a person’s spine pain could be read and understood. Joint pain was no longer a syndrome but seen as patterns of change away from the normal. But more interestingly, change away from the normal for that individual person, their body part, their age and their physical history. An osteopath is agnostic to the person’s profession. I see little difference to treating a ballerina or roadie. Both require near perfect function of the musculoskeletal system to meet the high demands of their activity.

Early on in the osteopathic training we develop our ‘layer palpation’ – feeling and appreciating the different behaviors of skin, fat, fascia, muscle, tendon and joints. How they interact varies with the local musculoskeletal pathologies. The human body requires functional stability to manage force and perform physical activity. The active and passive musculoskeletal systems in one part of the body, however, do not alone account for the ability to generate and resist force. The relatively new science of Biotensegrity, which concerns fascia, may account for much of our ability to resist damage (Lathey, 2019). In a sense fascia ‘binds us together’. As an osteopath we conceptualize fascia as existing throughout the body, providing an additional link between one body part and the next and between the external and internal milieu (Scarr, 2020). Fascial tensions vary dependent upon the role they play and the degree to which the tissue has been insulted.

‘Joint Play’ assessment is both intuitive to those who work in the PA field, and crucial to what makes osteopathy different. Barriers of motion develop and come in as a gradient, assessed in the context of protection or damage to tissues. We can understand changes in tension and ‘give’ when approaching those barriers as signposts to past, present, or future problems.

As an example, you could place your 1st, 2nd and third fingers of each hand over your TMJs. These are both ‘feeling hands’. Whilst sat quietly, gently partly open and close your jaw a few times. Feel how the tissues tension under your fingers increases and relaxes – are they uneven, and to what degree? Repeat, but assess speed and degree of downward and forward action of the mandible there. Don’t measure distance travelled (range of motion), but quality – is there an unevenness through that range, and which side slows its travel first? Can you surmise which feels the more ‘abnormal’ side? If you are successful in picking up these subtle differences you are already probably going to make an excellent osteopath. Imagine how it is when you can describe such dysfunctions in, for example, the radio-humeral, subtalar, sterno-clavicular, or costo-transverse joints.

A good osteopath devises treatment and on-going management based on repeating these hands-on biomechanical assessments of the same patient through subsequent visits. Many of the treatment techniques are common to several Musculo-skeletal professions (strengthening, stretching, articulations, muscle energy, counterstrain, thrust techniques etc). Measuring outcome is less reliant on hard parameters such as pain scores, power, endurance, or cardio-vascular reserve. Rather, the osteopath assesses whether the supporting tissues are normalizing, equalizing, and showing greater ‘ease’.

Osteopaths are integrating modern pain theories with their historical philosophy and utilizing these in a broader sense. This holism typifies our way of thinking (Tyreman, 2013). Central sensitization (increases in membrane excitability in nociceptive pathways and reduced inhibition, working at a spinal level with influences at a higher centers) can be considered distinct from central sensitivity (sub-clinical discharge exhibited in C-nociceptors) (McGlone, et al., 2017). Central sensitivity may be driven by multiple low-grade inputs rather than one or two higher grade inputs to the nervous system. The appreciation of central sensitivity can be used holistically because pain does not need to be present (ie not consciously perceived) for such a syndrome to arise. The relevance is that subclinical conditions that indirectly increase central sensitivity may also affect fine motor control, causing additional stresses on joints and tissues. Unresponsive musculoskeletal conditions in the clinic may require these associative summating drives to be addressed (Wallden, 2020).

A common criticism of osteopathy is that the practitioner is at the core of decision-making and the intervention rather than the patient. Such a locus of control has been shown to negatively affect outcomes. In addition, exercises fall into the efficacy trap – people tend to lose motivation and not follow recommendations (Wallden, 2021). Modern osteopathy is redefining major parts of its philosophy to include the Biopsychosocial model (Thomson, et al., 2013). The reciprocal interrelationship between structure and function, that osteopaths hold dear, will always veer towards ‘malfunction’ whilst patient mal-adaptive and aberrant behavior persists. In this respect our end of session discussion of self-care has moved away from simple ‘choice of lifestyle factors’ to aspects of Behavioral Medicine. The holistic osteopath integrates the evidence-based BPS model to understand what drives such behavior, and potentially how the patient may become aware of their behavior and modify it (Penny, 2013).

Many Osteopath-Doctors are able to work solo if they are wishing to provide their own treatment. They are also extremely useful members of rehabilitation teams - contributing elements of knowledge about the problem at tissue level, yet also offering an insight into how the patient is integrating into their performance environment. All therapists bring something useful to the table and can enjoy participating in shared care for the benefit of the performer.

Of possible interest to you, as a BAPAM physician, is the availability of a part-time course in London for doctors to train to become fully-fledged registered osteopaths. It takes place on two days per week over an eighteen-month period. From ‘ground zero’ the trainees bring their own existing medical and specialist knowledge and add in all the elements of an osteopathic education. There is thus the opportunity to become a super-charged assessor and therapist. From personal experience as an osteopath my confidence in working as a GP and orthopaedic physician has been boosted massively. Osteopathy has positively impacted on my ability to handle a wide range of musculoskeletal problems, in both solo and team-based settings. Details of training at the London College of Osteopathic Medicine are to be found at https://www.lcom.org.uk/

Dr Damon Murgatroyd is a Fellow of the London College of Osteopathic Medicine, where he is a member of the education faculty and is a technique tutor there. He has worked in general practice and musculoskeletal medicine, now concentrating on osteopathic practice. As a youngster he was a bassoon player, attending the Royal College of Music junior school in Manchester. He enjoys Muay Thai and Karate for fitness.

References

Lathey, C., 2019. Applying osteopathic principles in sports medicine. Osteopathy Today, Issue Feb/Mar, pp. 24-25.

McGlone, F., Cerritelli, F., Walker, S. & Esteves, J., 2017. The role of touch in perinatal osteopathic manual therapy. Neuroscience & Behavioral Reviews, Volume 72, pp. 1-9.

Penny, N. J., 2013. The biopsychosocial model: redefining osteopathic philosophy?. Int J of Osteopathic Medicine, Issue 16, pp. 33-37.

Scarr, G., 2020. Biotensegrity: what is the big deal?. J Bodywork & Movement Therapies, Issue 24, pp. 134-137.

Shoup, D., 2006. An osteopathic approach to performing arts medicine. Phys Med Rehabil Clin N Am, Volume 17, pp. 853-864.

Thomson, O., Petty, N. & Moore, A., 2013. Reconsidering the patient-centeredness of osteopathy. Int J of Osteopathic Medicine, Volume 16, pp. 25-32.

Tyreman, S., 2013. Re-evaluating 'osteopathic principles'. Int J of Osteopathic Medicine, Issue 16, pp. 38-45.

Wallden, M., 2020. Central sensitivity and motor control. Osteopathy Today, Issue April/May, pp. 33-34.

Wallden, M., 2021. Movement as medicine. Osteopathy Today, Issue Feb/Mar, pp. 34-35.

Wallden, M. & Chek, P., 2018. The ghost in the machine - is musculoseletal medicine lacking soul?. J of Bodywork & Movement Therapies, Issue 22, pp. 438-448.