Positive Health Online

Introduction

There was one day during the agonizing process of registering as an osteopath that I panicked. All osteopaths were invited by the newly formed General Osteopathic Council to submit a claim to be included on their new register, which opened in May 1998. If my claim was rejected, then by law I would not be allowed to follow my chosen profession. I would lose my livelihood overnight. All my training would have come to naught.

My claim was challenged. I was forced through a nightmare process of interviews and attendance of an 'Assessment of Clinical Competence' (how humiliating). The stress through these months was overwhelming, Eventually I cracked and decided that I couldn't face failing and so began to contemplate how I might market myself in some other way with all these osteopathic skills. So far, I had numerous qualifications in stress management, holistic massage, myofascial release, sports massage, together with the Diploma in Osteopathy. I was fortunate to have a full patient list. I was privileged to be working at the Bristol Cancer Help Centre using mind/body work and apart from the normal client base was working with international and professional athletes - who all knew me as an osteopath.

Then in one of those moments of genius, the perfect title came to me. In the event of failing to qualify as an osteopath, I would call myself an integrative bodyworker - after all, with the skills I had acquired I was already practising integrative bodywork.

Fortunately for me, there was a happy ending to the above story. I was fully registered as an osteopath (with flying colours and a commendation from the GOC's assessment team) so I never got to call myself an integrative bodyworker. However with all the thinking required to process my fears, the concept has stuck with me.

All Bodywork practitioners diagnose and treat their clients
through listening, touch and laying their hands on the client's body.

Many labels - One Thing in Common

I work within a multi-disciplinary natural healthcare network. This means I can refer to or be referred to by a very wide range of natural and manual/physical therapists. A number of these are bodyworkers such as other osteopaths, chiropractors, physiotherapists, massage therapists, Rolfers, Bowen Technique practitioners, AK practitioners, craniosacral therapists and shiatsu practitioners. And there are many more bodywork disciplines out there including related hands-on work such as the Alexander Technique, Shen Therapy and the newly created Osteomyologists.[1] We all have one thing in common, we diagnose and treat a person through the means of listening and touch, together with skills applied by laying our hands on the client's body.

Acquisition of Tools of the Trade

Probably many of us have gone on to collect further girl guide/boy scout badges - I mean supplemented our initial training with many other tools and skills. The courses out there are limitless -

'Advanced this', 'Advanced that', and one I am currently marketing, 'the Psycho-neuro-positional-structural-soft tissue-biodynamic-indirect-seated body technique course'! It does make marketing ourselves, or explaining to the public exactly what we do, somewhat difficult - I often feel the advertisement should be accompanied by a glossary to help define our very obscure terms.

Have you noticed that a good bodyworker intuitively discovers and develops ways of working with the body to aid the body's self-healing mechanism? I've been on a number of these boy-scout badge collecting courses often to be disappointed - I had already discovered that technique or something very like it. Maybe someone with marketing nouse had decided they could make a name or some money out of promoting this or that particular tool.

However we have gained the skills, it strikes me as I look out over the sea of hands-on complementary health (or on the web) that we have dozens of marketing labels of modalities such as osteopathy, physiotherapy, massage, shiatsu etc., often all using very similar skills and tools. Most of the books listed below carry an introduction saying how these skills are applicable across the full range of modalities.

Let Integration Begin

Hasn't the time come for much more cross-discipline discussion and debate even the trading of skills and understanding? I was excited to see Leon Chaitow's initiative last year in setting up a conference entitled 'Integrative Bodywork' - there's nothing new under the sun, I thought - and his interview with Elsevier Books.[2] In this he says: "I foresee a time in this century where the actual differences between osteopathy, chiropractic and physiotherapy (manual medicine) will vanish, with similarities in assessment and treatment being so obvious, with clinical methodology being based on evidence rather than theory, that a merging of training will eventuate. The only thing stopping this now is professional stubbornness and the egos of practitioners and their leaders."

I notice physiotherapists are setting up courses to teach osteopaths e.g. exercises to promote core stability. I applaud these initiatives and hope this essay will promote more discussion and debate.

Philosophy

In order for integration to grow, I believe there are a number of issues to consider. Firstly, some acknowledgement and recognition of the different philosophies and beliefs behind the specific modality is crucial (this also includes any specific history). Even within osteopathy there is great diversity on these issues. For example some osteopaths are solely biomechanical in approach - and even within this view there is diversity in thinking about biomechanical principles (see chapters 6 and 7 of Science in the Art of Osteopathy by Caroline Stone[3]); some will only use involuntary mechanism techniques - gentle and subtle; some hold strongly to the values of AT Still, the founder of osteopathy, and his claim that osteopathy can relieve all kinds of disease, mechanical and visceral dysfunctions. To quote Still: "I can truthfully say that I am satisfied that osteopathy is the natural way by which all of the diseases to which the human family is heir can be relieved, and a large majority of them cured";[4] some have a strong holistic approach and I am keen to acknowledge the current thinking and work of Walter McKone;[5] another view of the holistic approach is offered by Dr Alain Abehsera DO MD under the concept of Connective Osteopathy.[6]

Equally, with other modalities such as chiropractics and shiatsu, there are different approaches based on varying beliefs and principles (searching the web I found the modality new to me of 'Movement Shiatsu'). I believe each modality must be respected and acknowledged for its formative past thinking, to be able to understand the purpose, use and function of that modality. From this basis of respect and understanding we can then look at our different assessment methods, philosophy supporting our diagnosis (e.g. reductionist or holistic - eastern and western approaches are very different) and treatment plans - the philosophy and hands-on skills.

Research

Secondly, I believe each modality needs to conduct simple research (this could be quantitative or qualitative) so that what we claim happens when we treat is more research/evidence based. I believe this will yield enough trust and reasoning to let us relax our long-held beliefs and begin to merge our assessment and treatment methodology. I believe this approach could happen across all bodywork modalities, both east and west. It would provide a pool of knowledge and wisdom that practitioners could draw from which, ultimately, would help us all achieve our aim, that of improving the condition of our patient/client and encouraging good preventative healthcare.

I readily acknowledge that initiatives such as these are happening across the world, but this is not happening fast enough. We need our beliefs challenged - as indeed I found I had to when facing loosing the label osteopath (it really is only a marketing badge - after all I believe people come to see Ian not the osteopath).

Education

Thirdly, the question of education. I admit that it will be a long time before colleges/schools emerge teaching integrative bodywork, but I relish the challenge of devizing a syllabus for a diploma in integrative bodywork. I spent two years with colleagues developing an open-learning osteopathic diploma of considerable standard. This experience gives me confidence that such an integrative diploma could be developed. However there are numerous hurdles to jump, least being the various modalities' governing bodies and the huge variety of standards required. Such a diploma would need to satisfy these demands.

Each practitioner obviously needs insurance to practise. I do not believe this integrative approach would pose a problem for the insurers, however much discussion would be required with governing bodies. Perhaps solid research, reasoning and a will to make it happen are what are required.

Marketing

Fourthly, as far as marketing is concerned, I'm sure the individuality of practitioners will reign supreme! We shall continue to come up with creative slogans and weird words to describe what we do and we'll still need to explain what on earth that is to the public. In the mean time, we will survive individually on word of mouth referrals, as we have done for time immemorial.

Whether we dispense with our modality labels, only time will tell!

The Tools We Use

To offer an insight into how we could integrate, I would like to offer a classification of bodywork skills and tools and ask if bodyworkers reading this essay could fit their techniques into the classification or contribute to the discussion by offering their own classification or enlargement of the list.

1. Articulatory/mobilizing techniques - this means techniques primarily for moving and mobilizing a joint;

2. Soft tissue techniques - this would include all movement massage techniques such as Swedish, sports massage, deep tissue, lymphatic drainage techniques and I would include stretching in this section;

3. Muscle energy techniques - active muscular relaxation techniques;[7]

4. High velocity, low amplitude techniques - thrust techniques which directly engage a restriction of movement in a joint, often employed by osteopaths, osteomyologists, chiropractors and some physiotherapists;

5. Functional techniques - all techniques which do not directly engage a restriction - these might include passive motion, harmonic,[8] rhythmic, involuntary mechanism, craniosacral, spontaneous release-type techniques;

6. Strain/counter-strain techniques - there is a long history of such positional techniques so although they could be included in the above indirect technique list, I feel these deserve a separate classification; I would include positional release techniques[9] in this section;

7. Neuromuscular techniques[10] - these would include trigger point techniques;[11]

8. Myofascial release techniques[12] - techniques which effect the myofascia and are often combined together with counselling or psychotherapy;

9. Direct pressure techniques - these would include energy-effecting techniques such as reflexology, shiatsu, Anma,[13] acupressure-type techniques;

10. Fascial Distortion model techniques - a model which attempts to unify orthopaedics and osteopathy by using manipulative techniques which effect the connecting structures of the musculoskeletal system (ligaments, tendons, fascial bonds, retinacula) often distorted during injury.[14]

I've probably left out the techniques most obvious to you, so please feel free to contribute.

In all this I believe we must constantly hold in mind that whatever the modality or skill, it is the individual practitioner/client relationship which is key to healing. It is this relationship together with the individual beliefs, worldview and personal development of the practitioner that very often determines the outcome. It is not the actual skills themselves but how they are applied.

Are There Dangers?

There could be pitfalls with using an integrative approach with cross-modality skills and tools. To give one example, I was once working with a professional athlete who came to see me as a referral only knowing me as a sports massage therapist. He wanted help with an Achilles tendon problem. However, during my assessment (this involved an assessment viewing the whole person using all the modalities I've been trained in, including an osteopathic assessment) I noticed a mechanical dysfunction of the spine. Should I treat this and the Achilles tendon as they were inextricably linked osteopathically? I discussed this with him, and he informed me that he already had an osteopath who had not diagnosed any kind of dysfunction of the spine. This had the potential of setting his osteopath and me at odds with one another. He obviously felt concerned because he thought he had only come to see a sports massage therapist. What was I to do? Well the sensible thing was to ask the client's permission to discuss this matter with his osteopath, which we did. The outcome we agreed was that the athlete's osteopath would treat the mechanical dysfunction and I would treat the soft tissue components of the lower leg whilst monitoring the changes in structure, and communicate as necessary. We achieved a successful outcome for the client.

Since this time I generally make it a rule to inform a potential client of my skill- base and philosophy for treatment and request that I be responsible for all the issues that come up in an assessment. If another therapist is involved we negotiate a way forward. I have successfully worked with other practitioners on the same client, but made sure there are little or no overlaps in the treatment plan. Otherwise it leads to the situation where neither practitioner is sure which modality is working.

Conclusions

In this essay my aim is to call for recognition amongst bodyworkers that most of us already practise integrative bodywork and in so doing, maybe we could begin to relax our sometimes heavily guarded positions. I would also like to promote a wider debate on the issues raised regarding integrative bodywork. I appreciate the editor of Positive Health magazine providing such an opportunity through these pages. If there is willingness then maybe we can come together in a workshop format to begin sharing our philosophies and approaches.

When I began my training as an osteopath, I remember attending my first annual school dinner and awards evening. The guest speaker was the renowned and respected osteopath Harry Hawes (who has since passed away). I was told he had been practising for over 50 years as an osteopath. In his speech he made mention of the growing national debate over the impending statutory registration of osteopaths, and the protection of the title. I was amazed to hear him say that in his opinion the name didn't matter. He would be very happy to call himself a massage therapist. I found this one of the most humbling statements I had ever heard. The stature of the man made the statement carry even more weight. I have never forgotten his humility and certainly don't mind following in his footsteps in being known as a massage therapist.

Notes and References

1. Osteomyologist website: www.osteomyology.co.uk
2. www.harcourt-international.com/chaitow/interview.cfm
3. Stone C. Science in the Art of Osteopathy. Stanley Thornes. p122f. ISBN 0-7487-3328-0.
4. Still AT. Osteopathy Research and Practice (preface). Maidstone College of Osteopathy. 1910.
5. McKone W. Osteopathic Medicine. Blackwell Science. UK. ISBN: 0632052635;
Lecture entitled The Cartesian Corpse; website for the future book: Female Science: Happiness and Fulfilment in a World of Wholeness. www.femalescience.com
6. www.connective.org
7. Chaitow L. Muscle Energy Techniques. Churchill Livingstone. ISBN 0-443-05297-2. 1996.
8. Lederman E. Harmonic Techniques. Churchill Livingstone. ISBN 0-443-06162-9.
9. D'Ambrogio and Roth. Positional Release Therapy. Mosby. ISBN 0-8151-0096-5. 1997.
10. Chaitow L and Walker DeLany J. Clinical Application of Neuromuscular Techniques, Vol 1. Churchill Livingstone. ISBN 0443062706. 2000.
11. Travell and Simons. Myofascial Pain and Dysfunction, the Trigger Point Manual (Vol 1 & 2). Williams & Wilkins. Baltimore. 1999.
12. John Barnes' brilliant books and popular website: www.myofascialrelease.com; Manheim Carol J. The Myofascial Release Manual, third edition. 2001.
13. Mochizuki J. Anma - The Art of Japanese Massage. Kotobuki. ISBN 1-57615-000-3. 1999.
14. Typaldos S. Orthopathic Medicine. OGH Publications. ISBN 0-9659641-2-4.