Manual Medicine is a term used in modern day medical practice to refer to hands-on bodywork performed by a medical doctor. More familiar to most people in the US is the term chiropractic. In Europe more people are familiar with the term osteopathy as there are more osteopaths and osteopathic colleges in Europe than chiropractic colleges. So what are the differences?
In truth, there is probably more variation within any one of these fields than there is between manual medicine, osteopathy and chiropractic. Chiropractic is manual medicine practiced by a licensed chiropractor. Some chiropractors only adjust the spine. Others also adjust the extremities. Some use their hands, others an adjusting tool. Some practice SOT technique, others Gonstead technique.
What most people think of as “chiropractic” is the HVLA adjustment. HVLA refers to “high velocity, low amplitude.” In this type of adjustment, the joint is taken to the extreme end of it’s range and then ideally a very short quick controlled thrust is made that pushes the joint just a bit further but not so far as to cause tissue injury. It’s been shown scientifically that this procedure has a quieting effect on the nervous system, especially the part of the spinal chord innervating the joint adjusted. The result is akin to rebooting your computer when it is misbehaving. Call it a neurological reset.
Osteopathy also uses the HVLA adjustment, but tends to rely on other procedures as well to obtain the same results. Positional release is taking the joint in the exact opposite direction to the joints restriction until the tense soft tissue becomes so slack that it no longer sends signals to the spinal cord. Holding this position for 60 seconds and then slowly releasing the joint back to neutral results in a reset to nervous system as well. Instead of breaking through the barrier with an adjustment, we merely take all the tension of the joint until everything resets. In another variation called Functional technique the osteopath seeks to position the joint into a position where all of the tensions around the joint are perfectly balanced. One will feel an almost instant release of the tight spasmed muscles around the joint.
So the point of all of these descriptions is to understand that we, as manual medicine practitioners, are working with the nervous system, not simply moving displaced bones back into place. Bones and joints are controlled by the soft tissue structures attached to them, and the those soft tissues are controlled by the nervous system. In truth the situation is even a bit more complex because not only does the nervous system control the soft tissues, the soft tissues talk to the nervous system and tell the spinal cord and brain what the situation is locally. This input can affect what sort of output we get. Bad input equals bad input. “Garbage in = garbage out” as they say.
So basically we are dealing with a feedback loop. If a joint is in pain, then signals into the spinal cord cause that part of the cord to become hyperfacilitated, that is, hyperresponsive to incoming signals. As a result we see muscles around that painful joint receiving instructions from the nervous system that make them become stiffer, resistant to changes in position, or in extreme cases the muscles may resist any movement at all. Anyone with chronic back pain knows this all too well.
Old time osteopaths used to say that 80% of the problems were in the input, not the output. The nervous system receives far more incoming signals from the body than it transmits outgoing signals to the body. As we have just discussed, noxious or even just garbled input to the nervous system results in abnormal output, and that is the essence of manual medicine treatment. If we can normalize the inputs, we get better outputs and thus a freer moving body.
This brings up an interesting point. If your horse has a visceral problem, say a gastric ulcer, then we know there is abnormal noxious input (pain) coming into the spinal cord. We would then expect that part of the cord to become hyper-responsive to any incoming signals, even from healthy tissue innervated by the same segment of the spinal cord. The outgoing response from that segment is over-responsive to the inputs it receives, and we may see increased tension or stiffness in related muscles, increased heat or sweating on the skin innervated by that segment. Even further, normal input of sensations may suddenly be interpreted as pain. A heart attack manifests as pain in the left arm. An inflamed gall bladder manifests as pain in the muscles between the shoulder blades.
The important take away is that good equine bodywork is not simply the physical “putting things back in place,” it is a dialog with the horse’s nervous system. My equine osteopathy teacher Janek Vluggen DO used to say that our primary goal as equine osteopaths was to merely get good normal pain free movement back into the dyfunctional joint. Get good input happening and then let the body fix itself. The founder of osteopathy, Andrew Still, taught his students “find it, fix it, and then leave it alone.” Let the body heal itself.
I’ll finish by briefly talking about physical therapist David Butler’s work with pain management in his human patients. He loves to tell the story that the first thing he has a new PT student do is go sit in an emergency room for a shift and just watch. What the student comes away with is a realization that the level of pain often does not match the level of damage. The most minor of injuries can be excruciating while the most horrific of injuries may not cause any experience of pain at all.
Butler approaches pain as a psychological issue as much as an orthopedic issue in his practice. Rather than having a patient merely stretch and strengthen an ailing knee, he has that patient sit down on the edge of the bed before sleep and simply visualize in their mind moving their knee without any pain. This alone is enough to reeducate the nervous system so that the patient can move that knee without pain.
So, I think there is deep wisdom in the concept that we do manual medicine, whether chiropractic, osteopathy, or massage, not to put parts back into place, but to re-educate the body especially the nervous system, to interpret the world and to behave in a more normalized fashion. “Find it, fix it and leave it alone.” As they say “Garbage in=garbage out.” Luckily for us though, normal input leads to more reasonable and healthy output. Giving a joint the experience of movement without tension and pain is at the same time a reeducation of the nervous system and that is where the real impact occurs.