What’s the difference between an osteopath, chiropractor, physiotherapist and what you do?

Is question I get asked a lot and it is a reasonable question as we can appear to be quite similar in that we all work hands-on the body doing manual therapy techniques to help people with musculoskeletal complaints including chronic pain, repetitive strain, movement difficulties, an old injury, nerve entrapment, and postural alignment issues to name but a few. The answer lies in the basic philosophical approach that each discipline takes in dealing with a particular issue, which then ultimately determines the techniques which will be used.

The definitions looked at here will mainly apply to UK trained practitioners, but more international and generic supplemental information can be found in the links to various related Wikipedia entries at the end of this particular article. Additionally, one should bear in mind that many practitioners once they’ve gained their basic qualification often go on to do any number of post graduate courses and in fact it is not uncommon for osteopaths, chiropractors, physiotherapists, massage therapists, nurses, movement instructors (such pilates) and many other professionals licensed to do hands on manual therapies to be all attending the same courses – as I myself have done numerous times – this has not only enabled me to learn some profoundly effective hands-on therapy skills which build upon my existing knowledge but also gaining a deeper appreciation of what the other practitioners do in their respective modalities. Ultimately, the aim of course at the end of the day is to be able to serve our clients better and more effectively, no mater what therapy we’re practicing.

Physiotherapy

Traditionally, physiotherapy (also known as PT or Physical Therapy in other countries) uses a mixture of hands-on palpation and various client lifestyle assessment strategies to determine an appropriate course of treatment. The treatments strategies can include massage, but most usually will be an appropriate rehabilitation regime designed to strengthen the pertinent areas of the body involved in the patient’s presenting condition. This would probably be a fair basic definition of the type of service that a physiotherapist in private practice might be offering their clients. Unfortunately, I can already hear the voices of those people who have had very disappointingly different experiences of physiotherapy from practitioners operating from within the public National Health Service (NHS), and yes from numerous anecdotal stories I’ve heard assessment is done entirely hands off (due to time constraints of 20 minute appointments for assessment and treatment) and the solution is almost always focused exclusively on getting the client onto a routine of strengthening exercises. This exclusive focusing on strengthening (of muscles) can lead to imbalance problems where already over tight opposing muscles to the damaged area are not being identified as needing to be released first and so are getting even more tense when the imbalance is magnified as the weakened area becomes stronger through the rehab process. Also in the last 10-15 years, hands-on skills in massage work within a typical physiotherapist’s degree training program has been greatly reduced to the point now where even an massage therapist with just the most basic level (ITEC or equivalent) of qualification in the UK will have done more hours of practical training in massage than a more recently qualified physiotherapist. This is in a quite way ironic, as therapeutic and remedial massage for clinical benefit was actually what physiotherapy entirely about at one point in history, nowadays the massage element has been replaced by ultra sound devices and other technological devices. My advice would be to search out a good private physio who has additional training or expertise in the type of issue you are seeking help with, if you have only ever experienced physio on the NHS. I’ve personally learnt some great soft tissue manipulation techniques for the spine which was taught by a practitioner who is both a musculoskeletal physiotherapist, a remedial massage therapist as well as a yoga teacher, all elements feeding into the course she taught including yoga exercises which were indicated as useful rehab exercise for spine issues.

Chiropractic

Most people associate chiropractors as being people who adjust, manipulate and crack the bones of the spine in order to re-align it. Chiropractors adjust the spine not only to benefit the physical posture of a person, but also because they view the spine as being the organizing focal point of health because all the nerves supplying control and feedback pathways from the brain out to the major organs and peripheral limbs of the body emanate from the spine. Therefore, any entrapment of nerves due to pressure from misaligned vertebral bones of the spine could also affect the person’s health due to misfiring nerve signals (or be contributing to musculoskeletal issue). Chiropractors in the UK in common the UK trained osteopaths go through a 5 year training program which covers the exact same level of anatomy, physiology and pathology training that a GP (General Practitioner) would receive, except that there is considerably less training in pharmacology (training in the use of pharmaceutical drugs) and instead this is replaced with the techniques and philosophies pertaining to that particular modality’s way of treatment. Chiropractors (as with osteopaths) are also trained to give nutrition as well as other life style advice, although for some reason this is not an area I’ve heard people mention when they go for a chiropractic visit, it’s always about the adjustment! For those that have been to a chiropractor already or have yet to go, but either way are put off by all the forced crunching and clicking I would urge you to think again and look up the McTimoney Chiropractic approach. McTimoney chiropractors are so different in their approach to performing adjustments as to be almost polar opposite when compared to traditional chiropractors, McTimoney practitioners still make adjustments to the spine but do so in a much more subtle, gentle, less force but still effective manner. I’ve actually been an on-looker observing a McTimoney trained chiropractor at work, and it is indeed hard to believe some of the moves which passed for adjustment procedures were so subtle and gentle could be having the kind of effect they were supposed to be having, but the proof was indeed in the pudding for the person who was on the table at the time!

Osteopathy

In common with chiropractors, osteopaths are best known for the adjustments that they make between joints using what are known as high velocity thrust (HVT) techniques, what are usually referred to as the adjustment or cracking and clicking. A generalization to differentiate chiropractic from osteopathy, is that whilst chiropractors concentrate on the spine, osteopaths concentrate on all bony joints and junctions in order to align the physical structure of a person for optimal health. This alignment strategy, as with chiropractic looks at not only the bones but the nerves and fluids flowing between the bony junctions. Osteopathy itself when you look into the various schools can be quite wide ranging and eclectic once you get passed the core principles. There is a branch of osteopathy which deals with the subtle movement and manipulation of the individual bones of the skull known as cranial osteopathy. A further development of cranial osteopathy is cranial sacral therapy which take the underlying soft tissues and fascia (connective tissue) of the brain and spinal chord as well as the fluid (CSF – Cerebral Spinal Fluid) surrounding these structure to be a kind of respiratory system in its own right which can be worked on and so affecting health in the wider body. Yet another popular branch of osteopathy is visceral osteopathy (also sometimes known as visceral manipulation or visceral release therapy), where organs of the abdominal cavity can be gently coaxed and released into a more optimal suspensory state within its own (but not totally isolated) web of connective tissue, this in turn can have significant impact on musculoskeletal issues which can then be traced back via certain predictable physical interconnection routes. Visceral manipulation in common with craniosacral therapy both work with the fascia system of the body and are both modalities that I have trained in as they involve working with the fascia (connective tissue of the body), which is in turn soft tissue related work and so finally leads me nicely on to what I do…

Soft Tissue Therapy

Soft tissue therapy is not one thing but a eclectic collection of tools, but in common all these tools are hands-on techniques that are designed to work with, affect or manipulate the muscles, fascia and other soft tissues of the body. The soft tissue therapist’s approach is to work with the soft tissues of the body in whatever way is appropriate, this could be light massage to encourage circulation, precision deep tissue massage, soft tissue manipulation, fascia release work, trigger point work, facilitated stretching, etc. The approach then is to release tension in the soft tissues which in return could cause a release of a stuck junction between bone joints if appropriate. The approach that a chiropractor or osteopath often uses is to manipulate the bone or joint itself directly and have the soft tissue follow along (hopefully correctly) afterwards. Emotional or physical trauma as well as unremitting stress is often imprinted in the cellular memory of soft tissue structures experiencing dysfunction and unease, soft tissue therapy due to its non aggressive approach encourages not only a physical release or unwinding of ravelled tension to happen under the guidance of your body’s innate intelligence system (the same intelligence that causes a cut or wound to heal), but also can spontaneously cause the previously locked in emotions or trauma to safely release, this is also often a missing link in the recovery process that wouldn’t otherwise be addressed by other means. As there is more soft tissue in the body than bony tissue, it is often the case the probably as much as 85% or more of issues can be resolved more effectively using a soft tissue approach as a first port of call, and then further follow up with physiotherapy (for strengthening work), osteopathic or chiropractic work if necessary for bony manipulation work or more intractable issues.

Useful links and resources

http://en.wikipedia.org/wiki/Osteopathy
http://en.wikipedia.org/wiki/Chiropractic
http://en.wikipedia.org/wiki/Physiotherapy
http://en.wikipedia.org/wiki/Soft_tissue_therapy

Soft Tissue Therapy Practitioner in Exeter (Devon), UK –
http://www.isca-therapies.co.uk

Are trigger points the answer to your unresolved soft tissue pain?

Almost immediately after I had completed my initial basic training in massage, I happened to come across across a series courses for already qualified therapists such as myself, the courses were modular and taught remedial soft tissue techniques and skills to profoundly affect soft tissue pain conditions for the better in clients. This new information opened up a whole new range of clients for me whom I’d never have thought of working with before and changed the course of my practice. Trigger point therapy along with myofascial release are the joint top 2 remedial techniques that appear to have the most profound affect on clients I have worked with, especially ones who have been around the houses already to see conventional health professionals and other alternative therapists without much of a result.

Trigger points are basically a single point of very tight knots in the fibres and fascia (connective tissue) of a muscle which causes pain to be felt as result, these knots can vary in size from a pea to a grain of sand. An appropriately experienced remedial therapist will normally be able to detect these knots through palpation or touch alone, but often will also require verbal feedback from the client in order to confirm whether a sore spot is being pressed upon. Trigger points can be caused by repetitive overuse, over strain, stress, injury, accident or trauma. These knots impede the flow of fresh blood to the area where the knots are, this constriction also means that metabolic waste and toxins which are normally flushed away back into the circulatory system cannot escape so there ends up being a build up in this confined area which is what causes the pain. Trigger points may need to have pressure applied to them in order for the pain pattern to become activated or the trigger point may be in such a state that it is always actively causing the pain regardless. The muscle knots that form a trigger point site do not tend to respond to standard kneading type massage movements, they require precisely aimed static pressure, pressure which shouldn’t be too hard either as this will just make the muscle go into further contracture and hardening. I usually apply up to 12 seconds of constant static pressure on a trigger point, within that time frame the client should be experiencing levels of pain no greater than a 7 out of 10 (and much less is fine), before that time is up I would expect the client to perceive a change in the quality of pain, either getting less or changing say from a sharp pain to dull ache and this would be a sign for me to cease pressing. I could also choose to follow the movement of the tissues as they begin to ease and release, so combining a myofascial release technique (more on myofasical release in an upcoming article).

The most distinctive attribute of most trigger points is their ability to refer pain, so that pain appears to be experienced at a remote and apparently unrelated location to that of where the trigger point actually physically is. Not only are most trigger points able to set-up pain referral conditions, but all these pain referral patterns have been proved by research to be consistently reproducible and predictable. Books and charts have therefore been produced showing typical trigger point locations on a diagram of a muscle along with the expected pain referral pattern(s).

There has been plenty of scientific and medical research conducted into the efficacy of trigger points, but despite this it is still not part of any of the qualifying training that a conventional medical doctor would go through, so therefore most would be ignorant of this phenomenon. Dr Janet Travell who was also president John F Kennedy’s personal physician, was one of the main pioneering figures behind research into the theory and practical implications of trigger points.

Here are so common examples:

Reoccurring headaches where the pain is usually felt in the same predictable areas on the skull every time are usually caused by trigger points in the muscles either side on the side of the neck.

Sciatica and the characteristic shooting pains down the back of leg is often caused by trigger points in the gluteal region muscles and the resulting nerve entrapment that occurs of the sciatic nerve (usually the piriformis muscle deep in the mid region of the buttocks).  Can also cause lower back pain issues.

Shin splints are usually usually caused by trigger points in the (tibalis anterior) muscle on the outside front part of the lower leg just a few inches below the knee.

Tingling or numbness sensations in the fingers often accompanied by RSI (repetitive strain injury), carpel tunnel or thoracic outlet syndrome type symptoms are usually caused by nerve fibres (of the brachial nerve plexus) being entrapped by tight muscles containing trigger points, namely the muscles at the base of the neck (scalenes) and the muscles in the chest area either side on the front of the rib cage just a bit below the collar bone (pectoralis minor).

This website I came across whilst researching this article gives an excellent extract from a book about trigger points, but provides an even fuller commentary than here if you are interested in reading more, so I’d point you there for further reading as it’s really very good and saves me from trying to re-invent the wheel here so to speak:

http://saveyourself.ca/tutorials/trigger-points.php

And to see pictorial diagrams and a very comprehensive listing of pain related symptoms that can be related to trigger points in a certain muscle, have a look at this highly informative website:

http://www.triggerpoints.net

Here are 2 books that I use myself during client consultation sessions and come highly recommended as well if you are interested in looking into self treatment (click on the images for more details):

Trigger Point Therapy for Myofascial Pain – Fernando & Fernando:

The Trigger Point Therapy Workbook – Davis & Davis:

Thera cane: an essential self treatment tool (comes with instructions)