“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” – The World Health Organisation, Constitution of WHO: principles
I have a friend who is a pilates instructor. Before she was a pilates instructor she was a dancer. She asked me to help her out with some ankle pain she couldn’t seem to get rid of. We met, had a chat and I tried to check if anything was structurally wrong. We couldn’t really reproduce her ankle pain, and she wasn’t experiencing any decrease in function. She was just experiencing occasional pain, and had been feeling it for almost a year. I was about to talk about chronic pain, models of health and understanding modern pain science with her but she said:
‘Maybe I’m just so well aligned that when my body gets even slightly out of alignment, I notice it. I think that I just need to keep focussing on that. I’m happy that there’s nothing serious though!’
I didn’t really know what to say after that. I thought back to people I knew, and worked with and their chronic pain issues. Nearly all of them were trying to work on fixing structures or alignment. They were attempting to heal asymmetries using functional movements or core exercises. Back pain, neck pain, shoulder pain – some had been suffering for many years. Everything was about fixing alignment, improving posture and muscle balance. No-one was looking the big picture.
Models, usefulness & pain
“Remember that all models are wrong; the practical question is how wrong do they have to be to not be useful.” – George E. P. Box.
This is an important quote. When we talk about the body in terms of systems, or metaphors. It’s not going to be ‘Truth’. It will be a model to work with. There are different ways of treating an illness or injury. Lets give a simple example of a disc herniation in the lumbar spine, and you have been suffering for 6 months with back pain: Often (depending where you are located in the world, and perceived best practices) you may be offered some combination of pain killers, spinal surgery and/or physiotherapy. There is a logic behind the choices of treatment, based on what is believed to be causing your pain. That logic, is based on a model of cause and effect. What is causing you to feel pain, and the best way to either stop the pain, or fix the underlying problem. Unfortunately, it might not be that simple.
You are a gestalt of your systems, practices and processes. Of your mind and body. Or Body, Mind & Soul. Or just your body. Or whatever conceptual framework you wish to work with, because that’s how we describe complex phenomena. It’s too much to understand this interconnected, intertwined, biosphere we live in, and our place in it, without using models and concepts. The models and concepts we use won’t necessarily be accurate, in the same way a flawless sculpture of a person might bear a near-indistinguishable likeness to someone, but it won’t be the same as them. It will be a model of them. There are many more things affecting our experiences and interpretations than can be succinctly explained. There are models and metaphors that might help though (more on this later). In healthcare, as in other fields, there are competing ‘models’ sometimes that people will disagree with about the accuracy or validity of.
The question to ask yourself is ‘Is this model useful?’
In the case of fruitlessly chasing better ‘biomechanics, structure & posture’ for months or even years – I’d suggest there are better models of health to work with.
The biopsychosocial model
When we look at our body in terms of health & pain and we only see us as machines, we are missing lots of things about ourselves. It is easy to fall into mistake of believing that pain = damage to the body, and therefore pain = something that needs fixing in the body. In many cases, that might have truth to it, but it is only a part of the problem. Like looking into a room through the keyhole and believing that what you see, is all there is inside. We can be less wrong in how we look at things, we can be more useful.
One such model I believe to be ‘less wrong’ is the biopsychosocial model of health.
“The biopsychosocial model is both a philosophy of clinical care and a practical clinical guide. Philosophically, it is a way of understanding how suffering, disease, and illness are affected by multiple levels of organization, from the societal to the molecular. At the practical level, it is a way of understanding the patient’s subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care.” (Borrell-Carrió et al., 2004)
Where all three circles interact, the sum of each of the three factors, could be called ‘biopsychosocial health’ or ‘current wellbeing’. We’ll come back to this later, after talking about pain.
Where all three circles interact, the sum of each of the three factors, could be called ‘biopsychosocial health’ or ‘current wellbeing’.
Health, under a microscope
‘”Look. Now there’s your atherosclerosis. That’s it. A thickening of the intima. That’s really what it is.” And then he adds, after a little pause: “Under a microscope.”‘ – Annmarie Mol, The Body Multiple: Ontology in Medical Practice
The above quote is from an excellent book called ‘The Body Multiple: Ontology in Medical Practice’ by Annemarie Mol. The book is written as two parallel texts… The upper half of each page is the journey of her research, the lower half of each page is the reflections and analysis of the journey. I suggest it to everybody with an interest in medicine or healthcare. In the book Annemarie Mol is observing how atherosclerosis is treated in dutch hospitals. One of the most interesting findings is the difference between what a disease is in the clinic, and what it is in the lab. That’s the difference between how a person experiences a disease, and the findings in the lab. The experiences of disease that different people have almost no correlation to their different lab findings.
And then we come to the enormous paradox we face in when trying to understand healthcare. As an osteopath, or physiotherapist etc, when we look at patients ‘under a microscope’ as we have been trained, we see biomechanics, muscle imbalances, joint misalignments or fascial adhesions. And then we go about treating these things we have found. The things we find ‘under a microscope’ do not often have any real bearing on that patients health, wellbeing or symptoms (Paul Ingraham has a great summary of ‘structuralism’ written here).
What would happen if we were to change the way we saw patients? If we looked at the way our patients enacted their problems, we might see that actually they need to change their habitual behaviours a little, make a few lifestyle adaptions. They might be better off learning to reduce stress, eat better, sleep better, and do more exercise. What we want to do, surely, is affect how their health is enacted; improve they experience their wellbeing. It’s easy to get drawn into the jargon of being ‘unaligned’ or whatever other terms people are labelled with.
Not all ‘microscope’ practice is bad, but lots of it is unnecessary. And what would be possibly better is to see people using ‘bigger picture’ models like the BPS model, and educating people about the things not under the microscope.
The current challenges we face, as a species, is to deal with the environment of modern lifestyle:
- Sitting all day
- Lack of physical movement
- Perpetually entertained, and not able to control our attention
- Stressful work culture & environment
- Internet as a (social) stress force multiplier
- Air quality diminishing
- Overfed, undernourished
- Mental health issues increasing
- Increasingly fragmented society & families
These are potential barriers to our health. My goal is to facilitate not only ways to overcome the ‘known’ barriers, but also develop mental and physical (and even social) flexibility, adaptation and qualities that mean we can thrive in adversity and uncertainty.
While the BPS model might not please everybody, it can help us see that health is about our habitual behaviours, relationships and thought processes – as well as what is happening in our physical body.
I hope that we begin to recapture the spirit of ‘health’, rather than chasing images ‘under a microscope’; That we will educate and be self educated to understand our own health – Our bodies are strong adaptation machines – we can guide them better.
Borrell-CarriÃ³, F., Suchman, A.L. and Epstein, R.M. 2004. The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry. The Annals of Family Medicine. 2(6),pp.576-582.
Ingraham, P. n.d. Your Back Is Not Out of Alignment. http://www.PainScience.com. [Online]. [Accessed 12 August 2017]. Available from: https://www.painscience.com/articles/structuralism.php.
Mol, A. 2003. The Body Multiple: Ontology in Medical Practice. Durham: Duke University Press.