Diagnosis and Osteopathy

Many Osteopaths have a problem with the term ‘Diagnosis’. There are several reasons.

For a start, we have a problem with the way the term gets (mis)used in medicine.

It is a fundamental tenet of medicine that you make a diagnosis and then treat the diagnosis. ‘Symptoms’ are what the patient feels. The diagnosis is ‘what is causing the symptoms’. So you treat the Diagnosis – the ’cause of the symptoms’ – to cure the condition rather than just providing relief of the symptoms. There is a valid place for treatment aimed at symptom relief – this is palliative care for example in end of life care for the terminally ill. It is for when you cannot do anything about the disease itself, and making the patient comfortable is the best you can do.

In medicine there is a principle: no diagnosis, no treatment. If you do not know the cause of the problem, how can you treat it? So far, so logical.

What counts as a diagnosis? If you go to your doctor with leg pain and are sent for an X-ray and told you have a broken leg, things are pretty clear-cut. There is a definite diagnosis and the diagnosis determines the treatment given. If you go to a doctor with back pain, the vast majority will not examine you, will prescribe Paracetamol and Ibuprofen, and send you away for 6 weeks, with a “diagnosis” of ‘mechanical low back pain’.

Now, that’s where we have a problem. ‘Low back Pain’ is a symptom – it is what the patient feels. ‘Mechanical’ tells us that the doctor doesn’t think it is Cancer or a nerve disease, or any other kind of illness that could end up killing you. It doesn’t tell us what the cause of the symptom IS, just what it ISN’T. So this “Diagnosis” really means: ‘You’ve told me your low back hurts and I am pretty convinced it is nothing drastic, so I cannot be bothered to try to work out what the problem is. Go away. Oh, and here’s something that might cover up the symptoms a bit’ That’s not a diagnosis, that’s a dereliction of duty! The treatment is palliative (supressing the symptoms), not because the condition is terminal but because no-one can be bothered to work out the cause.

The reason why Osteopaths are best known for ‘treating bad backs’ is because we DO examine the patient (having first satisfied ourselves it isn’t something that is likely to kill them) and try to work out exactly WHAT the problem is. That isn’t just working out what particular tissue is causing the pain (is it coming from a herniated disc, a torn muscle, a sprained ligament etc?) and what the mechanism of the pain is (is it due to inflammation, pressure on a nerve, protective muscle spasm, etc?) but also WHY it has happened (has that joint been overloaded because something else isn’t working properly, have you had an accident, is there something in your history that would make you vulnerable to this kind of injury, etc?)

Then we can treat the patient (not the diagnosis) to help the body get itself back to health, rather that just supressing the symptoms enough for the patient to soldier on with slightly reduced pain.

This is the problem we have with the medical term ‘Diagnosis’: it so often is just a convenient label stating the main symptom, and not a diagnosis at all. There are many other examples, like ‘Fibromyalgia’. This is a diagnosis which has essentially been invented to allow a group of patients with a collection of symptoms to claim on their health insurance. ‘Fibromyalgia’ ONLY tells us what the symptoms are – it says nothing about their cause(s). What it does do is reinforce the ideas that the cause is the same in all patients, and that it is a distinct, self-contained entity. In reality, patients with ‘Fibromyalgia’ are part of a spectrum that includes M.E. and chronic fatigue syndrome, with symptoms including varying degrees of fatigue and widespread pain, and the causes are likely to be both complex and varied. Whatever they are, they have evaded us so far.

IBS is another “bucket diagnosis”. It refers only to the symptoms and makes no attempt to identify a cause for them. As a result, ‘treating the diagnosis’ means the same as ‘palliating the symptoms’, and patients have no hope of a medical cure, merely the hope that sufficient drugs will dull the symptoms enough to stop them hassling their doctor.

So, apart from the dishonest way the term ‘Diagnosis’ is bandied around, what other problems do we have with it? ‘Treating the diagnosis.’ This presupposes that the cause of all diseases are distinct, discreet, uniquely defined entities, that the cause of the disease is always the same for all patients and that all patients will respond in the same way. Reality is a bit messier: conditions may be caused by the interaction of a complex set of different factors, different factors may cause the same disease response in different patients and the very fact that a ‘Normal Distribution Curve’ exists is proof that different individuals will respond differently.

The over-arching principle of Osteopathy is that our bodies normally fix themselves. We can dress that up in all sorts of physiological terminology and then refer to it as ‘spontaneous resolution’, but the essential idea is that, given a chance to do so, our bodies will return themselves to health. That isn’t some kind of pseudo-religious doctrine, just a statement about the way our bodies are. Therefore, if you want to ‘cure’ someone, the best way is help get their body back into a condition in which it has that chance to return to health. How you do that will depend more on the individual than on the ‘diagnosis’.

So that’s why some Osteopaths don’t like the term ‘Diagnosis’. Too often it doesn’t do what it says on the tin, and even if it does, it is often not much use.