THE VALUE OF MANIPULATION
Not to discover what is new, but to see what has been discovered with my own eyes. - Goethe.
There is no doubt that manipulation of the spine is a simple procedure to master but there is also no doubt that many doctors cannot learn it. I know that a few doctors, after being instructed and having done the movements on patients themselves, return to their own offices and soon abandon the method. It reminds me of the difficulty of teaching orthopaedic residents to apply Denis Browne splints to an infant with club feet. Some of these welltrained young doctors simply cannot learn to apply them, whereas the junior nurse who is standing watching may grasp it immediately. So the obsolete treatment of club feet by wedging plaster casts persists by default.
In manipulation of the spine I think the basic element of the doctor's failure is his fear. He is afraid of injuring the patient, which for all practical purposes, is impossible. The new patient may emit a howl at the momentary pain, which may cause the doctor to be abashed. In a few moments the patient may be smiling but the doctor may have been severely and permanently shaken. Also, as sometimes happens, if the patient comes back in a somewhat hostile frame of mind after his first visit and says, "That treatment you gave me yesterday made me worse," the doctor should realize that another one or two treatments are likely to make a vast improvement. The doctor may fear that patients may regard him as a chiropractor and that other doctors will regard him as a quack. Then there are always the colleagues who forecast frightful disasters. One of my students was warned by a respected senior physician that if he persisted in spinal manipulation he would "fill the morgue." Another was similarly warned that if be persisted in manipulating the cervical spine he would cause cerebral haemorrhages. At last report both were receiving a great number of referred cases of spinal pain from neighbouring colleagues.
The temptation may be strong to return to the easier routine of muscle relaxants, pain pills, sleeping pills, injections of cortisone, lumbar belts, cervical collars, heat, short-wave, and sound waves; in short, the futile gestures which drive patients to lay manipulators.
A good deal has been written about the instantaneous relief as a result of spinal manipulations. It is true that the spectacular result does occur. The often excruciating first attack of spinal pain is usually relieved immediately. The patient may be brought into the office on a stretcher or a wheel chair apparently totally and permanently crippled and walk out fifteen minutes later apparently completely cured. The following typical cases are also common.
A doctor was unable to get out of bed one Sunday morning. Any movement caused excruciating pain in his low back. His lumbar spine was manipulated and within the hour he had had breakfast and departed for the golf course where he played eighteen holes.
Another doctor was unable to get out of bed one morning. His previous history was that he had had low back pain for several years, running the usual course of acute exacerbations and incomplete remissions. Two years previously he had worn a plaster body jacket for three months, an experience he did not wish to repeat. Manipulation of his lumbar spine was performed as he lay in bed and in half an hour or so, he too was up and about his duties. He had three further treatments during the next month, and although he is now apparently cured, further exacerbations are to be expected.
A lawyer managed to get into a sitting position on the edge of his bed and sat there for three hours unable to move. His daughter, who had become increasingly alarmed, telephoned. He too, in half an hour or so, was up and around giving little evidence of disability. In the following two years he had two treatments each for three much less severe exacerbations. The acute case, and to a lesser extent the acute exacerbation, if promptly treated, responds rapidly.
But, the doctor must realize that with patients who have long histories he may have to continue treatment for many months and thereafter at intervals, for years. A forty-year-old patient of mine presents an example. Her general health was excellent but she had suffered from "migraine" of increasing severity for twenty years. During the worst attacks she took to bed in a darkened room for two or three weeks at a time, with the constant application of cold packs to her head. She said that she had taken, at various times, "every drug in the pharmacopoeia." During the severe attacks she suffered a great deal from nausea and vomiting. Slhe was never free from pain, but she knew when a "bad one" was coming. At first she was treated every day for a week or so and she, as with most patients with long histories, enjoyed the relief she got sufficiently to continue coming. She was treated three times a week for many months. After eighteen months she has been reduced to one visit about every six weeks. Since the first treatment she has not had a single severe attack. When she recognizes the prodromal symptoms she comes in at once. Her insurance company surveyed the situation and decided that she was being over-treated, and refused to pay. As usual, with organizations that interfere with the practice of medicine, explanations proved to be useless. She paid her own bills.
The patient must be told to expect recurrences and when the pain returns to attend at once for treatment, in which case the doctor is likely to secure relief either immediately or after two or three treatments.
The following case illustrates many of the points we have been discussing. Every doctor in practice has similar ones.
The patient bent forward and lifted a ten-pound sack of sugar. He was seized with severe pain in his lumbar spine and was unable to straighten up. He was referred by his doctor for consultation and treatment four days later. He was in great distress. He needed assistance to walk, to sit down or rise from a chair and to get on to the examining table. He had been on Compensation for several months for a low back injury twelve years before. He had never been completely free from pain since and his disability had run the usual course of acute exacerbations and incomplete remissions, but he managed, with considerable difficulty, to keep working.
The radiation of pain was into the right buttock and down the right leg into the toes. There was also radiation of pain from the low lumbar spine to just below the knee on the left side.
Traction and manipulation were applied and this made it obvious that a nuclear lesion at the level of the disc at L 4- 5 was present and it did not seem to be far from an operative case. This was reported to the Workmen's Compensation Board.
The patient continued to improve slowly under traction and manipulation treatments for about two months, and then reached a stage of no further improvement. Disability though less, was still considerable and there was no possibility of the patient's returning to work.
There was not, at any time, any motor or sensory paralysis.
A myelogram was obtained after securing the permission of the officials of the Workmen's Compensation Board. It showed the expected indentation of the dural tube at the level of the L 4- 5 intervertebral disc. It was reported by the radiologist as being "strongly suggestive of a protruded disc at the L 4-5 level."
The following report was then sent to the Workmen's Compensation Board: "The myelogram showed a disc lesion at the level of L 4-5. I believe there is no alternative now but to proceed with the excision of the nucleus of the L 4-5 intervertebral disc. May I have permission for this operation?"
Four months passed, during which time treatment by traction and manipulation of the spine was continued. The patient got some relief from the treatments but no real improvement.
In a typical example of state-controlled practice of medicine, during this period the patient was subjected to about six different examinations by a variety of Compensation Board doctors and consultants. The usual astounding conclusions were reached. The highlights were that he "showed no objective sign of constant root pressure," there were no "root signs" and incredibly, the myelogram was declared to be negative. The patient's profound disability remained unnoticed and the claim was declared closed.
When this intelligence was received, a report was sent to the Board that there were only two alternatives in this case. One was that the operation must be performed, or two, that the patient must be granted a permanent total disability pension. This was ignored. Like Lord Byron, "I stood among them, but not of them, in a shroud of thoughts which were not their thoughts."
Two days after the claim had been closed, with no possibility of appeal, or change in the decision, the patient bent over to open a drawer and was transfixed and completely immobilized by pain. Surgery had become mandatory.
At operation an incompletely herniated nucleus on the right side of the L 4-5 intervertebral disc was removed. As usual, there had been no pressure on a nerve root. The patient made an excellent recovery.
The opinions of doctors who have had long experience in spinal manipulation should be weighed.
The following are testimonials, but they are testimonials in the best sense. They are the beliefs of colleagues who have long and earnestly pondered the ubiquitous problem of backache.
BANKART - 1932
The following is an extract from the book "Manipulative Surgery" by A. S. Blundell Bankart, an English orthopaedic surgeon, who is well known for the operation for recurrent dislocation of the shoulder, which bears his name.
"The association of manipulation with bone-setting, and other forms of unqualified practice and the preoccupation of surgeons with the bigger things of surgery generally, has led to much misunderstanding and neglect of this valuable resource in the field of legitimate surgery.
"This book is intended first of all, for the general practitioner, who finds himself up against all the activities of bone-setters and other unqualified manipulators whose methods he can neither criticize nor emulate, because he knows nothing about them. All he knows is that a great many of his patients go to bone-setters and say afterwards that they have been cured by them.
"Generally, the results of manipulative treatment are most satisfactory. Most of the cases respond readily, and over 90% are cured, or sufficiently improved to be able to resume full work in short order. The medical man cannot afford to ignore the art of spinal manipulation. He will meet it at every turn, and unless he knows something about it, he is helpless, both in criticism and in action.
"In recent years, a great volume of literature has grown up around the subject of pain in the lower. part of the back, or as American writers have called it, "low back pain." Under this title, a number of clinical and pathological conditions have been described, with a profusion and variety of detail which is quite bewildering. We believe that the symptoms and signs of most of these conditions have been needlessly elaborated, and that the majority of people who complain of pain in the back, are suffering from some simple affliction which is easy to recognize and generally not difficult to
treat. The great majority of these cases can be cured by manipulation; yet it is common practice to treat them with rest, local applications of massage, and exercises, while in some clinics, the search
for, and elimination of hidden sepsis and intestinal toxaemia is vigorously pursued. Some of the measures advocated are indeed calculated to make a dreadful impression on neurotic patients . . .
"Occasionally, as the result of manipulation, the cure is sudden and dramatic. It is exceptional to meet a case which obstinately resists treatment by manipulation . . .
"It will be noted that manipulative surgery is but a small part of surgery; but it is a very important part, if only for the reason that the cases which can and must be dealt with by manipulation are exceedingly common throughout all classes of the community. The medical man will find manipulation an invaluable and indeed, an indispensable aid in the treatment of a great many cases."'
MENNELL - 1934
James Mennell was in charge of the treatment of backache by traction and manipulation for about forty years at St. Thomas's Hospital in London. The following is quoted from his book:
"A cause of the fog of misunderstanding about manipulation has been the incredible cures that have been and still are claimed for it, even though there can be little doubt that an enormous amount of human disability and suffering is amenable to treatment by manipulation . ..
"Unfortunately, many writers who favour conservative treatment also issue warnings against any form of manipulation, Experience has shown that this fear of doing damage is grossly exaggerated.
The percentage of recovery sufficient to go back to full laborious work, perhaps even after a few days, would be considerably improved if more use were made of manipulation. One thing seems to be reasonably certain - namely, that so long as the medical profession withholds this method of treatment, so long will patients, whether operated on or not, seek the advice of manipulators outside the profession; and so long also will the reputations of these manipulators be enhanced by their success in curing where other methods of treatment have failed.2
MERCER - 1950
Walter Mercer in his book "Orthopaedic Surgery" (1950) stated:
"Manipulative surgery is a branch of surgery which has been undeservedly neglected by our profession, and it has in consequence fallen largely into the hands of unqualified practitioners. That it should have done so is a real misfortune, as manipulation, properly carried out on suitable cases, can be a most valuable therapeutic agent ......
BURROWS AND COLTART - 1951
H. Jackson Burrows and W. D. Coltart are English orthopaedic surgeons. Both are members of the Editorial Board of the British edition of the journal of Bone & joint Surgery. They dedicated their book "Treatment by Manipulation" (1951) to Reginald Cheyne Elmslie "who throughout his career taught the value of manipulative treatment, in this, following his predecessors Sir James Paget and Professor Howard Marsh." They wrote:
"The profession has been charged with neglecting manipulative treatment and with dwelling on the disasters of the 'bone-setter' (or the 'osteopath' or the 'chiropractor') rather than upon his known successes. It may be that many members of the medical profession know too little of the selection of cases for manipulation, its technique and the results which may be expected from it . . .
"An uncommon condition in which manipulation may bring immediate relief is that which was formerly ascribed to cervical 'subluxations', in spite of the lack of radiological evidence. The patient is seized with sudden cervical pain and rigidity, which may cause an acute torticollis. Of ten the onset is in the early morning, waking him from sleep. Possibly many or all of these cases are due to injury of cervical intervertebral discs, the clinical picture and the response to manipulation suggesting comparison with 'lumbago' from presumed rupture of an intervertebral disc at another level ...
"Just as a ruptured intervertebral disc may give root symptoms and perhaps signs, as in 'sciatica' from interference with the fourth or fifth lumbar or first sacral root, so may a ruptured cervical disc produce root symptoms, and perhaps signs, in the upper limb.
"It has long been known that the agonizing pain and severe stiffness of 'lumbago' could be relieved by manipulation; and this was puzzling in a condition which was ascribed to acute lumbar fibrositis. Now that we believe many of the cases to be due to internal derangement of a joint, the dramatic improvement has become more explicable . . .
"Another acute condition is the so-called sacroillac 'subluxation' in which acute sacroiliac signs come on suddenly and can be relieved equally dramatically by manipulation without the use of anaesthesia. The radiological evidence of subluxation is equivocal, and the true nature of this condition must therefore be regarded as uncertain."
WILES - 1955
Philip Wiles in his book "Essentials of Orthopaedics" (1955) wrote that:
"Manipulation is an important feature of the active treatment of both acute and chronic back pain. It is a simple business and should be part of the therapeutic armamentarium of every doctor.
"No satisfactory reason has so far been advanced to explain why manipulation often relieves pain, nor it is likely that the problem will be solved until the causes of the pain are better understood."5
CYRIAX - 1955
James Cyriax of St. Thomas's Hospital is the author of several books and many articles on our subject. In an article in the British Medical Journal (1955) he wrote:
"At a meeting of orthopaedic surgeons, the following statement was made and the following question asked. One-third of all orthopaedic patients complained of low backache. Had the panel any suggestions for coping with this vast number? - They had none."
"Neglect by medical men to consider manipulating a spinal joint, even after they themselves have stated internal derangement to be present, has created a group of laymen styling themselves osteopaths, chiropractors, and bone-setters. Patients do not wish to seek treatment outside the medical profession; but they find that they have to go to a lay manipulator; and one must admit that, though devoid of diagnostic skill, such laymen often, in spite of not realizing the nature or level of the lesion, relieve the patient immediately by a few simple manipulations."
Cyriax' article caused a roaring controversy to erupt in the correspondence columns of the British Medical Journal which continued for many months. One doctor wrote that the attitude of the orthopaedic surgeons to this problem seemed to be "reassurance without treatment"
Others attacked Cyriax; but it was painfully obvious, and a silent reflection on our scientific attitude, that not one of these doctors gave any indication of his having gone to St. Thomas' Hospital in London to examine and to evaluate for himself what was being done.
BARBOR - 1955
R.Barbor, an English general practitioner, wrote in Cyriax' book, Disc Lesions for the General Practitioner. Cassell, 1955.
"For the past four years I have tried these methods out and can assure my colleagues that they are perfectly applicable to general practice. I also find the results astonishingly good. These cases find their way into the doctor's office every day and I am afraid they are only too often dismissed as "fibrositis" or "rheumatism." Treatment is therefore, as dull for the doctor as it is unrewarding for the patient . . . "
PARSONS AND CUMMING - 1958
In The Practitioner for August 1957, a symposium by several authors on low back pain was the feature of the issue. One of the authors wrote that "manipulation is a bitter price to pay for restored mobility."
"This," commented W. B. Parsons, in an editorial in the Canadian Medical Association Journal, "from the country that had produced such men as Sir Robert Jones, Blake, Marlin and Mennell, is unexpected, since the world beat a path to the door of these physicians because they brought relief by means of manipulation."'
Parsons and Cumming (1958) wrote that:
"Manipulation will relieve back pain in many instances; and few will disagree. There the agreement ends. Those who manipulate swear by it. Those who do not, condemn it. Those who do not manipulate warn of all the catastrophes that can result from the practice, while the patients of those who do, flock to their offices for relief. This conflict comprises one of the medical anomalies of the twentieth century. The standard medical treatment for lumbago and other acute backache is rest in bed and sedation, counter irritation and heat, possibly supplemented by massage and injections of procaine. The doctor whose therapeutic armamentarium is thus limited is at a disadvantage. His patients soon find that in the majority of instances they can get relief without the loss of time from irregular practitioners. These practitioners can often relieve the pain, but their lack of training has made them simply mechanics ...
"Our treatment by manipulation (of the spine) has for twenty years brought gratifying results with none of the disasters that so many predict. The reason we took up manipulation was an interest in backache, with the early discovery that many patients who failed to respond to routine medical treatment went to a manipulator and received immediate relief.
"Manipulation is an art as old as medicine. The secrets of its practitioners were usually handed down in the family. The operator himself was often attached to a monarch, or a wealthy household.
"Unlike the barber-surgeons, the manipulators were not taken into the fold of orthodox medicine. Nevertheless, a few doctors, particularly in the United Kingdom, took up the art; and many of them became great names in medicine. But their ideas were not generally accepted by the medical profession at large, and though their methods are available to all, few have taken them up.
"Much is said about the hazards of manipulation. We do not know what they are. Possibly the fear is of displacing the disc to the point where it will be impacted, and laminectomy will be required. In the cases we have referred for laminectomy, the pattern did not change from the beginning; and it was our feeling that the protrusion when first seen was irreducible. It may be that manipulation can cause harm, but we have not seen it. It is our belief, based on long experience, that manipulation is no more beset by hazards than many other recognized procedures in therapy, while its results are often more dramatic and sure."'
WILSON - 1962
D. G. Wilson reported in The Lancet (1962) on a ques tionaire he sent to members of his College of General Practice in the North of England:
"Out of the ninety-two general practitioners who replied to the questionaire thirty-eight themselves manipulate their patients. Their training varies from the rudimentary to the sketchy. In any other branch of medicine, this would rightly create anger, alarm, and despondency and provoke demands for proper training and the provision of a list of those trained. But here the situation seems different. It can hardly be claimed that those practitioners are irresponsible who themselves give manipulative treatment, and that they expose their patients to danger - though this is the view of a minority. They have acted in response to the pressure of events, spurred on by the success of the osteopaths, and the relative ineffectiveness of the consultant services . . .
"It is to be hoped that the presentation of these facts will alert those responsible to the existence of a yawning gap in both undergraduate and postgraduate teaching. It is obvious that, in this field, doctors are being trained in one way, and then laboriously re-training themselves in another. In the process, they become dissatisfied with the help they receive from the consultants in orthopaedic surgery. It is hoped that the figures presented in this paper may help to persuade consultants of the importance of this type of treatment, and cause them to take their rightful place in training general practitioners to treat their own patients. Perhaps though, the consultants will first have to undertake some retraining and reorientation themselves.
Quis custodiet ipsos custodes?
There is no good explanation for the fact that manipulation has been neglected by the medical profession. It is not taught in medical schools with the exception of St. Thomas's Hospital and the Middlesex Hospital in London. Hence, few general practitioners know anything about it, even though almost every doctor in practice has been shaken by the fact that patients of his, for whom he could do nothing, have been cured by the bone-setters. It is an inadequate excuse that the association with bone-setting and other forms of unqualified practice causes many orthopaedic surgeons to hesitate to adopt it. They may not know that it is an ancient medical art dating back beyond Hippocrates. Unfortunately, the dangers of manipulative treatment are emphasized by doctors who give no evidence of ever having used it, or even of having seen it used, which is again a comment on our scientific approach.
I have corresponded with all the available authors mentioned in this chapter. They regard the possibility of injuring the patient as remote or even impossible. In my own practice, I have, in error, applied traction and manipulation on several occasions to each patient, to cases of early tuberculosis of the spine and to cases of early malignant disease of the spine. Before long the error became obvious. No harm seemed to have been done to any of them. I have applied the same treatment to many cases which later proved at operation to be herniations of the nucleus. They were not improved, but they were not harmed. The fear of causing "massive prolapse" or some such disaster is groundless.
In nuclear lesions of the intervertebral discs there is no alternative to and no substitute for, manipulative treatment. If this falls, the surgical removal of the nucleus must be considered and the possibility of an error in diagnosis evaluated.
In the use of spinal manipulation in the treatment of spinal pain a doctor has an insuperable advantage over a bone-setter. He can select his cases with exactitude, whereas the bone-setter, who believes that all diseases arise from "a little bone out of place" somewhere in the spine, is perfectly willing to manipulate cases of smallpox, diphtheria, or bubonic plague.
We have thought over various alternative methods of treatment but have not undertaken any of them.
Investigators who have been noted earlier in the text have injected the nuclear space with saline and other solutions and have noted inexplicable relief of pain in many patients thereafter. The fluid supplies a cushion between the fibrous nucleus and the posterior annulus. It is probable that if these injections were done deliberately so that the needle was thrust barely through the posterior annulus excellent results would be secured, because if some lamellae remained intact, the fluid would remain almost permanently. However, thrusting a needle into the nuclear space is a miserable experience for the patient, and it has its elements of danger. If one were to inject the wrong nucleus a new nuclear lesions would be started. And, there is always the spectre of infection.
Some bacteria secrete substances which dissolve fibrous tissue so it is theoretically possible that a substance might be developed which would dissolve the fibrous nucleus. It would have to be minutely and exactly selective so that while dissolving the nucleus it would not also dissolve the surrounding cartilage and the bone. It seems unlikely that a substance of such definite selectivity could be developed. If it could, we would again be faced with the objections of driving a needle into the nuclear space. We prefer therefore to remain with the safe method of traction and manipulation, and to operate only when driven to it.
A CONSIDERATION OF METHODS OF TREATMENT AT PRESENT IN VOGUE
1. BED REST
This is debilitating to the patient both physically and mentally and has no influence on the progress of the nuclear lesion. The patient may be comfortable while in bed, but as soon as he gets up and moves about the erosion of the annulus begins again.
2. TRACTION IN A HOSPITAL BED
This is really simply bed rest, as the traction applied is completely ineffective. Judovich" aided and advised by a physicist, made live subject and cadaver studies on the effect of traction in bed. He found that the average surf ace- traction resistance of the body in a hospital bed is approximately 26% of the total body weight of the patient. Therefore, if one wished to apply one pound of traction to the lumbo-sacral joint in a two hundred-pound patient, it would be necessary to apply fifty-two pounds of traction to the legs before any force was exerted on the lumbo-sacral joint, and then one pound extra would apply one pound of traction.
The application of traction to the cervical spine by means of a head halter in a hospital bed is (at least in nuclear lesions) a pathetic demonstration of helpless futility.
3. THE PLASTER JACKET
A plaster jacket will partially immobilize the spine and relieve pain to a considerable extent, if not completely, while it is retained. It is cumbersome and uncomfortable to the patient, and after it is
removed the erosion of the annulus starts again. The same objection applies to corsets, belts and to neck- immobilizing apparatus.
The injection of "trigger points" or tender "myalgic spots" with anaesthetic or other solutions is rarely indicated.
The application of heat is a comfort to the patient with severe pain; but most of the relief is from the prone, immobile position. The application of various rays has no effect, neither has massage, except possibly mild palliation.
A popular method of treatment is to hand out prescriptions for pain pills, sleeping pills and muscle-relaxing pills. If the patient does well under this regime his doctor has good cause to suspect that a lay manipulator has been consulted.