You bend down to lift something heavy, perhaps your own child, and feel something ‘go’ in the small of your back. You feel an exruciating pain and cannot even get up. One day, you feel pain and stiffness in your neck and you think that it may be due to an odd position your neck was in while sleeping.
Coming down the stairs you slip and sprain your ankle joint, or you open your mouth to yawn and cannot close it.
These pains start so suddenly and should have an equally short and effective treatment by which whatever has happened can be reversed. A lot of physiological changes occur in the pelvic region of the mother during childbirth. These may leave her with a low back pain. It was formerly thought that the cause of the pain was lack of proper care given to the mother after delivery. This is not true. Some re-adjustments which should take place of their own accord after the child is born, do not take place and the pain persists. Hence the cause of pain is purely mechanical.
Not only this, but a wrong method of sitting, standing, doing household work, or even a proloriged illness may leave you with a persistent back pain, sciatica, spondylosis, brachial neuralgia, headache, insomnia or even dysmenorrhoea.
There are innumerable problems which can be narrated one after another, and which are so common. What are the possibilities for their cure and what possible remedies can you get for them? The pain may clear in a few days and you may think it was a simple sprain or myalgic pain. Or when it is unbearable, you may land in hospital where a lot of investigations are conducted and x-rays taken. You may be told that the pain is due to a slipped disc or spondylosis.
You are probably advised to take complete bedrest for a few weeks, undergo diathermy (which will emit heat heat to your deep-seated joint) or massage, continuous or intermittent traction, wear a collar or belt, take medication, use applications, do remedial exercises or try out some other treatment.
There is a possibility of getting cured. But it is also probable that in spite of devoting a lot of time, undergoing torturous treatment and heavy expenses, the pain persists. Ultimately you are told by a specialist or a consultant, ‘you are going to have this pain throughout your life; this pain will not go and you should learn to live with it.’ You may also be advised to have disc surgery without any assurance about the result. And even if you are cured following the operation, you will have a weak back and will live the rest of your life, taking a lot of precautions and observing many dos and don’ts.
Many patients end up going to a healer who may hang them upside down and tie their ankles to the roof, for half an hour every day, day after day. Some may be given electric shocks. In other cases red hot iron rods may be pressed over the area of pain. Some patients even resort to witchcraft, faith healers, sadhus and mullas. They may be asked to wear a copper bracelet, or they may go to a bone setter and get cured by sheer luck. If they are wise, they will resort to vertebral manipulation.
After my medical graduation I joined the Central Institute of Orthopaedics, New Delhi, one of the most reputed orthopaedic institutes in the country. Patients with various types of pain came in large numbers and in spite of the best facilities of diagnosis and treatment, we did not seem to be helping them much. Week after week, month after month … the treatment seemed to be unending in quite a few cases. While we were so effective in the treatment of fractured bones and other ailments, I kept wondering why we could not help patients with chronic aches and pains. I consulted my orthopaedic books to find that manipulation was mentioned as one form of treatment. Why were we not using it? I tried to question my teachers but they could not give me a satisfactory answer. I then decided to go to England to become an osteopath.
Manipulation is an art, a science and a philosophy. Manipulation is sometimes called orthopaedic medicine or finger surgery by medical practitioners. Manipulation is one of the oldest techniques used for healing different ailments of the body. Bone-setters have been known to exist since olden days in almost all parts of the world. However they seem to have confined themselves to fracture cases, and used a few manipulative manoeuvres. Manipulation has been successful in a few cases though without carrying out any diagnosis. It was mostly done by lay persons without any knowledge of human physiology and pathology.
Hippocrates, the father of medicine, used to manipulate the spines and joints of his patients. A table used by him for this purpose is still preserved at the Welcome Historical Museum, London. Sushruta, the famous surgeon of ancient India, used to manipulate many of his patients; he described this in his Asthichikitsa (Bone Treatment). This method of treatment is not readily accepted by modern medical men. Manipulation attracts criticism, misconception and scepticism, and rightly so, as it has mostly been done by lay manipulators. In the absence of knowledge of pathology, grievous injuries may be caused to patients. It has often been referred to in the following manner; ‘A brutal and blind treatment …’ ‘A dangerous form of psychological treatment …’ ‘An occasional good result does not compensate for the accidents it can produce…’ Often these criticisms stem from people who have not participated in a well-conducted manipulation session. This criticism is, however, now dying out, since many medically qualified people are being drawn towards it. It is now being built upon a sound scientific base and is the main therapeutic used by orthopaedic surgeons abroad and by a few in India as well.
Many appreciative comments have also been coming forward: ‘Results are astonishing …’ ‘It shortens the period of recovery and protects a patient from prolonged agony and mental apathy …’ ‘It avoids many an unnecessary operation …’ With the development of the osteopathic profession and hospitals, colleges and research centres, manipulation has become more accurate and scientific. Several orthopaedic surgeons abroad manipulate each and every case, and resort to an operation only when manipulation fails. There are signs of increased respectability being given to manipulation as a therapeutic measure. If a patient wants to recover fast, the physician is also equally anxious to cure his patient as fast as he can. This gives him great work satisfaction.
When I got admission to the London College of Osteopathy in September 1966, most of my colleagues were British general practitioners who had 10-15 years of lucrative general practice behind them. They were not happy with their results; sometimes they did not know how to help their patients. After hearing about manipulative treatment, they tried to learn one or two techniques from a friendly osteopath, used them casually on their patients and were so happy and surprised at the results that many of them decided to leave their practice, learn manipulation more thoroughly and in greater detail, and after completion of the course, and convinced of its efficacy, settled into full-time manipulative practice. At first it seemed unbelievable to me that patients could improve so much with the use of one’s hands. How right was the saying that a certain physician had ‘fame in his hands! His mere touch was enough to cure! This may have been an exaggeration, but the importance of hands cannot be denied, especially for a manipulative physician. A physician’s hands convey compassion and understanding – more so those of an osteopath who makes use of his hands more than any other physician.
Susceptibility of the Spine to
Why is the spine so susceptible to pain? The answer lies in man’s acquisition of an erect posture. During the process of evolution, man became a biped from a quadruped. When walking on four feet, the spine was supported by the two hands and feet. It never had to bear the flexion strain as it had no need to bend forward, being supported by the feet.
When man assumed an erect posture, the compression and flexion strains were added to the spine, for which it was not designed. Worst of all, each pair of nerves emerged from the weakest portion of the spine–that is, the intervertebral joints. Moreover each joint contained a disc (except the two uppermost) – a ring of fibro-cartilage with a pulpy centre, and a nucleus pulposus, adding further to the spinal weakness.
The physical and mechanical factors which influence the body are complex entities. Apart from environmental and inherent factors, gravity, pressure, weight, elasticity, leverage, movement, and so on, also play a great role. The normal contraction of muscles counteracts gravity, the elasticity of ligaments allows the joints to move, while countless mechanical forces act and interact with each other. This is the realm of applied mechanics of the human body. The spine is vulnerable even to normal mechanical stress. This abnormal stress due to bad posture, or an abnormal strain due to jerk, twist or strain, or a fall can produce a mechanical disturbance in the spine known as an osteopathic lesion.
An osteopathic lesion is a condition of impaired mobility in an intervertebral joint, in which there may or may not be an altered positional relationship of the adjacent vertebrae. When there is restriction of movement it is always within full range of movement. It can be caused by:
An osteopathic lesion is not as pronounced as dislocation. A lesion causes pressure on the nerves, altered blood circulation, oedema, tissue changes, muscle spasms. In the case of a chronic lesion, the adjacent joints sometimes become hypermobile and compensate for the restricted movement. This restricted movement at a particular intervertebral joint is difficult to diagnose, since the movement at these intervertebral joints is very small individually. But in combination with others, it is very marked. So if there is a little restriction at one or two intervertebral joints, it may not be noted in certain cases and this is why it produces a lot of difficulty in diagnosis during the clinical examination. There shouls be an osteopathic examination to detect this condition.
Apart from a clinical examination, osteopaths depend on palpatory diagnosis: the feel of the tissue, the feel of the muscle, the feel of the movements at the intervertebral joint. To be familiar with this type of feel and appreciate and distinguish the variation in different patients by a physician who is not trained osteopathically, is difficult. Clear demonstrations of these changes by a measuring gauge or a clear distinction and demarcation is not possible. This is also one of the causes due to which physicians look at their osteopathic colleagues with scepticism.
Osteopaths have to use their hands a lot in diagnosis and treatment. Their sense of touch improves with constant use, the feel becoming more refined. They are able to distinguish even a small tissue change, muscle spasm, difference in the warmth of the area; even the difference in mobility or restriction of movement with the help of their fingers, with the help of their sense of touch. They try to ‘see’ through their fingers, they have ‘thinking’ fingers. Blind men, for instance, have a much more refined sense of touch and a much sharper feel. This refinement comes through constant use.
At the London College of Osteopathy, we were each handed a six-pence coin. We were told to keep it in our pockets, and feel it constantly with our fingers. We were asked to try and located the queen’s crown, the nose, the ears – to just feel and keep on feeling so as to be able to distinguish them easily. A student in medical college is raw; he has to build upon the clinical knowledge he acquires at college to become a better physician or surgeon. So it is with an osteopath. When an osteopath comes out of an osteopathic college, he has only a base. With the constant use of his fingers and his clinical sense, the precision of his judgement makes him a better osteopath.
Every doctor cannot be a good surgeon; similarly, everybody cannot become a good osteopath. This is why osteopathy has been called an art. Everybody cannot be a master of the sitar or violin. It calls for a natural instinct and inherent qualities, besides rigorous training. Osteopathic treatment cannot be prescribed like medicine three time a day. An osteopath cannot say, ‘Take traction for 15 minutes every day with a fifteen-pound weight for ten days, or take diathermy for 10 minutes every alternate day for ten days’. It is difficult to prescribe the amount of force to be applied or the sequence of manoeuvres. Having a comprehensive grasp of the subject, osteopaths diagnose the disease as they go on with the examination and programme their techniques accordingly. The same thing is repeated at every visit of the patient. Osteopathy is not just manipulation. It includes understanding the mechanical problem, the patient, the contributory factors, and then adapting the technique at the time of treatment to the patient.
A few techniques can definitely be taught to general practitioners or physiotherapists, and applying them will definitely give them a certain amount of success. Who can densy the fact that bone-setters are sometime successful? They have learnt a few manoeuvers as a family tradition and use them on patients. In recent years a big advance has been made by the medical profession in using manipulation as a therapeutic measure. Way back in 1945, Cyriax made it know that back pain, sciatica, cervical spondylosis and brachial neuralgia were due to a slipped disc. Since then manipulative treatment has obtained a firm footing in the medical world. The most effective treatment for a slipped disc or protrusion of the intervertebral disc now is to slip it back to its normal position. This is what osteopaths aim at. Most orthopaedic surgeons use manipulation on their patients. Treating these cases with heat, liniment, muscle relaxants and pain killers implies sticking to the old medical belief which considered the cause of pain to be muscular, and so named it fibrositis or myositis.
If the number of disc operations being performed five years ago was one hundred, these have now been reduced to about five. How has this figure fallen so drastically? The answer lies in manipulation. Surgeons have begun to understand better the futility and poor results of disc surgery. Surgery can lead to neurological damage.
Osteopathy recognises the structural abnormality of the spine. It aims to normalise the mechanical defects and when this is not possible, it tries to make the body adapt itself to the Structural weakness. Structural abnormality has an adverse effect on the harmony and efficiency of the body. These faults sometimes persist long enough for diseases to appear. The body is constantly trying to restore itself to normalcy, and thus to normal health. A spontaneous restoration to good health after an accident or illness is the rule. Most fractures unite whether we help nature or not, but the result is functionally better, if during the repair, we splint the bone into normal alignment. It should be our aim to help nature as much as we can by removing mechanical hindrances.
When we manipulate the spine, we are not so concerned about putting the bone back into place, as with removing mechanical hindrances, if any, and the restoration of normal movements in the affected joints. Or effort does not embrace the static structural problem. We are more concerned about the dynamic structural problem. Mechanical disturbances can adversely affect the body in the following way:
When mechanical adjustment is done, it stops deterioration of the bone and tries to normalise abnormalities as far as possible. Lord Brain (1963) maintained that the chief reason for manipulation was to reduce an intra-articular displacement. Since cervical spondylosis is secondary to the changes in the disc symptoms, in the early stages it stems mainly from a minor degree of disc protrusion. We have clear confirmation that prophylaxis and the treatment of choice in these cases is manipulative reducation. It is the first treatment to be considered unless some contraindication exists.
Myrin (1967) compared a series of cases of pain in the lower back treated by conventional methods (rest in bed, physiotherapy, corsetry, and so on) and manipulation, and his results were tabulated as follows:
Effectiveness of Spine Manipulation
R E L I E F
According to the Sunday Citizen of June 20, 1975, an American firm compared the effect of manipulative treatment of backache for 15 months with that of traditional treatment given for 15 months earlier. They found that the total days lost from work dropped from 1,203 to 119. Disorders causing neck stiffness, arm pain, sciatica, and so on, can be usually recognised for their true nature. However, when spinal disorders occur in the area where they cause remote symptoms resembling heart disease or gastro-intestinal disease, then the situation become difficult. It is disastrous when a life-threatening disease goes unrecognised. But it is equally disastrous to be given a false diagnosis of heart disease or lung disease or some other serious affliction, when in reality the cause lies in the accessible and treatable condition of the spine.
We are apt to label a normal heart as diseased because of the failure to understand the mimicking effect of the mechanical disorder of the musculo-skeletal system. This problem is a serious one and is one of the main concerns of the osteopathic profession. In fact the differential diagnosis of pain is one of the main concerns of the medical profession. To ignore the fact that pain in a remote area may be caused due to a disturbance in the musculo-skeletal system will be to ignore a major fact of medicine. Doctors of medicine are beginning to write articles and books on this finding.
Ordinary backaches and recurrent headaches are annoying but do not provoke fear. It has been determined that a common cause of headache is the disorder of the cervical spine. It iis very important that any mechanical disorder of the cervical spine should be recognised and treated as a common cause of headache.
Symptoms often appear at a distance at a distance from the lesion, as for example:
If this is possible why it should not work the other way around too? Our nervous system is not a one-way street. It conveys impulses from the inside of the body outwards and from the surface of the body inwards. This fact has long been known but never appreciated. Disturbances affecting the surface of the body skin, muscles, ligaments and tendons may simulate diseases of the body organs. So the mimicking effect of these disturbances, while making a diagnosis of a certain disease, should definitely be given consideration.
A patient with disorders of the musculo-skeletal system is often treated as a ‘neurotic’. This are cases on record, where electric shock treatment has been given for a ‘neurotic-back’ patient; this was later corrected by osteopathic manipulative treatment. The sixty per cent of the body mass which comprises our musculo-skeletal system should be given due consideration in any diagnosis.
Manipulation can be done in four ways:
<>BDirect. The method of applying direct pressure is used on the spine itself. This manoeuvre is generally used by chiropractors. Pressure is applied by the heel of the hands. The exact force is short and sharp. It is mostly applied at a level of transverse processes. It necessitates a strong pressure which cannot be graded. It is often unpleasant and sometimes painful, and often has limited use.
Indirect. The manipulations are done indirectly through levers formed by the hands, shoulder, pelvis and legs. No pressure is put directly on the spine. The osteopath manipulates in all directions, through every vertebra, and the strength used is always possible to grade. The patient is properly positioned. This helps the operator to execute measured mobilisation and this movement can be repeated. This manoeuvre is mostly painless. A very mild push, a slight jerk, a little passive movement – all bring great relief.
Semi-Indirect. This is applied for higher precision in different regions of the spine. Direct pressure is applied to the manipulated segment with the help of the hand, knee or chest . Manipulation is accomplished by a sudden movement of a distant part. Counter-pressure is applied by the hand, knee or chest.
Constant Pressure. This is used for the cranial region. It is applied in a particular direction depending on the articulation of the cranial bones. There is no possibility of using leverage as the shape of the skull does not allow it.
When bones are moved while manipulating, a click by a palpating hand is sometimes audible even from a distance. This is not due to the disc being pushed back into position. It is the sound of separation of the two surfaces in a particular joint. The sound originating from the disc is a very soft one; it is generally not audible but definitely palpable.
Manipulation often needs to be repeated in a long-standing cast at certain intervals-generally of one week. This provides a complete opportunity for the repair and healing process of the torn fibrosis and intervertebral joints which have moved slightly. The time interval of one week may be shortened or prolonged in selective cases.
In a disordered intervertebral joint, the muscles and ligaments get shortened and fibrosis takes place. Manipulation is done to remove the fibrosis and to position mal-positioned bones, ligaments and muscles. This manoeuvre quite often needs to be repeated. Generally, relief starts from the very first treatment. Occasionally, two to three treatments are required before relief is felt. No fixed rule can be laid down about the number of times treatment may be needed for a particular case. Each case is subject to individual assessment.
An osteopath generally does manipulation without anaesthesia. Here the patient’s own resistance also comes into play and helps to avoid over-manipulation of the joint. A mild push, a very slight jerk or even a little passive movement is far more helpful than great force or a loud noise.
Manipulation is of great help for faster recovery and also in cases which are not amenable to other forms of treatment. This is so however, only if it is used wisely. Manipulation should be done only by properly trained persons who have mastered the art. They should understand pathology before manipulating and diagnose the disease properly with the help of a proper clinical examination, X-rays and laboratory tests. It is necessary to have a good X-ray picture. A poorly taken X-ray may miss out on a fracture of a vertebra which is an absolute contraindication to manipulation. The actual pathology of the spine where the bone itself is involved must be understood before manipulating a patient. Manipulating a case of tuberculosis of the spine or cancer or a tumour of the spinal chord may land a manipulator in trouble.
A patient suffering from incontinence of urine or uncontrolled bowel action is not a case for manipulation. A patient who has severe pain and cannot move in bed should not be manipulated till the pain has subsided considerably through bedrest and other therapeutic methods . In fact 1 to 2 weeks should be allowed to pass before manipulative treatment is given.
Manipulative manoeuvres also differ in different cases. In one case, forceful manipulation may be needed but in another, mild manipulation may do. It is always better to adopt a milder manoeuvre than a forceful one. Manipulation should also be tried in cases where it cannot cure completely, but can provide considerable relief. Cases of old-standing osteoarthritis of the knee and spine ankylosing spondylitis or bamboo spine) can get considerable relief by this method. Some cases respond in a very short time, others take longer. A patient who has been suffering for a long time takes a longer time to heal than a person whose pain is of a shorter duration. In old cases, where there is disuse of a particular limb as a result of pain, there may be muscle wasting or reduction in girth, but the patient recovers as the pain disappears and normal use of the limbs is resumed.
Manipulation should not be repeated too often, and should not be carried out till improvement continues after the first treatment. Ideally, it should not be repeated without a gap of a week or fortnight, or till considerable recovery has taken place. A few patients need maintenance manipulation twice or thrice a year, so that recurrence of the disease does not take place, specially in cases of postural strain.
Many patients with a prolapsed disc in the lumbar spine feel better while walking and standing rather than sitting. They are advised to maintain a horizontal or vertical position and to avoid half-lying or sitting for long periods. Prolonged bedrest is not desirable; it does not accelerate recovery and tends to weaken the general musculature. The morale of the patient also reaches a low ebb.
Activities which accentuate the pain should be avoided, especially those activities following which pain is accentuated. This is an indication that the nerve root has been irritated and has got inflamed due to activity. A corset (belt) can be worn for short periods. It reduces the risk of irritation to the nerve root and reminds the patient to take care, thereby helping to avoid recurrence of the problem. If it is worn for a longer time, however, the muscles become weak and wasted. Thereafter, taking off the corset becomes difficult. After recovery, the patient should be encouraged to do certain exercises to strengthen the muscles and to develop a natural corset of his own muscles, thereby discarding the artificial one as soon as possible.
Manipulation is safe and complications do not occur if due precautions are taken, and unnecessary force is not applied. An occasional accident cannot be completely ruled out. But merely for this reason it is neither fair nor wise to condemn manipulation. If an occasional death under anaesthesia, a fatal haemorrhage or surgical shock, or failure of surgical techniques led to total condemnation of surgery, then the human race would be worse off. Similarly it is unwise to condemn all manipulations, simply because on one or two occasions, the patient’s condition has worsened. The fault lies with the manipulator and not with manipulation!