CORRESPONDENCE near Ma ^am , Having suffered from recu rren t attacks o f low back- r : fo r th e past 20 years, I have developed an interest ■ t h e subject and have also been tr e a te d . by several Orthopaedic Surgeons, P hysiotherapists and a C hiro- Pfw y O rth o p a e d ic colleagues have been a t a loss to volain the acute locked back and referred m e fo r hvsiotherapy. T hose physiotherapists, un ab le to m an i­ pulate and using U ltraso u n d o r SW D alone, have usually been e ith e r ineffective o r have aggravated the ^T hose persons practising gentle rep etitiv e m a n ip u ­ lation (M aitland), have alw ays been successful in 1 o r 2 treatments in effecting a longlasting cure. Having o p erated on m any cases o f disc prolapse, I am able to offer m y in terp re tatio n o f the acute locked kck, and ch ro n ic backache. fTh'e nucleus pulposus is n o rm ally a gelatinous material contained w ithin th e in terv erteb ral jo in t by the flat surfaces of the vertebral bodies and th e annulus fibrosis. T h e la tte r is reinforced by th e a n te rio r and posterior lo ngitudinal ligam ents. W ith age the nucleus pulposus loses its elasticity and takes on the consistency of fibrous tissue, w hich on rem oval looks like ‘crabs meat”. At o p eratio n several features a re interesting: • T he disc contents m ay have ru p tu red th e annulus and dissected under the p o sterio r longitudinal ligament. • The h ern iatio n m ay be lateral, com pressing a single nerve root, causing u n ilateral sciatica. • T he h e rn ia tio n m ay be central, causing e ith e r severe backache o r b ilateral sciatica. • T he disc contents m ay be to tally sequestrated and lying free in the n eu ral canal. I have rem oved a piece m easuring 4 cm x 1 cm in diam eter. • On probing a prolapse, th e disc contents m ay ooze through the hole like to o th p aste o r be teased out w ith a p ro b e in a solid lum p. • A disc space m ay be found to be em pty — p ro ­ bably th e result o f lateral sequestration. • P rolapse o f the disc, is m ore o ften th a n n o t at a level o th er th a n the o n e reported as narrow ed on \ ro u tin e X -ray of the lu m b ar spine. 3 Plain X -rays' are valueless in localising th e sym pto­ matic level. F ro m these o bservations degenerate disc is solid and not gelatinous. T h e solid m aterial w ithin the intervertebral jo in t m ay be loose and squirm w ithin that space. T h e disc contents are insensitive, b u t the surrounding ligam ents are p ain sensitive and cause the backache o f a to rn m eniscus w ith locking, giving way, pain and swelling. Squirm ing.causes local protective m uscle spasm w hich frequently localises to th e sacro-iliac joint, th e o rig in o f part o f the sacro-spinalis muscles. Should th e contents squirm to one side, the back will lock and lean aw ay from th a t side. F lexion, especially w hen associated w ith rotation, causes p o ste rio r squirm ing and stretching of the annulus and p o ste rio r longitudinal ligam ents. W hen also associated w ith lifting a heavy w eight, those liga­ ments w ill stretch o r ru p tu re w ith fra n k disc prolapse. T he acute locked back o r sm all prolapse w ill respond to gentle rep etitiv e m a n ip u la tio n and traction. F ra n k (MART 1978 25 p ro lap se will be aggravated b y traction and requires surgical rem oval. F o rcefu l m a n ip u la tio n m ay cause fran k prolapse, especially u n d er anaesthetic. M ild sciatica is caused by local oedem a o f th e nerves. P ro fo u n d sciatica is caused by disc prolapse i.e. nerve com pression. O ne cannot localise the side o f prolapse from looking a t the sciatic scoliosis as this is dependent on w hether the nerve ro o t is compressed fro m above o r below. I h ave om itted to m ention o th e r causes o f backache e.g. p rim ary an d secondary tum ours, fractures, infec­ tions, in stab ility and spinal stenosis, as space does not perm it. I am n eith er im pressed w ith the vague diagnosis of strained muscles, ligam ents o r a rth ritis o f the spine, n o r do I believe th at patients should b e relegated to a lifetim e in a corset o r labelled psychological. B ackache is very real, and w hen p ersistent, justifies p ro p e r in­ vestigation and treatm ent. M. J. B IR D M.B., Ch.B. F.R.C.S. O rth o p aed ic Surgeon T H E IM PORTANCE OF H A N D S M adam , I t is great concern fo r the im age an d fu tu re of p h ysiotherapy th at prom pts m e to w rite this letter. O ver th e years I have heard a variety o f com m ents fro m m em bers of th e m edical profession ab o u t the p ractice of physiotherapy, b u t none so disturbing as m any I have h eard m ore recently. I quote: • W hile I was treatin g a general p ra c titio n e r w ith b ro n ch itis, w hich involved h a rd physical la b o u r on m y p a rt in o rd e r to clear his secretions, he m ade the statem ent th at “of course ultra-sound h ad m ade things so m uch easier fo r the p h y sio th erap ist because she no longer had to use h er han d s fo r m assage”. • A t a professional m eeting, a th o racic surgeon stated th a t he did n o t call the p h y sio th erap ist into h is in ­ tensive care u n it an y m ore, p referring to teach his sisters th e ro u tin e he had learned fro m the physio­ th e ra p ist in a previous unit. W hen questioned fu rth er, he explained th a t “the p h y sio th erap ist wheels along a B ird v en tilato r and asks fo r a suction tray; d o n ’t you know th a t the p a tie n t’s ow n efforts a t breathing and coughing a re fa r m ore effective and less dangerous th an any m achine. D o n ’t you learn to use your hands any m ore; they are o f m o re benefit to m y p atien ts” . • A d ire c to r o f h ospital services has been h eard to say th a t he regards p h y sio th erap y as unnecessary. H an d s are th e best tools in th e p h y sio th erap ist’s kit. M r G . D. M aitland has m ade us aw are o f o u r hands again w ith his m obilisations o f spinal an d p eripheral joints. I w ould like to m ake a plea here fo r the return to th e use of o u r hands in th e treatm en t o f chest disorders o f all kinds, and to th e neglected skills of m assage. M achines, used intelligently, are m erely a useful adjunct, w ith o u t feeling. A t a tim e when we are seeking professional status w ith its com m ensurate increase in salary scales, is it n o t also the tim e to take a close look a t o u r p rin ­ ciples and practice of P hysiotherapy? S. H . M. B LA C K W O O D M .C.S.P., D IP . T.P. D u rb an F I S I O T E R A P I E R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )