SPINAL MANIPULATIONS Jam es C yriax, M .D ., M .R .C .P ., fo r m e r Orthopaedic P hysician S t. Thom as’s H ospital, London; visiting P rofessor in Orthopaedic M edicine University o f R ochester, N e w York. V e rteb ra l m a n ip u la tio n h as lain u n d e r a c loud all this c entury. U n d e rsta n d a b ly so ; fo r m o st m edical m en have little experience o f it. In d e ed , m an y d o n o t m a n ip u la te th e spine a t all. By c o n tra st, m any laym en m a n ip u la te w hoever crosses th e ir th re sh o ld . B oth these policies a re e qually m istaken. T he p ro p e r a ttitu d e is m an ip u la tio n fo r th o se likely to benefit, its av o idance fo r th o se w ho will n o t. T h is m o d e ra te view, h ow ­ ever logical, pleases the extrem ists o n ne ith e r side. M e a n ­ while, so m u ch spinal m a n ip u la tio n is c arried o u t in B ritain u n d e r a n ae sth esia , fo r u n su itab le lesions, a n d by u n tra in e d persons th a t it occasions little su rp rise th a t m a n y m edical m en regard it as d a n g e ro u s o r a t best useless. H ow ever, every d o c to r kn o w s o f p a tie n ts w h o have benefited. C learly the real p ro b lem involves the p ro p e r selection o f cases. M a n ip u ­ lative tec h n iq u es m a tte rs m uch less. O ste o p a th s use one set o f m an o e u v res, c h iro p ra c to rs a n o th e r, bo n e se tters a th ird . In E n gland to d a y , m o st m a n ip u la tin g laym en a re self- styled, n ever h a ving received a n y real tu itio n a t all. Y et even these u n tu to re d in d ividuals have th eir satisfied clients. C a n th ere be th e slightest d o u b t th ere fo re th a t it is the p h y sio th era p ist w o rking w ith th e d o c to r w h o is ideally placed fo r m a n ip u la tin g the cases he so rts o u t fo r h e r? T w o responsibilities lie h e re: 1. T h e d u ty o f th e d o c to r to single o u t all su itab le cases a n d send th em im m ediately to th e physio th erap ist. 2. T he d u ty o f th e p h y sio th era p ist to have m aste red the p re -m a n ip u la tiv e clinical e x am in atio n , a n d the m an o e u v res called fo r by each different lesion. H e re she is in a m ost a d v a n ta g e o u s p o sitio n as re g ard s laym en, w ho use n e ith e r o u r m e th o d o f e x a m in a tio n n o r o u r techniques, a n d thus c a n n o t escape avo id a b le failures. C ases like th a t re p o rte d fro m th e U .S .A . are n o t infrequent. A p a tie n t w ho h a d received th irty c h iro p ra c tic a d ju stm e n ts w ith o u t benefit w as fully relieved in o ne single session by a g ra d u a te p h y sio th era p ist fro m St. T h o m a s ’s H o sp ita l (C o ld h am , 1975). P h y s io th e ra p y is clearly th e p rofession th a t w o uld benefit m o st fro m th e a d o p tio n o f th is policy. T h ey a lre ad y receive th e right p a tie n ts by th e sc o re; now is the m o m e n t fo r ap p ly ­ ing th e rig h t tre a tm e n t. T h ere is no d o u b t th a t this c an be d o n e ; fo r this was initiate d in 1916 by M ennell a n d c arried on by m yself fo r thirty-five years. O u r g ra d u a te s a re esteem ed all over the w orld fo r this e x tra know ledge a n d prow ess. A. Importance o f Manipulation M a n ip u la tio n o f th e spinal jo in ts is im p o rta n t to p h ysio­ th e ra p ists fo r fo u r reasons. 1. T h e lesions, th o u g h restricted in n u m b er, a re very com m on. T hey p rovide th e co m m o n e st re aso n fo r a fit m a n being off w ork. 2. M a n ip u la tio n is o ften im m ediately successful, p ro viding d ra m a tic relief in one o r tw o sessions. G ra titu d e a n d esteem th u s re m a in confined w ithin th e m edical a m bit. 3. T he successful m an o e u v res a re sim ple to lea rn , well w ith in th e c o m p a ss o f th e a verage stu d e n t a n d , c o u ld easily be fitted in to th e c u rriculum . 2 P H Y S I O O P S O M M IN G Volgens die sk ry w e r se ondervinding is die enigste goeie rede vir spesiale m anipulasie, tussen werwels servikaal drie en luim baal v y f ’n p o ging om die verplasing van 'n klein diskus fra g m e n t te reduseer. D is wat lekem anipulators steeds sonder om d it te besef, vir die afgelope honderd jaar reeds doen en baie noem m ee verw erf het. D it het getei tot onaanvaarbare hipoteses. 'n P oging is aangew end om geldige anatom iese verklaring vir hierdie sukses daar te stel in die vertroue dat d o kters en fisioterapeute nou hierdie logiese m aatstaw w e sa l aanvaar en in hulle daaglikse p r a k ty k insluit. H E R A P Y JUNE, 1976 4. Every tim e th a t a p a tie n t relievable by a spinal m a n ip u la ­ tion visits his d o c to r, a n d n e ith e r he, n o r th e physio th erap ist, carries this o u t, a g ra tu ito u s a d v ertism en t is a fforded t o / j \ laym an. Since these laym en claim to c u re d iso rd e rs t h { ) . m an ip u latio n c a n n o t possibly affect, this is h a rm fu l to the p o p u latio n in general, since the relieved sufferer spreads e rroneous p ro p a g a n d a to his friends, m uch futile trea tm e n t ensuing. T he obviously false claim s o f these m en justifiably engender m u ch scepticism , b u t this m u st n o t b lind us to the fact th a t th ey do have th e ir successes to o . T h o u g h the diagnosis is o ften w rong, th e tre a tm e n t h a p p e n e d to tu rn out right. It behoves b o th m edical m en a n d p h y sio th era p ists to study, n o t la y m a n ’s failures, b u t th e ir successes. H o w did they ever get as far as th e laym en, w hen a few simple m anoeuvres by the p h y sio th era p ist w o uld have g ot the p atient rig h t? I know th a t p h y sio th era p ists a re well su ited to th is work. C onfirm ation com es fro m a n unexpected source. I n A ugust 1974, the c h iro p ra c to rs o f O n ta rio , C a n a d a , p e titio n e d the M inister o f H e a lth to p ro h ib it spinal m a n ip u la tio n by p hysiotherapists. C learly they w ere finding th em so successful th a t it was m a k in g in ro a d s on th eir p o c k ets; th is is th e m ost cogent co m p lim e n t laym en h a v e ever p a id t o a profession ancilliary to m edicine. P U R P O SE S O F M A N IP U L A T IO N M a n ip u la tio n o f jo in ts has three p urposes. (N o m ention will be m ad e o f re d u c tio n o f frac tu res, dislo catio n s, hernias, etc., since n o co n tro v e rsy exists there.) 1. To break adhesions. M in o r a d h e re n t scars m ay fo rm w hen e.g. the breach in a sp ra in ed ligam ent unites, re stric tin g ite m obility. T hey c a n be ru p tu re d by a sh a rp je rk in t l f j j direction o f th e lim ita tio n . I n tennis-elbow , the p ainful scav in the extensor te n d o n c a n be sn a p p e d by a su d d e n stretch. M ajor adhesions severely restrict m ovem ent a t th e jo in t after, say, im m o b ilisa tio n in p laste r fo r fra c tu re . T hese require ru p tu re by a stro n g stre tc h u n d e r anaesthesia. 2. To stretch o ut a contracture. B o th c o n genital a n d acquired contractures need e lo n g a tio n by g ra d u al increasing sustained pressure. C o n genital to rticollis a n d talipes e q u in o v a ru s are obvious exam ples; a rth ritis a t sh o u ld e r a n d h ip represent acquired cap su la r c o n tra ctu re . 3. To reduce an intra-articular displacem ent. H e re lies the m ain object b u t, curiously en o u g h , also the m o st c o n troversial aspect o f m a n ip u la tio n . In general, a ph y sic ia n ’s first th o u g h t when a displacem ent is fo u n d p resent is th e feasibility of reduction. I n frac tu re, dislo ca tio n , h e rn ia o r breech p re se n ta ­ tio n o r indeed a su b lu x a te d m eniscus a t th e knee o r ja w jo in t, the advisability is c o nsidered a t once. B u t m an ip u lativ e reduction a p p e a rs scarcely to figure in m edical th o u g h t when a fragm ent o f disc is fo u n d o u t o f p o sitio n a t a n in te rv erte b ral jo in t. Before 1929, w hen D a n d y a scribed sc iatica to a disc- protrusion, th e d iso rd e r w as re g ard e d as “ sciatic n e u ritis” fo r which m a n ip u la tio n w ould have been a b su rd . U ntil 1945, w hen K ey a n d I se parately p u t fo rw a rd the c o n ce p t of a postero-central d isplacem ent o f a frag m e n t o f disc as the 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. ) se o f lum bago, this d iso rd e r h a d been a scribed to sp o n ­ taneous inflam m ation o f muscle. A s long as these tw o m is­ taken hypotheses rem ained o rth o d o x , no re aso n fo r m anipulation c o uld be a d vanced. N ow , how ever, th a t o u r t h o l o g i c a l c o ncepts h ave been accepted everyw here, reason dem an d s logical tre a tm e n t based on th is m echanical aetiology- By no m eans d o all disc-lesions re sp o n d to m an ip u latio n . S u itab ility is based o n the size, d u ra tio n , p o s itio n a n d c o n ­ sistency o f the displacem ent. M o re o v er, the p a tie n t’s age, o c c u p a t i o n a nd s e n s i t i v i t y to pain m u s t all be ta k e n i n t o a c c o u n t. I n the lu m b a r region, m y experience is th a t tw o- thirds o f all cases o f b ackache, b u t o n ly o n e -th ird o f all sciaticas prove tr a c ta b le th a t way. Reduction o f a fra c tu re o r o f a d islo catio n is a scertainable objectively. By c o n tra st, a t a spinal jo in t, it is a subjective event. It is only w ith the p a tie n t’s c o -o p e ra tio n th a t the operator can tell w hen all the spinal m ovem ents h ave becom e free, a n d straig h t-leg raising has becom e painless a t full range. T he pa tie n t is exam ined im m ediately before the -ession sta rts a n d a fte r each m a n o e u v re so th a t th e d isplace­ ment can be w atched shifting. T h e im m e d ia te result is jlc e rta in e d ; also, w hich m easure has th e best effect. A ll this knowledge is denied to the m a n ip u la to r u n d e r a naesthesia, who c a n n o t even tell if he is m ak in g th e p a tie n t b e tte r or worse, let alone w hen to go o n a n d w hen to stop. T h e reaso n why it is n o t possible to be sure in ad v an c e w hich m anoeuvre will help m ost is th a t e x am in atio n m ay well show a displace­ ment to exist, b u t c a n n o t show if it has em erged fro m the right, the left o r th e centre, in o th e r w ords, in w hich d irec tio n to thrust it back. T h is is discovered as th e session advances, when the effect o f each se p a ra te m an o e u v re is assessed seriatim. C ERV ICA L D IS C -L E S IO N S T hese present them selves in five different w ays a n d , to a dd to the c onfusion, have been given nam es th a t d istrac t attention from th e a ctu al lesion. Clinical E xam ination This has five purposes. T h e fu n c tio n is assessed o f: 1. The Cervical Joints. T he p a rtia l a rtic u la r p a tte rn indicates internal deran g e m e n t. In such a case, o f th e six active m ove­ ments, tw o, th ree o r fo u r h u r t ; fo u r, th ree o r tw o do not. M oreover, the p a in is usually u n ila tera l, th u s ind ic a tin g that only one side o f the jo in t is blocked. 2. The Cervical M uscles. M o v e m en t, a tte m p te d a g ain st such ^ is ta n c e th a t the jo in ts rem ain still, discloses th e sta te o f flth m uscle-group in tu rn . 3. The Cervical N erve R oots. M o n o ra d ic u la r palsy indicates a d isc -p ro tru sio n , N e u ralg ic a m y o tro p h y , n e u ro m a , secondary ne o p la sm , neuritis, p u lm o n a ry sulcus tu m o u r set up w eakness in w holly different p a tte rn s. 4. The Spinal Cord. W h e th e r th e p y ra m id al deficit is caused by a d isc -p ro tru sio n o r n o t, objective signs o f spinal co rd involvem ent wholly c o n tra -in d ic ates m a n ip u la tio n . 5. The Upper L im b . T h is m ay well c o n ta in a se p a ra te lesion causing p ain in the a rm . E vidence is so u g h t a t th e sam e tim e as the u p p e r lim b is exam ined fo r ro ot-w eakness. Radiography N o n e o f this vital in fo rm a tio n is o b ta in a b le by in spection of ra d io g ra p h s, o r even m yelogram s. A displaced fragm ent of disc w ithin a n o ste o -a rth ro tic jo in t is o ften ju s t as re ­ ducible by m a n ip u la tio n as o ne in a ra d io g ra p h ic a lly n o rm al joint. E very tim e a physician pays excessive a tte n tio n to a few harm less o steophytes, pro jec tin g m o reo v e r a n te rio rly where th ey m enace n o th in g , a n d w a rn s th e p h y sio th era p ist not to m a n ip u late, h e is c rea tin g o ne m o re o p p o rtu n ity fo r a laym an to score. T h e only reliable basis fo r a decision on w hether to m an ip u late o r n o t rests o n careful a n d inform ed e v aluation o f clinical d a ta . JUNIE 1976 3 B y c o n tra st, n o rm al ra d io g ra p h ic a p p e a ra n c e s m u st n o t be allow ed to lull th e m a n ip u la to r in to a false sense o f se c u rity ; since c h o rd o m a , m yelom a, n e u ro m a a nd e arly se c o n d ary n e o p la sm d o n o t show up a t first. Clinical Types o f D isc-Lesion 1. A c u te Torticollis. T h is is the an alo g u e a t a cervical jo in t o f lu m b a g o . T he y o u n g p a tie n t w akes w ith his neck fixed in a p o stu re o f gross deform ity. M a rk e d lim ita tio n o f o ne ro ta tio n a n d o ne side-flexion m o v em e n t is fo u n d ; the o th e r fo u r m ovem ents a re o f full range. R e d u c tio n is secured in p a tie n ts u n d e r th irty by m a n ip u ­ lating d u rin g stro n g tra c tio n o nly in the d irec tio n o f full range. W h en th is m easure has secured as m uch im p ro v e m en t as possible, th e p a tie n t lies d o w n a n d his h ead is pushed over m o re a n d m o re in the d irec tio n o f lim ited ran g e. I t m a y well be o n e o r tw o h o u rs b e fo re full ra n g e is re sto red by th is m eans. In p a tie n ts over th irty , m a n ip u la tio n d u rin g tra c tio n , first in painless direc tio n , th e n in th e p ainful, suffices. 2. “ Scapular fib ro sitis.” T h is is th e u n fo rtu n a te n am e th a t h as been given to cervical disc lesions causing, as they usually d o , p a in felt in th e m uscles a b o u t th e scapula. T h e lesion is n either sc a p u la r n o r is it c aused by in fla m m a tio n o f fibrous tissue. C linical e x a m in a tio n show s th a t th e passive, b u t n o t the resisted m ovem ents o f the cervical spine b ring on th e pain, th u s show ing its cervical a rtic u la r o rig in ; a n d th a t th e resisted m ovem ents o f the sc a p u la are n e ith e r w eak n o r painful, th u s e x cu lpating th e stru c tu re a b o u t th e sc a p u la . In o th e r w ords, positive signs a t a jo in t o f th e neck are c o rro b o ra te d by negative signs fro m the c irc u m sca p u lar tissues. O ne such m uscle, show n to fu n c tio n perfectly, o ften c o n ta in s a ten d e r a re a , m isnam ed “ trigger s p o t” , “ m yalgic a re a ” , “ fib ro sitis” . T h is is a se c o n d ary p h e n o m e n o n , as a nyone c a n confirm w h o m a n ip u la te s the neck. T h is shifts th e alleged lesion fro m m uscle to m uscle in stan tly , a n d all tenderness ceases as so o n as painless range in e ach d irec tio n has been re sto red to the affected spinal jo in t. I t used to be the fa sh io n to infiltrate these te n d e r sp o ts w ith p ro c a in e ; now ad ay s a stero id in jection is given in to the w ro n g sp o t instead. M edical m en are a ccustom ed to cervical lesions causing sc a p u la r p ain a n d accept th is extra -se g m e n tal reference. R eference to the p e cto ral a re a is ra re , b u t w hen it does occu r, diagnoses like a n g in a m ay be reached. W h en now a lay m a n m a n ip u lates th e neck a n d relieves th is sy m p to m , b o th he a n d th e p a tie n t m ay well im agine th a t th is m ea su re has c ured som e o bscure fo rm o f h e a rt disease. P hysicians m ust be o n th e lo o k -o u t fo r such cases, fo r they stre n g th e n th e a ssiduously fostered id ea th a t lay m a n ip u la ­ tio n cures visceral disease. M a n ip u la tio n d u rin g tra c tio n is sim ple a n d usually com pletely successful in o n e o r tw o sessions. T he d istra c tio n relieves pain, by rem oving th e c entrifugal fo rce o f c o m ­ pression, th u s en ab lin g th e p a tie n t to re la x ; it do u b les th e w idth o f th e jo in t (C yriax 1954) th u s giving the frag m e n t ro o m to m ove. I t also exerts c en trip e tal force on th e d isplacem ent b o th by su ctio n a n d by ta u te n in g th e p o ste rio r lon g itu d in al ligam ent. F in a lly it disengages the facet jo in ts , th ere b y allow ing m ore m o v em e n t a t th e in te rv erte b ral jo in t. It is a re m a rk ab le fact th a t o ste o p a th s c row d th e facets to g eth e r w hen th ey m a n ip u late — th e y m istakenly call it “ lo ck in g ” — w hereas displacem ents m ove m o re easily w hen the a rtic u ­ latin g surfaces a re b ro u g h t as fa r a p a r t as possible. T hey are p ro u d o f th is ja m m in g , blissfully u n a w are th a t by d o in g so th ey m u ch dim inish the lik elihood o f success. H e re m u st lie th e re a so n w hy sem i-experienced p h y sio th era p y stu d e n ts, usin g d istra c tio n tec h n iq u es, m ay well secure full re d u c tio n w hen experienced laym en fo rcin g th e jo in ts to g e th e r before a p p lying th e ir th ru s t, h a v e a lre a d y failed. It c ertainly explains w hy they need so m an y m o re sessions o f m a n ip u la ­ tio n th a n d o St. T h o m a s ’s g ra d u ates. 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. ) 4 P H Y S I O T H E R A P Y JUNE, 1976 3. “Brachial N euritis." T h ere a re m an y re aso n s fo r p ain a n d p a rae sth esia in the u p p e r lim b, b u t th e c o m m o n cause is a disc p ro tru sio n com ­ pressing a cervical n e rv e -ro o t; if so, th e lesion is n e ith e r b ra ch ial n o r a neuritis. I f no ro o t palsy is p re sen t w hen the u p p e r lim b is exam ined a n d the spinal c o rd c o n d u cts no rm ally , re d u ctio n is often still possible p ro v id ed th a t unila tera l ra d ia tio n to th e a rm has lasted less th a n tw o m o n th s. I f a r o o t palsy has supervened a n d m uscle w eakness is a p p a re n t, m an ip u la tio n alw ays fails a n d sp o n ta n e o u s recovery fro m p a in (th ree to fo u r m o n th s since th e b ra ch ial p a in , n o t th e sc a p u la r p ain, sta rte d ) a n d fro m the m uscle paresis (six to eight m o n th s) m ust be aw aited. M a n ip u la tio n is also a p t to fail w hen o n e or m o re o f the n eck m ovem ents p ro v o k e th e p a in d ow n the u p p e r lim b, a n d w hen th e sym ptom s a p p e a r in th e reverse o f th e usual o rd e r, i.e. p a rae sth esia e in the h a n d , th en a ch in g in the lim b, th e n sc a p u la r pain. I n B rita in a very a n n o y in g situ a tio n exists. In cervical ro o t-co m p ressio n , the p a in in th e sc a p u la and a rm goes on g e tting w orse fo r tw o to th ree weeks. D u rin g ,th is tim e, the p a tie n t’s physician prescribes ev er-stro n g e r analgesics. By th e th ird o r fo u rth w eek the p ain is a t its w orst, a n d lack o f progress leads to reference to h o sp ital. T h ere e x am in atio n reveals th e ro o t-p alsy , c onfirm ed by e le ctro-m yography. P h y sio th e rp y , tra c tio n or a c o lla r is p rescribed, all in vain. A t th e e n d o f tw o m o n th s, ju s t w hen the sy m p to m s are a b o u t to w ane, th e d e spairing p a tie n t tak e s him self off to a lay m a n ip u la to r. Since his tre a tm e n t sta rts a t the sam e m om ent a s sp o n ta n e o u s subsidence o f th e p ain, m an ip u la tio n twice a week for, say, six weeks coincides in tim e w ith the a d v e n t o f sp o n ta n e o u s recovery. A gain, b o th th e m a n ip u la to r a n d the p a tie n t m istak en ly ascribe to th e m a n ip u la tio n s. H o w is e ith e r to k n o w ? 4. Acroparaesthesia. B ilateral ro o t-p re ssu re m ay set up pins a n d needles in b o th h a n d s to g e th e r w ith only vague aching in th e u p p e r lim bs. (D iffere n tia tio n betw een th e th o rac ic o u tle t sy n d ro m e a n d a bila tera l c a rp a l tu n n el sy n d ro m e m ay p resent difficulty.) M a n ip u la tio n m ay help. O ften the d iso rd e r proves in tra c t­ able, b u t th e sym ptom s are never severe. 5. P osterolateral Sclerosis. E vidence o f pressure o n the spinal c o rd c o n tra in d ic ate s m a n ip u la tio n . Pins a n d needles in th e h a n d s a n d feet (o r p o stu ra l vertigo in d icating basilar ischaem ia) a re n o t a n a b so lu te b a r, p ro v id ed the lay m eth o d s a re a v o id e d ; these are d a n g ero u s a n d d e ath has resulted. S tro n g m a n u a l tra c tio n w ith o u t ro ta tio n m ay succeed a n d in m y h a n d s n o lasting h a rm h as resulted. I f the a pex o f the s p u r c o m pressing th e spinal c o rd consists o f a frag m e n t o f c artilage, m a n ip u la tio n d u rin g stro n g tra c tio n c a n still shift it. I f th e p o in t is osseous, m a n ip u la tio n m u st fail a n d the p re v en tio n o f p a rap leg ia due to c o m pression o f the a n te rio r spinal a rte ry is now lam inectom y. P re v e n tio n o f c o rd pressure is feasible. T h e o steophyte arises in th e first place by tra c tio n o n the p o ste rio r longi­ tu d in a l lig a m en t from a p o ste ro -ce n tra l bulging o f the disc. T h e p e rio ste u m a t th e edge o f th e ve rte b ral b o d y is elevated a n d b o n e grow s to reach its lim iting m em b ran e . T h e p ro ­ phylaxis o f a n o ste o p h y te increasingly m enacing the spinal c o rd is to h ave c a rrie d o u t m an ip u lativ e re d u ctio n years ago. H E A D A C H E T here is o n e type o f he ad a ch e th a t physicians o ften fail to recognise — th a t a risin g fro m th e ligam ents a b o u t the o c c ip ito -a tla n to id a n d a tla n to -a x ia l jo in ts. T hese jo in ts are developed w ithin the first a n d second cervical segm ents a n d th ere fo re re fe r p a in alo n g th e re levant d e rm a to m e s in the u sual way, i.e. to th e b ack o f th e h e ad ( C l ) a n d th e forehead (C2). T h e p a tie n t is a n elderly m a n (w om en a re a lm o st im m u n e ) w ho describes o c cip ito -fro n tal h ead ach e every d ay o n w aking. A t first it has e ased by m idday, late r by th e after­ n o o n ; it never lasts all day. A t his age, som e e levation of b lo o d pressure m ay be fo u n d present. T h e he ad a ch e is a ttrib u te d to th a t, th e m o re so since th e ra d io g ra p h s o f the u p p e r neck show n o m o re o ste o p h y to sis th a n a n y o n e th a t age often has. O ne session o f m a n ip u la tio n o f th e neck during tra c tio n n early alw ays affo rd s full relief lasting a t least a c ouple o f y ears. T h e laym an m ay cure this type o f headache If so, again b o th he a n d th e p a tie n t u n d e rsta n d a b ly , but m istakenly, tak e fo r g ra n te d th a t high b lo o d -p ressu re has been relieved. T h is n o t u n c o m m o n m isdiagnosis provides renew ed “ evidence” th a t m an ip u la tio n cures visceral disease. T H O R A C IC D IS C -L E S IO N S T hese a lso p re sen t u n d e r m isleading n am es, e.g. fibrositis of chest wall, m uscle stra in , p leu ro d y n ia (because a deep breath h u rts), in te rco stal n euritis. D ia g n o sis is n o t difficult if th o rac ic disc-lesions a re k ept in m ind. T h e influence of p o stu re a n d e x ertion on th e p a in is m anifest in th e history T he difficult cases a re those w ith a p rim a ry postero-laterA*' o nset, th e r o o t p a in felt in th e a n te rio r th o ra x o r a b d o m e v c o m in g on w ith o u t p revious backache. E x h au stiv e exam ina­ tio n o f visceral fu n c tio n n a tu ra lly reveals n o a b n o rm a lity , and such p a tie n ts are o ften dism issed as n e u ro tic, o r alternatively, w ith som e vague label such as “ g a stritis” o r “ c h ro n ic chole­ c y stitis” is a pplied. A. T. Still, the fo u n d e r o f osteopathy, describes h ow he h a d p a in in the reg io n o f his ow n heart, which ceased with a click d u rin g pressure a t his m id-thoracic v ertebrae. In th is type o f case the p a in is o ften wrongly a scribed to som e vague visceral d iso rd e r, a n d th e layman once m o re cashes in on o u r m istake. O bviously vertebral m an ip u la tio n relieves, n o t visceral disease, b u t th o se pains actu ally o f spinal origin th a t have been m istakenly a ttrib u te d to a viscus. N e ith e r p a tie n t n o r n o n-m edical m a n ip u lato r realises th a t, n o r w ould it suit the la tte r’s b o o k if he did have d o u b ts. Examination T h is com prises eliciting: 1. A rticular Signs. T h e p a rtia l a rtic u la r p a tte rn indicates in te rn al deran g e m e n t. Som e, b u t not all, o f the six m ovem ents p rove painful. 2. D ural Signs. N eck-flexion a n d sc a p u la r a p p ro x im atio n d ra w the d u ra u p w a rd s a n d increase th e th o rac ic pain. 3. R o o t Signs. T h o u g h ro o t p a in felt as a ru le a lo n g t b ; low er c o stal m argin is c o m m o n , neu ro lo g ica l deficit is rtf! J a n d suggests a n e u ro m a ra th e r th a n a disc lesion. ^ 4. C ord Signs. I f evidence o f p y ra m id al pressure exists, m a n ip u la tio n is wholly b a rre d ; lam in ec to m y sh o u ld be c onsidered, a n d th e so o n e r th e better. A rtic u la r signs a cc o m p a n ied by d u ra l signs clearly indicate a p o ste rio r d isc-displacem ent, since th e d u ra m a te r lies behind th e jo in t. M a n ip u la tiv e re d u c tio n d u rin g tra c tio n is usually very easy. L U M B A R D IS C -L E S IO N S H ere, to o , th e situ a tio n is o bscu red by m any different names fo r th e sam e d iso rd e r — pulled m uscle, lu m b a g o , sciatica, sacro-iliac stra in , s p ru n g b a ck , lu m b a r o r g luteal fibrositis, spinal a rth ritis o r spondylosis. T he sam e p h e n o m e n o n th a t is so co n sp icu o u s a t th e n e ck — e x tra-segm ental reference from the d u ra m a te r w ith a se c o n d ary localised te n d e r sp o t within th e p ainful a rea — occurs also in lu m b a r disc-lesions. Since a p o ste ro -ce n tra l d isc -p ro tru sio n bulges o u t a g a in st the p o ste rio r ligam ent fa r e n o u g h to com press the d u ra m ater, re m a rk a b le areas o f reference a re re p o rte d by sufferers from a cu te lu m b a g o , e.g. to o ne o r b o th g roins, to the lower 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. ) jU N IE 1976 F I S I O T E R A P I E 5 abdom en, up to the low er p o ste rio r th o ra x . W hen the referred p ain o vershadow s local p a in , it is n o t u n k n o w n fo r a low lu m b a r disc-lesion to be m ista k e n for c h ro n ic a p p e n ­ dicitis, since the w ay th e d u ra m a te r refers p a in m isleadingly (Cyriax 1975) is n o t recognised by m ost d o c to rs. Clearly, spinal m a n ip u la tio n m ay well relieve such a p a in in th e iliac fossa, a n d the m istaken n o tio n o f a lay m an ip u la tio n cu rin g visceral disease is once m o re strengthened. D etailed diagnosis is m o st im p o rta n t; fo r it is by no m eans e n o u g h m erely to sta te th a t a lu m b a r disc-lesion is p re sen t; its d u ra tio n , size, p o sitio n , consistency a n d sta b ility have a || to be c o rre la te d with th e p a tie n t’s o c c u p a tio n , age and sensitiveness. A sm all c artila g in o u s d isplacem ent sh o u ld be r e d u c e d by m a n ip u la tio n ; a sm all n u c le ar p ro tru sio n sh ould be reduced by daily tra c tio n . If the p ro tru sio n is large, n either m ethod is app lic ab le a n d th e de se n sitiz atio n o f th e nerve- root at th e p o in t o f im pact by the in d u ctio n o f e p id u ra l local anaesthesia o r a sinu-vertebral block is th e tre a tm e n t of choice. Examination F o u r d a ta are so u g h t: Articular Signs. T hese co m p rise : I. visible d e v ia tio n ; 2. lim itation o f m ovem ent in som e d irectio n s b u t n o t in others. In early disc-lesions a p a in fu l arc, usually o n tru n k - flexion, is o ften present. T h e p a rtia l a rtic u la r p a tte rn indicates internal d erangem ent. Dural Signs. L u m b a r p a in p ro d u c e d by neck flexion and bilateral lim ita tio n o f straight-leg raisin g indicates th a t the mobility o f the d u ra m a te r is im p a ired on stre tc h in g from above o r below . W hen, in sciatica, th e stra ig h t leg is raised as far as possible, neck-flexion m ay increase th e ro o t p ain, again as th e result o f pulling on th e tense n e rv e-ro o t via the dura m ater. Nerve-root M o b ility. A t th e th ird ro o t, this is tested by prone- lying knee flexion. D isc -p ro tru sio n a t the fo u rth o r fifth lum bar level m ay com press the fo u rth lu m b a r to second sacral nerve-roots. T h eir m o bility is assessed by straight-leg raising. T he fo u rth sacral nerve does n o t reach th e low er lim b and c a n n o t be stretched. Nerve-root Conduction. M uscle w eakness, im paired reflex a n d /o r c u ta n e o u s analgesia in d ic a te a degree o f p ro tru sio n too g reat fo r m a n ip u la tio n o r tra c tio n to be practicable. Radiography \ C hoice o f tre a tm e n t in disc-lesions rests o n w hat is found w h e n these fo u r essential elem ents in clinical ev alu atio n are Correlated. N o n e o f these findings em erges fro m inspection of a stra ig h t ra d io g ra p h n o r is a p p rec ia b le help affo rd ed by positive o r negative m yelographic a p p ea ran c es. M A N IPU LA TIO N In a n y displacem ent th ro u g h o u t th e body, th e physician s first th o u g h t is th e feasibility o f re d u ctio n , by h im self or by the p h y sio th era p ist. In the p a st, fo r som e re aso n obscure to me, this re aso n in g was th o u g h t n o t to ap p ly to th e spinal in tra -articu la r c artilages, th o u g h it was o rth o d o x y a t the knee o r jaw . T h is gap in logic on o u r p a rt left th e field wide open fo r laym en, w ho have achieved q u ite a re p u ta tio n with patients on th e stre n g th o f a few sim ple tw ists. T h is sh ould now cease. M anip u la tiv e re d u ctio n sh ould be c a rrie d o u t as so o n as the diagnosis o f a re ducible d isc -p ro tru sio n has been reached. Im m ediate re d u ctio n saves the p a tie n t p a in a n d e conom ic loss; saves in su ra n ce co m p a n ies m o n ey a n d the likelihood o f long-draw n-out litig a tio n ; a n d saves th e d o c to r a n d p hysio­ therapist tim e. M an ip u la tiv e re d u c tio n th en is p e rfo rm e d a t once unless a co n tra -in d ic atio n is fo u n d o n clinical e x am in atio n . Contra-Indications to Lumbar Manipulation T hese a r e : 1. N o t a Disc Lesion. C learly m a n ip u la tio n is p o in tless unless a reducible lesion is present. 2. D anger to the Fourth Sacral Root. A n y co m p la in t o f w eakness o f b la d d e r o r re ctu m o r o f p erineal, testic u la r or saddle parae sth esia suggests severe stretching o f the p o ste rio r lon g itu d in al ligam ent. I f this sh o u ld ru p tu re d u rin g m a n ip u la ­ tion, m assive p ro tru sio n o f the w hole disc m ay result, leading to severe b ilateral sciatica and d am age, possibly p e rm a n e n t, to th e in n erv a tio n o f th e b ladder. In such cases lam inectom y is u rgently required. 2. H yperacute Lum bago. M o s t cases o f lu m b a g o re sp o n d very well to m an ip u latio n . H ow ever, in a few cases the p a tie n t is so fixed th a t the slightest m ovem ent p ro v o k e s such sh a rp stabs o f p ain th a t the a tte m p t becom es u n th in k a b le . I f so, e p id u ra l local anae sth esia is induced, w h e reu p o n the d isplace­ m ent im pinges a g ain st th e now -insensitive d u ra m a te r a n d all p ain ceases for th e tim e being. S p o n ta n e o u s re d u c tio n is aided d u rin g th is perio d o f painless m obility if the p a tie n t lies p ro n e fo r as long as th e anae sth esia lasts. 3. P regnancy. D u rin g th e last m o n th m a n ip u la tio n is im practicable. D u rin g th e first fo u r m o n th s, p ro n e p ressures as well as the ro ta tio n m an ip u la tio n s a re q u ite safe. 4. N eurosis. V ery n e rv o u s p a tie n ts, o r those w ho, ow ing to a legal suit p e nding, have to m a in ta in disa b le m en t, a re n o t suited to m an ip u latio n . Manipulation Useless but not Harmful 1. Too Large. R e d u c tio n is im possible w hen th e p ro tru sio n is larger th a n th e a p e rtu re w hereby it em erged. S ciatica w ith signs o f im paired c o n d u ctio n a t one o r tw o ne rv e-ro o ts (m uscle paresis, loss o f reflex, c u ta n e o u s a n algesia) show th a t re d u ctio n is im possible. T hese p a tie n ts sh o u ld h ave the ro o t desensitised by th e im m e d ia te in d u c tio n o f e p id u ra l local a n aesthesia. G ro s s lateral de v ia tio n o f the lu m b a r spine m ain tain ed by sciatic p a in (C yriax 1954) often calls fo r lam inectom y, all conservative tre a tm e n t being a p t to fail. B ut one e p id u ra l injection is usually w orth trying. 2. Too Long. W h en ro o t-p a in has lasted six m o n th s o r m ore, in a p a tie n t u n d e r sixty years o f age, the a tte m p t is a lm o st sure to fail. 3. Too S o ft. N u c lea r p ro tru sio n s require o ne to th ree w eeks’ daily tra c tio n fo r 30 to 45 m inutes, a t a d istra c tin g force o f 80 lbs (m inim um fo r a frail w om an) to 2 0 0 lbs (fo r a large stro n g m an .) T h e tre a tm e n t is entirely painless (C yriax, 1950). I t sh ould never be used fo r a c u te lu m bago with twinges, which is m ad e m uch w orse. T h ere exist eight different p osi­ tio n s o f the p a tie n t o n th e couch a n d , in a difficult case, the ph y sio th era p ist tries o u t the v a rio u s p o stu re s u n til the effective one is a sc ertain e d (C yriax, 1975). I f a n y p a in is caused, so m ething is w ro n g ; a n d if no painless p o sitio n can be fo u n d , the case is u n suited to trac tio n . M A N IPU L A T IV E T E C H N IQ U E S T h e m anoeuvres them selves a re n o t difficult to m aster. T he im p o rta n t p o in t is a low couch, a b o u t 36 cm s high, so th a t the o p e ra to r’s b o d y weight c a n be used to reinforce the pow er o f th e arm s. T h is is p a rticu la rly necessary w hen a sm all p h y sio th era p ist is faced w ith a large m an, a n d explains why a stro n g laym an using a high co u ch m ay fail yet o ne o f m y y o u n g physio th era p ists succeed. T h e fam ily d o c to r, if he h as tim e, sh o u ld c a rry o u t these m anoeuvres as so o n as th e clinical e x am in atio n is com pleted. But a session o f m a n ip u la tio n m ay well tak e h a lf-a n -h o u r; hence this w o rk is best p e rfo rm e d by th e p h y sio th era p ist. 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. ) 6 P H Y S I O T H E R A P Y JUNE, 1976 T h is policy p roved successful a n d p o p u la r (b o th w ith the p a tie n ts a n d th e p h y sio th era p ists) d u rin g m y fo rty years a t St. T h o m a s ’s) a n d sh o u ld be a d o p te d all over the w orld. The p a tie n t re m a in s u n d e r m edical su pervision th ro u g h o u t a n d is tre a te d by tra in e d e th ic al personnel. A ll th a t need be d o n e no w is fo r d o c to rs to recognise su itable cases a t once a n d fo r p h y sio th era p ists to e q uip them selves to tre a t accordingly. N e ith e r p resents th e slightest difficulty, m erely th e exercise o f a little goodw ill. S U M M A R Y I n m y experience, th e only g oo d re a so n fo r spinal m a n ip u la ­ tio n betw een th e th ird cervical a n d fifth lu m b a r v e rte b ra is an e n d e a v o u r to reduce a displacem ent o f a sm all frag m e n t o f disc. T h is is w h a t lay -m an ip u lato rs, still w ith o u t realising it, have been d o in g fo r th e p a st h u n d re d years a n d h ave gained m uch k u d o s thereby. T h is h a s led th e m o n to unten a b le h y potheses. A n a tte m p t is m ad e to su b stitu te a valid a n a ­ to m ical e x p la n a tio n fo r these successes, in th e h o p e th a t d o c to rs a n d p h y sio th era p ists will n o w accept these logical m easures a n d in c o rp o ra te th em in th e ir daily practice. R E F E R E N C E S C O L D H A M , M . (1975). C h iro p ra c tic . C a n a d .M e d .A ss.J. 929. C Y R IA X , J. (1945). L u m b a g o : T he M e chanism o f D u ra l P a in . L an c et, ii, 427. C Y R IA X , J. (1950). T re a tm e n t o f L u m b a r Disc-L esions. B rit.m ed .J., ii, 1434. C Y R IA X , J. (1954). T e x tb o o k o f O rth o p a e d ic M edicine. Vol. I, P la te s 5-6. C Y R IA X , J. (1975). Ibid. Vol. 1, 6th E d. 462. C Y R IA X , J. (1975). Ib id . Vol. 2, 8th E d . 274. D A N D Y , W. E. (1929). L o o se cartila g e fro m In te rv e rte b ra l D isc sim u la tin g T u m o u r o f Spinal C o rd . A rc h .S u rg ., 19, ii, 660. K E Y , J. A . (1945). In te rv e rte b ra l D isc L esio n s: C o m m o n e st C ause o f L ow B a ck P ain. A n n .S u rg ., 121, 534. The Value of Deep Transverse Frictions in Sports Injuries with particular reference to the knee M A R G A R E T C O L D H A M , M .C .S.P . D e ep tran sv erse frictio n is a n in v alu a b le tre a tm e n t fo r sp o rts injuries. H ow ever, w hen this type o f m assage is being c arried o u t, it m u st be given to th e exact', sp o t a n d in the c o rre c t w a y ; it is o f n o use to look fo r th e ten d e r a rea a nd to m assage there. O ne m u st e xam ine the p a tie n t, find o u t which tissue is a t fa u lt a n d 'th e n look fo r tenderness alo n g that stru c tu re . T h e friction m u st th en be given transversely to the tissue, n o t longitudinally. A IM S O F D E E P T R A N S V E R S E F R IC T IO N S 1. In m u sc u la r lesions th e aim is to m obilise th e m uscle by s e p a ra tin g th e a d h esio n s betw een th e in d ividual m uscle fibres th a t a re re stric tin g its m o bility to w a rd s b ro a d en in g e ac h tim e it c o n tra c ts. T h e m uscle m u st be k ept fully relaxed d u rin g th e friction. 2. In lig a m en to u s lesions, th e objective is to m ove the lig a m en t to a n d fro o ver a d ja c e n t b o n e in im ita tio n o f its n o rm a l b e h a v io u r a n d th u s m ain ta in its m obility. 3. W h en a te n d o n h a s a sh e a th , c re p itu s m ay be present in d ic a tin g ro u g h e n in g o f the te n d o n sh e a th . D e ep transverse frictio n sm o o th e s the gliding surfaces. D u rin g th e transverse fric tio n th e te n d o n m u st be k e p t ta u t. I n te n d o n s w ith o u t a sh e a th , d eep tran sv erse frictio n s b re a k u p sc a r tissue a t the in se rtio n o f th e te n d o n in to b o n e o r sc a r tissue w ithin the te n d o n . T E C H N IQ U E S O F D E E P T R A N S V E R S E F R IC T IO N S 1. A s m en tio n ed e arlier, th e right s p o t m u st be fo u n d . ^ 2. T h e p h y sio th e ra p ist’s fingers a n d th e p a tie n t’s skin m ust m ove as one. I f m ovem ent tak e s place betw een th e p a tie n t’s skin a n d th e p h y sio th e ra p ist’s fingers, th e n th e m assage reach es o nly th e skin a n d n o t th e tissue a t fa u lt, a nd will also give rise to a blister. 3. T h e frictio n m u st be given across th e fibres com posing th e affected stru c tu re s, i.e. transversely. 4. T he frictio n m u st b e given w ith sufficient sweep. 5. T h e frictio n m ust re ac h deeply e n o u g h . It is m ore effective to m assage deeply fo r a few m in u te s th a n to go on indefinitely w ith gentle m assage. 6 . T h e p a tie n t m u st a d o p t a su itab le p o sitio n which ensures th a t the tissue is e ith e r ta u t fo r a te n d o n sh e a th or relaxed fo r a m uscle. I f th e stru c tu re to b e tre a te d is ordinarily o u t o f re ac h o f th e p h y sio th e ra p ist’s fingers, th e n a position m u st be a d o p te d w hereby th e tissue becom es accessible, e.g. the su p ra sp in a tu s te n d o n a t th e sh o u ld e r. T h e a rm is put b eh in d the p a tie n t’s b a ck w hilst th e p a tie n t is in th e half- lying p o sitio n , th ere b y fixing th e a rm in a d d u c tio n a n d m edial ro ta tio n . I n this p o sitio n , th e te n d o n c a n b e easily felt as it passes fro m th e base o f th e c o rac o id process d irectly forw ards over th e h ead o f th e h u m eru s to the g re a te r tu b ero sity . 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. )