It’s been a while since we’ve had A Flashback on a Friday (glad we decided not to go with that as a title for the series), but here are two that seem relevant today
The Golden Click
The lure of the “golden click” has been with patients and manipulators for ages – the idea that there is a way of manipulating the spine, thus providing a panacea for many conditions. Those who manipulate have experienced tantalising hints of it – the instant removal of a headache with upper cervical manipulation, relief of gut symptoms with a thoracic manipulation…
The manipulation
She returned two days later. “Absolutely no different” she said. I don’t know what came over me. I got her to stand up. I stood behind her on the London Phonebook, grasped her by the elbows, put my ribs in around T5 and gave an almighty lift. Well……..she gasped, there were about 50 huge cracks, maybe more and then I had the unusual experience of a heavy unconscious female sliding down the front of my body onto the floor….
A long 45 seconds later, just before I was about to call emergency she opened her eyes, looked at me and said “thankyou” and lapsed back into unconsciousness. I was trained by Geoff Maitland and he always insisted that we seek a reassessment but right now I thought “that’s the best reassessment I will ever get.”…
I am leaving it open – what would you do with such a patient, would you manipulate and what are your thoughts?
– David Butler, December 2010
Fred and Half a Sheep
Meet Fred
Fred was a patient of mine. He was about 55 and came from the far north of South Australia and only came to the city once a year. He used to call in to see me for a bit of physio and he frequently brought a present – usually a piece of lamb, but occasionally a lump of beef that I am not really sure which part of the animal it came from.
Anyway, Fred used to say “the second and third are out in the neck, have been for a few months since I came off the motorbike; I reckon the L5 is out too and the hip might be going out too. Can you whack them back in. By the way, I have half a sheep in the truck for you. Mind you with the drought they are a bit dry, but you did say once that you liked mutton. And another thing – don’t give me any exercises, like you tried last year. I get too much bloody exercise on the place these days”.
Share my quandary
I take a breath and reflect….”but these days I am supposed to be evidence based and offer more self management, graded exercise and neuroscience education. I even wrote a book on what you are supposed to do. How did I get it so wrong with Fred? And what would my students be thinking now if they were watching this clinical encounter?”
Judge my therapy
I assessed Fred, I was interested in the motor bike accident so I checked him out as best I could for any contraindications to “whacking things back in”. There was a bit of stiffness in the upper neck and low back and I “whacked them back in” (grade 5 rotation for the lumbar spine, and lateral flexion grade 5 for the C2-3 joint or thereabouts). “Beautiful”, says Fred, jumping up and playing with his new neck movement. “Did you hear that neck go back in…still a bit out in the low back. Give it a bit more of a whack will you.” I did just that. Fred handed over the half a sheep, shook my hand and said “see you next year”…
What’s in a whack?
Was I wrong? I know that my therapy doesn’t follow any recent guidelines for chronic spinal pain and I know that the efficacy of manipulation is not that strong…
I don’t think anything goes out except fires and me on occasional Friday nights. Joints may get a bit stiff or rarely, locked, but that is about it. I am happy that I probably manipulated Fred’s perceptions as well as perhaps doing something to the joint structures. You could call it a placebo treatment but then again I am reminded by a Patrick Wall comment “In the end if many treatments are shown to be placebo, then we should work out what it was in the placebo that was the active ingredient.” There may have even been something helpful in the swapping of the sheep and the manipulative techniques.
-David Butler, May 2008
What would YOU do if your patient asked you? (apologies to Dr Seuss)
-Tim Cocks
Get your think on and get up to date at a noigroup course or immerse yourself in some brainy books with Explain Pain 2nd Ed and The Graded Motor Imagery Handbook.
Both of the cases of above are very interesting. Both in this post and Convoluted Manipulations I have read that the “efficacy of spinal manipulation is not strong.” Does this consider manipulation as treatment for any type of spine pain, or manipulation as a part of a treatment based classification system? My understanding is that, when used as a part of a classification system, manipulation is more effective because it is being applied to the appropriate patients. Additionally, the classification system does not rely on pathoanatomic diagnosis, and so manipulation used in this way would likely create improvement due to neurologic input, which reduces threat level in the brain. I would refer to the Brennan et. al 2006, or the Flynn et. al 2002 articles for more background information. Don’t these articles represent stronger evidence for spinal manipulation? Isn’t the implication here that if we select manipulation for the appropriate patients then there is good evidence to support its effectiveness?
Hi bigd7876
The whole subgrouping question is a curly one – Neil O’Connell has dealt with it much better than I could at BiM in a number of posts-
http://www.bodyinmind.org/exercise-for-chronic-back-pain/
http://www.bodyinmind.org/back-pain-start-back-research-lancet/
And has written in more depth with Ben Wand in an open access paper-
http://www.biomedcentral.com/1471-2474/9/11. A lot of the work cited has been done with low back pain, but I’m aware of similar work with cervical pain, WAD in particular.
Brennan et al (2006) reported significant benefits when, in retrospect, the patient was found to have been matched to the treatment regime suggested by the subgroup criteria. But, the two experienced, expert physiotherapists were only able to agree on the correct subgroup about 80% of the time – how do you think this might affect subgrouping in a clinical setting?
I’m interested in your comment – “Additionally, the classification system does not rely on pathoanatomic diagnosis, and so manipulation used in this way would likely create improvement due to neurologic input, which reduces threat level in the brain.” Could you expand on the notions of nerologic input and reducing threat level in the brain in the context of manipulation?
Thanks
Tim
Thanks for your reply Tim. I have been under the impression that the mechanisms behind manipulation, or for that matter, many manual therapy techniques are unclear. In other words, while doing manipulation, you are not necessarily stretching the joints, or increasing mobility, but providing a high velocity thrust through a joint. So the question is, why does this improve pain (assuming it does). The way this has always been explained to me is that quickly stretching those tissues creates neurologic, often sympathetic, input which can help reduce muscle tension, or many other things. Ultimately it is the sympathetic input that creates a positive neurologic state and reduces threat levels in the brain. This could also be correlated to peoples beliefs about their conditions. How many times have we all heard a patient say something like, “I feel like if someone could just crack my back, it would feel better.” Thus providing what they want, may provide some relief due to decreased threat, improved cognitive state, and maybe a little placebo. I think that I also think of other manual therapy techniques (soft tissue mobilization, joint mobilization, stretching) in similar ways. I think I explain this to my patients something like this: “when I stretch your muscle, I am not necesarily physically lengthening those tissues, but I am providing input to your nervous system, which will inhibit some reflex arcs in your spinal cord. Because muscle tension may cause your brain to perceive a higher threat level, reducing this muscle tension may reduce your pain.”
What are your thoughts on this?
Hi bigd7876,
Some really interesting and pertinent points.
I don’t know how a manipulation might “work” – I have no doubt that there is significant input, but I don’t think we can isolate any of it. That is, there will be various input from soft tissues around joints, but also from muscles and the skin. As you mention, there will also be beliefs at play and the “input” of context. The human being undergoing the manipulated will use all of this incoming information in a recursive manner to construct an ongoing conscious experience which may or may not include pain. I don’t think that we are able to suggest that a particular manipulation technique alone will reduce the sense of threat. My thoughts are that explanational theories including sympathetic reflex arcs and activation of high velocity threshold mechanorecpetors in joint soft tissues are post-hoc attempts to create an explanation for an interesting, observable phenomenon that has been incorporated into various therapy rituals and lore.
It’s an interesting point in regards to providing a patient with what they want and/or expect, that is, in the sense of “it feels like it needs to be cracked”. I think the important question here is where did these desires/beliefs/expectations come from? I suspect that they were created by successive generations of therapists telling the general public that backs “went out” and could be “cracked back in”, rather than the general public having an a priori belief about any therapeutic benefit of manipulating joints.
I think your explanation to a patient about what might be occurring when a muscle is passively stretched is quite nice. Again, i suspect that the effects can not be isolated to spinal cord reflex arcs, with any change being an emergent construction of the human in response to you, your handling, your touch, the context, their beliefs, values, past experiences and so on.
I think the most powerful idea in this is that your words, explanation and narrative can have as much of an effect as your technique!
Thanks again for your comments and the engaging discussions!
Cheers
Tim