First Chapters

The pages through the first three chapters are sequenced: 1 | 2 | 3 | 4 | 5 | 6 

To those who are frustrated in pain, perhaps unnecessary pain – chronic pain – this book will bring hope and the peace that comes from knowing that you are not alone, crazy, malingering or faint of heart.

Recent research in the neurophysiology of chronic pain makes this book even more important and well timed. Dr. Lidbeck states in his abstract, “Recent investigations of dysfunctional pain processing in the central nervous system have contributed much knowledge about the development of chronic musculoskeletal pain. Many chronic musculoskeletal pain syndromes – including regional myofascial pain syndromes, whiplash pain syndromes, work related neck-shoulder pain, certain types of chronic low back pain, fibromyalgia and others – may essentially be explained by abnormalities in central pain modulation.” When musculoskeletal injuries are treated early and effectively as described in Release From Pain, then this central pain modulation can be modified, even prevented. When patients have not been treated realistically according to the dictates of their injuries, and chronic pain has developed, Dr. Goodley illustrates how the restoration of function and tissue balance can still benefit and relieve pain. Under any circumstance, once the pain dynamic has become resident in the central nervous system, the expectation for full relief being provided must be markedly modified – all the reason for the main contention – the need for early accurate diagnosis and treatment.

David Butler, a physical therapist, has authored a textbook, The Sensitive Nervous System , and he and G.L. Moseley have written a book for patients entitled Explain Pain. The knowledge in these books helps both the patient and the therapist to understand pain from the perspective of the scientist, Dr. Goodley's book - ¹

Release From Pain - comprehensively approaches such problems from practical perspective to present clinical tools to more effectively treat such patients plagued by unremitting pain from musculoskeletal injury and the neurovascular consequences of that injury. In this area of medicine, now, nothing is more important to patients than their own knowledge about their conditions from which they may no longer be passive recipients of therapy but can reasonably assess what is being done to them.

For those who are ready to hear, now listen. Each generation of healing professionals make contributions that allow us to do more for patients with chronic musculoskeletal and neurovascular pain. Dr. Goodley's unique contribution arises from his having reintegrated his medical background with manipulative (and other) skills he learned from osteopaths, chiropractors and physical therapists from which he offers as his legacy this powerful expounding of history, wisdom and commentary dedicated to understanding and treating patients with chronic pain.

Peter I. Edgelow, MAPT (DPT candidate)
Associate Clinical Professor UCSF/SFSU Graduate Program in Physical Therapy
Consultant, Department of Vascular Surgery, UCSF Medical Center
Recipient:
Royce P. Noland Award of Merit, California Chapter, APTA, 1988
Henry O. and Florence P. Kendall Practice Award, APTA, 1999²

¹Butler , D., The Sensitive Nervous System. 2000: Unley. Noigroup Publications.

²Butler , D.S. Moseley, G.L., Explain Pain. 2003, Adelaide , South Australia : Noigroup Publications www.noigroup.com

PREFACE

“I swear eternal hostility over every form of tyranny over the minds of men.”

Thomas Jefferson

When Nebuchadnezzar, king of ancient Babylon , destroyed Jerusalem , he called the elders of Israel before him to boast of his power. They responded that all he had done was grind fine flour. He was only the instrument of their punishment because they had neglected the fundamentals that had been entrusted to them.

From the Los Angeles Times Editorial Page July 26, 1993 written by Evelyn Storr Smart:

"Commentary - Perspective on Health Care - You Bet Your Life on the Doctor Lottery - Whether we pick our physician or are assigned by a plan, bedside manner is good. But expertise is better.

...The following month, suffering from a severe case of bursitis, I consulted his replacement, a skinny little kid with a beard. 'I believe we'll find calcium deposits in your shoulder, which will probably require surgery.'

'No, thanks,' I said. I left and did the only thing I knew how to do - asked for recommendations from my other bridge-playing buddies.

Helen's doctor pulled what appeared to be a 2-inch needle out of a drawer. ‘This is cortisone and Novocain. I'll inject it directly into the joint and inflammation will subside.' Sarah's doctor prescribed muscle relaxants and instructed me to keep the arm moving to prevent ‘freezing.' Mary's doctor put my arm in a sling and told me not to use it or ‘the erosion could cause deformity.'

All my friends' doctors had very nice personalities, but the divergence of their opinions was startling...."

The confusion is admitted. The American Medical Association (AMA) is not shy about publishing these inadequacies although it has no idea of its fundamental. The American Medical News has a "First Person" Section. This appeared in its November 23/30, 1992 issue:

" Minneapolis --- I am offering this advice as a public service to all male physicians. Do not - I repeat, do not - start your conversation with a woman patient with the words, 'Have you been under any stress lately?'

I believe that, just as some women have successfully used PMS as a defense for murder, any female patient who attacks her doctor after he asks this question also will be acquitted. Especially if the jury is made up of other females.

I remember the first time a doctor began his conversation with me using that phrase. I was in his office because my back hurt, and I wanted to know what I could do to relieve the pain. The day before, I had packed and moved 40 boxes of books so a painter could paint our family room.

'I see that you have back pain,' the doctor said after he glanced at my chart and shook my hand, 'Have you been under any stress lately?'

I was much younger then. I thought that moving 40 boxes of books maybe wasn't a good enough reason for a backache, so I tried hard to think of stresses in my life. There weren't any. I felt that I had failed as a patient. The doctor, after all, had studied medicine for many years, and I was a novice at having pain.

Years passed. I got out of bed one morning, and each time I put my left foot on the floor, I was in agony. I made an appointment with a doctor.

'I see that your leg hurts,' he said after he glanced at my chart and shook my hand, 'Have you been under an stress lately?'

'I don't think so,' I said politely.

'I think I might be having trouble with my leg because I slipped and fell down the stairs while carrying the laundry yesterday.'

'Maybe I should have a look at your leg,' he said sheepishly...."

Those stories hurt. It is not a matter of healthy differences of opinion. That is not the issue. The fundamental approach is. The Fundamental Flaw is. What is up front in the doctor's mind in the initial encounter is³.

There is no substitute for what only focused minds, eyes and hands may be skilled to provide for the relief of pain and impairment.

This is the entire authoritative story of the Pandemic unimpeachably proven in the lives of real people: the history, the thinking, the methods, the potential results and reflections about how we may reverse the recent past and restore medicine's essential foundation.

What we now call medicine began to coalesce in the prehistoric mists. Methods slowly evolved and only persisted if they helped often enough. One essential was the concept that the body is a structure whose function can be influenced for worse or for better through its mechanics. Eventually the word manipulation was used. The penalties for ignorance about such vital knowledge are profound. If the function of a doorknob is denied, the essence of the door is denied as well, yet in principle that is precisely what traditionalism did - and still largely does. That is the Fundamental Flaw.

Despite that hands-on care of the body's biomechanics had been in medicine's tradition for millennia, medicine irrationally repudiated them during one of its lowest intellectual ebbs and unwittingly shattered and scattered its foundational principles among what became three competitive professions. As the schism established osteopathy, then chiropractic - whose approaches centralized around manipulation – medicine reacted with disdain.

Logic died.

Despite the pleadings of some strong voices, no reevaluation was attempted. The passage of time only resulted in further festering of the wound at any mention of “manipulation” as the mantra repeated: “If we don't teach it, of what possible value could it be?” The answer had to be self-evident: “It couldn't be, it mustn't be valuable! It had to be below our standards. It had to be below our science!”

Eventually, while the schism's origin was lost like dark legend, the prejudice against manipulation self-perpetuated, and evidence was always available to justify this attitude. There have always been charlatans. So, instead of the manipulative fundamental dynamically developing as a cohesive, trustworthy guide within traditional medicine, it was discredited as the synonymous derelict symbol of its most despised competitor - chiropractic. And f uture generations born into a hardening tradition of pervasive belligerence against anything manipulative unquestioningly accepted this verdict.

In recent years, while there have been isolated beginnings of change, nothing has improved institutional understanding. And now we are confounded, as well, with managed care, which so often divorces itself from medical wisdom that it has no resource to comprehend the long-range savings from sound, comprehensive early-on care: no power structure exists that will likely spontaneously lead in correcting the Fundamental Flaw. So, the wheel goes ‘round and round' as the costs go up and up while

traditionalism has religiously insisted on its doctrinal correctness. Most of you who required, and require, these methods for your relief became fodder in the pervasive war of the Pain Pandemic.

The conflict remains so near unimaginable that future historians may well describe the past century as a time of unnecessarily perpetuated pain.

Only recently have there been coalescing efforts for change. “Alternative Medicine” has within it a vital seed. On November 11, 1999, sixty-one international medical organizations announced the “The Bone and Joint Decade, 2000 – 2010, for Prevention and Treatment of Musculoskeletal Disorders” in the journal SPINE. Initially, the membership was dominantly surgical. In its admirable evolution, medical specialties and both osteopathic and chiropractic organizations are now represented.

There have been many reactions to this book. A few doctors were enraged. An orthopedic surgeon of thirty-five years' experience paled when he met me after reading it as he confessed that he had not realized he'd been a “barbarian” throughout his career and that he had to first barely survive his scorching from the Introduction before not being able to put it down for the next “250 pages.” An editor who prided himself on remaining uninvolved commented that he had to wear asbestos gloves when he read it. Above all, people long disappointed because of their persisting pain despite numerous attempts to seek help have gratefully praised this book for its practical value in providing real answers and guidelines. They insisted that it must be published to spare others the anguish of being subjected to baseless procedures and unwarranted assaults on their character and mental state when “nothing was found,” and they didn't improve. Their most poignant anguish is that no one believed them. Their most common insult is that they must be imagining their pains.

Declaring the extent of traditional ignorance about the commonest of pain conditions is not new revelation. The literature is sprinkled, even from the White House, with commentaries concerning the failure of American medicine to teach fundamental biomechanics. The failure was laid directly on the medical schools. That was in 1932! Yet, nothing improved. In fact, the situation continued to deteriorate. Editor's Notes in The March 1999 issue of The Physician and Sports Medicine, by editor-in-chief Gordon O. Matheson, MD, PhD, reports “Roughly one quarter of visits to primary care physicians are for musculoskeletal problems, but typically less than 3% of the undergraduate medical school curriculum is spent on musculoskeletal medicine.”

All this is only preamble. This story soon gets frighteningly more painful in very practical terms. For example, News Briefs had a caption, “Med School Graduates Weak in Musculoskeletal Knowledge.” It refers to a recently published paper in an authoritative journal. With the emphasis now that primary care physicians will be your major provider, “The authors administered a validated musculoskeletal knowledge exam to 85 new residents at the University of Pennsylvania School of Medicine in

Philadelphia . Seventy of the 85 failed.” All the questions were culled from the knowledge that is traditionally taught! None of it had anything to do with the fundamentals this book describes!

An example of the drought in care that this has produced appears as major captions in a pamphlet I received in the mail on August 4, 2000. The colorful front page is titled, Treatment of Acute Back Pain – An Interdisciplinary Approach . Six physicians are listed, including a primary care physician associated with a university program. As well, an emergency physician and a neurosurgeon, also university affiliated, are among those whose statements are emphasized in bright colored boxes.

The primary care physician stated, “Mechanical or primary back pain has been a useful umbrella under which we place the poorly differentiated or poorly defined syndromes of patients who have no demonstrable pathology in the back nor any secondary gains that would cause them to magnify their symptoms.” (Italics mine) Release From Pain completely refutes much of this generalization.

Furthermore, the emergency physician contributed, “Although common in the emergency setting, mechanical back pain must be a diagnosis of exclusion because of the potential of underlying causes that may be life-threatening.” The first paragraphs of the first chapter of this book disprove this statement as well. Precisely diagnosing a benign condition up-front can abort the need to do anything else!

Finally, the neurosurgeon declared, “It is important to perform the physical examination, neurologic examination, and appropriate tests to determine that the diagnosis is primary back pain. Only then can you initiate treatment.” This statement is so self-evident, its utterance stuns. No diagnoses can be made without appropriate tests! Only because of the general tragic lack of valuable knowledge about the commonest of pain complaints would any professional feel compelled to make a declaration of such an embarrassing platitude as if it were a pearl of wisdom. This statement's only merit is to declare the enormity of the confusion in the trenches caused by the medical profession's never having been trained in even the basics about how to approach primary back pain. What was so readily published reveals the fruits from generations of teaching that demanded that manipulative thinking be deplored and ignored.

For five decades, the stories my patients and their tissues have told me taught me more about how I might help them than any other single source. Because it is a basic truth is that each of us is our own most authoritative text.

Release From Pain is obviously not the first book to address the merits of tissue-directed care, but others only deferentially discussed so they obscurely gather dust while the casualty list continued to increase while our world still largely has no idea that the battle is raging.

Release From Pain voices the anguish of the myriads afflicted and the legions of practitioners sent out too poorly equipped to aid them. Beneficial change only begins from the first honest look. Release From Pain fulfills that need.

It challenges reality to assume that medicine in the United States is superior just because so many seek to emulate it.

(Written in 1992 but still largely relevant.) Why must you need to choose between three distinct professions with contradictory perspectives when you seek care for treatment of the most common pain problems? There are Medical Doctors (M.D.s), Osteopathic Doctors (D.O.s) and Doctors of Chiropractic (D.C.s). Each contends to influence according to often vastly different understandings. There is not even agreement among them on a basic vocabulary! So, w ho is to be trusted to attempt to relieve your pains? What basic knowledge and skills does the practitioner you choose need to possess? Today, unless you are aware about these issues, you are doomed in confusion.

Your goal must not only be pain relief but the correction of its cause(s) and, if possible, assurance that there is no residual "smoldering" that will likely eventually re-erupt as your condition degenerates towards chronicity. Herein, I promise you dedicated guidance for you to be reasonably confident about your care. My primary purpose is to educate you to the fundamentals.

Whether you are in pain or involved in the healing arts, there is something in Release From Pain that you need to know. Will Rogers said it well, “ We're all ignorant. We're just ignorant about different things.” But there are some issues none of us can afford to be ignorant about.

The dam is broke! Our world is inundated in a flood of unnecessary pain! The whole story has to be told so the Pain Pandemic will end!

³From the Los Angeles Times Editorial Page July 26, 1993 written by Evelyn Storr Smart:

"Commentary - Perspective on Health Care - You Bet Your Life on the Doctor Lottery - Whether we pick our physician or are assigned by a plan, bedside manner is good. But expertise is better.

...The following month, suffering from a severe case of bursitis, I consulted his replacement, a skinny little kid with a beard. 'I believe we'll find calcium deposits in your shoulder, which will probably require surgery.'

'No, thanks,' I said. I left and did the only thing I knew how to do - asked for recommendations from my other bridge-playing buddies.

Helen's doctor pulled what appeared to be a 2-inch needle out of a drawer. ‘This is cortisone and Novocain. I'll inject it directly into the joint and inflammation will subside.' Sarah's doctor prescribed muscle relaxants and instructed me to keep the arm moving to prevent ‘freezing.' Mary's doctor put my arm in a sling and told me not to use it or ‘the erosion could cause deformity.'

All my friends' doctors had very nice personalities, but the divergence of their opinions was startling...."

The confusion is admitted. The American Medical Association (AMA) is not shy about publishing these inadequacies although it has no idea of its fundamental. The American Medical News has a "First Person" Section. This appeared in its November 23/30, 1992 issue:" Minneapolis --- I am offering this advice as a public service to all male physicians. Do not - I repeat, do not - start your conversation with a woman patient with the words, 'Have you been under any stress lately?'

I believe that, just as some women have successfully used PMS as a defense for murder, any female patient who attacks her doctor after he asks this question also will be acquitted. Especially if the jury is made up of other females.

I remember the first time a doctor began his conversation with me using that phrase. I was in his office because my back hurt, and I wanted to know what I could do to relieve the pain. The day before, I had packed and moved 40 boxes of books so a painter could paint our family room.

'I see that you have back pain,' the doctor said after he glanced at my chart and shook my hand, 'Have you been under any stress lately?'

I was much younger then. I thought that moving 40 boxes of books maybe wasn't a good enough reason for a backache, so I tried hard to think of stresses in my life. There weren't any. I felt that I had failed as a patient. The doctor, after all, had studied medicine for many years, and I was a novice at having pain.

Years passed. I got out of bed one morning, and each time I put my left foot on the floor, I was in agony. I made an appointment with a doctor.

'I see that your leg hurts,' he said after he glanced at my chart and shook my hand, 'Have you been under an stress lately?'

'I don't think so,' I said politely.

'I think I might be having trouble with my leg because I slipped and fell down the stairs while carrying the laundry yesterday.'

'Maybe I should have a look at your leg,' he said sheepishly...."

Those stories hurt. It is not a matter of healthy differences of opinion. That is not the issue. The fundamental approach is. The Fundamental Flaw is. What is up front in the doctor's mind in the initial encounter is.

⁴Wilbur, Ray Lyman: Body Mechanics: Education and Practice, White House Conference on Child Health and Protection, 1932.

⁵Freedman KB, Bernstein J: The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg (Am) 1998;80 (10):1421-1427.

INTRODUCTION

"In the last analysis we see only what we have been taught to see. We eliminate and ignore everything that is not part of our precedent."

Dr. Jean Marie Charcot

Principia Primum! – (Fundamentals First!)

This story begins from a basic truth: machines work better when their moving parts are aligned, balanced and operating smoothly. Function is impaired when they aren't. Your body works in much the same way. Its bones, joints and related tissues are fundamental structures of your function. Much of your pain and dysfunction are the equivalents of a machine's squeaks and rattles. The science is called biomechanics: m echanics related to living tissues.

Exploring a problem to its source is the best means to efficiently correct it. Otherwise, it may persist and commence a degenerative cascade with long-lasting and far-reaching adverse consequences. Diligence in seeking the source is also the best way to monitor whether therapy is succeeding. If the originating abnormality in the tissues can be effectively relieved, recurrence will be unlikely. Any other approach is substitutive, relatively undirected, probably disadvantageous and possibly hazardous.

The concept of manipulation implies observing a biomechanical pathologic process and then applying skillful force to restore normal relationships, appropriate motion - and release from pain . If resolution of pain and impairment hinges on restoring the alignment of the moving parts, then the logic of manipulation is obvious. And because your body is, in fact, a functional unity, there is much more involved, as well.

The pages through the first three chapters are sequenced: 1 | 2 | 3 | 4 | 5 | 6