First Chapters

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

Again, joint dysfunction implies mechanical impairment. Something interferes with articular relationship and movement that may be relieved by methods similar to those used by a carpenter, machinist, more apropos perhaps, a watchmaker. C raftsmen know their materials and approach their tasks without preconceptions or assumptions. Ideally, particular interests and attitudes do not fetter their thinking. They accept without emotional interference that what is – is.

If a door can't be closed, first logic expects that it be tested to learn if it or the frame is warped or if a hinge is stuck. If machinery malfunctions, it is first observed overall, e.g. are the fuses blown? Then the tests proceed through its particular parts in order, e.g. are the belts adjusted? Is the wiring intact? Principia Primum! (Fundamentals First!).

Eyes, hands and basic skills explore essential questions and decide what might be done next. The principles of investigation are immutable, and physicians need similar mental tools and skills. The examination table is the physician's workbench, the place for fundamental inquiry - from which may eventually arise the need for technological assistance to answer reasoned questions. Appropriately applying technology needs to imply its reasoned usefulness to the task at hand, but the reality is sadly another face of the Fundamental Flaw tragedy. Too often the instrument, inherently remote, is not even designed to reveal what it is hoped that it will. At such times, data can be worse than irrelevant because it seems to give objective substance to the self-deception. When technology does not demonstrate an abnormality, it can too easily encourage the conclusion that nothing is wrong.

On the other hand, “seeing something” too easily satisfies the illusion that it is applicable and that a real examination has, after all, been done. While it is true of halitosis that bad breath is better than none at all, that does not apply to bad data. Praying to technology is only another form of idolatry.

The Fundamental Flaw is clearly revealed in the traditional medical examination for almost any ache or pain because it ignores exploring the segmental biomechanics that may fully reveal the cause of the complaint. And here is where technology is too readily thrown into the gap as a – consciously realized, or not - desperate attempt to compensate for The Fundamental Flaw. X-rays will almost certainly be taken, often initially.

While the traditional examination favors a search for serious pathology - threat to life, limb, neurological injury, or for a specific disease, like some form of arthritis, or cancer - when such conditions are not found, the examination more likely sputters despite the physician's obligation is to study what is there - and with the same commitment! But the expectation cannot be honored because allopaths in general do not have the necessary tools. But you have to be given something. A pill and/or some therapy may be prescribed. (And it is so expedient to write a prescription. And it is so expected.) Possibly an injection into a part will be administered (but even then its effectiveness will likely depend on its accuracy of placement, which largely depends on the knowledge intimately expressed through the hands-on skills). In this battle to protect one's sense of professionalism, as you will eventually see, a doctor's defensive mental gymnastics can became an overwhelming force. In finality - since the potentially effective examination cannot be performed, the possibilities for the patient's receiving relief is greatly impaired. That is the proverbial bottom line of The Fundamental Flaw.

But there are no absolutions for the unfortunate patient. The penalties accrue regardless of good intentions when care is rendered without attending fundamental foundations. With the incomplete examination, a condition may hide and persist slipping into a chronic state without raising even a suspicion that the culprit may well have been apprehended at the first encounter . However unwittingly, the doctor was an accomplice to the crime.

Besides the patients who are being ill served by the medical profession, those who feel the pain of the Fundamental Flaw tragedy are the honest physicians who learn that the hands-on essentials eluded their training. Other practitioners become angrily defensive and vent their frustration in all sorts of ways, including vociferous conviction that the way things are is the way they're supposed to be. T he heralds - the osteopaths - are mostly so busy emulating allopathy, they disproportionately detract attention from these vital issues. They should know better, but succumbing to the “power” is the easier path, and too many of them just want to survive somehow. And, of course, the additional difficulties that managed care is inflicting can be used as another excuse for the inaction of the medical profession.

Medicine is supposed to protect what is priceless: human life. It is supposed to cherish and advance each individual's potential. It is supposed to represent the highest aspirations of civilization. But we doctors were not careful with what we were entrusted with, and we are no longer trusted and admired as we once were. Our loss of knowledgeable hands-on care is one of the reasons.

Ultimately, the meeting of doctor and patient is one on one. Each encounter is an opportunity to preserve life and/or improve its quality. Success happens or fails only in that relationship.

I founded The American Association of Orthopaedic Medicine in 1980. On October 17, 1982, a small group convened to formalize it. Peanuts was looking up at me from the Sunday comics in the hotel lobby.

Linus is looking off into the distance and sees Snoopy jogging towards him.

“Hi, I thought maybe that was you. I've been watching you from way off. You're looking great.”

Snoopy reflects, “That's nice to know. The secret of life is to look good at a distance.”

Attempting to look good at a distance is the essence of medicine's blunder. Failure to move in close is the cause of the Pain Pandemic. And it is fed by the predisposition for the sensationalistic at the loss of refining the common that is good.

While in high school, I worked weekends at Beverly Park, a children's amusement park, in West Los Angeles where Beverly Center now stands. Often I loaded and unloaded kids into the Toonerville Trolley next to the merry-go-round. It became so routine that there were times I would see it going around the track while having no recollection when I had loaded it up and started it. There were many afternoons when I would suddenly realize it had been hours since I had heard the calliope although it had been blasting in my ears all the while. The mind can do the same thing when a reality becomes constant. That is what has happened to all the suffering because of the Fundamental Flaw. The pain is there regardless. We just have to hear the screams again.

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Orthopedic Surgery and the Pain Pandemic

In 1992, I was an invited lecturer at The XI World Congress of the International Federation of Physical Medicine and Rehabilitation , in Dresden , Germany . That is where I met Dr. Tomio Yamamoto. My German colleagues had made the evening sound so casual that I had taken a leisurely stroll from my hotel and arrived what I thought was only a few minutes late. To my consternation, the ballroom was packed with hundreds of people long settled at their tables. As I stood there very alone, the flow opened for a moment on the crowded dance floor, and I saw what might be one vacant seat at a table on the far wall. Hopefully, I worked my way to it. To one side of the seat were a few Thai physicians I had already met. We greeted each other, and they said that no one in their party was occupying the empty seat. The distinguished Japanese gentleman on the other side said the same so I took it. His name is Dr. Tomio Yamamoto, Chief of Orthopedic Surgery at Osaka Koseinenkin Hospital in Japan .

I cannot think of an equivalence to emphasize the power of his insight, his integrity and the reality he expressed. Of course, his statement was relative. The joint conditions he was referring to were those I had described but that he had never been exposed to in his surgical training. From an orthopaedic ⁸ medical perspective they are common impairments. And most of orthopedics is, in fact, medical. Till then, he had never realized that his training had so seriously skewed his perspective.

For this very special physician to make such an admission to someone like me who is not an orthopedic surgeon in a conversation focused on joints - his area of expertise – is testimony to the incalculable incomprehensibility in which the Pain Pandemic exists. Dr. Yamamoto hit a primary chord. We had traveled approximately equidistantly to Dresden to sit together. From so far to so near, we opened long ignored doors to begin to resolve the Pandemic by his admission how deeply his specialty is implicated in the Fundamental Flaw because it filters virtually everything through its surgical perspective.

Orthopedic surgery became imbued with extraordinary privilege and authority that it accepted - and with it commensurate responsibility for all that followed. Hopefully, it will now reflect on its participation in ‘the law of unanticipated consequences' and assert its influence for the necessary changes.

It seems unthinkable today that medicine is obligated to reconsider the adequacy of its accepted principles of the orthopedic examination - to audit what is so fully taken for granted - to commence from scratch with what engineering calls "systems analysis." But such an investigation is essential! The traditional orthopedic examination today begins far beyond where the essential clues first appear. By doing so, orthopedics essentially denies that the signs exist - and with no perception at all that the orderly sequence has been lost. That is the Fundamental Flaw.

Hippocrates wrote, “ The physician's job is to cure. How he does it matters not a wit.” This implies that, above all, physicians care for their patients. While most do - it is that caring that must be acknowledged in action now.

⁸Throughout I will use two spellings for one word: When I am making a distinction, "Orthopedic" refers to the orthopedic surgical perspective. "Orthopaedic" refers to the medical.

CHAPTER TWO

OZZIE'S NECK

"The most inestimable merit is a complete appreciation of the usual."

Henry James                    

•  The beginning of the mission

It happened because of a splinter that Ozzie Hansen got under his thumb fingernail. It was from dunnage, contaminated lumber that lies around wharves to support loads from ships from wherever. Ozzie's was big and had penetrated deep down to the bone. I trimmed back the nail, cleansed the wound extensively and asked him to return the next day because of the potential for serious infection.

Ozzie was on his way back to my office when his car was violently rear-ended by an Army officer rushing back to his base weaving through traffic at seventy miles an hour. The crash broke Ozzie's seat and hurled him into the rear of his vehicle. He arrived at my office by ambulance, and I followed him to the hospital.

There was no gross neurological deficit, fracture or head injury, but Ozzie's neck was virtually locked with his head thrust forward. The pain was intense and became excruciating with any attempt to move it. As the spasm receded, I palpated an obvious and remarkably tender walnut size mass high on the left side of the back of his neck just under the skin.

After nine days, Ozzie insisted on being discharged although his pain hadn't diminished. I pleaded with him not to, but he was a respected longshoreman supervisor, and he insisted on returning to work. He returned in only a few hours on the edge of shock, and two more weeks barely provided further relief.

The orthopedic surgeon I consulted claimed, "Since all soft tissue heals within two weeks, any complaint thereafter must be imaginary or faking." He didn't have the slightest idea what I was talking about when I asked him about the "walnut," and no one else I referred him to did either, yet it never changed. The orthopedic surgeon compounded Ozzie's injuries another way, as well. Because of his report, Ozzie's very legitimate lawsuit was dismissed. Later, he told Ozzie that if he still “thought he felt pain,” he could hang his head in traditional "over-the-door" cervical traction, and so trusting Ozzie had sat up shivering and suffering through many a sleepless night during that unseasonably cold winter.

Shortly after Ozzie's accident, I received an announcement for a twenty-hour course in basic joint manipulation in half-day sessions for a week. Manipulation was ridiculed in medical school, but my former brother-in-law had attended osteopathic school because he had repeatedly been rejected for admittance to medical school, so I'd heard the word often. In fact, I had heard the word ad nauseum but had never been shown anything. Later, some of my patients had told me they'd been helped by it, and by then I knew something basic was missing from what I – a traditionally trained M.D. - had to offer.

I tried the basic manipulation I'd learned on Ozzie, but he couldn't tolerate any motion at all. I attempted everything I could think of. It was 1962, and a drug called Tubadil ® was available. It contained curare, found by witch doctors and used by native African hunters. It was the most powerful muscle relaxant ever known and could produce total muscle paralysis. It was mixed with peanut oil for intra-muscular injection, and each dose had to be meticulously measured and subsequently increased by only 0.1 cc., about 2 drops, while the critical response was watched for: In the sequence of effect, about 0.4 cc. paralyzes the eye muscles, and any increase after that blocks the diaphragm and terminates breathing. I took Ozzie right to the edge and supplemented it with morphine, but even then any attempt to mobilize his neck was instantly agonizing. Nothing helped until I purchased a “Neuro-Orthion” traction table for him that immobilizes the entire body by clamping both the head and feet. With it, Ozzie was able to to get a few hours sleep.

Nine months after his injury, Ozzie attempted to return to work although I protested again. On his second day back, he was standing on a ship's deck guiding the winch. As he began to look up to direct the hook through a hatch, he blacked out and started to fall into the hold towards the steel deck thirty feet below. Another longshoreman barely caught him by his sheepskin coat and saved his life. After that he didn't return to work.

His case was reviewed by Neuro-Radiology at UCLA because it was suggested he might have sustained a small fracture and that a bone callous had compressed his vertebral artery, which ascends to back of the brain, but no fracture was discovered. For fifteen months, I watched helplessly as Ozzie lost about forty of his once vigorous one hundred seventy pounds.

Then one day, he came to my office Loretta, his wife. Always respectful and quiet despite his pain, he looked at me from across my desk with an additional sadness in his now gaunt and haggard face. He was near exhaustion, and this gentle man paused a little longer before he spoke so I sensed all the more the gravity of what he was about to tell me.

"Doctor, Loretta and I are here to thank you for all you've tried to do for me. You were always there, and we're grateful. We've talked it over. I've decided. I just can't take any more of this pain. If there's nothing else to do, I've come to say good-bye before I take my life."

Loretta's eyes hadn't blinked. Ozzie had done all that I'd asked and allowed all I'd offered. I looked at him knowing how truthful he was, and as I sank back aching into my chair I knew that I had no choice.

"Ozzie", I said finally, "there is only one thing I can think of that I haven't tried." It was something I had learned from the doctor who had taught my first course in manipulation. He had told me a story of a woman who had been disabled with headaches. There had been no injury. He hadn't found anything on examination: no joint restriction, no signs of localized changes of any sort, but on an unexplainable impulse, he had offered to manipulate her neck under general anesthetic. He claimed she had accepted and, for reasons unknown, she had been relieved. It had happened in England .

There was no similarity between Ozzie and the English woman. Ozzie's neck was virtually stuck. Manipulating a neck when general anesthesia is depressing the protective reflexes is one level of jeopardy, but the exact nature of Ozzie's pathology was a mystery. Any movement beyond an unknown boundary could totally paralyze or kill him. But his desperation was frightening, and I recalled the story despite the danger.

At that time, I had been manipulating for about a year and had experienced some dramatic successes even from the rudimentary procedures that I had learned, but I had never done anything remotely like what I now contemplated. There wasn't a hospital in the United States that would allow me to do such a procedure, and I had never administered a general anesthetic. Nonetheless, I offered the procedure, explaining the fullness of the risks. I would have to do it in my office. If they accepted, I insisted on one stipulation. Loretta had to be in the room. Whatever happened, she had to witness it. They looked at each other… Ozzie nodded.

For three days I studied, prepared, and prayed. The morning of the procedure, everything was surreal. I couldn't speak knowing I was about to jeopardize Ozzie's life, my license, my family's livelihood and my freedom, but I couldn't allow myself to linger on it. I walked out the front of our home and across the lawn into the front door of my office. Ozzie and Loretta were sitting there waiting, seemingly calm. Without a word, we entered the small room where I'd prayed and carefully set out all the medicines and emergency equipment the night before.

Ozzie lay on the examining table along one wall. Loretta sat against the opposite wall only a few feet to his side. I started an intravenous drip, and when he said he was ready, I slowly injected Brevitol®, an ultra-short acting anesthetic into the tubing. As Ozzie sighed and his chin slumped, I softly placed my hands onto the back of his now limp neck. For the first time since the injury, the “walnut” (of segmental spasm) was gone. Ever so slowly, I began to rotate his neck first to one side then the other, tucking his chin toward the curvature above his clavicles (collarbones).

Surprisingly, after all the time that had elapsed since the injury, there was almost no resistance from scarring as the room filled with the most alarming, loudest staccato of popping noises I've ever heard, even till now. Then I gently applied a series of transverse sheer forces at each vertebral level as the POW... POW... POP... persisted.

Except for her widening eyes, Loretta sat pale and absolutely motionless.

"What's happening?"

I looked helplessly at her unable to offer any adequate answer.

"I don't know."

When apparently everything in Ozzie's neck had moved and there was quiet, I began to sag under the dread heaviness of every passing second.

Ozzie's eyelids finally fluttered.

"When are you going to do it?" he whispered.

"It's already done.” Each question was a dry mouthed, apprehensive plea: “ Ozzie. Can you move your toes?…Ozzie, can you move your fingers?… Ozzie, can you open your eyes?” Ozzie, can you sit up?…Ozzie, can you move your neck?"

Sitting and facing Loretta, Ozzie turned his neck painlessly through a full range of motion. Loretta slumped for a moment. Then she came to us where I was already holding Ozzie. We stood there for a long time, our faces together and arms around each other, our body's wracked, tears flowing freely as we praised and thanked God. I looked up and raised my arms thanking Him again. I knew He had put my feet on a path that I swore I would never abandon.

Ozzie's neck began to tighten again a week later. There had to have been some contractures after so long. I more confidently repeated the procedure, and Ozzie obtained complete and permanent relief. He promptly returned to unrestricted work for six months when he had a mild heart attack and retired. I examined him annually for ten years, when I again x-rayed his neck. We remained in contact through the fifteenth year. Never again did he experience neck restriction, or pain, or headache. ⁹

In the following few years, I repeated the procedure over a dozen times. Half the patients were markedly improved, and there were no complications.

⁹I treasure a letter postmarked September 30, 1976.

" Dear Dr. and Mrs. Goodley,

Enclosed is a clipping from Long Beach . If we had known about the party I am sure you know that your names would have been on top of the Guest List. We had a very wonderful day. Our one Granddaughter by marriage said that if Dr. Goodley had walked through the door she would have kissed your feet. Her dad was one of your patients in Wilmington a Mr. Smith and you really helped him and put him back on his feet. He is now in Hawaii in a Travel business. Ozzie is still doing fine.

As ever, Ozzie and Loretta Hansen"

The clipping, dated one day previously, reported their fiftieth wedding anniversary to which more than 150 friends and relatives had attended.

CHAPTER THREE

A SURVEY OF TECHNIQUES

There are many paths to the top of the mountain, but the view is just the same.

Chinese Proverb        

• Demystifying manipulation
• What manipulation is
• How the force must be asserted
• Hazardous force
• The precious “pop”
• Descriptions of some techniques and illustrative cases
• Frequency and effect?
• Chiropractic commentary
• My recommendations about manipulation's use
• Warnings
• Some general recommendations for the candidate
• Why pain can be a liar
• “Trigger Points”
• Spasm
• * A brief lesson in good posture
• * A block on the floor for back pain

Joint manipulation is neither a generic term, like “cottage cheese,” nor is it mysterious. It implies the application of force to relieve abnormal relationships of tissues, usually about joints, in order to restore physiological function.

There are a number of explanations for manipulation's effectiveness when it works, the most obvious being that gapping a joint may release entrapped tissue. That would be consistent with a number of my experiences, but the actual frequency of such circumstances cannot be known. Many other factors are involved as a complex of neurological/muscular responses are invoked.

At one time, the definition of manipulation was limited to the delivery of a sudden and precise force that is faster than the patient's ability to react. In contrast, mobilization was considered the slow, sometimes rhythmic delivery of force that always remains under the patient's final control.

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