First Chapters

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

The therapy is simple and usually works, as it did for Sarah. With the hand in place as before, the patient takes a few deep breaths, lets all of it out and then stops breathing for as long as possible. “Respiratory assistance” is sometimes irreplaceable. I ask my patients to visualize that they are deep underwater and fighting to reach the surface for a life saving breath. I want that first inspiration to “explode” into the lungs. The longer the breath is held the better. At the instant it begins, the examiner rapidly withdraws the hand, thus releasing the pelvic diaphragm to the reflex influence of the descending respiratory diaphragm. The restoration of pelvic diaphragmatic movement implies that its “paralysis” was more a matter of its having been in “shock” than that an organic condition exists.

The term “myofascial” inseparably binds the relationship of muscle and fascia, yet sometimes it is the muscle alone that can be involved. While I was teaching at USC, in the Department of Emergency Medicine, one evening the most powerfully built man I have ever examined walked in. With a big smile, he gave his history that he worked at a wrecking yard picking up engine blocks and throwing them onto a truck - one-handed, that is - either hand.

He wasn't having any pain at all. He explained that while he was playing with his “toys,” his right arm suddenly wouldn't elevate higher than horizontal. There was absolutely no other impairment other than the absolute restriction to 90 ° . Something just “ran out” halfway up. I don't exaggerate his strength. I could literally do a chin-up on his outstretched arm. I was able to passively completely elevate his arm without difficulty, and the entire remainder of his examination was normal. His problem was a remarkable expression of what this entire theme is about - not manipulation but manipulative reasoning – hands-on familiarity .

Muscle contraction results from a series of electrical, chemical and mechanical actions. In its basic, microscopic-size rods slide among and in and out of each other, which results in the shortening and lengthening of the muscle fibers. The chemical process depends on calcium transfer. Anatomically, while the arm's initial approximately 90 ° upward movement results from its swinging on the scapula ¹³, it is the swing of the scapula on the chest wall that provides the remainder of full elevation. I reasoned that something had to have happened to the upper trapezius muscle , the prominence of the top of the shoulder, the primary rotator that swings the scapula to the top of its arc.

I stood behind him and palpated deep into its immense mass and eventually palpated the sense of a tense rod. As he had been strolling along and tossing the engine blocks over his shoulder onto the truck, the calcium flow into and out of the myelin sheaths had blocked. His muscle had been trapped shortened so there was insufficient contractility to complete scapular rotation.

It was a time when I was constantly encountering skeptical orthopedic surgical residents. As they watched, I stood behind him, hooked the index and middle fingers of both my hands around the front of the muscle, leaned back and waited. Slowly over a few minutes, the superficial fibers started their “myofascial release” taffy-like stretch out, and my fingers began to get down to the rod, which also eventually “went.” The procedure must be “timeless” time! Whatever it takes! Then, as I felt the “give,” I put my thumbs that were along the back of the muscle together and pushed forward while continuing to pull back with my other fingers, making the muscle into a big “W” for maximum stretch. I'd never seen it done that way, but it was logical, and that was all that was necessary. The block was over. His happily elevated his “tree trunk” straight up and went back to his engine blocks laughing. That was the night they named me The Musculoskeletal Wizard. Cute.

Essentially the same thing happened to Dr. Wayne King, an acquaintance who lived up the street from my house in the ‘70s. Wayne ran the Emergency Department at San Pedro Community Hospital. His daughter, Corinne, was horse jumping, and they had gone to a ranch to see about buying one.

The gracilis is a long cord-like muscle that runs down the medial side of the thigh from the pelvis to the knee. His were as tense as guitar strings. As Wayne lay there, I asked him to relax and accept a bit of pain for a few minutes. I hooked each muscle in turn, waited for the “give,” did the “W” for good measure, and it was all over.

You will realize that these techniques approach the shortened muscle fiber problem exactly the opposite from CounterStrain, which I didn't learn until years after some of these experiences happened. CS might have worked for some of them. I don't know. Both have their place. Whatever works.

MAITLAND TECHNIQUE

G.D. Maitland, an Australian physiotherapist far removed from the rest of the world where the manipulative techniques were developing, devised a unique method that bears his name. It predominantly employs a graded series of oscillations delivered onto the joints with the thumbs. It is another approach that is often successful. While I obtained basic training in his technique and have used it occasionally, I found that my familiarity with others was sufficient for my purposes. Others skilled in his technique do well with it.

Osteopathy in the Cranial Field is in a class by itself and will be described separately.

HOW OFTEN? CAUSE AND EFFECT?

One of the major criticisms of chiropractors has been their too frequent tendency to be highly repetitive with manipulation and even build entire practices on “regular maintenance.” I have discussed the issue with many of them. Since manipulating is what they must do (Although some insist on attempting to further distinguish their craft by calling them “adjustments.”), it isn't surprising that they attempt to justify their practices by describing a wide variety of influences that they claim direct their decision-making.

Some offered precise guidelines concerning how many manipulations they would perform and when they would stop. Unfortunately, I found little correlation of what they said they do to what they do. Criticism of such tendencies is necessary, but I can't leave this paragraph without balancing the scale with the proverbial story of Ear, Nose & Throat specialist(s), as only an example, who would categorically lecture medical students on the limited indications for tonsillectomy only to then enter the operating room and yank out a dozen or so in a morning. Every profession and specialty, as members of an all-too-human society, has its exploiters.   The economic issues heavily influence our times.

A long time ago, insurance companies began paying more for instrumented procedures than for hands-on care, such as manipulation. The discrepancy became and remains a prime attitudinal motivator. Chiropractors cannot perform instrumented procedures, so many of them try to compensate by doing many, many manipulations, yet I have been repeatedly surprised by how rarely they state that they had ever witnessed an episode of dramatic and lasting relief from a single manipulation, as I sometimes have.

A few questions need to be asked (although satisfactory answers may not be forthcoming): When a patient does not improve, when should manipulation be abandoned? If the patient did improve but only after a long time, did manipulation have anything to do with it?

My general practice is to limit the number manipulations I will perform without observable results. Every time I treat a patient, I want to promptly find some objective evidence of response. I have only rarely extended the treatments to ten during, perhaps, three or four weeks before discontinuing and in those cases only for special reasons. There are just so many "silver bullets" - the number of times a treatment should be attempted before its effectiveness diminishes, if it had any.

Any treatment that can relieve can also afflict! And its misuse is a search for misadventure! Manipulation must never be considered benign therapy.

I have witnessed catastrophes, and I will discuss them. Banging away daily is far more a risky manipulating of the cash register than the provision of professional care. Bad stories of patients who have been victimized by years of relentlessly unsuccessful manipulation unfortunately are true. I occasionally see them.

One was a man with persistent shoulder tendinitis who was persuaded by his chiropractor to return repeatedly for almost two years. One injection of cortisone relieved him. Such cases are remembered. But the other side of the ledger is also loaded - people who have endured numbers of surgeries who were cured with one manipulation. I've done that, as well. For all that, a rigid protocol is unwise.

The need for manipulative effort exists along a spectrum, and sometimes it is only the response that can justify the attempt. A major medical aphorism is that common conditions are, in fact, common, and rare conditions are, in fact, rare. While it sounds obvious, it is valuable because it asserts an easily forgettable basic truth. But rarities still happen!

Each potential case for manipulation needs to be individually considered. There is always the exceptional patient who requires more than average, just as there are the Ozzie Hansens. An exact line can hardly be drawn that excludes manipulative procedures despite the presence of other conditions that complicate the consideration. Rheumatoid arthritis of the cervical spine is supposed to be an absolute contraindication, but it is also a question of technique. What specific joint(s) may benefit, and what is (are)its (their) relationship(s) to where there is jeopardy? I have sometimes manipulated, sometimes with dramatic success, when such “contraindications” existed.

A member of the U.C. Davis paraplegic basketball team was injured during a game when he spun aggressively and dysfunctioned his mid thoracic spine similar to my first little lady in Chapter One. He came off the court in pain. I performed a similar maneuver as he sat in his wheelchair, and in less than a minute he was pain free and back out on the court.

JOINT HYPERMOBILITY

Joint hypermobility is another serious problem. If a joint can be hypo mobile, it can also be too loose. Continuing to "slap" it back in place may be useless or harmful, like trying to balance ice cubes or continually closing a drawer that insists on reopening. Manipulation that

predictably provides only a few minutes, or hours, of relief is not only not warranted, it is exploitation. Rational therapy seeks to correct the looseness and end the Las Vegas prayer – just one more pull of the handle… one more roll of the dice… That is why I told Vendyl he would need prolotherapy.

PAIN IS A LIAR

Often the site of the pain is not the site of the instigating dysfunction. While all doctors are familiar with the concept of referred pain - pain emanating from one place but being experienced at another - as when a heart attack is felt in the arm or the jaw - that is not what I am referring to here. A joint that is pathologically locked may be silent. Then, another joint, or joints – perhaps its mate across the midline (like the paired sacro-iliac joints) - has to overwork in an attempt to compensate regardless of its mechanical disadvantage. A twin-engine plane with an engine out doesn't become a single engine plane. It's a crippled twin. The same applies. It is the otherwise normal but overworked joint that often becomes painful, so the uninitiated give it all their attention, and the problem perpetuates, as time passes and becomes an implacable enemy. The most urgent need is to recognize the restricted, injured joint and then to restore balanced movement, hence the need for manipulative understanding.

“TRIGGER POINTS” AND SO-CALLED…

The manipulative arena is infused with other terms and procedures that require comment because they may injudiciously be considered alternative therapies. So-called trigger- points became fashionable some years ago. The term is now even in the official codebook for reimbursed treatment by injection, which, of course, “justifies” their use to too many as it became a death sentence to rationality. The term became so popular it is now a buzzword lacking definition. Anything tender is likely to be called a trigger-point in spite of the fact that the definition applies to a site that causes pain elsewhere when it is pressed, hence the trigger. The distinction is critical.

Entire practices have been built on “having to” inject again and again because, after all, if the “trigger point” recurs, isn't it chronic? So doesn't it need ongoing treatment? Such practices give new meaning to whether it is more blessed to give than receive. However, while there are genuine trigger points that sometimes do respond completely to injection, in my experience, many of the so-called trigger points are often associated with dysfunction about the spine or are soft-tissue conditions that respond well to the techniques I have discussed and which have the considerable advantage that they treat the incitement.

As an incidental of value, being able to monitor how tenderness responds to treatment is similar to the wise approach to observing the course of a patient's fever. While, in contrast to tissue tenderness, fever is a sign of the body's defense attacking an infection, they both are trustworthy guides whether a successful agent is being used in the treatment of the core problem.

Unless it gets out of hand, fever is friend, not foe. It “burns up the bugs.” It is the best single gauge to judge whether a therapy is effective. Similarly, tissue change observed hands-on during hands-on treatment is the best single guide to whether a dysfunction is resolving.

Unfortunately today, treating such conditions for long-term relief is increasingly becoming an act of nobility because it requires some thoughtfulness and skill, takes more time

initially than an injection and isn't as well compensated financially. All it has going for it is truth, professionalism and avoiding the risks of injection.

SPASM

The general use of the word “spasm” and how it is treated can fall into the same confusion as trigger points and is among the most misunderstood, misdiagnosed and mistreated of musculoskeletal conditions. Muscle is the virtual obedient slave of its master, the motor nerve. When the nerve is irritated, spasm naturally results. It is a result not a cause. It can involve the musculature of an entire back, or it can be exceedingly small and limited to only a single segmental dysfunction, yet it is still consequential and commensurate to the problem.

Spasm treatment flourishes in the world of the Fundamental Flaw. The drug companies predictably follow the market, so enter exploitation second only to the brilliance of the Vikings who went west drawing maps that labeled an ice forsaken island Greenland and a near-paradise Iceland thereby protecting themselves from tourists for five hundred years. The drug companies marketed “muscle relaxants” that became among the biggest sellers in history. ‘ Got a pain? Blame the muscles! Pop a pill!

Because traditional medicine does not study the machinery of the body hands-on, does not check the "hinges," does not appreciate manipulation, a "muscle relaxant," or injection, seem to be reasonable primary treatment. Thus, as some chiropractors can be accused of "cracking everything that moves," allopathy, and osteopaths who seek to emulate us, are also guilty for their own predilection to expediency.

MY BLUE BALLOON

Successful manipulation is naturally assisted by the maintenance of good posture, which I define as standing relaxed as tall as nature intends one to. A balanced structure best prevents the strains that otherwise can accumulate until they cause a dynamic breakdown. There are many variations of the theme on how to develop good posture - from the severe military brace (chin in, stomach in, rear tucked under) to other multiples - all of them difficult, especially when not obligatorily done within a social system. One of the most valuable lessons I teach my patients is extraordinarily simple and requires only one focus. It works well, and to whoever taught it to me, I extend my, and many patients, ongoing gratitude.

Consider the posture of a ballet dancer in repose. Everything appears relaxed. The arms hang from the upright torso; there are no considerations about where the abdomen is. In fact, everything just “hangs out” except for the ¹⁵one vital focus.

I ask my patients what their favorite color is. Then I ask them to visualize a balloon of that color that has been blown up with the most buoyant helium ever. (If they say “blue,” I give them mine.) I ask them to visualize a string a little longer than a foot in length tied to it. I ask permission to touch them at the lower part of their sternum ¹⁵. Then, holding one hand on top of the balloon, I “attach” the end of the string there, remove my hand from the balloon and ask them to feel the pull of it lifting the sternum.

That's it. Just the elevation of the sternum, and the entire posture is immediately improved and provides a normal foundation for the neck. Respiration improves as the diaphragm is unburdened. Instantly, the individual looks better. It is so easy to do that there can be a tendency to do more, such as tightening the neck or making the shoulders rigid, so I stand there and coach until the simplicity sinks in. If there is difficulty grasping the concept, I have the patient put one hand on my chest and the other at my back so they can feel the physical lift. All that has to be remembered is the balloon.

A BLOCK ON THE FLOOR

I have another basic to offer for back pain that happens from standing - standing at the sink to wash dishes - standing at the sink to shave…The simple trick of standing with one foot slightly elevated can make a big difference. It is the reason saloons usually have long brass rails along the bar. In the Old West, they had to be hauled from far away places, but the bar was usually there, and not for esthetics. It was because cowboys' backs hurt, and the longer they stood there, the more drinks they bought.

I recommend a block about the size of a Kleenex box. It should be sturdy enough so it doesn't collapse yet light enough that the individual won't trip over it. It's worth a try. If it works, you're welcome.

¹⁰ Melody lives in Sugarloaf, Big Bear Lake , California .

¹¹Barbara now owns The Barnstorm Cafe at the airport in Big Bear City , CA .

¹² Sarah lives at Yishuv: Ma'aleh Levona, D.N. Ephraim 44825, Israel

¹³shoulder blade

¹⁴ "Intertester Reliability of Judgments of the Presence of Trigger Points in Patients With Low Back Pain" multiple authors, Archives of Physical Medicine and Rehabilitation, October 1992.

¹⁵ The breast bone.

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