FIRST ISSUES: VALUE OF THE MANIPULATIVE APPROACHES
AND PENALTIES OF IGNORANCE
In the country of the blind, the one-eyed man is king.
First decide the principle. Then decide what to do about it.” Anonymous
The essential story. Lessons about chest pain
Distinguishing cardiac from skeletal pain
The manipulative process
The first physician/patient encounter
The time for advantageous technology
The obligations of examination
Penalties of inappropriate examinations
Beginnings of chronic pain
The medical ideal
The Pain Pandemic and its internationality
The responsibility of orthopedic surgery
The need to rethink the problem
She was a frail, elderly, little lady in severe pain. Her near-frantic children towered closely over her, gaunt ebony saplings arched anxiously high over her like a tremulous cathedral. Near-reverently, they were struggling to support and protect her as they slowly shuffled into the emergency room of the University of Southern California/Los Angeles County Medical Center, one of the busiest in the world. She could only take a few short wracked steps before she froze with a tremor as their frustrated hands trembled to relieve her while sensing that their grasping was aggravating their mama’s agonizing spasms.
That night, I was standing the late night watch as Chief Admitting Physician, and I watched them as they came through the door. The stark poignancy of it struck me as they slowly inched towards the admitting desk and were immediately directed to the closest examination cubicle. Standing at the curtain, I heard “heart” mentioned because the pain was in her left anterior chest, but I had observed that her jolts were synchronized to her breathing and to the touching about her rib cage. The tired “moonlighting” resident commenced the usual chest pain work-up as I took one of her children aside.
"Please tell me exactly what your mother was doing when the pain started."
"She was just sitting on the couch, watching TV"
"Is the couch firm, or is it soft?"
"How long had she been sitting?"
"For a long time."
"Exactly what was she doing as the pain started?"
He paused. "She was turning around to reach for something.”
"I moved close behind her and ran my fingers gently down her upper back.
"Please," I said softly, "lean back against me."
Carefully crossing her arms over her chest, I cupped her elbows into my hand and drew her closer. “Please, just relax completely against me - just open your mouth and lie back and trust me."
I lifted gently, paused and waited, then eased my chest against her mid-spine. There was a barely perceptible release, and it was all over. Immediately, she took a long, deep pain-free breath, then turned slowly and easily to look up into her closest son's anguished face.
"It doesn't hurt any more,” she said softly.
In the first minutes of an initial examination, as a safe therapeutic trial, an intensely painful injury was instantly relieved, totally confounding the traditional expectation. It was accomplished with a well-founded suspicion, a focused observation, a directed history and a manipulative maneuver. Not a single laboratory test had been done – not an x-ray or electrocardiogram or blood panel. Virtually all medical expenses had been avoided. No prescriptions were written. And her loved ones were spared the relentless uncertainty that regularly disrupts the lives of so many under such circumstances. In her case, there were no weeks lost, no repeated series of puzzling negative tests while the process possibly persisted and insinuated itself towards chronicity.
What had happened to her? What had I done?
After sitting for a long time on the soft sofa, her vertebral column had developed a focal impairment of its normally coordinate flexibility. Then, the usual glide and slide had "jammed" as she twisted. The spinal reflexes act literally. Any perceived threat to its vital contents instantly results in whatever it takes to prevent any further movement. The ribs can lock in the “jam,” so trying to take a full breath can be agonizing, as well.
Lifting her had eased the tension in the vertebral column. Then, the pressure asserted through my chest into the dysfunction had manipulated it free. I t is all in the timing. Performing it so soon after the injury had prevented the secondary changes of tissue congestion, nerve irritation and major spasm. Furthermore, if it hadn't worked, from that particular manipulative procedure, nothing would have been lost.
I left the cubicle and was behind a partition reviewing a chart when one of the daughters approached the resident who happened to be standing on the other side. In an awed voice, she asked, "What kind of doctor is he - that all he did was put his hands on my mother...and the pain was gone?" Why should what I had done be so out of the ordinary? (And why didn’t the resident ever ask me about it?)
Touch is the most fundamental, the most primitive of the senses. Yet traditionalism’s denial of its value in applied biomechanics – the essence of manipulative principles - is among the most costly tragedies in Westernized medical history. While the manipulative therapies are essential to competent and efficient care, allopathic doctors (M.D.s) have been denied virtually all education about them for more than a century despite their being at least as essential as a stethoscope.
The Locked-In Syndrome
Could there possibly be a worse nightmare than instantaneous, total, permanent paralysis with all other functions fully preserved? Except for being able to grunt, move one’s eyes and wrinkle one’s forehead, all other voluntary movements are irretrievably lost; yet full consciousness and sensibility remain intact in unimaginable frustration and helplessness for the remainder of a normal life expectancy. It is called The Locked -In Syndrome. It occurs because of a unique anatomic circumstance: there is a minuscule site high in the spinal cord where almost all nerve tracts that transmit the commands for voluntary motion are confluent: they exit from the two sides of the brain and merge and cross to innervate the opposite sides of the body. When a blood clot precisely obstructs the circulation of that remarkably tiny territory of only a few millimeters, it inflicts such total and irrevocable loss.
I was involved for only one afternoon with such a patient when I was requested to examine him during a special court hearing at the world famous Rancho Los Amigos Hospital, in Downey, California. He was a man in his mid-thirties. He had been at work swinging a sledgehammer when he suddenly experienced sharp pain in his upper back radiating into his left anterior chest. Just a glance at his chart revealed all the elements of a probable musculoskeletal injury, however his doctor didn’t pursue it, and there is no charitable explanation for why he promptly scheduled a diagnostic cardiac catheterization. The doctor wasn’t skilled in the procedure, and as he fumbled with the catheter for over an hour, a blood clot formed in the man’s heart, entered his circulation and did its devastation.
I was asked to examine the patient primarily because of the insurance company's untenable position that a conscious being could not exist in such a condition, from which they contended that their liability was limited. It was a court proceeding. A large group, including the jury and representatives of the involved companies ,stood at the foot of the bed.
Just my asking him to blink his eyes a specific number of times easily contradicted the insurance company’s contention. I asked him to subtract one seven-digit number from another, and, as I enunciated them, his eyes widened in horror until he realized they were actually only four digits apart, and, with a series of rough grunts, his pitiable equivalent of a laugh, he blinked four times correctly, and the show was over. The remainder of my examination was only for completeness.
In the end, the patient most needed acknowledgment. I gave him what I could by dictating my report at his bedside to, at least, let him know that his torment was understood, as his wrenching sobs tragically communicated his appreciation. His case was promptly settled, and he was provided with lifetime assistance.
Some twenty years later, in the early cool of a California August evening, I was walking across my daughter’s back lawn to the Jacuzzi. As I lay there relaxing in the wonder of what hot water does, however such things happen, in my imaginings I was in Downey again, and I began to reminisce about him and what I might otherwise have dictated:
‘By the cruelest of fates, this man was permanently and terribly victimized by the purposeful propagation of ignorance and the cavalier misuse of technology. It was then intended that his condition be maliciously misrepresented within the system that was supposed to protect him.
The clot that so terribly damaged him didn’t need to be of any size at all as one ordinarily thinks of things, but it was sufficient to fully enforce its fateful reality.
This is an otherwise normal man, with normal desires and needs, who will continue to experience them increasingly for their failure to be satisfied in any normal way until some time, prayerfully, when a Higher Grace may relieve him of want of them in some measure.
He will always be totally dependent on others to meet even his most basic needs, and he will have to struggle to receive even a small measure of satisfactions others so naturally take for granted.
For the remainder of his time, which should be a normal span by any normal measures, his primal challenge will be somehow to preserve his sense of purpose of self. And that is how he will spend his life until he dies.’
He will never even be able to sit up, or get out of a bed, or walk to a window, or take anyone into his arms, or talk, or move even a finger. He will have to endure every minute totally helpless for the remainder of his life.
This tragedy would less likely have happened if traditional medical training taught that any joint can dysfunction from a sudden disadvantageous, uncoordinated movement.
Pain from the structures of the body frame - the muscles, joints, ligaments, fascia and associated tissues – is different from pain originating in internal organs like the heart. Pain from dysfunction is not likely to be vague and oppressive. It is sharper and is altered by movement. Cardiac pain is not!
Gently rotating the torso left or right usually instantly increases dysfunctional vertebral pain, from which the pain may radiate along the course of a nerve to the anterior chest. Deep breathing can do the same as the ribs are increasingly engaged. Cardiac symptoms are not influenced by such challenges. Localized vertebral tenderness in the midline chest area occurs with both conditions.
Those simple tests and a few which examine segmental movements easily reveal such dysfunctions. All practitioners involved in chest pain - which is virtually everyone - need to be at least familiar with the possibility of such occurrences. Most are not. So, too many people with precordial (anterior chest) pain are quickly suspected of having cardiac disease, which traditional medicine is quite comfortable to investigate.
Over the years, I have instantly relieved fifteen patients - cured their “heart attacks” after they had been hospitalized in intensive care units for as long as five days. During that time, many studies, electrocardiograms and other "grams," serial blood tests and others, had been repeatedly performed while patients and their families were unnecessarily subjected to the anguish of uncertainty. Each episode was the result of a thoracic dysfunction. Each was relieved with a single manipulative procedure after an on-the-spot diagnosis was made exactly as I have described. In each, the distinction between musculoskeletal pain and cardiac pain was clear. And, once more, if the manipulative attempt had been unrewarding, nothing would have been lost! As I have implied, performed skillfully, this particular manipulative procedure is virtually risk free, although, it must be remembered, that any treatment that is sufficiently potent to cure may also afflict. No manipulative procedure should ever be used casually.
I once received a surprise visit from a college acquaintance. He was about to be admitted to St. Vincent’s Medical Center across the street from my institute because he had been experiencing pain in his high abdomen each time he swallowed. The likely diagnosis is called cardiospasm (referring to the esophageal sphincter into the stomach, not the heart). It had been persisting for weeks.
As he visited, without really a conscious intent, my fingers moved along his mid thoracic and discovered an area of unsuspected mid-thoracic tenderness and spasm. Surprised, he asked me what I could do about it. I manipulated it, and incredulously to him - and a delight to me - his symptoms completely disappeared in less time than it took to write this. Once again, if it hadn't worked, nothing would have been lost.
Throughout their training, medical students are constantly reminded of Hippocrates' first principle: Primum non nocere (Above all, do no harm.) The manipulative principle asserts the other hand: sometimes, it is the not doing that is harmful – a result of the manipulative procedures being selectively excluded from the medical methodology. Of the higher order to “do no harm” is the implicit obligation to relieve, if there is a way. In these cases, there is. Enforced ignorance about them does not carry absolution with it. Any persistence of pain is iatrogenic, regardless the absence of application of any therapy.
The body’s moving parts resemble machinery. Whatever else is the marvel of the living body, it is also coordinate mass of mechanisms. The joints are levers; the muscles are motors. When function is impaired, often the body responds with pain, which is among the commonest of life’s complaints.
As manipulation seeks to realign dysfunctional structures, it simultaneously tends to accomplish considerably more because the procedure intrinsically influences numbers of other activities through the body that are predominantly mediated through nerves. There is hardly a discipline in medicine that may not, in some way, be more effective with the knowledgeable application of manipulation.
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, or more apropos, perhaps a watchmaker. Craftsmen 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 essentials and decide what might be done to relieve the problem. The principles of fundamental 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 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 the technology is applicable and that a real examination has, after all, been done. While it is true of halitosis, bad breath, is better than none, 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. But here is where technology is too readily thrown into the gap as a – consciously realized, or not - desperate attempt to compensate for imposed ignorance: the Fundamental Flaw. So, x-rays will almost certainly be taken, often initially, even before any clinical examination.
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 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 patients have learned to expect to receive something, and the doctor’s self-respect has its incessant demands. A pill and/or some therapy may be prescribed. (And it is so expedient to write a prescription.) 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. And what was injected? Why? How much? How often? All depend on realistically appreciating what is being treated.
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.
Patients do not positively participate in the rituals of professional self-preservation. There are no compensations for the unfortunates. 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 and slip imperceptibly 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, the pain of the Fundamental Flaw tragedy regularly visits 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.
The heralds - the osteopaths - are now mostly so busy emulating allopathy - dissimulating the wealth of their heritage - that they disproportionately curtail attention to 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, especially now with obamination “care.”
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 that with which we were entrusted. We are no longer honored 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 in Dallas, Texas to formalize it. As I entered the hotel, 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. I often 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 that 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 virtually any 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.
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 banquet sound so casual that I had taken a leisurely stroll from my hotel and arrived in what I thought was good time. To my consternation, the ballroom was packed with hundreds of people dancing who had 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 whom I had already met. We greeted each other, and they said that no one in their party was occupying the seat. The distinguished Japanese gentleman on the other side said the same. I gratefully sat down and we began to converse. We exchanged cards. Dr. Yamamoto was Chief of Orthopedic Surgery at Osaka Koseinenkin Hospital, Osaka, Japan.
He told me he really hadn’t the foggiest idea why he had traveled so far to come to the meeting. We talked orthopedics, of course, and in a short while he stunned me with one of the most extraordinarily candid and courageous statements I have ever heard. That distinguished orthopedic surgeon, his bushido - the distinct Japanese sense of honor – obviously operating deep within him paused and gazed off reflectively, and then, quite slowly and deliberately, he said, "You have spoken to me about three joints...and I don't know anything about them."
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 medical perspective, they are common impairments. And most of orthopedics is, in fact, medical. 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 dominates all orthopedics for a number of reasons that I will describe later in depth. But because society long ago accepted the surgically-minded version of what is in reality medical treatment, and because ignorance about the manipulative arts is general, and because a medical specialty does not (yet) exist that effectively balances orthopedic surgery’s dominating influence, the limited surgical perspective has prevailed overall.
Orthopedic surgery became imbued with extraordinary privilege and authority that it accepted - and with it, desired or not, 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.
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