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 almost magical instant effects on an “OA hip” with a properly executed lumbar manipulation. However, we all know that it doesn’t always work.

The clunk between the shoulder blades
My patient walked in slowly to the outpatients department in an English hospital. She looked ill and drawn. “What is wrong with you” I said. She replied “I rolled over in bed about 5 years ago and something went clunk in between my shoulder blades and I have been the same ever since… constant pain, dizziness and headaches.” “What is life like?” I said. “Well I do a bit of part-time work for my husband, I am stuck at home most of the time, I don’t like to travel far as I get sick and dizzy quickly, I can’t sleep very well and there is not much happening in the social world as you can imagine.” “Has your thorax been treated?” I asked. “Only with heat – most of the treatment has been aimed at the neck – they said it was referred pain.”

The examination and treatment
I examined her. I noted that any neck and thorax movements were very limited and evoked pain and made her dizzy. In sitting, if she extended either her left or right knees it pulled in her thorax and evoked nausea and pain “I am used to that – carry on” she said. There were no hints of serious pathology and she had been through a medical workup recently “we can’t find anything wrong except a stiff back.” I could find no hard neurological signs with my testing. I gently touched her mid thoracic area. She recoiled instantly. A straight leg raise of 20 degrees also made her recoil and feel ill. I suddenly realised that I had no idea what to do. I reached for the ultrasound and gently sounded the back. There was silence (nothing worse than a lonely ultrasound!). I put a hot pack on. (This was some years ago!) “I don’t think that will help” she said. In my heart, of course, I knew it wouldn’t either.

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. It was my turn to gasp! – there was a student therapist following me for the week who was now all eyes and hand on mouth and all I could think to say was “quick, let’s pick her up and put her on the bed before the boss comes!” I got her on her side, remembering my first aid…. she seemed OK, unfortunately just unconscious. 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.”

She came to, I let her lie for while and rang for her family to come and pick her up. I half carried out this bedraggled patient, lipstick smeared all over her face, hair in the air, and handed her over to her family. As she left I remembered to say “By the way, this may be a bit sore after, you may feel a few odd things, it’s quite common after such a treatment, just let me know and I’ll see you in four days”. Phew…. back I went to work, with a very wary student and somewhat limiting my manipulation treatments that day.

The follow up!
Four days later, there she was in the waiting room (at least she came back I thought). With some trepidation I asked her how she was. “You were right about me being sore and sick. I vomited for 2 days and couldn’t get out of bed for 4 days. I was in terrible pain. My husband kept wanting to ring you but I stopped him because you said it might be a bit sore after.” I wiped my brow and she went on …..yes it was awful, but you know in the last couple of days I reckon I am bit better, I don’t get as sick and I can move a bit more.” There was hint of a smile. I felt a sense of pride almost, but then I looked at the student who had been following me around and she looked down and just shook her head. It dawned on me that she didn’t want to go through the shock again, a “please don’t do it again look”.

I didn’t manipulate her in the same way again. We started some gentle graded neural mobilization and some mobilisation and gentle “screw type” manipulations to her thorax. She slowly improved over 3 weeks. I had to leave the country for various reasons so I had to pass her on to another physio. On parting she said “thanks for doing what you did on day 2.” I often think of her and in particular – would I do it again, would I do it differently these days and if so how? Is there a golden click worth chasing, could I have harmed her and what was the response due to? Has manual therapy moved on?

I am leaving it open – what would you do with such a patient, would you manipulate and what are your thoughts?
-David

A happy Christmas to all our readers
Thanks for the massive response to last month’s “NOI Notes on Central Sensitisation” It was so reassuring to get so many emails about how you integrate it, use it and are challenged. And I realise that the note was a bit of a rant, perhaps inspired by dealing with too many over the top biomedicalists during the week.

Some readers rightly pointed out there were others who were pushing a barrow for central sensitisation in rehabilitation around twenty years ago and I would like to acknowledge them. In addition to Pat Wall and Clifford Woolf there were others such as John Loeser and John Graham in Adelaide. A very influential read for me, encouraged by Judy Waters, editor at Churchill Livingstone was the British Medical Bulletin (1991) Vol 47, No3, with contributors such as McMahon, Bowsher, Main, Wall and Dickenson. Perhaps the article which influenced Louis Gifford and I, more than any, was by Benjamin Crue (1983) The peripheralist and centralist views of chronic pain. Seminars in Neurology 3:331-339, still a brilliant read and worth hunting out. In the physio world, my interactions, either clinically or by writings with Louis Gifford, Peter Edgelow, Mark Jones and Max Zusman, the warrior from West Australia provided the confidence to get out and teach as many undergrad and postgrads as I could about central sensitisation. Max’s article in 1992 Central nervous system contributions to mechanically produced motor and sensory responses in the Australian Journal of Physiotherapy 38:4; 245-255 and the follow up with Structure orientated beliefs and disability due to back pain AJP 44: 13-20 certainly stirred the interest of local and international physios though not everyone was enamoured in those days. We estimate that NOI has taught around 50,000 therapists at least something about central sensitisation and are keen to keep doing it.

Another legendary NOI Instructor
Adriaan Louw completed his first tertiary studies at the University of Stellenbosch in Cape Town, South Africa, where he graduated in 1992 from an extensive physiotherapy program, including a very stringent manual therapy based training. He has since completed his graduate certificate in Research Methodology from the University of South Australia and more recently has finished his Masters degree in research into spinal surgery rehabilitation at his alma mater, the University of Stellenbosch.

Adriaan is one of the keenest NOI instructors and seems to be constantly flying all over the US to teach both the Explain Pain and MOTNS courses. He is currently well into his PhD under the supervision of Dr Ina Diener and Dr David Butler which is all about therapeutic neuroscience education for patients undergoing lumbar spinal surgery and is anticipating some great research results.

Adriaan is an adjunct faculty member at Rockhurst University, where he teaches spinal manipulative therapy as well as guest lecturer for several universities in the United States and South Africa and has been a NOI instructor since 1998. He is a part-time clinician and spine specialist and has taught numerous post-graduate courses and conferences throughout the world on topics related to spinal disorders and pain management. Adriaan and his wife, Colleen, own and operate International Spine and Pain Institute and organise numerous NOI courses each year within the United States. www.ispinstitute.com

Adriaan next teaches:
Explain Pain in Clearwater, FL (Feb 19-20, 2011) Enquire here

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2 Responses to “The golden click”

  1. Chris Bacchus Says:

    Go for the click…and in fact the traction manipulation you did is thought to be safer that your subsequent “gentle” screw type manipulations. Screw manips force extension and you can hurt many backs this way…including fracture ribs. Traction manips are safer, I would then choose as a next option a roll down distraction manipulation and only in race cases would I use a screw manip. Unfortunatley many believe that they are “safe”, but I feel they are in fact more dangerous.
    I showed a student how to do a traction manip the other day in the clinic. We had a 25 year old male race walker with right sided thoracic pain on rotation to the right. Traction and then right rotation was pain free. I performed a traction manipulation (in sitting – not off the yellow pages, but I also do it in standing). There was a greater than 50% reduction in pain and similar increase in ROM immediately post. We then gave him some ROM exs. I had him come back the next day. He was 100% pain free and full ROM.
    Manipulation is an excellent treatment option.
    Chris Bacchus – University of Canberra

  2. Chris Bacchus Says:

    should say rare cases,,,,not race cases!

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