It’s been a while since we’ve had A Flashback on a Friday (glad we decided not to go with that as a title for the series), but here are two that seem relevant today
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…
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….
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.”…
I am leaving it open – what would you do with such a patient, would you manipulate and what are your thoughts?
– David Butler, December 2010
Fred was a patient of mine. He was about 55 and came from the far north of South Australia and only came to the city once a year. He used to call in to see me for a bit of physio and he frequently brought a present – usually a piece of lamb, but occasionally a lump of beef that I am not really sure which part of the animal it came from.
Anyway, Fred used to say “the second and third are out in the neck, have been for a few months since I came off the motorbike; I reckon the L5 is out too and the hip might be going out too. Can you whack them back in. By the way, I have half a sheep in the truck for you. Mind you with the drought they are a bit dry, but you did say once that you liked mutton. And another thing – don’t give me any exercises, like you tried last year. I get too much bloody exercise on the place these days”.
Share my quandary
I take a breath and reflect….”but these days I am supposed to be evidence based and offer more self management, graded exercise and neuroscience education. I even wrote a book on what you are supposed to do. How did I get it so wrong with Fred? And what would my students be thinking now if they were watching this clinical encounter?”
Judge my therapy
I assessed Fred, I was interested in the motor bike accident so I checked him out as best I could for any contraindications to “whacking things back in”. There was a bit of stiffness in the upper neck and low back and I “whacked them back in” (grade 5 rotation for the lumbar spine, and lateral flexion grade 5 for the C2-3 joint or thereabouts). “Beautiful”, says Fred, jumping up and playing with his new neck movement. “Did you hear that neck go back in…still a bit out in the low back. Give it a bit more of a whack will you.” I did just that. Fred handed over the half a sheep, shook my hand and said “see you next year”…
What’s in a whack?
Was I wrong? I know that my therapy doesn’t follow any recent guidelines for chronic spinal pain and I know that the efficacy of manipulation is not that strong…
I don’t think anything goes out except fires and me on occasional Friday nights. Joints may get a bit stiff or rarely, locked, but that is about it. I am happy that I probably manipulated Fred’s perceptions as well as perhaps doing something to the joint structures. You could call it a placebo treatment but then again I am reminded by a Patrick Wall comment “In the end if many treatments are shown to be placebo, then we should work out what it was in the placebo that was the active ingredient.” There may have even been something helpful in the swapping of the sheep and the manipulative techniques.
-David Butler, May 2008
What would YOU do if your patient asked you? (apologies to Dr Seuss)