Manual therapy – A unique method of treatment known to people from time immemorial. Even thousands of years ago there were healers who could "set down" spine and joints, and one of the founders of scientific medicine, Hippocrates, even two and a half thousand years ago, surprisingly accurately evaluated and characterized manual therapy:
"This is an ancient art. I have the deepest respect for those who were its pioneers, and those who contribute with their discoveries to the further development of this art.".
"The vertebrae do not move much, but quite a bit. Therefore, nothing should slip away from the eyes and hands of an experienced physician, which he could not use when repositioning displaced vertebrae without harming the patient.".
"It is necessary to study the spine, since many diseases are associated with it, and knowledge of the spine is necessary to cure many diseases.".
It is simply amazing that these words were spoken two and a half millennia ago. They are quite relevant now and could belong to the pen of any of the modern medical luminaries. However, another thing is surprising: despite the good results of treatment, from the beginning of the first millennium of our era for several centuries manual therapy was practically not recognized as a science and remained largely the prerogative of healers who did not have special education and were not approved by official medicine. Only in the middle of the XIX century was again "is open" value of manual therapy and developed its scientific methods. And already at the end of the 19th century, there was a split in the camp of manual therapists, and since then there are two competing directions: school "osteopaths" and school "chiropractors" (or "hiropracts", as they are called in America).
Chiropractors use mostly sharp manipulations, a short strong push "resetting the vertebra". Chiropractors can rightly be called chiropractors.
Osteopaths act with soft lowering movements, apply light massage and pulling effects on the muscles, and the arms, legs, and head of the patient play the role of a lever in these manipulations. It was osteopathic methods that first of all formed the basis of modern manual medicine and were reflected in most textbooks on manual therapy.
In general, it should be noted that the differences between the hiropractic and osteopathic schools concern not only the principles of impact on the spine. Chiropractors and osteopaths also argue about what exactly changes occur in the intervertebral joints before and after treatment. True, there is no unity on this issue even within these schools, as there is none among the representatives of all official medicine. Currently, several theories have been put forward, stating the reasons for "blocking" joints.
Similar theories say that joint blockade can occur due to:
- subluxation and displacement of the joint;
- impairments of small meniscus-like cartilaginous bodies between the upper and lower surfaces of the joint;
- infringement of the soft sheath of the joint (villous membrane) between the articular surfaces;
- spasm of small muscles around the joint and counter "stresses" joint tissue.
In fact, it is not so important what specifically causes the blockade of the joint. It is important that only manual manipulation can eliminate it – no other method "unlock" joint is impossible. Accordingly, it is by manual techniques that patients can and should be treated in all cases when there is an acute or chronic blockade of the intervertebral joint, but in the absence of contraindications to such treatment.
It would be a mistake to use manual therapy for inflammatory rheumatic diseases of the spine, for cancer lesions of the back (that is, for benign and malignant tumors) and for fresh injuries (fractures) of the spinal bones.
Very carefully and carefully, it is necessary to carry out manipulations with those patients who have increased bone fragility – in osteoporosis and Scheuermann’s disease.
Carefully and thoughtfully need to treat patients with "fresh" herniated intervertebral disc. As already mentioned, very often the first manifestation of lumbar hernia is a lumbago attack, that is, the appearance of acute pain solely in the lower back. Radicular pain (on the leg) sometimes joins only a few days later. So, if you start treatment in the first period, "lumbago period"then the expected radicular pain would then be connected in the mind of the patient with the actions of the doctor, and it would be very difficult to convince the patient that his worsening should have happened by itself.
In the treatment of muscular hypotonia, manual therapy is used in a minimal amount and only in combination with an active strengthening gymnastics. Otherwise, if we confine ourselves to manipulations alone, the result will be an even greater decrease in muscle tone and increased excess mobility, "looseness" spine.
I am often asked: is it possible to conduct manual treatment for elderly people? Of course, sometimes it is possible, but taking into account the mobility of the spine and the state of the bones. And of course, in treating the elderly, the doctor should not use a gross impact – the so-called "hard manipulation". At the same time, with the right, gentle use of manual techniques, even in very elderly people, it is sometimes possible to achieve excellent results.
The situation is more complicated with the treatment of pregnant women. And although manual therapy is not contraindicated even for pregnant women, I refused this practice. Frankly, I do not want to be groundlessly accused in the case of a complicated (or unsuccessful) course of pregnancy, possible for any woman. I make rare exceptions only if necessary to treat the cervical spine.
Another question that I often get asked is: does it make sense to carry out manual therapy for true spinal osteochondrosis and spondylosis? My answer is this: if it is a question of curing these conditions with the help of manual therapy, then no, since it is unrealistic. Manual manipulation cannot break "spikes" (osteophytes) in case of spondylosis or to grow new cartilage discs in osteochondrosis. But in those cases, when osteochondrosis or spondylosis occurs in parallel with the blocking of any part of the spine (and this happens often), manual therapy is not only possible, but necessary.
Another thing, if the reception comes "amateur" manual therapy, which overestimates its capabilities or just likes to be treated. Periodically such appear. Nothing hurts a person, nothing bothers him, but he asks for a manual therapy "just", for prevention, because I heard that manual therapy is good for everyone. Every time in such a situation, I have to explain to people that manual therapy is a serious procedure, the directed effect of which on the damaged part of the spine is somewhat akin to a surgical operation, only bloodless. Therefore, it is carried out exclusively for medical purposes in the presence of certain injuries. You will not do a surgical operation just like that, for preventive purposes, or to drill a healthy tooth for prevention – only so that this tooth does not get sick in the future.
Yes, it is possible to do gymnastics and prophylaxis with a preventive purpose, you can even drink chondroprotectors (good, they are harmless), but we will leave manual therapy to extreme necessity, especially since it is not advisable to do it very often. Now you probably ask the question: what is very often and, in general, how many manual therapy sessions can and should be done? Usually, treatment of one damaged spinal segment requires about 3 sessions. But this does not mean that the treatment of any of the spine (cervical, thoracic, lumbosacral) requires only 3 sessions: after all, any of the spinal sections consists of several segments.
For example, a person on the first examination found serious damage to two segments with severe pain and muscle spasm in response. I spend 3 sessions treating these damaged segments, and the person first becomes very good. The pain and muscular tension goes away, but it turns out that behind the serious injuries of those two segments there were minor changes in the other, adjacent, segments of the spine. They were simply invisible due to pain and muscle spasm and "got out" just now, after eliminating the spasm. So, to finish the job, I will need another 2 – 3 sessions. In total, 5-6 manual manipulations per treatment course are obtained.
But in difficult situations and this is not the end. Sometimes, in the intervals between manipulations, an additional 5-6 sessions of post-isometric relaxation and massage of the affected area are required. In general, in some situations, 2 – 3 sessions may be enough for recovery, while in others – the treatment course is stretched to 10 -12 meetings of the patient with the doctor. In this case, the procedures are carried out not daily, but with an interval from one to seven days.
Very often, patients ask: why it is impossible to carry out manipulations on a daily basis in order to finish the treatment as soon as possible? The fact is that, although blocking is eliminated by manipulation instantly, surrounding muscles and ligaments take some time to "pull up" and fix the achieved position, and therefore it is possible to continue treatment only after 40 – 48 hours.
Now let’s talk about how a session of therapeutic manual therapy actually takes place. Just make a reservation: I express my view on the procedure. Another specialist may have a completely different method and his own vision of the problem, and at the same time he may not receive the worst results of treatment.
So, if a patient comes to me for treatment, then after determining the diagnosis and identifying a blocked segment, I will first try to ease the tension of the blocked segment of ligaments and muscles around me, using massage or post-isometric relaxation.
Having reduced muscle spasm, I will ask the patient to turn "until it stops" in the right direction and at a certain angle, and then its intervertebral joints will occupy the most extreme, "borderline" position After that, I will need to fix the blocked joint with the fingers of one hand, with the other hand to slightly press that part of the body that acts as a lever. If done correctly, a click sounds (but not always), and after that the patient feels some relief. I will only have to work a little again with the muscles and release the patient home before the next procedure, giving "homework" (for example, therapeutic gymnastics) or asking to observe certain restrictions.
True, we have to admit that not always patients are "obedient" and follow medical advice and necessary restrictions. I will give an illustrative example. Once, a patient was brought to me at the reception (!), Which for 3 years had actually not left the house due to severe dizziness – it was just "rocked" when walking. The trouble was caused by damage to the upper cervical spine. Surprisingly quickly, in just two sessions, it was possible to rectify the situation. With a feeling of deep satisfaction, I informed the woman that the treatment was over and she could return to normal life. The only thing I asked the patient for was not to lift weights for a month and not to do heavy household work that requires physical exertion. In addition, I strongly recommended two weeks to wear a special cervical fixing collar.
What was my surprise when, after only ten days, the woman was again brought into my office. It turned out that, feeling well, the woman decided to go to the grocery market and, of course, did not put on a collar (this is ugly! – she said). In the market, having bought food (more than ten kilograms, as it turned out), the woman folded them into one big bag and jerked her up. She only had time to feel the crunch in the neck and fainted. As a result, we had to start the treatment anew, and we didn’t have enough two sessions this time.
And you know what impressed me most? When asked why she did not listen to me for the first time, the woman replied that she had to feed her family.
Now let’s think: if the family somehow managed for 3 years while the mother of the family was not able to carry bags with food, could this change 2 or 3 more weeks needed to fully restore the spine? Unfortunately, a similar case in my practice is far from being isolated. Despite all the entreaties and exhortations, every third patient has to be treated anew precisely because of noncompliance with the regimen and recommendations. It has always been this way and, I fear, it will continue this way.
Dear readers, please try to remember that the treatment is not limited to those manipulations carried out by the doctor. No matter how skillful he is, the whole positive effect of his actions can be negated by the patient’s wrong behavior. To defeat the disease is possible only with the joint efforts of the doctor and the patient.
Article Dr. Evdokimenko © for the book “Pain in the back and neck,” published in 2001. Edited in 2011 All rights reserved.