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"A movement a day keeps adhesions away."
Among manipulative authorities outside of chiropractic, there is some question as to whether it is beneficial to manipulate the normal joint. In fact, most medical authorities maintain that it might even be harmful to manipulate a joint that does not specifically need it. In most conditions requiring joint manipulation, two or three manipulations are usually all that is needed. A subluxated joint, or a joint that is binding, may be released in one manipulation. On the other hand, adhesions in a joint, following infections or injuries, might require several graded manipulations, sometimes under an anesthetic. joints subluxated or deformed by contractures of muscles and ligaments might require more extensive treatment.
Normal movement in the spine occurs in such a manner that little movement actually takes place between any two specific vertebrae. In flexing the spine forward in order to touch the toes, for example, a total of joint movement over the length of the entire spine -- more than 50 joints -- allows one to bend a considerable distance, even though movement in any one joint is slight.
The weight of the body upon the spine is supported primarily by 23 intervertebral discs (cushions) distributed between 26 or more vertebrae. (In the young person there are 33 vertebrae -- 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal; in the adult, however, the sacral and coccygeal joints unite to form two vertebrae, reducing the total number to 26.) The joint surfaces of the vertebrae act chiefly as guides for movement, while the contour of the joints allows movement to take place in certain directions to a certain degree. In the lumbar (low back) region of the spine, for example, most movement is limited to forward flexion and backward extension. In the cervical (neck) area of the spine the arrangement of the joint surfaces allows movement to take place in more directions. In all of the joints, however, ligaments aid in checking movement of the joints beyond a certain point. In some joints of the spine, bony apposition may prevent movement in certain directions. In any event, safety checks are necessary in order to prevent excessive excursion of joint surfaces and still allow movement within a range not irritating to surrounding tissues, nerves, and blood vessels.
In the spinal column (housing one of man's most vital systems -- the nervous system), nature has ingeniously designed articulation and movement allowing complete flexibility of the body's trunk while, at the same time, providing bony protection for the most sensitive of human tissue: the nervous tissue. The brain, within the bony vault of the skull, and the spinal cord, surrounded by rings of bone and dense ligaments, are, of necessity, two of the most protected structures in the human framework. Thus, the spinal column, endowed with the important function of protecting the nervous system, in addition to forming a central support for the body's structures, is a remarkably complicated and efficient structure -- barring the presence of abnormalities interfering with its normal functions.
As we have mentioned, nature has so designed the spinal joints that, in addition to preventing movement in certain directions or beyond a certain point, movement of the spine does not normally take place without the involvement of a considerable number of spinal joints. In other words, voluntary movement cannot occur in a single joint. When an awkward or excessive movement does occur, placing an unusual or abnormal amount of movement upon a single joint, strain or subluxation sometimes occurs. This occasionally results in pressure upon adjacent nerve fibers or blood vessels (pressure that is often caused simply by swelling of the surrounding tissues), causing symptoms in addition to those of a local joint disturbance. Some of these cases, especially those of fixed bony displacement, when properly selected, will benefit remarkably from scientific manipulation.
Considering the manner in which most of the joints are articulated, however, it seems likely that strain is apt to occur more often than subluxation since, in a subluxation, the joint must be locked or maintained in a position of displacement with the joint surfaces still in contact. For this to occur within normal ligamentous and bony bounds, there would probably have to be movement over and beyond some bony irregularity within the joint. Occasionally, however, a severe and excessive movement may suddenly strain the soft tissues, causing muscle spasm to hold the joint in a locked position. (A lock of this type is often reduced by the simple prescription of drugs to relieve the pain and, consequently, the muscle spasm.) In grossly excessive movements, the ligaments may give way and result in dislocation of the joint before any semblance of true locking occurs. In less severe displacements of the vertebrae, such as those not acutely locked in an abnormal position but simply straining against the limits of ligamentous or bony checks (often caused by postural strain or a prolonged abnormal gravitational pull), simple exercise is usually a sufficient remedy.
Occasionally, joint injuries result in the formation of adhesions, and a "stiffness" of the involved joint occurs if proper aftercare is not undertaken. When adhesions do occur, manipulation is often the only treatment of any real or permanent value.
Although dislocations of joints are always recognized and appropriately treated, it is significant to note that few people have had any treatment other than rest for conditions of the joints that are less serious. Since the majority of them seem to recover without manipulations of any kind, it would seem that either the locking of a joint is a relatively rare condition or that the condition corrects itself with time and subsidence of muscle spasm. Many subluxated spinal joints -- often diagnosed as strain, ruptured intervertebral disc, and so forth -- are probably corrected in the routine application of spinal traction. While there is little doubt that appropriate manipulation could drastically shorten the recovery period in acute binding of the joints, it is important to remember that millions of people have suffered acute back pain, resembling a condition of "locked spine," and have recovered without having had any more treatment than rest, heat, traction, or sedation. In the vast majority of cases, it seems that only strain occurs, with severe pain and muscle spasm, needing only rest and exercise for recovery.
Although not every case of spinal disorder is a case for manipulation, there are a sufficient number that can benefit from such treatment to provide an accredited technician or specialist with a busy practice -- if such cases were referred to him by other practitioners. Unfortunately, those who do the most spinal manipulation -- the chiropractors -- have not specialized their practice in the treatment of such conditions in cooperation with medical practice. Primarily, the manipulations of the chiropractor are designed to "remove nerve interference" in the treatment of disease. As a result, the treatment is routinely applied to the normal spine and to often imaginary "subluxations," while the treatment of joint conditions per se continues to fall within the realm of medical practice. Ironically, back troubles, one of the most common ailments of upright man, comprise only a small portion of the average chiropractor's practice -- primarily because the chiropractor, in his efforts to treat the broad scope of human disease, has failed to take advantage of the need for a "back specialty." As we will bring out in a later chapter, however, specialization in the treatment of back troubles, considering the complicated nature of the diagnosis and treatment of such conditions, would, of necessity, require extensive cooperation with medical and orthopedic specialties, since diagnosis and treatment of many painful back or spinal conditions would often require the use of certain surgical and medical procedures.
Many people do not feel inclined to submit their painful backs to the routine manipulations of one who uses much the same treatment in each and every case -- to one who is not a specialist in their particular difficulty. In addition, many extremely painful back conditions -- not necessarily serious -- will respond initially only to the drugs of a physician's prescription. Following the subsidence of acute pain in the first few days, it is often simply a matter of rest and rehabilitation for complete recovery.
One should not make the mistake of assuming that diagnosis and treatment of back troubles outside the occurrence of a ruptured disc or a fractured vertebra are simple procedures. It is imperative, for example, to determine whether a simple back injury is ligamentous or muscular if the proper treatment procedure is to be selected. Knowing when to rest or exercise, support or manipulate, when to use conservative therapy or surgical therapy, in the treatment of a back or spinal condition that must be differentiated from hundreds of other possible disturbances, often means the difference between recovery and chronic disability. It is most important, of course, to first determine whether a back disturbance is a mechanical condition, or whether it is a pathological disorder presenting progressive degenerative changes.
There is probably no better example of the influence of a creed upon human behavior than the "shame" of many chiropractors who refuse to be "lowered to the depths of a back specialist," yet who routinely apply a single treatment (spinal manipulation) to the broad scope of human disease. Selecting procedures in the treatment of "back conditions" would prove to be far more complicated than simple adjustment of the vertebrae.
When manipulating a normal joint, as is done in many routine chiropractic manipulations, a specific and abnormal amount of movement often forces the joint slightly beyond its range of normal movement. Thus, repeated, unnecessary manipulation of a normal spinal joint would probably place a strain upon the ligaments holding the joint together, and further put the intervertebral disc fibers through stresses they do not usually receive. We remember that, normally, only slight movement takes place in any one spinal joint and that no one joint functions independent of another. When one of these joints is selected for manipulation, it is easy to see how it might be placed through movement it does not normally undergo. For this reason, many orthopedic and physical medicine authorities recommend manipulative procedures that confine treatment to the disturbed joint. "It is undesirable to manipulate the normal joints," said a physical medicine specialist in a 1951 issue of the British Journal of Physical Medicine; "the manipulative forces must be so controlled that only the one joint involved is stretched."
While one may argue that such manipulation aids in developing ligamentous tone, it is doubtful whether any form of "abnormal" movement would be of benefit to a joint not designed to undergo such movement. Sufficient tone, strength, and flexibility of the joint structures could probably be maintained, for the most part, by frequent bending exercises that would place normal physiological demands upon the joints collectively and as a whole. It is a known fact that a joint once strained excessively in its ligamentous structure is not thereafter a thoroughly strong joint. A ligament cannot be rehabilitated like a muscle. While ligaments can be strengthened they cannot stand strain like a muscle that is rich in blood supply and recuperative power.
All joints should be regularly placed through a full range of normal movement in order to maintain the elasticity and tone of the muscles, ligaments, and tissues. If such full range of movement is not possible through voluntary effort, then manipulation is probably in order. Restricted movement in only one or two spinal joints might be difficult to detect, however, since it would be concealed somewhat by the overall movement of the spine. Loss of mobility in a joint, if corrected early enough by manipulation or exercise, need not lead to more serious disturbances. If routine use of spinal manipulation is employed to prevent the occurrence of minute joint adhesions, to the extent of manipulating the normal joint in the process, I am not sure of what might be considered a desirable frequency. Probably once or twice annually would be sufficient.
Some chiropractors, who build an extremely large practice on "repeat patients," boast of treating 50 or 60 patients a day, or more. I know of at least one chiropractor who claims to "adjust" as many as 250 patients daily by spending only a few minutes with each patient (only so long as is necessary to adjust a selected vertebra). Such methods of treatment are based on the theory that "displacement" of a single vertebra (the atlas, for example) is responsible for most of mankind's illnesses. It would, obviously, require a considerable amount of faith on the part of the patient to consistently continue such treatment, and faith, roguery, or both, on the part of the practitioner who aggressively promotes such treatment.
Proper physical and manipulative treatment of the spine would require considerably more time than the routine, wholesale, "cracking" procedure followed by those chiropractors who treat large numbers of patients daily.
According to Volume 3 of the Report to the President by the President's Commission on the Health Needs of the Nation, the average general medical practitioner, properly examining and treating his patients, sees only about 30 patients daily, spending about 22 minutes with each patient. Those who employ one or more full-time aides are able, of course, to see more than 30 patients daily. The full-time medical specialist, without a full-time aid, sees an average of 23 patients daily, spending about 28 minutes per patient .
In the field of physical and manipulative treatment, however, considerably more time is required in the treatment of the patient when it is properly done. This is the reason physical treatment is so often passed on to technicians in departments of physical medicine (physical therapists). The time and skill of the physician is considerably more valuable and expensive than that of the technician, although the technician, spending more time in the application of massage, heat, manipulation, rehabilitation measures, and other forms of physical treatment, is able to do more for the patient in certain conditions.
Considering the nature of the majority of back and spinal disorders, most of which require considerable time in each treatment application, it is easy to see how the chiropractor who treats his patients "by hands only" would prefer to build his practice on the theory that misplaced vertebrae cause most disease -- thus not confining his practice to the treatment of back conditions.
The ability to determine whether or not there is a disturbance in a joint would, of course, depend upon the practitioner's knowledge of the course and degree of normal joint movement. In the event of a bona fide joint disturbance, the range of movement within normal bounds would be limited or hindered by pain, muscle spasm, bony obstruction, adhesions, weakness, and so forth. When it has been determined that manipulation can be safely performed, corrective movements should not have to be performed too far beyond the joint's normal range of movement. We have already noted that, in manipulating a normal joint, sufficient force can be applied to move the joint abnormally or beyond its range of normal movement, thus causing a "pop" as the vacuum attraction of the two joint surfaces is broken. There is, in my opinion, probably no benefit to be gained -- other than psychological -- from manipulating a normal joint. Essentially, many chiropractors' manipulations are performed upon normal joints, forcing these joints beyond their normal range of movement. If this were not the case, those chiropractors who contend that vertebral misalignment is the cause of most human disease could not maintain a practice, since they necessarily manipulate the spines of the great majority of those patients who submit to chiropractic treatment. If the chiropractor manipulated his patients according to specific indications of limited or disturbed joint movement, he would probably find few cases actually requiring manipulation (in the general run of chiropractic patients) , even if every patient was the victim of an organic disease process.
It is now known that the presence of a real joint disturbance can and does cause symptoms in addition to those present in the area of the involved joint, and that correction of the joint condition will resolve the related symptoms. Many chiropractors, however, in rationalizing their contention that subluxated vertebrae are the chief cause of disease, maintain that some of the "subluxations" are so minute as to escape detection under ordinary examination. They simply "measure" the joints on an X-ray film in order to determine whether or not displacements are present. We have discussed the fallibility of this system in a later chapter. While slight displacement or disturbed function of a joint often cannot be detected by X-ray examination, it can usually be found under thorough clinical examination. Outside actual joint pathology, however, it is a weak stand indeed to assume that joint displacement that is not detectable (supposedly causing symptoms that are not obviously related) is putting pressure upon a nerve that is probably an eighth of an inch away from the bone surface on all sides. Although such conditions probably do develop (displacements and nerve pressure without obvious and specific symptoms), causing many vague and chronic symptoms, it does not seem likely that they occur with any great frequency. Detection of such disturbances would obviously be a highly selective procedure, with consideration first being given to the detection of more serious pathology. Treatment by manipulation may then be considered in its proper perspective.
"Doubtless there is still a good deal of prejudice to be overcome," wrote James Mennell, M.D., in his book, Joint Manipulation, "but it is not a great thing to ask that when symptoms do not conform to routine diagnosis or do not respond to treatment, the joints corresponding to the region of the symptoms should be examined. Few people would claim to be infallible in diagnosis, and if errors in medical diagnosis are to be reduced, the technique of joint examination should form part of medical training."  Thus, while many qualified medical physicians do consider the values of manipulative therapy in the course of their daily activities, there are others who are overly conservative and largely unaware of the fact that a few of their patients might benefit from scientific manipulation. Most chiropractors, on the other hand, continue to assume that there is "no one whose spinal column will not reveal one or more subluxated vertebrae," and that "in virtually all diseases a subluxated vertebra has something to do with their causation in one way or another ......
There are probably a great many people who could benefit from scientific joint manipulation if it were widely available in conjunction with medical procedures. It is unfortunate that manipulative procedures have been shaded by the doctrine and claims of many chiropractors on one hand, and pushed into the background by many medical practitioners on the other. As a result, a great many of those patients who seek such treatment do not need it, while many who could benefit from manipulation would not consider it. Patients who are routinely educated by the fundamental chiropractor are difficult to treat properly. Some want one "adjustment" for a vertebra that is "out-of-place," after which they expect immediate recovery, when they actually have a severe strain requiring two or three weeks for complete recovery. Others expect to get a long series of treatments in order to "get the vertebrae back-into-place" when they have only a simple condition that perhaps requires no treatment at all -- or a serious condition, not at all related to the spine, that might require specific and meticulous medical care. In many of these cases it is not usually the pain for which the patient seeks relief but a psychological fear that "a vertebra out-of-place," if present in his spine, might cause or perpetuate serious disease.
Although the "popping sound" associated with "putting bones back-into-place" (though it be accomplished by manipulating a normal joint) is one of the cleverest and most effective forms of suggestive therapy ever devised, its effect upon psychosomatic conditions is quite misleading when the same treatment is applied to actual organic pathology. We must never forget the power of the mind, however, for in addition to changing the course of certain conditions for the better, the state of mind will often convince a dying man that he is better when he is not. It shall always be necessary for the physician to examine the patient's state of mind in addition to his physical condition if the patient is to be treated properly. Although psychosomatic therapy is a very potent tool of the physician's trade, every capable physician is careful not to let such treatment replace more specific measures in the saving of life and limb -- regardless of what the patient thinks he needs.
In every outpatient clinic there are patients who are seriously stiffened by joint adhesions, patients who could possibly be mobilized by appropriate joint manipulation. Such manipulations would probably have to be performed by a medical orthopedic specialist. Without question, however, cases requiring manipulative treatment would have to be selected by a qualified orthopedic or physical medicine specialist. It is not inconceivable that trained technicians, working in cooperation with the physician, could perform the actual manipulation.
Unfortunately, little is actually known of the effects of joint manipulation upon certain types of diseased joints, irrespective of what the chiropractic doctrine has to say about it. This information should, of course, come from those who are well-grounded in the specialty of orthopedics.
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