To many physiotherapists and the majority of medical people, manipulation is synonymous with the forcible wrenching of joints by osteopaths, chiropractors, lay manipulators and the like. In many quarters it is even regarded as taboo, something which is dangerous and therefore not to be talked about. Some doctors even bracket it in their minds with quackery, obscure cult and charlatanism. These unfortunate and jaundiced views are a result of ignorance of a form of treatment which has been found therapeutically valuable since time in memoria.
Manipulation in this context is basically a skilful form of passive movement to a spinal or peripheral joint with the objective of relieving pain and/or restoring normal function. It is not untrue to say that sometimes the therapist has to impart a high velocity through low amplitude thrust on a joint. This, however, is rarely indicated. In fact only one out of every ten patients who require manipulation needs this form of procedure. Majority of patients only require the gentler techniques which are quite innocuous but with well proven therapeutic value.
The history of manipulative therapy is as old as the world itself. Man has been using manipulation to treat his fellow man before the dawn of recorded history. Historical evidence indicates that Hippocrates, “the father of medicine”, was the first man to describe manipulative procedures which he himself used. In “Mochlichus” one of his famous writings, Hippocrates described in detail how he used traction for reducing dislocations.
The “bench of Hippocrates” which he designed for the treatment of gibbosities is now a legendary piece of appliance. It also dramatizes Hippocrates’ familiarity with basic mechanics.
The art of bone-setting was practised in England for many centuries. The word “bonesetting” is a misnomer. The man or sometimes a woman (bonesetter) who practised this art did not set or reduce fractures or dislocations as the word implies in the modern sense. The bone-setter was often called upon to treat joints which were giving rise to symptoms.
The bone-setter did not go to any special institution to learn his trade. It was often a family concern and knowledge was handed down from sire to son. The secret of the art was jealously guarded and kept only within the family.
Bone-setting remained a mystery to orthodox medicine for a long time until a certain Doctor Wharton Hood published a book by the title “On Bone-Setting”. The way this book came to be published is interesting. Wharton Hood’s father who was also a doctor had administered treatment to one renowned bone-setter by the name of Mr Hutton. Hutton’s conditions improved remarkably but Doctor Hood (Senior) refused to accept any medical fees from him. This was because Hood thought that Hutton had done people so much good that is was not fair to ask him for fees. Hutton was very grateful and to show this, he wanted to reciprocate by showing Hood his “secret” manipulative techniques. Hood was, however, too busy at the time and he could not accept Hutton’s generous offer. It was Hood (Junior) who later accepted the offer on his father’s behalf, and he found Hutton’s techniques of bone-setting quite impressive. For him, it was an eye-opener. He himself used these techniques on his patients with great success. After the death of Hutton he published his observations in Lancet. It was an expanded version of this that he made into “On Bone-Setting”.
In 1915, one Doctor published a book entitled “Modern Bone-Setting for the Medical Profession”. Romer was heavily influenced by Paget’s historical lecture in September 1895, during which the illustrious English surgeon called medical attention to bone-setting by giving the merits and demerits of this procedure. The book was also an attempted “modernisation” of Hutton’s work.
Andrew Taylor Still (1829-1917) is a progenitor of osteopathy. He was a farmer’s son which spent his formative years in Virginia, USA. After bad weather ruined their crops, he thought he had enough of farming and he and his father moved to Kansas where they did missionary work amongst Red Indians.
In 1864 there was an epidemic of meningitis which caused the death of Still’s children. This tragedy was to have a significant effect on Still’s life and his whole philosophy. He watched the way doctors battled in vein to save children and this caused him to become disillusioned with orthodox medicine of the time which could not do much for his sick children and he wondered whether “pouring drugs about which he knew little into bodies about which he knew less” was the correct therapeutic approach to illness.
In a state of despondency, Still retired to the countryside where he assiduously studied the exhumed bodies of Red Indians. In 1874 the concept of osteopathy was born. It came to Still like a flash of inspiration. He concluded the spinal column was the origin of man’s illness and that structure was governed by function. This inference was probably a result of his obsession with meningitis and his intimate knowledge and preoccupation with the skeletal system. He also came out with the theory of “the rule of the artery” which he declared absolute.
Certain events in Still’s life served to fortify these dogmatic enunciations and his strong convictions. An example was when he suffered chest pains which he diagnosed as “heart trouble!” This trouble lingered on for some time and one day as he was lying down with his feet in the air, he twisted his back unintentionally. There was a clicking sound and after that event his heart trouble vanished. This was probably a thoracic lesion with symptoms mimicking signs of cardiac disease. By putting himself in a certain position he inadvertently did an automanipulation which got rid of his pain.
A lot of Still’s hypotheses could now be regarded as a load of poppycock in the light of today’s medical knowledge. One however, should imagine the climate of ignorance which existed at that time compared to the gargantuan strides which modern medicine has made.
Time and time again he observed that certain conditions were often accompanied by tenderness in the spine. He diagnosed these as “osteopathic lesions”. Manipulation of these tender areas often led to quick relief.
Still therefore established a philosophy which approached ill-health with a mechanistic system of which manipulation played a large role. To him, manipulation was the obvious answer to man’s many illnesses.
Osteopathic thought has of course changed a great deal since the days of Still. He became a prosperous man and it was he who founded the first school of osteopathy in Kirksville, Missouri, USA in 1874 where his pioneering work although now very much modified, is being perpetuated.
Before the death of Still in 1917 there was a split in the osteopathic ranks. One sect stuck rigidly to Still’s beliefs while another wanted change. This was to result in the emergence of chiropractic as a concept of therapeutics. They called themselves “Chiropractors”. They accused the osteopaths of heresy and the osteopaths in turn irreverently referred to them as “unskilled half-brothers”. This feud persists till today.
Chiropractic was founded by Daniel Palmer in 1895. He was a great chiropractor and in his day a path was beaten to his door with patients coming with their headaches, gall bladder troubles, gastritis and other sundry ailments to be cured by him. One of the incidents which boosted his fame was when he “adjusted” a cervical vertebra of one Henry Lillard and apparently “cured” his deafness.
Palmer founded the Palmer college of chiropractic in 1897 in Davenport, Iowa, USA. Chiropractors mushroomed in the USA and by 1957 their number was estimated to be 25,000
Manipulation in recent times
Since the late thirties of this Century it has become fashionable to label pain in the back as a result of a “disc lesion” or a “slipped disc”. This has caused attention to be focussed on a mechanistic approach just as Still did many years ago. This of course meant manipulation in its many forms.
In the face of medical opposition people like the late James Mennell, M.D., have made valuable contributions to knowledge about manipulation. His theories about “joint play” and “joint dysfunction” as being the key factors in many forms of joint pain, have given much food for thought. After his death, his son, John Mennell, M.D., was to continue the work of his father.
James Cyriax, M.D., M.R.C.P., is one of those who have strived vigorously to bring manipulation to the attention of orthodox medicine. He has been criticised for the roughness of his methods but many doctors, detractors and admirers alike agree that his techniques of examination prior to manipulation contain a wealth of medical logic and the rationale behind his manipulative technique is sound.
Recently the work done by G.D. Maitland, M.C.S.P., M.A.P.A., has helped considerably in understanding and acceptance of the subject. He has dispelled the age-old erroneous idea that manipulation is a rough handling of joints or a “hit and miss” form of treatment. By emphasizing gentleness and using the word “mobilisation” instead of manipulation in many cases he has reduced the emotional response which the word often conjures. Maitland’s mobilisation is now a household word amongst many physiotherapists especially those who have taken an interest in manipulative therapy.