Bernard ScullyWe have had some interesting discussion papers from Bernard Scully who is a practitioner in Australia as he says;

"I have no hidden agenda, just an active interest in anatomy and manual therapy. I'm in the latter years of life, but I still have thoughts and opinions, and ideas that I would like to share with anyone who wants to listen. My material is published in Australia, New Zealand, and the USA. NAMMT came up on a recent search of UK organizations, and I thought, why not?"

We are adding these pages for your interest, please let me know your thoughts. These are Bernard ‘s thoughts and not necessarily those of NAMMT.

If you have any comments either for Bernard (Send directly) or for NAMMT (send to me). We both look forward to hear from you.

The treatment table and its development.

I want to discuss something with you today that we all, to some extent, take for granted – a clinical treatment table. The earliest form probably resembled a slab of timber – sturdy, unyielding, accommodating water, oils,  - perhaps they are still in use today, particularly where copious amounts of water are a part of, or a finale to, the treatment.

Later came the addition of padding, a variety of fabrics, but usually with the intention of basic firmness – the massage person didn’t want the client to be resting on something resembling a soft bed, as too much yield distracted the therapist from the task – and washability, to allow the removal of oils.

Many therapists would agree that the next progressive step was the introduction of a mechanized form of height adjustment – hydraulics or electrics were made available for the therapist to set an acceptable height, or even change the height ,while the client was on the table.

Other features or accessories were introduced – lightweight, foldable tables, arm-rests, contoured sides, and face cradles, to name a few; the basic design however, did not change: a padded surface, covered with a durable layer of inorganic material, and offering a degree of comfort for the client that was tolerable, not luxurious. All models and makes are inclined to be cold in winter, and hot and sticky in summer – linen sheets helped, but these were an added expense for the clinic.

A later development involved the addition of a thin, water-filled membrane, to the basic table top; this membrane was made from similar fabric to the standard vinyl used on most tables –durable, and washable, but being filled with water gave it a degree of flexibility. Up to 60mm thick, it didn’t really convert the table into a “water-bed” as such – there was simply enough water to follow the contours of the client’s body. If the client was supine, for instance, the head, the scapulae, the buttocks and the calf muscles, including the heels, were still in contact with the underlying table, while other concave surfaces, such as the cervical spine, the lumbar spine, and the posterior knees were supported by water.

Aided by a small inbuilt electric heater, of about 100 watts capacity, the water filled membrane was kept at a constant level of warmth – clinic heating could now be turned off, and the gentle warmth was available just where it was needed – beneath the client. A thermostat allowed this temperature to be closely regulated.

BERNARD SCULLY.

NEWCASTLE, AUSTRALIA, APRIL, 2012.

The advance of science.

ABSTRACT. In the early times of manual therapy, indeed, in the early times of all accepted therapies, much reliance was placed on deduction , or ideas, derived from

• touch,
• experience,
•  the client’s story,
• previous history, and
• testing.

Other sources of information were available, but the advances of techniques such as radiology, and sonar examination, were some time away, and the skills of deduction, theory development, and trials were much relied upon by the therapist. Some might say that all professions have been able to advance rapidly with the benefits provided by scientific invention, but there  is a possibility that, like the maths student who revels in the availability of the electronic calculator, ( yet has lost the skill of mental calculation,) the therapist or the physician who, reliant on the data provided by say, an X-ray film, or a written report from a radiologist, overlooks the information that is available from other, basic sources.

I have no wish to denigrate the advantages of scientific progress – but I regularly see the deterioration of and the downplaying or devaluation of, evaluation by a therapist, based on experience, innate skill, and logic. This is a story based on such circumstances.

The client.

Mrs. V. is an 85 year-old, with a 2 year history of lower limb pain, and a steadily developing loss of mobility – not uncommon, you and I would think to ourselves, for someone of such an age. The difference in this story was, this woman had previously had no pain ………….

At her advanced age, visits to a medical practitioner were a commonplace event – not necessarily a daily event, maybe an annual practice. At her next consultation, she described the symptoms:

• pain in the anterior thigh, particularly on waking and rising – not sharp pain, more an ache, making the initial attempts to get out of bed and gain comfortable mobility uncomfortable , and
• combined with this, she felt a similar level of pain in the buttocks, and sometimes this was quite marked, in an area I estimated was the ischeal tuberosity.

The diagnoses.

The medical practitioner recommended an X-ray examination of the lower spine, maybe suspecting some sciatic nerve impingement source. The results of this exam listed:

• degenerative change with endplate changes suggesting instability, most marked at L3/L4, L2/3, and T12/L1 This is associated with broad based disc bulges and
• canal stenosis most marked at L4/5 and, to a lesser extent, L3/4 and L2/3 disc level, plus
• foraminal narrowing on the right side at L3/4 ……

None of these findings, or opinions, are debateable; the radiologist has a professional and legal duty to report all abnormalities revealed by the photos. What  Mrs. V., as the client, and we, the therapists, are entitled to wonder – such abnormalities exist, but are they solely responsible for – or even remotely connected with, the client’s complaints ?

Orthopaedic surgeon #1, on studying the photos, and considering the report, recommended spinal surgery.

Mrs. V. was not convinced, because she reasoned “ ….but I have no back pain..” After consulting the GP again, further X-rays were requested, this time of the knee. Back came the result of “…degeneration of the meniscae…..,and  effusion…” , and with it a recommendation by the orthopaedic surgeon #2 to replace the knee joints, at least on one side, with the second to follow shortly after.

The outcome.

The client is, understandably, somewhat confused at this point; two massage treatments of the hips and legs, together with flexion/extension stretches of the hip and knee joints produced a brief improvement in mobility, as well as a change in pain levels. Naturally, an opinion from a surgeon

far outweighs an opinion from a mere massage therapist; many more massage treatments were needed, before a more definite conclusion could be reached, from my point of view.

A date had been set for hospitalization and surgery, and in these days of overcrowded hospitals, this was almost inviting.

This is probably not the first time you have heard a story such as this; I’m not upset at the loss of the client, and I’m not critical of the surgeons, but it illustrates, in a fashion, my concern that: if the knee joints are the source of the thigh and buttock discomfort, and therefore, in need of replacement, wouldn’t there be other symptoms ? Once she has reached a level of mobility in the early mornings, she can happily stand, and move around the house in relatively painless comfort,  and, if the spinal vertebrae and discs have deteriorated to the  point where they are responsible for the thigh and buttock pain, and therefore are in need of surgical correction, why is it that the client can perform lumbar flexion and extension movements, ( with certain limitations from her age.) and feel no localized vertebral pain ?

My quiet answer, (only voiced to my readers,) : having been trained in the skills of surgery, maybe there is no need for an understanding in, and of, the basic mechanics of joint function. Maybe I haven’t expressed myself well here, chums – this isn’t jealousy speaking, this is another reminder of how precious those old, (not old-fashioned)- qualities and skills, of manual therapy are seriously under-used, and under-valued.

BERNARD SCULLY

NEWCASTLE, AUSTRALIA, 2012

ABSTRACT.  Scientific knowledge advances, sometimes at an astounding rate; a new discovery often promotes the formation of a new galaxy of ideas that fed off that earlier event. Older procedures and theories are left behind in the wake of this ship of progress, as it steams onwards; in this journey, you and I, and our successors are privileged to have access to such modern data when we seek assistance for whatever ailment besets us.

And yet, we cannot avoid paying the price for progress, a part of which is the eradication, or the elimination, or even the abandonment of much of the early knowledge.

I have discussed this topic previously – this loss of early knowledge – but I have returned to it today because of an experience I had with a client in the past three weeks.

Client.

Mrs K., a 40 year-old manager of a suburban branch of a finance company, consulted her local medical practitioner in 2009, reporting chest pains; she couldn’t recall such discomfort previously, and the worst of the pain was in the sternum.

This girl was, although in a sedentary job, an active person, attending fitness classes regularly, and swimming in the local public pool.

She was advised to undergo cardiac and respiratory tests; the results of these suggested no obvious abnormality. Blood tests and bone density tests followed – I’m not necessarily quoting these events in correct order, nor am I being complete, but I’m just trying to provide background for the rest of the story.

Appointments with specialist medical practitioners are not always available on short notice; sometimes, many months pass before the consultation can be secured, and many more weeks are needed to carry out tests and experiments. The point here, is, this girl has endured almost four years of waiting for an answer – during this period, she, and her medical consultants had to rely on speculation, based on the extensive data being produced by the tests.

There was a basic assumption that chest pain was often related to heart malfunction, she was advised to refrain from “vigorous” exercise; among the many medications that were prescribed for her was cortisone As a result of

• the cessation of exercise,
• the intake of steroidal medication, and
• the deep concern she was feeling,

she experienced an increase in weight of about 30 pounds, lost sleep regularity, suffered constant headaches, (for which more medication was recommended) and became a shadow of the person she used to be.

Aided by a sympathetic employer, she retained her job, but, as you perhaps can imagine, familial relationships were also tested.

Manual Therapy.

A month ago she attended a periodic consultation with her medical practitioner, who monitored her general condition, and issued prescriptions. On this occasion, being concerned at the level of her frustration – neurological examinations were being considered – speculated that perhaps something “anatomically mechanical” was playing a part here, and advised her to have a massage treatment.

Three treatment sessions revealed, and reduced, the contractions in her pectoral muscles; the origin of such contractions may never be found, perhaps this is not important, but there is a strong possibility that the early sternal pain arose from these muscles, and the programme of examinations over such a long period, added to an air of uncertainty that took over her life, maybe compounding this situation. The chest pains, meanwhile have gone.

The lesson ?

This is not a treatise on

v     how dangerously silly the medical profession has become,

v     how the fear of litigation has forced the medical profession to adopt lengthy, and costly procedures in the cause of thoroughness, or

v     how wonderfully superior the manual therapy business is.

Now I sit here contemplating the seriousness of this narrative – I have daughters much the same age as this woman – I really can’t tell you what the lesson is, or what path she should have traveled down in the first instance.

I simply regret that a physical examination, in its simplest form could perhaps have been carried out earlier in the story, during the lengthy delays between specialist appointments perhaps ?. This elementary, yet precious knowledge that we hold has been relegated to the category of “lesser importance.”

I await your welcome comments – from last week, Mrs. K. has commenced, as I call it, “regaining control of her life once more”. Swimming, walking, and conferring with her pharmacist on a programme of medication reduction.

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