Structure/function. It is perhaps the most essential and underlying concept in all of physiology and medicine. In this installment of reFLEXIONS and rePERCUSSIONS, Dr. Goodley delves deeply into the structure/function of back pain, its etiology and diagnosis, to discuss some fundamental questions still left unanswered in its treatment.
As always, I look forward to hearing from you.
Charles Kearns, PhD
Medscape Orthopaedics & Sports Medicine
"The truth lies in small distinctions."
(And when the distinctions are large, the truth must be all the more obvious.)
Give small children a functional model of a spine, and they will likely see it as a special set of blocks. No matter how they bend it, they will intuitively realize that the blocks themselves are not bending, just the interspaces, and that the appearance of unitary curvature, as if it were a spring, is an illusion. It may amuse them, but their innocent honesty will not let them be fooled while they may be impressed that many small contributions can become so much.
While they will not appreciate the concept of the spine as a wondrously integrated series of interrelated, reflexly mediated structures, their basic appreciation will have taken them a long, long way. So, it would be expected that such a fundamental would be easily appreciated by professionals responsible to treat disorders that can impair such an exquisitely constructed mechanism. The thought to ignore such basic reality would ordinarily be unthinkable.
Consider some of what may be observed, or, as a Yogi Berra, how much you can see just by looking:
Your patient complains of back pain. You have taken a history, and now you begin your examination. Your patient's back is bared and s/he is standing with legs squared and apart about the width of your foot and facing directly away from you.
Inspection is a subject of itself and not part of this stream of thought.
If you begin by requesting the standard forward and backward flexion movements and your patient completes a full flexion (despite pain), please first consider positively that it may well imply strong volition and confidence in you -- for which your patient's complaints may be all the more to be believed -- instead of it triggering the often wretched "gotcha" response that allows some doctors to conclude that they are off the hook with their questionable competence still undiscovered. There is so much more that can be observed and correlated from which to consider the possibility of such an unlikely self-betrayal later.
And, while your patient is flexing and extending, instead of just waiting to measure the end result, please observe the movements of the entire back for the "way of going," as first your patient's head flexes as the hands move towards the floor. Observe from high in the thoracic spine if sequential segmental flexion is occurring, or is there an "en bloc" flattening with several segments locked and moving as one? It's important. Does the curvature continue to reverse?
With your patient maintaining anterior-posterior erect posture, you may ask for side bending "metronome-like" movement: flowingly reaching down along one lateral thigh as far as possible and then the other, unstopping, no jerking, just left and right, repeatedly -- what I have termed Repetitive Bilateral Lateral Bending (RBLB). What happens to the pain? Is the changing curvature repeatedly symmetric? Does the angle of the curvature persist at the same level? Or does the level of the angulation change? Asymmetry instead of clear symmetry. If asymmetry, is there curvature to one side but sharp angulation of "straight" segments to the other? Does the musculature appear as single solid sheets coordinately tensing and untensing as the direction changes?? Are there what I call "action fasciculations"? This is fascinating physiology! With neural irritability, instead of full synchrony of segmental firing so the muscles appear to contract as if singularly innervated, the disturbance breaks the pattern and individual fascicles fire independently and are seen as sudden flicks, especially in a good oblique light that casts shadows. They are certain signs of neural irritation - no longer a sprain or segmental mechanical dysfunction but an expression of early neurologic involvement. This sign is especially valuable when it isn't originally present but appears after maybe 8 circuits, side to side, before it suddenly "flushes." There is so much that is valuable to see just by observing. And there is much more that may lead to effective treatment and assistance in assessing results.
Hands-on, I habitually commence a lumbar examination by first assuring that my patient is standing so that the feet and the head are aligned directly away, in the same direction. Gently, I reach from behind and place my middle fingers on the anterior superior iliac spines and then let my hands form around the hips. I then inspect. Are my hands symmetric? Is one middle finger more anterior? Is one hand more posterior? In other words, is the pelvis aligned to my patient's feet and head? Or is it rotated left or right, always a sign of dysfunctional abnormality that is usually correctable, often with relief of the pain.
With the patient standing, sitting, or horizontal, palpate for abnormal relative vertebral positioning with segmental stiffness, the persistence of what should be a transient movement but which can "lock" and is what constitutes dysfunction. It is never, or hardly ever, seen on x-ray. Diagnosing it is the first step to its correction to restore balance to the structure, then assess and observe the functional response. Remember that vertebral segmental movements -- side bending and rotation -- are coupled. They can't occur separately.
Examining the sacrum and the sacro-iliac joints are special opportunities. Symphysis pubis dysfunction is easily diagnosed and usually easily relieved. The pain is always in the lumbar area, never anterior. Testing for cutaneous hyperalgesia by skin rolling is a paramount fundamental test. (Much of this is scheduled for discussion and, of course, is in Release From Pain).
There is potentially so much more, all completely consistent with the inherent complexity of the structures and functions that may necessarily need to be examined to move towards effective treatment. Does anyone really believe that an organism so capable of seemingly infinite virtuosity of performance doesn't also possess similar potential for a spectrum of dysfunction? So, is it reasonable that such a mechanism would really relinquish critical signs to only gross inquiry -- or submit to irrational therapy? In another phrase, if a clinician becomes habitually frustrated in his or her efforts to treat such conditions, is it because the condition is habitually being insistently stubborn? I don't think so.
This, of course, is not specific instruction in a therapy which is largely a craft that requires hands-on study and practice. But I certainly want this to be a therapeutic instruction for you to appreciate reality that has been traditionally ignored for generations.
When "The Bone and Joint Decade" was announced 7 years ago, I was immediately interested and hopeful (although, candidly, I was skeptical because of the implications of the title, which was amplified when I read the list of participating organizations, virtually all of them surgically dominated). I commented on the problems in Release From Pain as I hopefully awaited prompt publication, but that didn't happen, so my concerns didn't have the opportunity to be widely disseminated. (At this time, Release From Pain still remains an eBook on my Web site.)
Then, last month, I revisited the "Bone and Joint Decade" Web site, now with only 3 years left of a venture to 'successfully relieve in this decade the roots of musculoskeletal pain,' a paraphrase whose exact words are readily available.
Memories of decades past returned - memories of the doctors who told me they were infuriated with me because they knew that I was right, their resentment never accompanied by a request to show them what I had done (because I surely wanted to) when I would relieve a condition such as the residual pain and impairment after arthroscopic knee surgery by restoring motion of the proximal tibio fibular joint - generally considered a nonentity by surgeons. I remembered again one of the quotes from my Introduction to this series: "Do not be angry with me if I tell you the truth -- Socrates."
A few weeks ago, I traded my Release From Pain for a copy of the hard cover Musculoskeletal Medicine, sponsored by The American Academies of Orthopaedic Surgery, Family Physicians and Pediatrics, a part of the Bone and Joint Decade's effort. The selection of the sponsoring Academies raises its questions while The American Academy of Physical Medicine and Rehabilitation (AAPM&R) is obvious by its absence. (My book provides what, unfortunately, is a justifying history.)
Regardless, Musculoskeletal Medicine is virtually an orthopaedic surgical product. The title returned me to 1974. Through a series of fated events, I was selected by Dr. William Fowler, my former Chief at the University of California at Davis, to establish a committee in the AAPM&R to introduce what was initially titled Orthopaedic Medicine. Dr. Fowler will always be to me one of the great men of my career. He observed my work and gave me space and wasn't threatened by what I did. He saw my discovery of another new medical diagnosis (soft-tissue entrapment in the acromio-clavicular joint [arthrograms observable on my Web site]) with the patient cured. If you want to approximate what she suffered, bite the inside of your cheek for 15 months. The entire story is in Release From Pain, and some of it -- ie, the reaction of the orthopaedic surgeons who were involved -- isn't a happy story. Dr. Fowler's only request was that I not embarrass him, so when we were requested to change the name because of certain physiatric sensitivities, and with the promise for full cooperation if we did, we chose Musculoskeletal Medicine.
My committee cooperated for 10 years, but the ending was also not a happy one. Everywhere in traditionalism, for one reason or another (or many), truths that are so obvious to children terribly threaten professionals trapped in their indoctrinations, credentials, and cherished reputations. And so the Fundamental Flaw feeds the Pain Pandemic - and the Bone and Joint Decade, declared to alleviate pain, remains an orthopaedic surgically dominated (I'm sorry) charade essentially devoid of medical perspective - or osteopathic or authoritative chiropractic influence - seemingly intent on amputating its resolve. It is generations overdue to realize that in the responsible arena of orthopaedics, surgery is only 1 arm. Release From Pain proves and discusses the issues extensively, but Musculoskeletal Medicine fully exposes the issues on its own.
Musculoskeletal Medicine is a handsome, heavy book. And here my pain increases because, while I appreciatively honor the courage with which it was sent to me, if I fail to honestly comment now I would refute the prime purpose of my professional life at a critical hour. A major opportunity to confront the Fundamental Flaw and terminate the Pain Pandemic will have been missed.
I began this writing with an allegory about children. I never expected to find that Musculoskeletal Medicine's description of vitally important basics about examination, except for a few phrases, are written literally for children -- providing nothing from which to form realistic concepts or build clinical confidence. Concerning the technical information in a book such as this, I suggest that it must be relevant to forming the foundation for clinical competence from which confidence comes. Which, continuing the cycle, requires the ability to comfortably apply applicable skills. Otherwise the information is (merely) an exercise in academics. I haven't yet read that aspect of the book, but regardless, as I sadly concluded, essential clinical information isn't there.
To illustrate: After a statement about inspection (page 331), the entire physical examination of the lumbar spine is on 1 page (333) largely taken up with white space and 2 large photographs of a handsome athlete flexing and extending his spine. The writing, in full, on the page is:
" Lumbar flexion and extension
What to do: Ask the patient to stand straight with the feet comfortably apart for balance. Then ask the patient to flex the lower back by bending forward to touch the toes (A). Measure how close the fingers come to touching the floor. Ask the patient to return to standing. Then ask the patient to extend the lower back by leaning backward as far as possible. (B). Visually note the angle of extension during the test."
"Normal: For normal lumbar flexion, the fingertips should reach within 10 cm of the floor. For normal lumbar extension, the patient should be able to lean backwards 15 o to 30 o from standing straight."
"Interpretation: If lumbar flexion is less than normal, lumbar radiculopathy or nonorganic pathology may be present. Pain with extension in young patients can be caused by spondylosis." 
The "examination of the cervical spine" section (page 332) is. . . even worse.
If nothing has been done to enlighten basic education, then nothing has been accomplished, and again, "The mountains labored and produced a mouse." Musculoskeletal Medicine is a cruise ship without an engine room.
Then what really motivated the "Decade?" I will be so grateful if someone proves me wrong, but a recent conversation convinces me that, again, in this issue, the emperor has no clothes.
Unforgettable is the orthopaedic surgeon who was being shown how to palpate basic spinal motion during one of the courses I attended decades ago. The subject was side lying on the examining table facing him, his hips and knees flexed with his forelegs against the surgeon's abdomen. As he rocked back and forth to slightly flex and extend the subject's hips and knees while palpating the reaction at the interspinous spaces, after some seconds he had looked up pale and sweating, his eyes wide, expressing shock that he had been operating on the spine for 35 years and that was the first time he had ever felt it move. Basic education could well begin obligating every orthopaedic surgeon to do that.
In my opinion, while there is now no hope for any conquest of pain in this decade, just maybe the remaining 3 years can, at least, yield a reality-based statement of recommitment to a fundamental "system analysis" from the beginning to examine what went wrong - and how to resolve it - the Fundamental Flaw.
Orthopaedic Surgery is a specialty especially bound to the athletic personality. While the (generalized) dark side is brittleness of ego, forceful projection of macho that powerfully interferes with sensitively approaching many, many painful conditions, the same characteristics are ingredients of courage, acceptance of high challenge, and tolerance of high failure.
As example, the failures in the attempted treatment of scoliosis are legion, but Orthopaedic Surgery acknowledged each defeat and tried again. But its greatest failure, evident for decades, is that while its surgical disposition usefully fragmented into so many subspecialties is an honest admission that there is too much required for any individual to be competent at, so much variation that "general" orthopaedic surgery hardly exists, it has done virtually nothing to extend that conclusion to the medicine of orthopaedics. But it demands dominion, nonetheless. Ladies and gentlemen of the jury, Musculoskeletal Medicine can easily be Exhibit 1.
The rational conclusion is that The Fundamental Flaw is largely an orthopaedic surgical legacy, a legacy that Orthopaedic Surgery would do great credit to itself by reflecting on now, acknowledging its share of the crisis, and mobilizing its power to resolve. But today, truly today, this effort to restore sanity to sound medical principles remains a choice of individual conscience and decision.
I am grateful for the responses I received to the Introduction to The Medicine of Orthopaedics, published 2 months ago. I am grateful for your recognizing truths that I have learned are essential. I now must begin to bring you into the mindset of the successful orthopaedic physician, which is of the same genus as the hunter's and the detective's, whose essential requirement is to perceive and accept what is -- to study the signs -- all signs, whether "hard" or "soft," that are commensurate with the condition, to utterly reject the popular, incredible demands that the quarry comply with rigid, preconceived, and inapplicable rules. The successful medical approach has its own rules. It sounds so simple.
"In the last analysis we see only what we have been taught to see. We eliminate and ignore everything that is not part of our precedent."
Dr. Jean Marie Charcot
As an encapsulating example, in 1982 I was invited to teach at Uppsala University, Sweden. The seminar concerned approaches to various orthopaedic problems, and during one of the sessions fractures of the wrist were discussed. As with the vertebral column, traditionalism ignores the anatomical reality and predominantly examines the wrist through its gross motions. The truth is that each articulation of the carpus can be specifically responsible for impairment. That is important, and before you have finished reading this, you will learn how to perform a simple yet invaluable manipulation in this area.
At Uppsala, as the treatment of fractures was discussed, I commented that force sufficient to fracture the forearm could certainly dysfunction the carpus, so it should be examined before the arm is casted. Otherwise, a pathologically stiff wrist may well result. I had barely finished when the chief of orthopaedic surgery came out of his chair to face me as he retorted that such conditions never happen.
"How do you know that?" I asked.
"Because if they did, we'd see them!"
One dysfunction that I have beautiful stories about in Release From Pain involves the ulno-menisco-triquetral joint. Sudden, unexpected forearm supination can "dislocate" the triangular cartilage, thereafter causing intense pain that exacerbates especially with attempted supination and dorsiflexion. (I have never felt it necessary to take an x-ray to rule out fracture when I suspect this condition.) Examination reveals localized tenderness often with some swelling about the joint, but there is no angulation or tenderness proximal or distal to it. The curative manipulation has been, in my experience, universally successful, can be performed one-handed, and is very simple. (I wish you would read my cases, including the anecdote about my own granddaughter when she was about 7 years old. All of my other cases were in adult men.)
Assuming the patient's right wrist is involved, and s/he reaches out to you with the forearm in pronation (the ulnar side of the arm toward you), reach out with your right hand, your index finger flexed and your thumb extended. Place the pad of your thumb under the hand at the triquetral bone. Place the flexed proximal interphalangeal joint of the index finger on the dorsum of the ulnar styloid. Then simultaneously '"depress" the ulnar styloid as you "elevate" the triquetral aspect of the carpus. In other words, slide the aspects of the joint past each other by applying a gentle but persistent clamp-like force. When you encounter the initial resistance, follow through. With success, the resistance will suddenly yield with a "grinding" or audible "pop" -- as the patient is instantly relieved and the "feel" of a repeat manipulation is normal. (Of course, initially practice this essentially most simple and potentially dramatically effective manipulation on normal joints.) You find one, it's hero time.
Please, one more thought for today: The international trend in medicine towards the domination of cost containment is increasingly evident. To illustrate, a newspaper I read just published a full page on "The prognosis for medicine," which, in summary, acknowledges the burdens of today's method of practice that is vastly overstuffed with exponentially increasing technological costs from which the anticipated solution will be the general loss of personal-care physicians who will be replaced by personnel who are trained to comply with the bottom-line efficiency directives that do not include any concept of revitalizing basics. The dominating edict is that the budget must support basic care of enlarging aging populations. Any reflection about our methods of practice that preceded and precipitated this tragedy ust emanate from medicine. It is our obligation and opportunity for penance. Orthopaedic Medicine -- directed to the commonality of pain -- is central not only to relieving a significant part of the problem but, regardless, is also at further threat to be suppressed if we fail to finally appreciate its centrality. Certainly, it has the qualifications to become its own specialty: a body of essential knowledge that is not, at this time, attended by any other specialty.
As an aside, but related to this, I will never forget listening to a National Public Radio discussion concerning managed care at its onset over 15 years ago when the purveyors of scientific greed first flaunted their power over medicine that we ourselves paved the path for. The spokesman being interviewed articulately described how costs were being reduced in pervasive ways including limiting office visit times and the reduction of physician and nurse salaries. As he attempted to continue describing his fiscal mastery, the moderator interrupted him by inquiring into the salary of the CEO of his organization, and without missing a heartbeat, he provided a figure in the millions annually with the addition of many millions in bonus money, to which the moderator asked how that reconciled with the cost savings so central to his thinking, to which, again without a missed beat, he responded, "Well, if you want quality people, you've got to be willing to pay them."
Regardless, the ideal of medicine prevails untouched by human mischief. Desperately needed now are courageous orthopaedic surgeons who will reassert it by openly acknowledging now that their specialty has inadequate interest and no inclination to dedicate themselves to processes and procedures that avoid surgery. Or, find colleagues who are and will influence change! Needed now is a newly educated breed of physicians who will reassert sound methodology while urging medical influence to the general direction of what historically was medicine.
Our world is in exceedingly treacherous times, nationally, internationally, and medically. And -- there is no time but now for us to declare our emergency -- and there are none but us to strive to resolve it. Legions of patients, wherever Westernized medicine is practiced, are unnecessarily in persisting pain because of impotent methodologies that we have established and maintained for long over a century, longer than anyone today can remember.
In partial answer to the question posed in the title, because it is The American Academy of Orthopaedic Surgeons.
Paul H. Goodley, MD
Medscape Orthopedics © 2007 Medscape
Cite this: Goodley Intentions: Why, Orthopaedic Surgery? - Medscape - Jan 30, 2007.