Treatment

Remarks | General Hygiene | Exercises | Traction | Injections | Supports | Medications | Surgery | Therapeutic Aids | Manipulations | Follow Up | Pain of Procedure | Elongation Treatment | Treatment No. 1 | Treatment No. 2 | Treatment No. 3 | Treatment No. 4 | Treatment No. 5 | Treatment No. 6 | Active Elongation | Equipment | Summary

Remarks

The chapter on testing was divided into sections; one group of paragraphs explained many of the accepted routines whereas Section D gave the purpose, procedure and rational of the elongation program. Likewise, this chapter will be similarly sectionalized.

This does not infer that the elongation program is a separate therapeutic entity sufficient of itself. It should be reiterated at this point that the program is another useful tool in the general armamentarium of low back treatments. True, it may be sufficient of itself in a majority of all low back cases, but this does not devaluate its worth as an adjuvant in the severer cases, such as herniated disc, bony anomalities or arthritis. The only contra-indications are ankylosing spondylitis, tuberculosis of spine and carcinomatous (cancerous) erosion or demineralization (less mineral substance) of vertebrae.

The clinical experience of the writers has been directed to the elongation program solely and independently of any other remedial agent. This procedure was followed purposely in order to evaluate the program on its own specific merits. However, it appears to coordinate its demands in no disconcerting manner to any of life's processes that nature requires; in fact, it is an enhancement of nature.

We are basically creatures of movement and any interference with this normal life process, except in certain instances, is not physiologically sound. Nature itself is the healer supreme and much of medicines effectiveness is in aiding nature. However, nature at times may do harm and must be altered. An example in point is the muscle spasm of back muscles and contraction of local connective tissue around an area of pain. Cancer is nature's processes on a rampage. Elongation tends to cooperate with nature in salient respects yet curbs her from over-reaction.

Thus the program sets up four requirements of the therapist:

1. Reassure the patient to have confidence in his body's ability to overcome the stresses.
2. Teach him to turn to treatment early.
3. Motivate him to keep on the job and in the swim of life.
4. Encourage him to be seen and checked frequently.

The following sections are included for the sake of mention in this treatise. Thoroughness would require a volume for each point.

General Hygiene

1. Rest and sleep—Sufficient rest is any amount which allows the person to avoid physical, mental or emotional over-fatigue. Inadequate muscular rest will tend toward slovenly postural habits. In patients with low back pain, a firm mattress with a board between it and the springs is a necessity. Soft mattresses twist the back just enough that a constant strain is present; the back needs support at rest.

2. Nutrition—Fresh vegetables, proteins, vitamins and trace minerals are important in proper nourishment to each body cell. Common sense is almost always correct in balancing the types and amounts of ingestants. Obesity is abhorred. To be temporate is the keynote of life; this includes exercising, eating, using alcohol or tobacco and resting.

3. Avocations—The patient should be kept busy or occupied. Everyone needs to feel useful and wants to be wanted. The triangle of body, mind and soul is inseparable and Medicine is discovering that the inadequacies of one of these affects the others. Diversity of interests is a potent factor in balancing the triangle. Personal insight is another balancing factor.

4. Posture—Two or three short daily interludes of the elongation procedures will aid development of proper posture. One should consciously practice standing with ears, shoulders, mid-hips and ankles in erect alignment and weight borne on outside of the parallel feet. In walking, the head should be erect, shoulders back and toes pointed ahead, feet being parallel. Desk posture should include a seat which is low enough to allow the feet to be flat on the floor, hips touching the back of the chair, torso not slumped, yet not overextended and head erect. The seat should be parallel to the floor; the chair back inclined backward about eight to ten degrees and without postural curves. Of utmost importance is the periodic shifting of weight and change of position; the person should stand up and walk at least once an hour.

Exercises

Here again, the elongation procedures suffice as exercises. The goal of exercises directs the type of procedure to be used. In general there are three types:

1. Postural—These are to maintain rhythmically the status quo of the body's coordination and posture.
2. Corrective—These are to correct any maladjustments to life's normal ways.
3. Calesthentics—These are exercises for coordination, strength or endurance above normal requirements. They are important but they have a tendency to strengthen the muscles which are already strong; frequently the equally important antagonistic muscles are neglected which causes greater imbalance in posture or action.

Literally thousands of articles and books have been written about exercises; they shall not be demonstrated here. It is evident, however, that exercises are a therapy toward a specific problem and should be intelligently prescribed.

Traction

The rational of traction includes stretching (elongation) and rest. Traction stretching is a slow and mild form of elongation program. Rest frequently slows the pace of healing. On the other hand, traction at times is imperative.

There are two general types:

1. Buck's leg traction is the type in which the legs are enwrapped along with lead-ropes to a pulley where weights are suspended freely to create a pull. (Illustration No. 30.)

2. Pelvic traction is a corset around the pelvis which is attached to the pulley and weights, thus applying a direct pull to the lumbar and lower abdominal areas. (Illustration No. 31.)

Injections

In frequent cases, a trigger area (Illustration No. 10) may fire-off the pain. These may be relieved, usually temporarily, by novo-caine or other local anesthetic injections. Theoretically, anesthetic injections should relieve the pain, thus relieve the spasm, shortening pain cycle. In actuality, injections are of limited value, even in series.

Supports

Temporary relief of increased lumbosacral angle may be obtained by various supports. Tincture-benzoin coated skin may be taped with adhesive. These strips should strap from axillary line to axillary line, overlap half width and run from lower sacrum to lumbo-thoracic line.

 

Fig. 30. A patient in Buck's leg traction.

Lumbosacral supports are less irritating to the skin and avoid maceration of skin. In passing, it should be mentioned that the so called sacroiliac belts are of questionable value in most low back cases. Many types of braces, Hauser jackets, plaster casts and cylinders are available. Let it not be forgotten, mobility should not be neglected. Infrequently, supports only delay the return to normal function.

Medications
Striated muscle relaxants have been disappointing in the clinic of the writers. Those tried have been physostigmine, mephenesin, zoxazolamine and curare derivatives. Cortisone and salicylates have their place with specific clinical entities. Analgesics (pain relievers) afford relief of pain and stall for time until the spasm or constrictions have relaxed. Yet this is wasteful of man's greatest asset—time.

Fig. 31. A patient in pelvic traction.

Surgery

Conservative measures are adequate in treatment of low back pain except for an extremely rare case. Only about 10% of proven ruptured disc cases require surgery; the question of fusing with bone graft the two vertebrae on either side of the affected disc is yet in orthopedic hash-pots. At any rate, operated cases use exercises and conservative physiotherapeutic measures in recuperative stages.

Physical Therapeutic Aids

Heat applications—Heat stimulates local circulation and engorgement; it affords a certain amount of relaxation to muscular and connective tissue fibers. It may be obtained from a variety of sources. Dry heat is afforded by dry packs, hot pads, infra-red ray lamps, diathermy, microthermy, ultrasound machines, and solar sources. Moist heat is acquired from wet packs and hot baths. The addition of epsom salts avoids white wrinkling of skin without decreasing heat penetration and acts as a hypertonic solution affecting involved tissue fluids. Heat should not be used promiscuously. It, like novacaine injections, may give the patient a false sense of security. Since muscle spasm invariably returns after these treatments, a chronic fear regarding mobility of the back may be instilled. It may initiate synovial inflammation. If actual tearing of muscle, fascia or connective tissue has occurred, the increase in local circulation will cause further edema, swelling, bleeding and pain. Furthermore, early heat and swelling will increase the resultant scar formation which later contracts and is relatively inelastic, causing almost irreparable damage.

High and low frequency electric currents have been used to create heat and ionic or chemical effects respectively.

In passing, the therapist may decide whether or not to apply heat prior to manipulation. Tearing of tissue is easier after heat; likewise, pain is not as apparent to guard against over-exertion.

Manipulation

As Mennell has aptly defined it, "Manipulation is a technique used in medicine to restore normal function to a joint, muscle or tissue whose function is impaired for normal use."

Actually manipulation is based on the works of a joint motion, i.e., flexion, extension, abduction, adduction or circumduction; beyond this is a second range of motion—joint play. On the other hand, it has been demonstrated that the two bone surfaces at a joint may bind together and produce a loss of function without demonstrable dislocation or any other gross pathology.
There are many schools of manipulation. This writing is concerned with the elongation of tissue methods and that program is hereby outlined.

Many of the maneuvers are similar to the tests as demonstrated in the previous chapter. This is an asset to any program in that it creates simplicity. The only difference in such steps is that in testing, the tester stops the maneuver at the point of pain whereas in manipulation he carries it through and beyond the point of pain.

Follow-Up

It is valuable to both patient and therapist to have the former return for frequent passive and active elongation sessions. However, the patient's continued interest and persistance in his home therapy is the only insurance of permanent relief. The program must be incorporated as a routine daily activity on the same plane as dressing, shaving, bathing or eating.

The writers routinely issue the following reminder to all low back cases at their first visit. It is based on a similar tract written by T. J. Bender, M.D., of Mobile, Alabama.

"Remember, low back pain must be lived with twenty-four hours a day; any laxity in observing preventive instructions may aggravate the condition.

1. Standing—in position of forward attack—never in the military position of attention. No high heels; this throws base of support forward, thus the lumbar spine must extend to avoid falling forward.

2. Bending and lifting—flex the lumbar spine, then squat by flexing the knees; lift with legs.

3. Sitting—well back in chair with knees higher than hips; never slump, but never overextend. Change positions often.
 
4. Lying-—hard bed or even flexion of hips and knees. Never lie on abdomen.

5. Driving—seat of car well forward then sit well back in seat; never slump, but never overextend.

6. Avoid extending the back.

7. Exercise—regularity, but not heroically; never to the point of fatigue."

Easing Pain Of Procedure

Since tolerance to pain varies widely from one individual to another, a general anesthesia may be given prior to treatments. Intramuscular injections of opiate derivatives; under physician supervision, gives somewhat inconsistent relief.

Our clinic uses 'Trilene' (Trichlorethylene) in a Duke inhaler which is chained to the patient's wrist. It is used in early labor with excellent success. It offers rapid induction of sleep, analgesia to pain, amnesia after awakening, rapid recovery and no residual effects such as dizziness, sleepiness or weakness. It is extremely safe. Each therapist should work with his supervising physician to access and apply any of the modalities of pain relief, if needed, during treatment procedure. Obviously, when anesthesias or analgesias of systemic or general application are given, a supervising physician should be at hand. A positive pressure resuscitator with oxygen and orophargneal catheters or intratracheal tubes should be available.

Passive Elongation Treatment

A. Treatment No. 1 for Test No. 2.

1. Purpose—Correction of the condition causing painful restrictions of the upper cervical muscle group as determined by the findings of Test No. 2, page 29, chapter IV. This may relieve headaches, eye aches and some blurred vision, stiff neck and scalp sensitivity.

2. Procedure

a. Patient is seated on straight-backed chair, hips firm against back. With feet locked behind front legs of chair to act as an anchor, the head is bent slightly forward. Left hand grasps side of chair.
 
b. Patient places his chin in palm of his right hand with fingers pointing toward the right ear and pushes the head to the right until a point of discomfort is reached.

c. Therapist places his left hand on top of patient's left shoulder. Right arm encircles patient's head, forehead in crook of elbow, hand firmly against back of patient's head.

d. By slow steady pressure, the therapist assists further rotation of the. patient's head, until a position of 90 to 100 degrees from starting position has been reached.

e. Throughout the treatment, the therapist must remain in an erect position directly behind the patient. As rotation is assisted, he pivots on his right heel and left toe with the trunk of his body following the direction of the turn of the patient's head. As pressure is applied by the right arm, a counteraction (back and slightly downward) is brought to bear on the patient's left shoulder.

Fig. 32 (Left). Positioning for treatment No. 1, upper cervicals.

Fig. 33 (Right). Positioning for treatment No. 2, lower cervicals.

f. Reverse procedures c, d, and e. 3. Physiology of treatment—Same as for Test No. 2. Illustration No. 32

15. Treatment No. 2.

 
Fig. 34. Positioning for treatment No. 3, thoracic area.

1. Purpose—Relieve restrictions of lower cervical muscle group as noted in Test No. 3, page 40, chapter IV. This also relieves shoulder, arm and hand symptoms.
 
2. Procedure—

a. Patient and therapist assume same starting position as in Treatment No.1.
b. Patient turns head 45 degrees to right with left hand grasping seat of chair; keep chin down; patient places right hand on left temple with fingers pointed toward left ear; right elbow slightly to rear of patient's shoulder tip.
c. Therapist places his right hand on patient's head with fingers spread; left hand is on patient's left shoulder tip.
d. Therapist applies a firm pressure backward and downward with right hand until head has been moved through an arc of pain. The left hand holds patient's left shoulder firmly in place throughout the movement.
e. Patient and therapist reverse position of head and hand to obtain same results on left lower cervical muscle group.

f. Overzealousness in this exercise may create damage; it is not to be feared, but caution should reign.

3. Physiology of treatment—Refer to Test No. 3 physiology for similarity. Illustration No. 33

C. Treatment No. 3.

1. Purpose—To lessen the constriction of movement of the thoracic (chest) region and shoulders, see Test No. 4. Many cases mis-diagnosed as heart attack or pleurisy are intercostal muscle spasm; these may be between the ribs.

2. Procedure—

a. Patient is seated in straight-backed chair, hips firm against back; with feet locked behind front legs of chair.
b. Therapist stands at right side of seated patient.
c. Patient twists body to the right.
d. Therapist places right hand on right forward side of patient's right shoulder. Left hand is placed on left back side shoulder.
e. Therapist applies pressure by pulling with right hand and leaning body weight on left hand. Always maintain patient erect with hips touching back of chair. Illustration No. 34
 
3. Physiology of treatment—Pain between shoulder blades, intercostal neuralgia, neuritis or pleurisy—patient's with negative organic heart and lung pathology may respond to elongation of musculature and connective tissue.
Intercostal muscle spasm regardless of cause, responds slowly; tell the patient that if he could stop breathing for two or three days, the spasm would subside more rapidly!

Fig. 35. Positioning for treatment No. 4, anterior abdominal and pelvic area.

Fig. 36. Positioning for treatment No. 5, upper thigh and anterior pelvic area.

Fig. 37. Positioning for treatment No. 6, leg musculature (hip abductors and leg extensors).
 
D. Treatment No. 4.

1. Purpose—To elongate muscle and fascial constrictions in the anterior pelvic area and/or of legs to back of knees (see Test No. 5).

2. Procedure—

a. Patient is in a face down (prone) position on treatment table.
b. Strap is placed at tip of sacrum and tightened firmly.
c. Therapist stands to right of patient, reaching across, grasping left knee. For balance therapist next places knee on treatment table.
d. Patient's leg is pulled to full extension and toward therapist across midline to adduction.
e. Therapist changes to other side of treatment table and reverses procedure to right leg. Illustration No. 35

E. Treatment No. 5.

1. Purpose—To further elongate muscular tightness of the anterior pelvic group. This may relieve groin pain and symptoms of upper anterior thighs.

2. Procedure—

a. Patient remains strapped to table (prone position).
b. Therapist extends arms and grasps patient under nearest knee.
c. Therapist fully extends leg and leans away from patient, abducting the leg slowly and without lunging.
d. Movement of leg is firmly performed through the arc of pain and slowly returned to normal position on treatment table. Illustration No. 36

F. Treatment No. 6.

1. Purpose—To elongate the posterior muscle groups of hips, thighs. and legs and to obtain relief of points of pain noted in the movements during Test No. 6.

2. Procedure—
a. Patient lies on back, with legs extended.



Fig. 38 (Upper). Active sitting treatment for back, thigh and legs—starting position.

Fig. 39 (Lower), Active sitting treatment for back, thigh and legs—initial movement.

b. Place strap at pelvis; distal to the Anterior Superior Iliac Spines. Strap should be padded by inserting a piece of one-fourth inch sponge rubber, six inches wide across pelvic area. Urinary bladder should be empty.
c. Place a second strap under left leg and across the top of the right leg, just above the knee cap.
d. Therapist stands on left side of table.
e. Raise the patient's left leg to rest on therapist's right shoulder.
f. Therapist positions right knee on table; place hands on knee to insure complete extension throughout elongation movement.
g. The patient should be reminded to relax as much as possible and let the therapist do the work. Also, warn him of pain he will experience during this elongation process.
h. Pressure is to direct movement of leg toward a point on right shoulder tips of the patient.

Fig. 40. Active sitting treatment for back, thigh and legs—reverse movement.

i. Relax pressure and slowly return the leg to its normal position on table.
j. Move to the right side of table; adjust strap under left leg
and anchor right knee to table, k. Repeat movement to the left leg.

 
Fig. 41 (Left). Active standing treatment for back, thigh and legs-starting position.

Fig. 42 (Right). Active standing treatment for back, thighs and legs-initial movement.

Fig. 43 (Left). Active treatment for anterior pelvic musculature.

Fig. 44 (Right). Active treatment of calves, thighs and heels.
 
Starting position -It is advisable to initiate elongation movement on the side of least constriction. This method can guide the extent of motion on the other leg. 3. Physiology of treatment—Refer to Test No. 6 physiology. Illustration No. 37

Active Treatment

After the therapist has applied the corrective elongation procedures, the patient is instructed to walk about for a few minutes.

The next phase of the program is that of instructing the patient to duplicate properly the movements used by the therapist (movements of muscular elongation to counteract nature's tendency to contract or shorten ligaments).

A. The patient is seated on a table, with legs extended and a strap is placed across the top of the legs to hold knees firmly in place.



Fig. 45. Active treatment for arm, elbow and wrist-starting position). Excellent in tenosynovitis of wrist or elbow.
 
B. Extend arms to side, thumbs pointing to ceiling. (Illustration No. 38.)

C. Therapist instructs the patient to bend with slight twist, moving right hand in an arc toward outside of left toe; keeping left arm and hand high, as it is moved backward. Do not lunge; create a slow, steady rhythmic motion.

D. Return to starting position and move the left hand toward outside of right toe.

E. Alternately repeat movement five times on either side. (Illustration No. 39.)

F. Remove strap, cross patient's right leg over left knee. In this position all outside aids and equipment have been removed. (Illustration No. 40.) This is the active phase of this exercise.

G. Have patient duplicate movement of bending forward (C) five times on right side; reverse leg position and repeat five times on left side.

Fig. 46. Active treatment for arm, elbow and wrist—initial movement.
 
H. Patient stands with back to treatment table; left hand moves to the tabletop for balance; cross the right leg over left, at knee; right hand on left shoulder. (Illustrations No. 41 and 42.) Patient bends forward, relaxes and bends forward again. Repeat five times, attempting to increase the range of motion with each effort.

This elongation procedure should be done by the patient three times daily.

I. The patient is next instructed to actively elongate the anterior pelvic area. (Illustration No. 43.)

Fig. 47. Equipment used in passive phase of elongation treatment.  
1. Patient stands erect, feet together, elbow, forearm and hand touching wall at shoulder height.
2. The opposite hand is placed in the hollow of the hip; fingers pointing toward the heel.
3. Tighten gluteal and abdominal muscles.
4. Shift hips forward to a point of muscular tenseness and then inward toward the wall by pressure of hand on outside hip.
5. Caution patient to keep knees straight, not to drop tip of shoulder or allow heels to rise.

J. Elongation of lower leg muscles. (Illustration No. 44.)

1. Patient places hand on wall, level with shoulder.
2. Keeping hands on wall; he slowly walks backward, keeping heels on the floor; when tension is noted in calf of leg; he slowly moves hips forward, holds position until he feels the muscles start to relax; increase forward movement of hips; hold in position and then slowly return to erect position.

K. Illustration No. 45 illustrates the starting position of an elbow and wrist exercise that has proven helpful in the treatment of arm pain; it is especially effective among new employees or workers returning from vacation. It is of value in teno-synovitis of wrist and numbness and tingling in fingers. It is used by trainers of several major league baseball clubs. The arm is flexed, fingers loosely pointing toward shoulder.

1. Instruct patient to extend elbow, with outward rotation of forearm, wrist and hand, as if they were bouncing a rubber ball off the upper arm (biceps), thumb supinated laterally as far as possible. (Illustration No. 46.)
2. Caution patient not to over-exercise.

It is readily observed that one advantage of this program is the. simple and inexpensive equipment or appliances the passive phases require, Illustration No. 47. A firm flat table and a strong belt or strap. The active phases may be performed by the patient without any equipment and at any place he happens to be at the time.

Furthermore, its value as a preventative process is immeasurable. It may be performed at the earliest hint of constriction and pain, thereby, avoiding increment in symptoms and may save a visit to the therapist.

SUMMARY

Low back pain is one of man's most common afflictions. Its causes are legion.

A simple plan of preventing and treating the syndrome is outlined. Certain background materials are offered for the education of the therapist. The program may be administered by a registered nurse or therapist without necessitating long-term training or outlay of money for equipment. It may be applied by the patient himself at the earliest stages of pain wheresoever he might be.

It may be applied to stiff neck, menstrual cramps, leg muscle cramps, tenosynovitis and many other disease entities.

Above all, it may be incorporated readily into the health habits of any individual at a cost of two minutes, three times a day.

It is hoped that the preventative aspects of the program will reward handsomely the disciple of elongation therapy.

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