American Journal of Physical Medicine 1964;44:55-69 The Concept of Painlessness and Opposite Motion in Spinal Manipulations Robert Maigne, MD, Physical Medicine, Hotel-Dieu Hospital, 75181 Paris Cedex 04, France Original translation from the French by Herman L. Kamenetz, M.D., Veterans Hospital, Rocky Hill, Connecticut

Summary. The author presented in 1964 a method of spinal manipulative therapy, based on the personnal concept of painlessness and opposite motion. This rule constitutes a reliable and exact guide for the planning of spinal manipulative therapy, including the selection of techniques and their execution. Accordingly to this principle, spinal manipulation is a medical, precise and perfectly defined procedure, strictly adaptated to every individual case. The method described by the author allows selection of those cases in which this treatment is indicated and those in which it is not. The method shows the important role of minor mechanical derangements of the intervertebral joint and allows their systematic study. Some examples of the application of this method are given.

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If manipulations of the spine do not always have a good reputation, we have to recognize that this is largely the responsibility of those who perform such procedures. Sometimes the method is performed incorrectly or is used without clear indications. Far too often the most important point is ignored, namely, the need for a definite diagnosis preceding the treatment. We have been using manipulations daily for over 15 years in the treatment of certain painful conditions originating in the vertebral column. The results obtained justify our conclusion that spinal manipulations, well done and applied to carefully selected cases, constitute a very efficient kind of treatment, without pain and without risk.

Most authors have described a certain number of maneuvers which can be applied to the various regions of the vertebral column, however they did not seem to be particularly interested in finding out whether or not there are specific maneuvers which are indicated for each individual clinical case of mechanical disturbance of the spinal column.
It is the purpose of this paper to suggest a logical method of spinal manipulation. This method is based on a systematic examination preceding the treatment and on a fundamental concept, namely, the concept of "painlessness and opposite movement." The manipulation is executed in a direction opposite to the motion that is painful and limited. It must be painless. This allows us to determine:

• Whether the manipulation is possible and desirable.

• The exact procedure to apply and its direction.

• How the treatment is to progress.

Spinal manipulations are precise maneuvers. Executed correctly, they have proved to be excellent therapy in a substantial number of vertebral pain syndromes. They deserve a large place in the practice of physical medicine.

Definitions

For the sake of clarity, we will define two fundamental terms, namely mobilization and manipulation.

Mobilisation
Let us assume a patient lying on his back. The physician, standing behind him, grasps the patient's occiput with his right hand, thumb pointing to the right, fingers to the left. His left hand grasps the patient's chin. While he applies slight traction to the cervical spine, he rotates the patient's head toward the right. At a certain point, he has the impression that he has arrived at the end of the range of the cervical spine motion. He returns to the point of departure and repeats the motion several times. These maneuvers are mobilizations by rotation to the right. Thus, mobilization consists of a series of passive movements within the normal and usual range of the joints, without going beyond it.

Manipulation
Manipulation has three phases:

• Positioning.

• Taking up the slack.

• Manipulation per se.

Let us take the same example of a patient lying supine. The operator has taken the patient's head between his hands as described above; this is positioning. Then he rotates the patient's neck toward the right to its full extent. The patient himself also feels that his neck cannot turn any further. The operator maintains this position of maximal rotation. That is what we call tightening. It is at that moment that the operator adds a very slight supplementary rotation by a small sudden thrust of his left wrist. He has suddenly the impression that a resistance has been overcome and that the spinal column has moved by a few additional degrees. This is accompanied by a characteristic clicking sound. This forced, short, unique motion, executed at the point of tightening, is the manipulation. A manipulation must always start at the point of stretch. It is a very small motion. One should avoid a large, forceful motion which cannot be measured, which is violent, painful and dangerous.

A manipulation carries the segments of the joint beyond their voluntary and usual range without, of course, going beyond its anatomic limits. It must be completely painless and should be under the perfect control of the operator. While this requires experience, it can be executed at any level of a normal vertebral column without any pain or discomfort by a well-trained operator. The clicking noise which accompanies the manipulation is due to the vacuum produced within the joint by the brisk separation of the articular surfaces. It is of the same nature as that which results from sudden extension of the fingers. It does not mean that anything is put back in place. It is possible to produce this click at any level of an absolutely normal spine. After a manipulation is doue it takes a certain time—sometimes minutes, usually hours—before a new manipulation will again be accompanied by a click.

Identification and description of a spinal manipulation

In order to adequately describe a manipulation, its direction is to be established, for example, rotation to the left. But this is not sufficient, unless the exact position of the spinal column during this rotation is also specified. It is essential to know whether this rotation is to be done on a spine that has been positioned and maintained in flexion, in extension or in a neutral position, or whether it has been flexed laterally to the right or to the left. For the exact identification of the maneuver, the direction of the thrust and the position of the spine during this forced motion have to be indicated. An example would be : cervical manipulation in rotation toward the right on a spine in right lateral flexion and extension. The first term names the executed motion ; the following terms indicate the position of the spine during the motion. It is sufficient to say on which vertebral segment the main force is applied : low cervical manipulation on C5-6 in right rotation, the spine being laterally flexed toward the right and in flexion.

Direct manipulation

Fig. 1: Direct manipulation

The patient is in prone position (fig. 1). The heel of the hand applies direct pressure on the spinal column either over the transverse processes or the spinous processes. The pressure is followed by a very quick release. These techniques are violent and dosage is impossible. They are frequently disagreeable if not painful, and, above all, their possibilities are extremely limited. They seem to us to be of little value and to be dangerous.

Indirect manipulation

Fig. 2: Indirect manipulation

The operator utilizes the natural lever arms of the body in order to act upon the spinal column. For example, in a patient lying on his side (fig. 2) pressure applied in opposite directions on the pelvis and on the shoulder will impose a movement of torsion upon the lumbo-dorsal spine. Or as mentioned above, in moving the patient's head the operator imposes motions upon the neck. A large number of maneuvers allows manipulation of ail vertebral segments in all desired directions. These maneuvers are gentle and progressive and mobilize the segment in question. They have the great advantage that they can be tried out before they are actually executed. The operator, by going as far as the phase of tightening, can establish easily whether the maneuver is painless, and therefore feasible. This is very important in the system of manipulation which we propose.

The precision of these maneuvers can be increased by utilizing what we call semi-indirect maneuvers. In these, the total movement is given at a certain distance (as in indirect manipulations) but the operator can obtain a more precise localization of the effect of the manipulation by using pressure and counter pressure at or below the segment treated. Figure 3 shows an example of an assisted semi-indirect manipulation in the low lumbar region.

Fig. 3: Assisted semi-indirect manipulation in the lumbar region

 

The concept of painlessness and opposite motion

We arrive now at the primary problems of treatment by manipulation. Manipulation therapy should not be given routinely on a vertebral segment, without consideration of the individual clinical case. It is, for example, illogical to treat all the "painful conditions of the low back" by three standard maneuvers routinely repeated whatever might be the individual problem. Every case demands a particular maneuver which has to be strictly adapted to its individual needs. Experience has shown that while forcing of a painful spinal movement sometimes results in an improvement accompanied by a sharp pain, this very frequently makes things worse. This is logical. There is a reason for the pain or limitation of motion. Forcing against this cause might overcome it, might, as is said frequently "break the adhesions", but obviously in case of a mechanical obstacle, there is a great chance of provoking irritation and inflammation which could make matters worse. We have seen this in daily practice.

By contrast, experience has also shown that in case a motion of the spinal column is limited, say in its rotation to the left, and is free to the right, a forced rotation toward the right will improve the condition, whereas one to the left will not. Thus, a patient with a traumatic torticollis, unable to turn his head toward the left but turning it freely to the right, will not be relieved of his pain by a forced rotation toward the left, even under traction. However, he will be relieved by a forced rotation of the head towards the right. This point is extremely important because, following this principle, the physician can proceed without pain. As confirmed by our experience this method is physiologic since it always results in a liberation of the locked movement. This extremely important point is the concept of painlessness and of opposite motion. It consists of making the manipulation in the direction opposite to that which is painful and limited. But, it is rare that it is only in one direction that motion is locked. As is well known, spinal motions are inter-dependent. The manipulation which is indicated is therefore the motion which will combine the various free directions.

Applications

How can the concept of painlessness and opposite motion be applied? It is to be assumed that the patient has been completely examined, clinically and radiologically, that all necessary laboratory studies have been done, and that the physician has established a diagnosis. Manipulation like any other therapy cannot be done without diagnosis. If it has been decided to use manipulation, how should one proceed? The motions of the vertebral segment in question are studied and marked as follows: one plus for a minor limitation; two plus for a moderate, and three plus for a severe limitation.

Example 1. An example of the limitations in a case of traumatic low back pain could be as follows: flexion, +; extension, ++; rotation toward the right, 0; rotation toward the left, +++ ; lateral flexion toward the right, 0; lateral flexion toward the left, + + +. This can be expressed in diagrammatic form (diagram of motion) as in figure 4, the cross-bars indicating restriction or pain. It is clear from figure 4, and is shown in figure 5, which manipulation is to be done—rotation to the right in right lateral flexion.

Fig. 4: Diagram of motion for the case of example 1. F, flexion ; E, Extension ; FR, right lateral flexion ; FL, left lateral flexion ; RR, rotation of the right ; RL, rotation to the left. Number of crosslines indicates severity of the limitation.

Fig. 5: Manipulation diagram for the case of example 1. FR, right lateral flexion ; RR, rotation to the right.

Example 2. Figure 6 shows a similar diagram constructed on the basis of the examination of a painful neck. The manipulation will be a rotation toward the left in left lateral flexion and flexion as indicated in figure 7. Several techniques could be utilized successively by combining these directions in several ways— for example, first a manipulation acting more particularly in rotation toward the left, then another one acting more particularly in lateral flexion to the left and finally a flexion technique.

Fig. 6: Diagram of motion for the case in example 2. F, flexion ; E, extension ; FR, right lateral flexion ; FL left lateral flexion ; RR, rotation to the right ; RL, rotation to the left. Number of crosslines indicates severity of the limitation.

Fig. 7: Manipulation diagram for the case of example 2. F, flexion ; FL, left lateral flexion ; RL, rotation to the left.

Example 3. Figure 8 shows the diagram of another case. In this instance, all the motions are limited or painful, and manipulation is contra-indicated.

Fig. 8: Diagram of motion for the case of example 3. F, flexion ; E, extension ; FR, right lateral flexion ; FL, left lateral flexion ; RR, rotation to the right ; RL, rotation to the left. Number of crosslines indicates severity of the limitations.

 

Example 4. In certain cases it is not easy to establish clearly whether there is limitation of motion and the pain is only slight. This is the procedure: we attempt the manipulation without actually performing it completely. In other words, we execute the first two phases of the manipulation, positioning and tightening, first in rotation toward the right, then in rotation toward the left, in lateral flexion right and left, in flexion and finally in extension. Thus, we can recognize clearly the motions that are hindered or uncomfortable for the patient.

Application in cases of sciatica
Many cases of sciatica can be treated by manipulation, especially those due to reversible protrusion of an inter-vertebral disk. Manipulations should not be routinely the same in all cases, but should again be adapted to every individual case. The determining factor is the accompanying scoliosis. We might distinguish two classes of sciatica, depending upon the associated scoliosis which is either convex (fig. 9) or concave (fig. 10) to the side of the sciatica. An example of each class is given.

Fig. 9: Sciatica with convex scoliosis
Fig. 10: Sciatica with convave scoliosis

Example 5. Right sciatica with scoliosis convex to the side of pain (fig. 9). Lateral flexion toward the left is free; lateral flexion toward the right is locked; rotation toward the left is free; rotation toward the right is locked. In general, extension is locked and flexion is rather free (fig. 11). The manipulation will be a rotation toward the left with lateral flexion toward the left on the spine in flexion. Various techniques can be used.

Fig. 11: Diagram of limitations for the case in example 5. F, flexion ; E, extension ; FR, right lateral flexion ; FL, left lateral flexion ; RR, rotation to the right ; RL rotation to the left. Number of crosslines indicates severity of the limitation.

1.A very good technique is shown on figure 12. The patient lies on his/her painful side, the left hip and knee flexed.

• First phase, positioning—the operator, with his left hand, stabilises the left shoulder of the patient and keeps it immobile during the entire maneuver. With his right forearm he leans on the left ischium of the patient.

• Second phase, taking up the slack—applying pressure to the ischium, the operator rotates the left half of the pelvis and brings the lumbar segment into a pronounced kyphosis.

• Third phase, thrust—having made sure that the tightening is complete, he continues the mo veinent of his right forearm, exag-gerating it by a brisk extra thrust.

Fig. 12: Example 5. First manipulation technique.

2. The astride technique is illustrated in figure 13. The operator brings the spine into a slight flexion and a pronounced left lateral flexion before executing the rotation toward the left.

Fig. 13: Example 5. Third manipulation technique (strap technique).

3. Provided the patient can assume the prone position, a third technique can be used as shown in figure 13. The patient's pelvis is strapped to the table. The operator rotates the lumbar spine toward the left (i.e., the non-painful side) while he flexes it strongly toward the same side by pulling the patient toward himself away from the table.

Example 6. Right sciatica with scoliosis concave to the side of pain (fig. 10).

Fig. 14: Diagram of limitations for the case of example 6. F, flexion; E, extension; FR, right lateral flexion; FL, left lateral flexion; RR, rotation to the right; RL, rotation to the left. Number of crosslines indicates severity of limitation.

In this case, the schema is: left lateral flexion is locked; right lateral flexion is free; left rotation is locked; right rotation is free (fig. 14). Actually in this type of case, extension is usually free and flexion is limited. However there are cases m which the opposite is true, necessitating a change in technique. In the given example, the following techniques can be used.

• 1. The patient lies on his non-painful, i.e. his left side, left hip extended, right hip and knee flexed (fig. 15). The physician stabilizes the patient's shoulders perpendicular to the table with his right hand. He applies his left hand firmly on the right iliac crest, as if he wanted to rotate it anteriorly (fig. 15). This will rotate the lumbar segment and bring it in lordosis (extension). The operator puts the region on a stretch and then executes the thrust.

• 2. In the astride technique, the operator brings the spine into lateral flexion toward the right, this being the side of free motion.

• 3. In the strap technique, the operator stands at the painfui side, the right in the given example (fig. 16). By pulling the patient toward himself and away from the table, he brings the spine in right lateral flexion and more or less rotation.
  There techniques must aiways be done by going through the three mentioned phases: positioning, tightening and thrust. Under no circumstances should the patient experience any pain during the entire maneuver. If one of the executed movements were painful this would mean that the direction of the motion is wrong. If all movements are painful, manipulation is contra-indicated.

Fig. 16: Example 6. Third manipulation technique (strap technique)

 

Indications and results

A full discussion of indications and results would require much more space than can be given to it here, because the actual manipulations which would be indicated (in cases of sciatica, back pain, cervico-brachial radiculopathy, etc.), would change with the clinical variation of every individual case. In certain cases, manipulation represents the treatment of choice, irreplaceable because of the quality and the speed of the results, which are sometimes instantaneous. In other cases, manipulation represents only an addition to other treatment, either physical or chemical. Even so, it may still be an important part of the over-all management.

The most important of the common indications for spinal manipulation are acute or chrome pain of the lower or the upper back, common sciatica, chronic cervical pain with limitation of motion and cervicobrachial radiculopathy. We find that manipulations are generally indicated in all those reversible and minor mechanical derangements (dysfunction) of the intervertebral joints, which have resulted in local or radicular pain or in involvement of the sympathetic nervous system. Junghanns calls the intervertebral joint a "motion segment." This motion segment includes the intervertebral disc, the posterior joints and the intervertebral ligaments. Together with other German authors, he insists upon the importance of the role played by the lesions of the small menisci between the posterior joints in the mechanical pathology of the vertebral column.
Our enumeration of the indications for manipulation is incomplete because it would require a special and detailed analysis to discuss the exact applications in every individual case. If we take, for instance, acute low back pain, we note that results are better in cases originating from a muscular effort or inappropriate movement than in those without a mechanical cause.

If we classify low back pain in two classes, according to the presence or absence of a grossly obvious antalgic posture, we find such antalgic deviation of the spine in 75 cases out of 100. Among these 75 cases, 40 have a scoliosis with convexity toward the side of pain, 25 have a scoliosis with a concavity toward the side of pain, 10 have a pronounced lumbar kyphosis. The 25 cases without spinal deviation present only moderate rigidity. In 20 of these patients, the spine cannot flex, whereas extension is free. In 5 cases, the patient is in a slightly flexed position, but he can neither extend nor further flex his spine. In these groups we find that one or two manipulations will result in complete disappearance of the pain in a considerable percentage of cases as indicated in table 1. It is well known that acute low back pain can disappear spontaneously in a relatively short time. Any new form of treatment should therefore produce either immediate or very rapid relief in order to be considered effective. For this reason only those cases in which immediate relief was obtained after one or two manipulations are included in the percentile figures in the third column of table 1. If a second manipulation was needed, it was aiways done 48 hr. after the first.

We have grouped 240 cases of chronic low back pain in three groups according to treatment procedures which consisted of: 1) manipulation alone, 2) manipulation and therapeutic exercises, 3) therapeutic exercises alone. Our conclusions are as follows:

• Group 1. In 73 per cent of the cases, complete disappearance of the pain occurred after one to six manipulations distributed over a period of from 1 to 20 days. After 4 months, good results were maintained in only 40 per cent of the cases. Repeated manipulations, however, produced again the same good results as were obtained originally. Most of these patients had suffered for a long lime and had previously received numerous other forms of treatment.

• Group 2. In addition to the manipulation, individually prescribed therapeutic exercises were donc by the patient daily for 4 to 5 minutes. Good results were obtained by this treatment in 72 per cent of the cases early and in 79 per cent after 4 months.

• Group 3. Therapeutic exercises were given without manipulation or any other treatment. After 20 days, 28 per cent were without pain and after 6 weeks, 45 per cent. After 4 months 55 per cent were without pain. However, the improvement was not as complete as in the cases treated by manipulation. Very frequently, there remains a certain discomfort or a painful point, usually eliminatcd easily by manipulation. It should be noted that, even if the exercise program is restricted to a minimum, it is difficult to have a poorly motivated patient do the exercises regularly.
  

These statistics illustrate the value of manipulation in one of its most frequent indications. We combine manipulation rather frequently with numerous other treatments depending on the individual case, such as injection of the ligaments, massage of painful points of muscles and skin, thermotherapy, electrotherapy, hydrotherapy and in some cases also X-ray therapy. But in most of these cases, manipulation is the mainstay of the treatment because in its absence, rapid and complete improvement is rare. On the other hand, manipulation is not always sufficient. Therefore, we frequently complement it by the treatment of ligaments which have remained painful, by correction of static deficiencies, by muscle reeducation, and by a correction of postural or occupational habits. In the medical service of a railroad company, where it is very easy to control patients over long periods of time, the introduction of manipulation in daily practice has allowed us to reduce by 40 per cent the number of workers' days of absence from work due to mechanical involvement of the lumbar spine, such as low back pain, sciatica, etc. We want to emphasize as a particular feature of our method of manipulation, the promptness of its results, the frequently immediate and prolonged subsidence of a long-standing pain or limitation.

Without being able to discuss in detail all the indications which we have mentioned, we would like to elaborate on a less well known indication in which this method is of particular value—this is in the cervical syndrome, whether it is caused by trauma such as a minor form of whiplash injury, by a rheumatic involvement, by degenerative arthritis of the cervical spine or simply by a postural defect. All these manifestations have been described in 1925 by Barre and Lieou under the name of Posterior Sympathetic Cervical Syndrome. This syndrome includes headache, vertigo, tinnitus, visual fatigue, a tendency to depression, etc. There is much controversy as to the pathogenesis of these symptoms. At present, many insist upon the important role played by the vertebral artery. We would like to mention the great value in the treatment of this syndrome of gentle and well selected manipulations applied according to the method that we have outlined. These procedures confirm the role of small, reversible, mechanical derangements in the production and maintenance of a large number of these complaints.

We would also like to mention the very good results which we have obtained in coccygodynia caused by a fall on the pelvis or after childbirth. Among 187 cases treated (with a follow-up of 2 years), 87 per cent have been cured after two or three manipulations. We have developed a new method of manipulation for coccygodynia, which has many advantages over the classical procedure. In our method the patient lies face down. The physician enters the right index finger into the rectum and places the anterior surface of this finger against the anterior surface of the coccyx. He then applies pressure to the sacrum with the heel of his left hand. The pressure is applied slowly and forcefully, while the right index finger remains against the coccyx without applying any pull. Pressure on the sacrum is maintained for 40 to 50 sec. The essence of this new method of manipulation is the application of the manipulating pressure to the sacrum rather than the usual method of manipulating and pulling the coccyx itself.

These examples cannot give a complete review of the therapeutic possibilities of the manipulative method which we have proposed. They are given here simply as illustrations of its value, provided it is applied carefully and all diagnostic precautions have been taken.

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References
BARRE, J., LIEOU, A. Syndrome sympathique cervical posterieur. Paris Med., 15: 266-269, 1925.
MAIGNE, R. Les Manipulations vertebrales. Paris, Expansion Scientifique Française, 1960.
MENNEL, J. B. The Science and Art of Joint Manipulation, Vol. 1 and 2. London, J. and A. Churchill, 1949.
SCHMORL, G. JUNGHANNS, H. Die gesunde und die kranke Wirbwelsäule in Kontgenbild und Klinik. Stuttgart, Georg Thieme Verlag, 1957.

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