J.R.Bayliss London England
Background: Medical doctors routinely favour muscle based therapies over Osteopathy. Whilst this may be changing is some areas, there is a long way to go.
One reason for medical doctor’s reluctance to recommend manipulative based therapies like Osteopathy is partly due to their commitment to the NHS. However, there is another reason, the lack of clearly defined research to validate that a manipulative approach is more effective than what they can already achieve. Especially when so many doctors have very limited real world knowledge of the subject.
One of the major reasons why Osteopaths do not have an abundance of validating research is due to limited funding but there is another reason; how do you compare a whole body treatment with another unrelated therapy?
When a patient is being manipulated, no matter how gentle the Osteopath is, for the technique to have any meaningful effect the patient becomes very aware that they are being manipulated and there is usually a series of audible clicks. This makes it impossible to judge the effects of manipulation directly with placebo.
Aims and Objectives: With the introduction of a new type of manipulative procedure called Passive-Patient-Technique based on the spinal theories by John Bayliss DO, for the first time Osteopaths should theoretically have the opportunity to compare the effects of manipulation directly with placebo? To prove if a comparison is possible, some basic research was needed to assess whether this could be achieved.
Discussion: Passive Patient Techniques abbreviated to (PPT’s) are not a variation of ‘Applied Technique’ (Modification of an existing technique). They are different and based on an entirely new set of protocols. Initial testing using the results from palpation, visual symmetry analysis and mobility tests has so far confirmed PPT manipulation has the potential to provide excellent results.
Conclusion: Three things had to be established to justify further research trials; 1) what do patients themselves think about PPT manipulation, 2) Could the patient tell when they had actually been manipulated and 3) Was the patient happy with the results.
Terminology: The ‘Taber’s Cyclopedic Medical Dictionary’ definition of subluxation is ‘a partial or incomplete dislocation’ and it is in this sense that it is being used.
A small and random sample of patients, chosen purely by the order they attended my clinic, took part in a survey to test the effectiveness of PPT’s. All had had traditional Osteopathy from me in the past, which included conventional manipulation. Their new treatment replaced the convention manipulation performed on their spines with PPT’s. All other parts of the treatment were the same. They were asked to fill out a simple one page research questionnaire to find out what their opinion was on being manipulated with PPT’s.
I wanted to know if they found the PPT’s effective and whether would they want such a treatment again. And importantly, could they actually tell when they were being manipulated.
PPT’s are totally original and are the direct result of my new ‘real world’ spinal theories that reflect the way the joints articulate singularly and synergetically in real world situations. Using PPT’s, even small framed osteopaths should be able to treat extra large and strong patients with comparative ease. So the potential is enormous.
PPT’s get their name from their function. The patient lies passively in a comfortable prone position and has no control over the timing of when the manipulation will take place or on which part of their spine or sacroiliac joints will be corrected. The control is totally in the hands of the Osteopath. The neck does not lend itself to the PPT manipulation, therefore it is not included.
Because the joints are made malleable by a very simple procedure, the manipulative force used to correct all of the joints in the spine and sacroiliac joints is no more than the force used in the following comparison test. Place the pads of your thumbs against each other and compress. When the skin turns white, that is the full extent of the force needed. It takes no more than that, even for the most stubbornly subluxated joint. Using this amount of force, joints can be actively felt slipping back into alignment. These are very gentle techniques.
When joints subluxate they do not make a click and therefore there is no reason why those same joints should click when they are corrected by manipulation. With PPT’s there is no click because the correction is simply a reversal of the forces that caused them. The trick behind PPT’s was finding out how the joints worked and became subluxated in the first place.
There are no aspects of PPT’s relevant to other people’s work that I know off, my theories and techniques are original, therefore this is the first reference to them.
A single page research survey questionnaire was given to patients who had been treated by me with conventional osteopathic manipulation in the past. They were asked to take the questionnaire home and to assess what they felt about the new manipulative techniques and to compare them from a patient perspective with the conventional manipulative techniques they had received in the past. Conventional techniques included side-role, Chicago, dog and toggle techniques.
Patients often want to please their therapist so a big point was made to them about how they were assessing the new techniques only and not me. They were asked to be as honest as possible, because only that way could any short comings of the new techniques be improved.
All preparation before manipulation was the same as on previous sessions where conventional manipulation was used. In summary this comprised of muscle stretching and balancing of all the spinal, pelvic, internal (psoas) leg and shoulder muscles, particularly the individual muscles found to be tight or in spasm. This was followed by Osteopathic articulation of all the joints of the body including the arms, legs and ribs, followed by a relatively deep massage of the back, neck and sacroiliac joints, in other words ‘Traditional Osteopathy’.
All patients consented to be manipulated with PPT’s. Before making it obvious that I had already begun their manipulative re-alignment, I furtively manipulated a subluxated thoracic joint to judge their reaction. None noticed, even when I asked them specifically if they felt any particular discomfort immediately after. Every one of the total who took part or who agreed to take part in the survey, was oblivious to having been manipulated. That was 100% who could not tell that they had just been manipulated.
Twenty seven patients agreed to take part in the research survey. Each was given a self addressed stamped envelope to return their answers. Of these eighteen replied. That is 67%.
Did you feel the new techniques were an improvement over previous manipulative techniques? Yes - No
To this question all said ‘yes’. That is 100%
One patient circled ‘No’ as well as ‘Yes’?
Would the new techniques make you more likely to have this type of Osteopathy again? Yes –No
Sixteen patients answered ‘yes’. And one put a question mark and another said that it depended on whether the techniques were effective, to which they answered ‘yes’ to the next question. That is either 88% or 94%
Did you feel the new techniques were effective? Yes – No
All patients answered ‘yes’. That is 100%
One patient answered that they were not qualified to offer comment.
Would the new techniques make you any more likely to recommend this type of Osteopathy to a friend? Yes -No
Sixteen patients answered ‘yes’. That is 89%
One answered ‘no’ and the other did not answer the question at all.
Did you think the new techniques helped to relieve your pain effectively? Yes -No
Seventeen patients answered ‘yes’. That is 94%
One did not answer the question at all
If you have had conventional manipulation before, did you feel the time taken for the new techniques to relieve your pain was as quick? Slower- The same – Faster
Thirteen patients answered faster. That is 72%
Three answered the same. That is 17%
Two did not answer the question. One of these made the comment ‘Not sure, different problem this time, so difficult to tell’.
Did the new techniques hurt you in anyway? Yes-No
All patients answered ‘no’. That is 100%
Did you feel the new techniques caused you any anxiety? Yes – No
All patients answered ‘no’. That is 100%
For comparison, did conventional techniques cause you any anxiety? Yes-No
Twelve patients answered ‘no’. That is 67%
Three patients answered ‘yes’. That is 17%
Two did not answer the question. Of these two made the comment ‘A little’
Since the new manipulations greatly help to align the body symmetry i.e. level of shoulders and ears etc, as a patient did you notice any difference? Yes-No
Fourteen patients answered ‘yes’. That is 78%
One did not answer the question.
Did you notice any changes to your general health and feeling of well being? Yes-No. If yes, in which areas: Stress levels, breathing, digestion, going to the toilet, other
Six patients answered ‘no’. That is 33%
Three did not answer the question
Nine patients answered ‘yes’. That is 50%
Of the (9) 50% who answered ‘yes’, six patients stated that it had helped their stress levels. Of these six, two stated that it had also helped with their digestion. And another two stated that it had also helped their breathing and of this category one stated that it also helped them go to the toilet.
One male patient reported that he had a better blood flow to the lower part of his body and that he was getting improved penile erections.
One patient reported that they felt taller and well balanced
One patient reported that they felt better altogether.
With the new techniques could you tell at what point you were being manipulated? Yes –No
Nine patients stated ‘no’. That is 50%
Nine patients stated ‘yes’. That is 50%
If yes, was it a lot of difference? Yes –No
Five patients stated ‘yes’. That is 56%
Three patients stated ‘no’. That is 17%
One patient did not answer the question.
One patient who stated ‘yes’ made the comment ‘Less physical than conventional techniques’
If the answer was yes again, where did you feel the manipulations the most? The sacroiliac, - The lumbar - The thoracic
Three did not answer the question (they came for lower back pain)
One patient stated the thoracic (they came to have their neck /shoulder pain treated) -That is 11%
Three patients stated sacroiliac joints (two stated they came to have their lower backs treated and one did not say) - That is 33%
Two patients stated the lumbar. (They came to have their lower back pain treated) -
That is 22%
After the treatment did the new techniques make you feel more or less sore than conventional manipulation? More- The same –Less
Thirteen patients stated ‘less’. That is 72%
Four stated ‘the same’. That is 22%
One stated ‘more’. That is 6 %
Due to the methodology used and the small numbers involved, it has to be accepted that the validity of the research survey results are questionable. This research was never meant to be any thing other than a toe dip in the water.
With a medical profession that readily offers pain killing drugs for back pain patients are used to the idea of taking a tablet to mask their painful symptoms. A common problem all Osteopaths face when treating these same patients is that the patient’s expectations are often that the pain will instantly disappear after the first session. However, Osteopaths do not work like that because they attempt to treat what they consider to be the underlying cause of the symptoms, ‘the immobile misalignment of the musculoskeletal frame’. Consequently some patients can confuse the pain they consulted the Osteopath with, with the treatment they received.
Osteopaths are taught to use mobility tests, visual assessment and palpation to find the source of the problem. This inevitably means that when using palpation in the assessment it has to be carried out through tight and inflamed soft tissue. During palpation when a considered amount of pressure is applied to asses the alignment of the joints, the patient often for the first time becomes acutely aware of the specific area the pain is originating from. Hence some patients can confuse the origin of their discomfort and think the Osteopath is the one causing their pain.
Therefore it is understandable that patients would feel discomfort or be aware of the force used for PPT manipulation when it is applied directly to a painful joint. This could offer an explanation why patients who cited the area they felt the PPT manipulation the most was the site of their original pain.
It was interesting to note the attitude the patients had after their first Osteopathic session incorporating PPT manipulation. Several came off the couch shaking their heads. That is until they stood up and found that they were standing considerably straighter than when they arrived and had a general accompanying feeling of looseness and mobility.
These same patients were used to being placed in contorted positions and hearing clicks. The click is an aural confirmation that a joint has been manipulated and for some, that they have had their monies worth. Initially I was concerned that the patients would not think that they had had a proper manipulative treatment, especially when I got the strange looks. I wondered if I had underestimated the placebo effect of the click in my eagerness to provide effective gentle manipulation without the click. I need not have worried because once the patients appreciated the effectiveness of the techniques; this was no longer a factor on the following sessions.
In retrospect the question about alignment could be considered leading; therefore the results should be read and interpreted in that context.
This simple research survey provides an encouraging introduction to my new techniques. PPT’s could easily be faked during clinical trials because it would be impossible for a patient to comprehend the difference at the time of delivery. So for the first time Osteopaths should be able to genuinely compare the manipulative part of their treatments with placebo. Depending on the results, we should be able to reply to the likes of Professors ‘Ernst and Canter with valid research results, which is in the end only what they are asking for.
Obviously there are those who will say quite rightly that Osteopathy is not just about manipulation. Of course this is true but manipulation is the meat on the plate and it is what most Osteopaths are judged by.
It is my hope that now that the Osteopathic profession have the product, the opportunity is embraced.
Bayliss J from DVD ‘Spinal Mechanics and Bony Locking for Health Professionals’ www.spinalmechanics.com
Bayliss J ‘PPT manipulation’ www.spinalmechanics.co.uk
Earnest E, Canter PH. A systemic review of systematic reviews of spinal manipulation. J R Soc. Med 2006-99:192-6
Hartman LS. Handbook of Osteopathic Technique, page 33. Publisher N.M.K.
Since this paper was written their have been many more advances in the application the PPT protocol. One of these is that the cervical spine can now be included as joints that can be manipulated.
Since this research study which was undertaken in 2008 PPT’s have been refined and improved to produce even better patient comfort and results.