Orthopedic principles

Modern medical treatment for back pain is closely linked to the emergence of the specialty of orthopedics.

Early orthopedics was mainly about childhood deformities, and orthopedics first took an interest in sciatica because of sciatic scoliosis. From these roots, orthopedics expanded in the second half of the 19th century to include all musculoskeletal problems. Interest in spinal deformities spread to sciatica and back pain, and focused on the spine. Previously, back pain and sciatica were regarded as separate diseases. From now on, they were linked in the spine. Ever since, failure to distinguish our ideas and treatment of back pain and sciatica has caused much confusion, which continues to this day.

There was no precedent for the scale of casualties in World War I. For the first time, medical concern with trauma matched previous concern with disease. It also brought the treatment of fractures within the scope of orthopedics. Between the two world wars orthopedic surgeons struggled to gain control of fractures and trauma and so expand their professional practice. As back pain was an injury, it automatically fell within the growing province of orthopedics.

The discovery of X-rays opened up a whole new perspective. For the first time it was possible to visualize the spine during life. Soon, every incidental radiographic finding became an explanation for back pain and sciatica. Different authors blamed lumbosacral anomalies, facet joint degeneration, and sacroiliac disease. The 1920s and early 1930s saw operations to correct these anomalies by sacroiliac fusion, lumbosacral fusion, transversectomy, and facetectomy. The problem of back pain remained intractable.

In the UK, the father of modern orthopedics was Hugh Owen Thomas, who was a qualified medical practitioner from Liverpool (Fig. 4.5). He came from a long line of Welsh bonesetters but worked with his father for less than a year before separating from him. There was an inevitable conflict of

Figure 4.5 Hugh Owen Thomas (1834-1891), the father of English-speaking orthopedics. From a sketch made about 1884 (Keith 1919), with thanks to the Royal College of Physicians and Surgeons of Glasgow.

interest between the new orthopedic doctors and lay bonesetters. Thomas (1874) incorporated many of the bonesetters' manipulative skills into orthopedic treatment of fractures and dislocations, but rejected many of the bonesetters' principles. In particular, he would have nothing to do with manipulation for musculoskeletal symptoms. Instead, Thomas proposed rest as one of the main orthopedic principles for the treatment of fractures, tuberculosis, and joint infection, which was actually quite reasonable in the days before antibiotics and modern surgery. Therapeutic rest must be "enforced, uninterrupted and prolonged." Orthopedics achieved this by bracing, by bed rest, and later by surgical fusion.

Bonesetters, like their descendants the osteopaths and chiropractors, held to the competing principle of mobilization. Their patients continued their daily lives and normal activities. Medicine moved back pain into a medical context. Back pain was now a disease and the sufferer became a patient. Medical treatment often made the patient stop normal activities and actually prescribed disability.

Dealing With Back Pain

Dealing With Back Pain

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