NOT THE SYMPTOMS TREAT THE CAUSE,
A MANUAL IN CLINICAL NEUROANATOMY & MANUAL THERAPY
DAVID FELHENDLER
NOT THE SYMPTOMS TREAT THE CAUSE,
A MANUAL IN CLINICAL NEUROANATOMY & MANUAL THERAPY
DAVID FELHENDLER
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors, or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific, or healthcare professionals and is provided strictly as a supplement to the medical or other professional’s own judgment, their knowledge of the patient’s medical history, relevant manufacturers’ instructions, and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures, or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ printed instructions, and their websites, before administering any of the drugs recommended in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately, it is the sole responsibility of the medical professional to make their
own professional judgment, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged, please write and let us know so we may rectify in any future reprint.
No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers.
I dedicate this book with gratitude to my parents, Solveig and Michael, and my wife, Lili, whose love and unwavering faith in me have encouraged me to finally write this book.
2. Anatomy and physiology
Foreword
I have known David Felhendler for more than ten years, and it is my pleasure to write a foreword for this wonderful manual. I first met David when I was teaching my ThompsonMinardi Technique Course in Sweden, and was immediately impressed by his enthusiasm for learning, the detail in which he asked questions, and his endless devotion in understanding why things worked. Over the years, he enrolled in more and more of my courses, and we became friends and colleagues with a common bond of seeking out knowledge.
As I read through this manual, those traits come through loud and clear as David does an excellent job in detailing such topics as anatomy, radiology, sensorimotor integration, and neurology to help identify the root cause of certain problems. In addition, several techniques and practices are outlined for the clinician to review and understand. David provides a basic awareness of these techniques overall function and gives practical advise on how to provide proper care to the patient.
This manual serves as a basic overview for the practitioner, equipped with specific problems to look for, sections for clinical significance, and all thoroughly referenced.
I applaud David for his hard work and effort in creating this detailed manual. It will assist many clinicians with how to serve their patients better.
I highly recommend this manual to anyone who wants to understand more about the human body and serve more patients.
Sincerely,
Dr. John Minardi BHK, DC
18 | TREAT THE CAUSE, NOT THE SYMPTOMS
Preface
My passion for learning more and sharing my knowledge with others has always been with me. I have been thinking about writing this book for a long time. Thanks to my wife’s encouragement, I have collected all the course materials from 25 years of teaching and then organized, expanded, and updated them. Now I finally see the result: a book that has become a journey through time.
Introduction
In the spring of 1994, I was working as a newly graduated physiotherapist at Vrinnevisjukhuset in Norrköping. During a coffee break, a colleague from the cardiac ward told us about a patient who had chest pains for almost a year without finding anything wrong with the heart. I suggested that the pain might be coming from the thoracic spine and offered to examine the patient.
The patient was very stiff in the thoracic spine, and I treated it with an adjustment technique. The next morning, I went to the cardiac ward to see how the patient was doing and barely made it through the door before the nurse in charge caught sight of me.
“What did you do with the patient yesterday?!” she asked.
“What do you mean?” I replied. I tried to look as cool as I could but probably failed miserably.
The nurse replied that the patient did not need any painkillers but had instead been singing and whistling all evening.
A little later on the round, I had to explain to the chief physician what I had done. He looked at the assistant physicians and the medical candidates and said:
“Watch and learn!”
This episode taught me how important it is to think about
the whole body and how our different skills can complement each other in healthcare.
When I began my physiotherapy training, I had already spent a couple of years working as a masseur. I was eager to expand my knowledge to help more people more effectively. However, upon completing my training as a registered physical therapist in January 1994, I realized that there was still so much I needed to learn to provide the best care for my patients. I found myself lacking in treatment techniques, and more critically, I felt the absence of a cohesive framework and a common thread in my practice. Additionally, I recognized significant gaps in essential information in neuroanatomy and neurophysiology.
I became interested in the nervous system early in my physical therapy education. This interest deepened when I discovered books and articles by David Butler and Michael Shacklock. Their work significantly increased my fascination with the nervous system, which gradually became the common thread I had felt was missing after my basic education. It provided me with a better understanding of how many seemingly different symptoms could have a common cause and offered a map to follow for diagnosis and treatment. Over the years, I have had the privilege of learning a great deal from many amazing teachers and therapists.
When a patient rattles off an endless list of symptoms, what would you give for a quick answer about what you should do? Most likely, quite a lot. Thankfully, such knowledge now exists, and it is evidence based. One of my guiding principles is to make everything as simple and rational as possible. To paraphrase Antoine de Saint Exupéry, “Perfection is not when you can’t add anything more, but when you can’t subtract anything more” (de Saint Exupéry 1939). I appreciate the principle of “Ockham’s razor,” named after the philosopher
William of Ockham (1287–1347), which suggests that if you can solve a problem with two things, don’t add a third, and if there are two solutions to a problem, choose the simplest one. Before tackling any task, always seek to understand why you want to do it before considering how to do it.
This book aims to provide you, the reader, with the common theme and framework that I initially lacked in my training. It includes many practical tips that can make your daily work as a clinician easier. I also hope to fill as many gaps in your knowledge of anatomy and physiology as possible, enabling you to work effectively with manual therapy. This book is the first in an upcoming series, with the following books including treatment techniques. This book consists of three main parts:
1. At the clinic
Part one contains clinical reasoning, along with an analysis of the scientific basis, or lack thereof, for various treatment methods and diagnoses. Each chapter lesson begins with a personal reflection aimed at highlighting the significance of the subject, which is then followed by facts and references. This section is well supplied with facts and references.
2. Anatomy and physiology
Part two contains “mini-lessons” on various topics within anatomy and physiology. Each lesson also begins with personal reflections aimed at highlighting the clinical significance of the subject, followed by facts and references. This section can be conveniently used as a reference guide.
3. Quick reference guide to 30 years of clinical experience
Part three serves as a quick reference guide for clinicians, providing insights on what to consider when a patient
presents with pain or dysfunction in a specific part of the body. This section is based on my more than 30 years of experience as a clinician and aims to offer a starting point for treatment, helping to reduce the uncertainty in the question “what should I do now?”
I also want to make you think twice and often ask the question “why?”
• Why does it hurt?
• Why do you examine and treat in the order you do?
• Why do you do what you do?
• Why are you doing a test—will it affect how you progress? If not, why are you doing it?
• Is there a risk that the test will provoke the patient’s symptoms? If so, is it worth doing the test?
• Can I relieve the pain instead of provoking it?
“We cannot solve problems by using the same kind of thinking we used when we created them.”
–
Albert Einstein
1 At the clinic
WHAT IS SCIENCE AND PROVEN EXPERIENCE?
In Sweden, we are required to base our work on science and proven experience. Although there is no formal written definition of “proven experience,” even at the National Board of Health and Welfare, it is generally understood to refer to methods that have been used extensively and successfully over time by a broad range of practitioners.
In the preparatory work for the Act on the Obligations of Health Care Personnel, which preceded the Patient Safety Act and the Patient Act, the following quote is found:
“… extensive clinical experience /can/ be the dominant basis for the acceptance of a treatment method, while the theoretical and/or experimental scientific evidence for its effectiveness may be limited.”
In manual therapy, the terms “manipulation” and “adjustment” are used with the same meaning. In this text, the term “adjustment” is used. Adjustment techniques have been used for over 100 years and are still practiced by thousands of practitioners. They fall well within the realm of proven experience. The knowledge has been disseminated through films, books, and other media, and experience has accumulated from many practitioners over a long period.
This process helps to filter out random observations and coincidences.
The requirement to follow both science and proven experience ensures that valuable accumulated knowledge is preserved and that we avoid constantly reinventing the wheel. Continued research on the underlying mechanisms is essential to deepen our understanding and refine these methods.
CLINICAL REASONING
The biopsychosocial model is a framework for understanding health and illness that integrates biological, psychological, and social factors. It emphasizes the complex interplay among these domains. Recently, there has been significant focus on psychological and social factors, which sometimes leads to the neglect of biological aspects.
It is important to remember that there are also intricate interactions among different parts of the body, highlighting the need to view the body as a cohesive whole. Recognizing this complexity ensures a more comprehensive approach to health and treatment.
While we excel at analyzing and breaking down issues into smaller parts, we frequently overlook the importance of synthesis—reassembling these parts to understand and address the whole picture.
It is also essential to explore research that supports our methods, rather than solely seeking studies that challenge our practices. This balanced approach can lead to more-constructive recommendations for improving our work, rather than merely criticizing existing methods.
Are we addressing symptoms alone, or are we investigating the root cause of the problem? This is similar to the difference between inflating a tire to temporarily fix it versus repairing the puncture itself, or retreading only part of the tire instead of addressing a problem with the front axle.
Tissue-based diagnostics often lack precision (Hancock 2007). The location and distribution of pain alone are not reliable indicators for identifying the primary source of the discomfort. This underscores the importance of adopting an examination and treatment methodology that emphasizes functional assessment, rather than a purely structural approach (McGill 2002).
Many people seek treatment for pain and joint problems. When a patient describes various symptoms, as a practitioner, you should begin by trying to understand where the pain is coming from, so you can provide the right treatment.
In this handbook, David Felhendler shares an evidence-based methodology that simplifies everyday practice for clinicians. With a focus on clinical reasoning, neuroanatomy, and neurophysiology, he offers practical tools and insights for identifying and treating the root causes of problems, rather than just the symptoms. Through concrete examples and reflections, clinicians are guided to make rational and well-informed decisions. With over 30 years of experience as a physiotherapist and private practitioner, this is an invaluable resource for physiotherapists, naprapaths, chiropractors, doctors, students — and anyone with an interest in manual therapy and clinical neuroanatomy.
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