Dr Cyriax and Frozen Shoulder
When I was training to be a general practitioner I realized there were many patients suffering from disorders of the moving parts of the body. That is, pain felt in the muscles or joints, such as stiff neck, shoulder pains, backache, sciatica, tennis elbow, etc. Further, it soon became clear to me that the orthodox approach to diagnosis and treatment of these disorders had little to offer. An X-ray of the affected part or a blood tests might be ordered and treatment offered with pills of one sort or another. Or the patient might be referred – after an inevitable delay – for physiotherapy.
I have the greatest respect for physiotherapists, and they do their best for patients who are often sent to them with neither a diagnosis nor a suggested prescription: ‘Re: Mrs X with shoulder pain: please see and treat.’
Then, by chance, I came across Dr James Cyriax. He was an English orthopaedic physician of impeccable medical credentials who had recently retired from his post at St Thomas’s Hospital in south London. He held clinics and ran courses at another hospital for interested doctors and physiotherapists. I enrolled in one of these week-long courses.
It was a revelation. Here at last was a system – based entirely on established principles of applied anatomy and physical examination – whereby one could reach a diagnosis in the majority of patients with aches and pains in the muscles and joints. And having done that, one could treat the part at fault using orthodox, logical, non-surgical methods. These included cortisone (steroid) injections, spinal manipulation and deep friction massage. When these techniques were applied in the correct manner to suitable patients, they resulted in many cases in the rapid relief of symptoms. I learnt as much as I could about this work, sitting in as an observer at his clinics and even for a time working with him in his private practice in Wimpole Street in London’s west end.
In my subsequent career in general practice I found that hardly a day would go by when I didn’t see at least one patient – and often I would see several – with one or more the above-mentioned disorders. And I have continued to this day to use Cyriax’s diagnostic and treatment methods with regularly good results – gratifying for both the patient and doctor.
So why haven’t Cyriax’s methods been widely taken up? He provided the answer, with slight irony, himself: ‘You’re not allowed to cure the patients the wrong way!’ In other words, a prophet is not without honour except in his own country – for his approach has been more recognised in the USA and parts of Europe than in Britain.
Although he had a dedicated following among many general practitioners and physiotherapists, he wasn’t popular with everyone. Maybe he wasn’t the most tactful person, and certainly in his old age he did seem to become slightly paranoid and he quarrelled with some of the doctors who worked with him.
Now what about frozen shoulder? This is a common disorder. For no obvious reason a middle-aged person develops pain and stiffness in one or other shoulder joint. The Japanese call it gojuu kata, fifty (year old) shoulder.
It gradually gets worse over about six months, stays the same for about a year and then slowly recovers. At the height of the disorder the patient is in a miserable state with considerable pain, much restriction of motion at the shoulder and sleep is disturbed. Orthodox treatments – pain-killers and conventional physiotherapy – are largely ineffective, doing no more than temporarily reducing the pain and not hastening recovery.
One of Cyriax’s most important discoveries was that in frozen shoulder, if the joint is injected with cortisone the pain will be rapidly relieved. One injection, however, is not enough; it needs to be repeated at gradually increasing intervals, perhaps half-a-dozen times in all. Is it safe to do this? Of course it must be done for the right reason, with the correct technique and with proper sterile precautions. I have treated hundred of patients with frozen shoulder in this way without any problems.
It’s a sound principle that a doctor shouldn’t do to a patient anything he wouldn’t be prepared to have done to himself. I use the masculine pronoun deliberately here, because the reader may be amused to learn that I have suffered from a frozen shoulder myself. I got my nurse to inject me and was soon cured.
One of Cyriax’s main ambitions was to obtain the widespread recognition of his work that he felt he deserved. To this end he established, with my help, the Institute of Orthopaedic Medicine. However, for various reasons including the fact that I was planning to move to Japan, I resigned from the Institute but it continued under a different name, the Society of Orthopaedic Medicine. Subsequently the name was changed yet again to the Society of Musculoskeletal Medicine (SOMM).
Now I am coming to the point. What is the aim of the SOMM? According to their website it is ‘to develop the seminal work of Dr James Cyriax MRCP and to promote the theory and practice of musculoskeletal medicine.’ And how do they do that? They hold courses, issue diplomas and prizes and hold conferences. This is all well and good. But it is not enough, in my view.
What the SOMM does not do – which it could if it was so minded – is to respond to the nonsense which is published from time to time in mainstream medical journals in the field of orthopaedic medicine.
For example, there was recently an article on the present state of treatment for frozen shoulder published in The British Medical Journal. It is almost a counsel of despair. Cortisone injections are mentioned only to be dismissed as ineffective. I had a letter published about it which interested readers can see: http://www.bmj.com/content/354/bmj.i4162/rr-4
But where, Oh where, was the voice of SOMM? I wrote twice to them asking why they don’t respond to articles of this sort, or, indeed, why they don’t carry out clinical trials of Cyriax’s methods to produce evidence that they work.
And what, do you think, was their response to my letters? Silence.
Cyriax must be turning in his grave.
Text © Gabriel Symonds