We are dedicating this issue of the journal to the life and work of Professor Karel Lewit, whose international recognition in the discipline of Manual Medicine and generosity to the physiotherapists, osteopaths, doctors, and chiropractors who were inspired by him is testament to his remarkable intellect, capabilities, and attention to the needs of all who met him, patients and clinicians. He was always supportive of the International Musculoskeletal Medicine, and the underlying principles of international cooperation, collaboration, and implementation of scientific evidence into clinical practice. Manual/Musculoskeletal medical practice has benefited enormously from his dedication to basic concepts and manual diagnostic and therapeutic techniques that he described and demonstrated so well. He will of course be sadly missed.
This editorial is based on a presentation made by Professor Lewit in England some years ago. The exact location and date are not of relevance as the message is timeless. The slide texts used by Professor Lewit are followed by my commentary.
Lewit: The examination and assessment of dysfunction of the motor system, by far the most frequent cause of so-called non-specific pain, cannot yet be done by apparatus, but only by those most sophisticated instruments, the human hands and eyes, and a little thought.
Comment: The haptic experiences (for both doctor and patient) remain the core component of diagnosis in manual medicine, though exposure to palpatory techniques and cognitive responses to those techniques during medical training is extremely variable and often poor.
Lewit: The problem of doctors. The modern Universities, proud of their scientific advance, impress their students with the latest achievements in genetics, molecular chemistry, and by the technical inventions. The student is crammed with theory, with technicalities, but lacks clinical experience.
Comment: The technological revolution of recent years, particularly the emergence of imaging/scanning for soft tissue disorders is a potential and actual deterrent to the achievement of a high standard of manual diagnostics.
Lewit: Only when he leaves hospital work does he realize standing on his own, that he has not been taught how to deal with the most common ailments, in particular with the ever increasing number of patients with ‘non-specific pain of the motor system’. He was never taught proper physical examination including palpation, or how to take a specific anamnesis, let alone how to think in terms of function.
Comment: The conceptual basis of soft tissue dysfunction and ‘non-specific’ pain must be learned in combination with relevant examination techniques and exposure to patients as early as possible during training.
Lewit: Many doctors then use manipulation only occasionally, using acupuncture, many types of physical therapy, applying it all mainly where the patient feels pain. Having reached a certain age, before getting involved in manual medicine, a few weekly or weekend courses are not enough to teach really good and gentle techniques, and to sense release.
Comment: True understanding and recognition of tension within the locomotor system cannot be developed by doctors if their hands-on experience is limited to examination and treating patients when they are in pain. Tension and release of tension cannot be learned overnight.
Lewit: On the other hand, the doctors are frequently crammed with subjects, they should have learned as students or in the course of specialization, but are taught far too little to think in terms of function, i.e. to understand the motor system as a whole and function as a program. When confronted with a trained therapist, whose main job is to apply his hands in a gentle way, he must be impressed.
Comment: Functional disorders of the locomotor system are the most common cause of pain. Its relationship to patho-morphology when relevant, are poorly understood by the doctor who has been exposed only to the biomedical model.
Lewit: The sad result is an ever-decreasing amount of creative scientific work by doctors in the field of musculoskeletal medicine, and their still negligible influence in universities. Doctors alone will never meet the enormous demand for properly administered musculoskeletal medicine.
Comment: Scientific work must be undertaken by all professionals who engage in manual medicine/manual therapy practice including physiotherapists, osteopaths, chiropractors, and doctors.