Third time lucky – the first two attempts to launch the course in research methodology for assessing the quality of manual test procedures failed to attract the interest of enough musculoskeletal practitioners. But as a joint venture between British Institute of Musculoskeletal Medicine (BIMM), International Academy of Manual/Musculoskeletal Medicine (IAMMM), and the British School of Osteopathy it was possible to run a full course of 20 participants. It was a truly interprofessional and international course with delegates from as far as New Zealand, Japan, France, and Norway.
The course helped the participants to deal with the methodological challenges of exploring the tools used in daily musculoskeletal practice. All the phases of a research project which can be run in low-tech, low-funding environments were visited: the logbook as hub of the project, the agreement phase, the test phase, the publication phase. Abduction of the shoulder served as a practical task for the group to exemplify the challenges of the methodology. Two experienced musculoskeletal educators as observers writing down their assessment of this basic test – this should not be a problem? However, the first phase of running the test and interpreting the test result yielded a rate of only 40% interrater agreement. Attention to detail, to the hand position, to the instructions of the interpretation, to what is called ‘positive’ or ‘negative’, to the underlying hypothesis and the minutiae of the procedure were the topics of further exploration. This was underpinned by the statistical steps of establishing the prevalence of the condition, which in this case is not a disease or a painful state; it is the distribution of observations in the test sample. The observations needed to be dichotomized for the sake of the statistical procedure. We created contingency tables for the observation results. We discussed the agreements for classification for kappa-values and agreement between observers. The difference between acceptance levels in the field of mental health sciences such as psychology and psychiatry and the medical field generated curious interest.
Where is the link between reproducibility studies and validity studies? How do we need to set up research to accept or reject a test? How can we prove the value of segmental mobility testing? How can we prove the effect of manual interventions on tissues in the region where we believe a mechanical effect takes place? These were the questions explored in practical work in the afternoon. Jacob Patijn shared his experience of years in musculoskeletal method research with the audience. A piece of work looking at tests used to detect hypomobility of the SI joint was his starting point. This work could not prove high correlations between the tests and also the three observers. ‘One observer got depressed, one became insecure, one became enthusiastic – guess who am I?’
The participants became temporary passengers in this journey of enthusiastic research into the mundane details of musculoskeletal practice: size matters, for example, the size of the hands of the observers, may it be a size 6 or size 8.5 hand. Position matters. Force matters. Everything matters.
The course was an encounter between an experienced enthusiastic researcher in the field of musculoskeletal test methodology and a heterogeneous group of interested practitioners. Where does the knowledge gained in this encounter, where do the skills gathered on this day, where do conversations with fellow practitioners from all over the world change daily practice?
The background of the day was our wish to make sense of the observed and perceived effects of our therapies. How tissue specific are the interventions, can they reduce peripheral nociception? What are we doing? How do we think about what we are doing? How do our beliefs and models influence – or cloud? – our judgements?
Such questions formed the background of the day. Looking at the link between the hands and the practical questions of the physical interactions between caregiver and patient was the foreground of the day.
The journey goes on….