Out of touch with the contemporary landscape of healthcare? Is manual medicine an activity of ‘grumpy old men’? And how can this branch of medical practice adapt to changing healthcare arenas? One speaker at the International Academy of Manual/Musculoskeletal Medicine meeting at Bratislava, 2012, suggested that the difference between manual medicine and manual therapy was the number of treatments – one or two in the former, unlimited in the latter; and that this was enabled by the holistic approach in the former, together with an understanding of psychosocial issues and co-morbidities. But if the former has usually less time in consultation, and much of the ‘extras’ can be covered by advanced training, we question why some consider that one approach is specific to one health discipline.
Theme of the first session was manual therapy in infants. The spectrum of treated disorders changed from torticollis to feeding and behavioural problems. The speaker, Heiner Biedermann, theorized that functional disturbances of the atlanto-occipital region associated with birth trauma generate a nociceptive barrage which affects feeding and makes the infant irritable as a whole. Some aspects of his management generated controversy, for example, routine use of X-rays in infants. Other aspects are linked to the activity of manual therapists: it is impossible to unpick in a complex intervention what the active treatment components are and how they interact. What one believes the dominant method of action is, may not be what actually works.
These uncertainties, the tension between externally validated knowledge and how knowledge is locally enacted, remained a theme throughout the conference. As much as musculoskeletal medicine strives to position itself in the positivist paradigm of evidence-based medicine it also is clear that there are phenomena which remain unexplained and possibly difficult to pinpoint, measure, and control. Aristotle's distinction between craftsmanship, theoretical skills, and applied wisdom provided a framework to compartmentalize what therapists do and how it gets taught. It is about distinguishing subtle differences in tissue texture. How reproducible is this?
This is one of the core questions of hands-on medicine. How can it be measured? And do skilled practitioners agree on their observations? One experiment consisted of comparing palpation of the painful side in a blinded situation. Two experienced therapists in France compared their accuracy in detecting the painful side in patients who complained of unilateral neck pain and back pain. The sad outcome was that there was very little accuracy in detecting the ‘correct’ side. The success rate ranged between 53 and 70% and none of the therapists was happy with the results. Is this something one should expect, as individuals differ in their judgment? Is this something to expect because a dialogue is needed to negotiate differing sources of information? A group in Germany used different textures of pads, hidden under a surface, to test accuracy in detecting the orientation of the hidden but palpable lines. It emerged that this task can be trained and also that there was not much difference between the teachers and disciples in the school of touch. An American group obtained a lot of funding from the Veterans Administration agency, aimed at improving the traumatized brains of war veterans who were exposed to physical and emotional trauma. So they could buy some gadgets to measure forces acting on soft tissues: no, not the initial forces resulting in tissue trauma, the therapeutic physical forces acting on the body of the traumatized veteran. This group of osteopaths theorizes that interventions aimed at improving cerebrospinal fluid flow may improve cerebral function and as a result the lives of veterans. And they set out to measure contact forces between their manipulating hands and the head of the patient using gloves with pressure-sensors. Afterwards they apply a prong equipped with pressure sensors to the tissues of the neck to measure the viscoelastic properties of the tissues.
This knowledge of manipulating tissues and the associated issues can be externally implemented. More often it is transferred, like the legends bards used to tell from person to person, as oral history – or in the way of manual medicine as apprenticeship and haptic history. Dr. MacDonald showed how this handed-down craft can actually be tested in the experimental format of a randomized controlled trial. ‘CARL is born’ stood for the trial exploring positional release using some specific points in the groin as a treatment for restless leg syndrome. In other words, for the treatment of a movement disorder (clearly thought to be a central process) by manipulating peripheral afferent information.
Several talks highlighted the importance of context – the context in which therapies take place, the context in which knowledge gets generated, the contextual effects which may also be called ‘nonspecific’ or ‘placebo’. Angela Clough explored how apparently the same injury – cervical spine acceleration/deceleration injury – is managed differently, depending on whether the causal mechanism was a road traffic accident or a sports injury, also depending on the setting in which the therapy takes place (private practice, sports infrastructure, National Heath Service primary or secondary care). It was one of the first examples showing how qualitative research adds useful information about the interaction between the social environment of the therapists and the studied condition.
There were also plenty of practical tips, ready to be used the next time a patient will be seen. Listening to the way people are walking may be an easy way to help: a heavy gait, lots of noise in the heel-on phase of the gait cycle indicates problems with the lower limb and also trunk anteflexion. Learning to walk ‘light’ will be then the self-management of dysfunctions in motor patterns and kinematic chains. The cervical spine rotation side-bending test may be specific in diagnosing first rib dysfunction and thoracic outlet syndrome. And very simple automobilization manoeuvres of scalenus medius and scalenus anticus, using rhythmic repetitive isometric contractions, may improve the situation. No rocket science, but some commonly overlooked items which came up during the conference were: (a) when you treat a child in pain you have to deal intensively with the caregiver; (b) the cross-legged slump test picks up central disc prolapses and indeed the cauda equina gets displaced by several millimetres in straight leg raises.
The gathering took place in a collaborative, cooperative atmosphere. The conversations showed both a dedication to use scientific methods to study what manual therapy as craftsmanship can do and an awareness of what also takes place in these hands-on encounters, but remains lost in translation, if it comes to words only. And back to the beginning, how can this business and its grumpy old men attract young practitioners, who grow up in the world of medicine as a sequence of investigations, prescriptions, referrals? An epiphany was suggested, possibly as the first person experience of being therapeutically touched.