The current state of musculoskeletal medicine

Musculoskeletal medicine, as practised by dedicated musculoskeletal physicians, provides an opportunity for translating conceptual beliefs into medical practice. Given the current level of angst regarding the National Health System (NHS) in the UK, it also offers me the opportunity for reflection.

I would initially like to review some aspects of the evidence for our practice. How did we obtain and how do we continue to obtain evidence? Do we believe that evidence-based medicine, as it has been understood since its formal inception, still works for us?¹ Despite the plethora of published scientific evidence and guidelines over the last 20 years, it is tempting and possibly true to state that the ‘evidence’ that we hold dear to us and use consistently in our medical practice comes primarily from those teachers with whom we had our first contact. There are still diverse beliefs, even a sectarian divide, among the musculoskeletal/manual medicine community. Within that community, decades ago, James Cyriax had (and indeed continues to have) many advocates. I have often used the term ‘structuralism’ to describe his approach, based on patho-anatomy and a beautifully devised examination system. ‘Across the divide’ is the traditional osteopathic approach (which Cyriax so despised) that is centred on somatic dysfunction, with its more subtle manual diagnostic findings, which can also be appealing too. Polarization of approaches to health issues have been present since the days of Asclepius (God of Medicine) and his daughter Hygiea (Goddess of Health) in Ancient Greece, though it is gratifying that in musculoskeletal medical practice in the UK over the more recent decades during which Still, Cyriax, and Lewit have been pre-eminent, there has developed a realization that we can live together, learn from each other, and practise the medical creed in which we have most belief, while acknowledging and implementing beliefs from ‘the other side’.

The international situation, particularly in Europe, with respect to musculoskeletal/manual medicine is much the same. Followers of gurus throughout Europe created sects, to the extent that in some countries opinions have been very much divided as to the direction that manual medicine should take, based on their initial teaching. However, this appears to have gradually changed, leading to combined efforts being made to establish an accepted subspecialty of manual medicine within the European Union of Medical Specialists (UEMS). In the UK, 1991 was a momentous year when the Institute of Orthopaedic Medicine (based on the Cyriax approach) held talks with the British Association of Manipulative Medicine, which was based on a pragmatic approach, and the London College of Osteopathic Medicine, based on traditional osteopathic concepts, and agreed to form British Institute of musculoskeletal medicine (BIMM), in which there would be full recognition of and acceptance of underlying concepts as described. BIMM has continued to promote this eclectic system ever since.

But what about evidence, which on a personal basis, tends strongly to be influenced by our formative years in which we become convinced of ‘truth’ and systems that make most sense to us? My personal career may illustrate the situation well. Having been a dedicated Cyriax disciple in my early years of medical practice, I became exposed to and used manual techniques associated with international osteopathic and manual medicine concepts, notably from the USA and from the Czech Republic. My mind broadened, and I believe that I have expanded my understanding of functional musculoskeletal problems considerably and am a better doctor for it. However, it is unwise to anticipate that one viewpoint or one sect will always be in the ascendency. The world does not work that way. There will always be clinicians practising musculoskeletal medicine whose views will differ conceptually from others, exemplified particularly by the difference in emphasis between those adhering strongly to structural pathology and those who accept the dysfunctional concept. In the UK, the GPWSI (general practitioner with special interest in musculoskeletal medicine) is in an advantageous position to engage in a truly holistic approach to patients with musculoskeletal disorders, based on an understanding of the psychosocial framework in which the patient's symptoms are situated. Time restriction is of course the perennial problem. Musculoskeletal physicians holding specialist posts, within the NHS or independent practice, are in a better position to hone their examination and therapeutic skills. That specialist group includes musculoskeletal physicians with an interventionist bent for injections, guided or otherwise.

An understanding of the drivers of pain, its chronicity and disability, and the adverse effects on the coping mechanisms of patients are such important concepts. As a consequence, my belief is that in the twenty-first century, behavioural psychology is an essential sub-discipline within musculoskeletal medicine with respect to an understanding of somatic symptoms. Perhaps social determinants of pain have always been with us, though periods of austerity, particularly combined with a change of cultural attitudes and public dissatisfaction with life (as recently), reveal a fascinating subculture of compensation and dependency. Are the musculoskeletal conditions with which we are confronted changing over time? Are our attitudes changing? Is evidence changing with increased recognition of the profound difficulties with bias in research? Is there a general recognition that scientific truths are contemporary, cultural, and contextual? Will our practice be the same in 20 years time? Will we become more conversant (as we should) with the interaction between functional pathology and the patho-morphological view of medicine?