Manual medicine: Out of touch with contemporary medicine?

Abstract

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 awhole. Someaspects of hismanagement 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 evidencebased 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 Correspondence to: Jens Foell, Blizard Institute, Centre for Primary Care and Public Health, Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Yvonne Carter Building, 58 Turner Street, London E12AT, UK. Email: j.foell@qmul.ac.uk