Manual medicine and the manual doctor

Manual medicine is originally aimed at examination and treatment of joints. And especially when it comes to looking for the optimal movement. The roots are in osteopathy and chiropractic, the development of which started in America at the end of the 18th century. In Europe, development only started after World War II when osteopaths and chiropractors settled here in because of the American army. The techniques were picked up by doctors and changed at critical points. What also changed was the open gaze to other methods and the incorporation (of parts) of this in manual medicine with sufficient substantiation.

The Netherlands lagged behind the rest of the world. It was not until 1967 that the Manual Medicine Foundation (SMG) was founded by Dr. ir. Ir. F.J. Philips († 2006), you know about the light bulbs, and was structurally working on building a training and an outpatient clinic. This outpatient clinic no longer exists. The position has been taken over by various other clinics in the country. Initially, doctors (manual medicine) and physiotherapists (manual therapy) were trained together. In 1986, the program divided into one for doctors in Eindhoven (SMG), and one in Amersfoort for physiotherapists (SOMT).

What is manual medicine

It is a comprehensive system of examination and treatment of musculoskeletal complaints. Initially focused on improving the movement function of joints. Soon the field was extended to muscles, tendons, nervous system because it was realized that a joint does not stand alone, but is embedded in various other structures. In fact, one region (eg hip) depends on the function of other regions (eg low back and knee). These posture and movement chains explain why a disorder in one area can give complaints in another area.

Due to the open character of manual medicine, we also looked at adaptable elements from other schools and techniques. A good example is the philosophy of Mechanical Diagnosis and Therapy, also known as McKenzie method. Under certain circumstances, people with (inter alia) low back pain can be helped quickly. More examples can be found in the Blog Musculoskeletal Medicine - Methods. It depends on the interest of the physician in manual medicine in which methods he/she has received extra training.

Examination

Only with good examination can a diagnosis be made and thus an effective treatment. That is the general statement of practice. For this it is necessary to have a good conversation with the patient: what is going on, when and why, what factors influence the complaint, and so on. With most patients it becomes clear what is wrong. This is followed by an extensive physical examination. On the one hand to test the ideas of the conversation, on the other hand to identify additional problems. In the physical examination attention is paid to posture, mobility in general and joints specific, strength, stability, interplay of muscles, and if applicable an extra neurological and orthopedic examination is performed. Research into the position of joints is also included, although this is less extensive than in orthomanipulation.

Therapy

Manual medicine has different options to treat. It depends a lot on the problem of the patient, the possibilities of the doctor manual medicine (what is he/she good at), but also the wishes and preferences of the patient (for example: I do not want manipulations) how the treatment will go.

1- Perhaps the most important thing about the consultation is information and advice. What is going on, what is good, and what solutions are there. In this way the problem is framed, the patient gets insight and a little control back. For some patients this is already half the improvement.

2- Exercises have a number of advantages: the patient regains responsibility, is activated, is inexpensive and is more likely to have a lasting effect.

3- Mobilizing is an exercise with the help of the doctor to improve mobility. It is a gentle and quiet technique without heavily burdening structures. The mobilization often turns into an exercise at home to maintain and improve the effect.

4- Manipulating is a method to treat the last piece of limitation in the mobility of a joint. It is therefore often not necessary, because with exercises and mobilization this can already be achieved. In manipulating, the patient is sittin or lying in a certain position. The doctor embraces the joint with the restriction and performs a quick, short movement. Sometimes you can hear a crack at the same time, but that is not necessary for the effect. In experienced hands it is a safe technique (contrary to what is often claimed in the media).

Example manipulation of the low back

Development

Manual medicine is constantly being adjusted on the basis of scientific research. Sometimes a technique is abandoned because there is not enough evidence for it or because of changing insights (reliability of research or effectiveness of treatment) and sometimes something is added (a new test or exercise). It is a profession in motion, literally and figuratively! Gradually, the term 'manual medicine' no longer covers the charge and we now speak of 'musculoskeletal medicine'. Opinions differ what it exactly means. In the narrow sense there is everything that has proven itself (scientifically) as reliable and effective. In a broad sense there is also something that is not (yet) sufficiently researched but is already being applied. What is proven to be unreliable and ineffective, or even harmful, is certainly not covered.

The manual doctor

The manual doctor is a doctor specially trained in manual medicine. His task is to recognize the disorders in the musculoskeletal system and to solve them with the technique that makes the chances of success the greatest. Every manual doctor will also have his/her preferences. The choice of method will also depend on the preferences of the patient.

References
Greenman PE. Principles of manual medicine. Lippincott Williams & Wilkins, 3rd ed, 2003.
Hutson M, Ellis R. Textbook of musculoskeletal medicine. 2nd ed, Oxford University Press, 2015.
Lewit K. Manipulative therapy. Churchill Livingstone, 2010.

Jorritsma W et al. Beroepsprofiel Arts Musculoskeletale Geneeskunde. Dutch Society of Musculoskeletal Medicine 2016.