380

Journal of the Royal Society of Medicine Volume 85 July 1992

The one-tool technician Musculoskeletal Medicine is not yet accorded universal medical acceptance. It is acknowledged that it exists, it is embraced by the few, distasteful to some, but the majority of the medical profession finds it of little importance. Interest is now awakening, but there is a wide diversity of beliefs within this broad field. This was highlighted in the series of RSM Colloquia on Medicine and Complementary Therapies held between 1984 and 1987 under the guidance of Sir James Watt'. This diversity is international, and it is subject to broad groupings, not infrequently distinguished by a paucity of sound validation. Two examples illustrate this point. First, the use of biomechanical models in no way overcomes the fact that, regardless of the difficulties of clinical measurement, the range of spinal segmental movement is widely and randomly variable2'3; and therefore the clinical identification of the normal range remains out of reach. This renders clinical identification of the abnormal impossible. Such studies must thereby be of limited value. Second, the application of overtly scientific procedures to subjective impressions does not confer the status of truth upon any thesis which may emerge. How the individual interprets what he feels cannot in this way be upgraded to scientific fact; palpation must remain a wholly subjective procedure. This diversity has become polarized in a variety of 'schools', each promoting its particular beliefs. The disparity to be found between them must mean that they cannot all be right! Unravelling these differences is made the more difficult by the common use of 'in-house jargon'. This implies acceptance of the ideas upon which it is founded, (the user at once being branded as a 'believer' in that ideology) and stresses the necessity to appear 'whiter than white' in any bid for acceptance, both in the quality of evidence adduced in support of the arguments put and in the language employed in putting them. It is commonly impossible to reach a firm musculoskeletal diagnosis, but this matters little in respect of choice of management4, although it does make validation and research more difficult5. These are unpalatable propositions - both for the orthodox, who believe that a diagnosis is a mandatory precursor of therapeutic decision, and for those of more sectarian beliefs, who 'know' they have made one. But it is the only logical interpretation of the evidence currently available. It is also impossible to make a sound prognosis in respect of the majority of modes of management4. Review of current teaching reveals examples of unacceptable diagnoses, some resting too heavily upon subject report, well known to be unreliable4, or on subjective clinical impressions of gait, when the phenomenon of muscle substitution

makes this and the clinical testing of individual muscle strength illusory8. Further, in comparison with other widely accepted therapies, manipulation is found to be quite remarkably safe6. The essential mechanism-whereby this therapy works is the inhibitory effect of A-fibre stimulation upon C-fibre activity, and there are several ways in which this may be set in motion7. Of course this is not the whole truth, but it is adequate clinically; and it is scientifically acceptable. Often the patient with a musculoskeletal problem lacks sound guidance; his doctor has commonly received but scant instruction in the -subject, while his neighbours will offer advice based on a varied personal experience of practitioners of a wide range of professional standing. Outside medicine he wiLl be offered a plethora of advice and treatment, much of which may well work (though unpredictably), and he will be confused by the profusion of ideas he will meet; all offered as being the truth. Because valid diagnosis is usually impossible, anyone who offers one is thereby the more likely to be wrong! Because the results of treatment are almost always unpredictable, therapy in this field must be empiricaL The 'one-tool iian' is necessarily at a disadvantage; if his sole treatment does not work, he may be persuaded to continue it in hope, too long. More important, his patient is at the same time denied other treatments that might serve him better. The evidence now exists to permit the medical profession both to adopt manipulation as an orthodox therapy and to teach the elements of musculoskeletal medicine routinely within its ranks. To hand over the patient to a 'one-tool technician' seems a sadly restrictive solution to a widely unrestricted problem.

John K Paterson Les Fitayes, 13640, La Roque D'AnthUron, France

References 1 Watt J, Wood C. Talking Health. London: Royal Society of Medicine Services Ltd, 1988 2 Hlilton RC. Systematic studies of spinal morbidity and Schmorl's nodes. In: Jayson MWV, ed. The lumbar spine and low back pain, 2nd edn. London: Pitman Medical, 1980 3 Moll J, Wright V. Measurement in spinal movement. In: Jayson MWV, ed. The lumbar spine and,low back pain, 2nd edn. London: Pitman Medical, 1980 4 Burn L, Paterson JK. Musculseletal medicine, the spine. Lncaster: Kluwer Academic Publishers, 1990 5 Wyke B. Presentation at 7th Congress of the Federation Internationale de M6dicine Manuelle, Zurich, 1983 6 Paterson JK, Burn L. An introduction to medical manipulation. Lancaster: M1TP Press, 1985 7 Noordenbos W. Prologue. In: Wall PD, Melzack R, eds. Textbook of pain. London: Churchill Livingstone, 1983 8 Basmajian JV, DeLuca CJ. Muscles alive. Baltimore: Williams & Wilkins, 1985

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070380-01/$02.00/0 O 1992 The Royal Society of Medicine

The one-tool technician.

380 Journal of the Royal Society of Medicine Volume 85 July 1992 The one-tool technician Musculoskeletal Medicine is not yet accorded universal medi...
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