Australia Papers - Part 1
Abstract. I refer to “ankle injury” in this discussion paper, yet many of my thoughts on this topic could apply to injuries of several other skeletal joints; I was prompted to send these thoughts because of the arrival of a young woman with an ankle injury – a regular client of mine, who also happens to be a fiercely competitive dancer, so joint injuries, for her, are not rare.
As I often do, I need to commence with the warning: I do not propose to give a lecture about the nature of injuries, how to diagnose, how to treat, or what to expect; most of you are more proficient than I – I simply want to put my thoughts to paper, to add to the mix that you have already prepared.
This 20 year-old was taking part in a netball game – if you are not familiar with the term netball, it’s a game similar to basketball, but with the vigour of rugby union, bear wrestling andr Irish hurling - and leapt into the air to catch a thrown ball, and, while in the air, rotated her body so that she was facing the team member she wanted to pass the ball to. When she hit the ground, she landed on the right foot, and the body weight, body rotation, and forward speed all helped to cause ankle failure.
The clinical appointment.
A client – one of your regulars, or a new contact - phones you; “ I have an injury, can you help ?”
How you respond to such a question is part of your clinical philosophy, and your commercial experience; if you are a new graduate, and keen to establish yourself, you might fall over in your eagerness to please, I know I did, all those years ago, or, if you are an experienced therapist, you might be more hesitant to commit yourself.
My approach is: it’s not easy to diagnose such things over the phone, so, provided you can travel to my clinic , and negotiate
the ten stairs down to my treatment room – that’s right, people, ten stairs, and I’m positive it has cost me many clients in the past 40 years, but here I am !! then I’m happy to examine the injury, and if decide not to treat you, I won’t charge you. Then, possum, you’ve got to find your way back up the 10 stairs.
Here is a picture of the woman under discussion; (well, at least a portion of the woman ) Her telephoned description of the event made me think at the time, “ probably an eversion thing…. “
And, here we are, with bruising to the lateral portion of the right foot and lower limb; these photos were taken by the way, within hours of the fall.
So, the obvious evidence is there; swelling and bruising to the lateral portions – I leave it to you to speculate about exactly what tissues have been damaged, and to what extent they have been harmed.
My interest is on three things;
should I apply manual therapy treatment, or send her home for a while ?
bruising means only one thing, evidence of bleeding, new or old, and
oedema, the swelling that accompanies such injuries, is part of a healing system, and, eventually, a deterrent to the healing system.
Early manual treatment can accelerate the bleeding, and late manual intervention can delay the recovery – hmmmmm, what to do, what to do.
This is for you to decide, and to discuss with your colleagues but wait, here’s another complication…..
Here is the same ankle, viewed from the medial side, which shows another bruised site.
This could be simply a migration of blood from the main injury location, but the sensitivity of this area, when probed gently, makes me wonder if .. tell me your thoughts, people.
Education, how we acquire knowledge, and how it is passed on, has fascinated me for many years; I have no formal qualifications as a teacher, yet for more than 20 years I have gained experience, and earned a respectable living, by acting, performing, as a teacher.
Let me explain to you a little part of my life history.
In December 1983, I had just graduated from a college of manual therapy, with a diploma of Remedial massage; my reasons for embarking on such a line of study were vague at that time – but the topic of human anatomy captured my attention from day one, and this interest has remained with me.
One month after my graduation, an old acquaintance contacted me; he explained that he had been appointed as administrator of a Newcastle Community College; it was an old institution that offered training courses for adults in many subjects, at what we might refer to as hobby level. He was quite concerned, because a course in massage had been advertised, and quickly filled to capacity – this good news was rapidly followed by the alternate news that the appointed tutor has left town !!
His question to me was, “since you are trained in massage, would you please come in and teach the thirty or so enrolled students ? I explained that the ink was still quite wet on my diploma, and I was not really ready to become a teacher of the subject.
The size of the predicament he had been left with won the argument, and I commenced teaching that week; here is the main point of my message to you readers: much of our education, maybe even the bulk of our education, does not come from text books or class-rooms. It comes from our application of school and book knowledge in our day-to-day activities.
For me to be able to transfer my new-found knowledge to students. I had to be prepared to answer their questions; to be able to answer their questions, I had to have a good understanding of the topic – a better understanding than I had at the end of my training.
I was terrified, and embarrassed back in those days, but I am extremely grateful for the experience that was thrust upon me; when I began teaching on a more serious level, I would tell the students my story, and impress upon them:
- in many topics, only some of your knowledge will come from books; most of the true learning and education will come from your clients. You listen, you study their ailments, you make an initial diagnosis, to be refined later, perhaps. Now begins a better understanding of, and growth in, the profession.
Approach the leaders of your association, and ask their permission to publish your special clinical experiences; you, and your readers will benefit from this shared knowledge, as I have.
The advance of science.
ABSTRACT. In the early times of manual therapy, indeed, in the early times of all accepted therapies, much reliance was placed on deduction , or ideas, derived from
- the client’s story,
- previous history, and
Other sources of information were available, but the advances of techniques such as radiology, and sonar examination, were some time away, and the skills of deduction, theory development, and trials were much relied upon by the therapist. Some might say that all professions have been able to advance rapidly with the benefits provided by scientific invention, but there is a possibility that, like the maths student who revels in the availability of the electronic calculator, ( yet has lost the skill of mental calculation,) the therapist or the physician who, reliant on the data provided by say, an X-ray film, or a written report from a radiologist, overlooks the information that is available from other, basic sources.
I have no wish to denigrate the advantages of scientific progress – but I regularly see the deterioration of and the downplaying or devaluation of, evaluation by a therapist, based on experience, innate skill, and logic. This is a story based on such circumstances.
Mrs. V. is an 85 year-old, with a 2 year history of lower limb pain, and a steadily developing loss of mobility – not uncommon, you and I would think to ourselves, for someone of such an age. The difference in this story was, this woman had previously had no pain ………….
At her advanced age, visits to a medical practitioner were a commonplace event – not necessarily a daily event, maybe an annual practice. At her next consultation, she described the symptoms:
- pain in the anterior thigh, particularly on waking and rising – not sharp pain, more an ache, making the initial attempts to get out of bed and gain comfortable mobility uncomfortable , and
- combined with this, she felt a similar level of pain in the buttocks, and sometimes this was quite marked, in an area I estimated was the ischeal tuberosity.
The medical practitioner recommended an X-ray examination of the lower spine, maybe suspecting some sciatic nerve impingement source. The results of this exam listed:
- degenerative change with endplate changes suggesting instability, most marked at L3/L4, L2/3, and T12/L1 This is associated with broad based disc bulges and
- canal stenosis most marked at L4/5 and, to a lesser extent, L3/4 and L2/3 disc level, plus
- foraminal narrowing on the right side at L3/4 ……
None of these findings, or opinions, are debateable; the radiologist has a professional and legal duty to report all abnormalities revealed by the photos. What Mrs. V., as the client, and we, the therapists, are entitled to wonder – such abnormalities exist, but are they solely responsible for – or even remotely connected with, the client’s complaints ?
Orthopaedic surgeon #1, on studying the photos, and considering the report, recommended spinal surgery.
Mrs. V. was not convinced, because she reasoned “ ….but I have no back pain..” After consulting the GP again, further X-rays were requested, this time of the knee. Back came the result of “…degeneration of the meniscae…..,and effusion…” , and with it a recommendation by the orthopaedic surgeon #2 to replace the knee joints, at least on one side, with the second to follow shortly after.
The client is, understandably, somewhat confused at this point; two massage treatments of the hips and legs, together with flexion/extension stretches of the hip and knee joints produced a brief improvement in mobility, as well as a change in pain levels. Naturally, an opinion from a surgeon
far outweighs an opinion from a mere massage therapist; many more massage treatments were needed, before a more definite conclusion could be reached, from my point of view.
A date had been set for hospitalization and surgery, and in these days of overcrowded hospitals, this was almost inviting.
This is probably not the first time you have heard a story such as this; I’m not upset at the loss of the client, and I’m not critical of the surgeons, but it illustrates, in a fashion, my concern that:
v if the knee joints are the source of the thigh and buttock discomfort, and therefore, in need of replacement, wouldn’t there be other symptoms ? Once she has reached a level of mobility in the early mornings, she can happily stand, and move around the house in relatively painless comfort, and,
v if the spinal vertebrae and discs have deteriorated to the point where they are responsible for the thigh and buttock pain, and therefore are in need of surgical correction, why is it that the client can perform lumbar flexion and extension movements, ( with certain limitations from her age.) and feel no localized vertebral pain ?
My quiet answer, (only voiced to my readers,) : having been trained in the skills of surgery, maybe there is no need for an understanding in, and of, the basic mechanics of joint function. Maybe I haven’t expressed myself well here, chums – this isn’t jealousy speaking, this is another reminder of how precious those old, (not old-fashioned)- qualities and skills, of manual therapy are seriously under-used, and under-valued.
NEWCASTLE, AUSTRALIA, 2012
Discussions have been taking place this week in Australia about the low standard of education (particularly in the subject of human anatomy), that graduate medical practitioners have received. Some of those interviewed expressed the opinion that they felt inadequately prepared for the task of diagnosing musculo-skeletal disorders – many of those interviewed had received only 50 hours of anatomical tutoring during their training.
My comments, based on my interest in the general topic of education standards, are not intended to denigrate these graduates. Rather, I wish to make the observation that advances in general knowledge come at a price: some subjects need to be deleted from the curriculum, to make way for the new subjects.
In automotive engineering, there is little need for a student mechanic to have a deep knowledge of the function of a carburettor – rather, much more time would be spent these days on the overall understanding and relevance of the on-board computer. The basics of (old-fashioned) fuel injection theory are left to the student with the enthusiasm to enquire further.
In the study of any subject involving mathematical calculations, the development of the electronic calculator has had a serious effect on the ability of the graduate to perform basic mental computations.
In electronics generally, the availability of the computer as a diagnostic tool, means that the detecting of say, an intermittent fault in a car, is beyond the skills of many technicians – if the computer can’t spot the problem, “come back when it re-occurs,” you might be told.
We can survive without these lost skills, and without this knowledge, in most instances; of course, the older members of the population will mourn the loss of some of these abilities, but the young will say – it isn’t important.
In the area of medical science education, we are not necessarily progressing backwards , but we have reached a dramatic point in our journey; students of medical science have to study, and absorb, as well as they can, far more information about pharmaceutical products, and radiological techniques (to name only two items), than they were expected to examine, say, 10 or 15 years ago. Consequently, space has to be provided in the timetable to allow the discussion of these additional important matters – the study of human anatomy, and the form and function of skeletal joints, is one of the casualties of this progress. After all, many of the joints in the skeleton can now be replaced with a prosthesis – and there has to be class-room time to understand this new subject of prosthetics!
I have a special interest in the function and the occasional malfunction, of the shoulder assembly. My studies, and my clinical experience over the past 20 years has indicated that almost 80% of clients visiting my clinic reporting shoulder pain, (who were advised to consider surgical intervention), received complete or near-complete relief from pain with simple manual procedures directed at mobilizing the shoulder assembly. When my animated film dealing with shoulder form and function is shown to medical practitioners, they almost always express surprise….one GP remarked to me, “we weren’t taught those details”…
Nothing will be gained by criticizing medical people for not knowing enough – we have an obligation to inform those interested that there is often an alternative to surgery – consult an informed manual therapist.
A significant point can be made here, of vital interest to manual therapists; if the medical practitioner has moved beyond what was originally thought to be basic anatomical knowledge, who is going to inherit the left-behind cases ? I’m not familiar with the situation in the USA, the UK or elsewhere, but here, in Australia, another group that we call the physiotherapy profession are also on a path of advancement – I repeat, we don’t criticize this progress, but, this progress can help to make our role as manual therapists much clearer, and more relevant.
Let me try to emphasise the point I am making here; the medical scientist has always been expected to understand far more about human functions than is possible. Step-by-step, specialists have been recruited. We have skin, neurological, orthopaedic, gastro, haemo, experts – and, aren’t we usually grateful that such professionals are around when we need them ?
I consider today’s informed, diligent and skilful manual therapist has the opportunity to assume the mantle of musculo-skeletal specialist. Not because we are seeking a grander title, but because we are taking over abandoned territory.
May 21, 2010