An exploration of Manual Medicine – the forgotten speciality

A guide to a career in manual medicine - an opportunity to nurture, expand and enrich your professional life

Are you tired of protocol-driven medicine, the lack of creativity in clinical practice and the absence of treatment options for patients that do not fit in a particular box or algorithm? This is where I was at after trying various specialities, including surgery, pharmaceutical medicine and general practice. Then I discovered manual medicine and my career took an unexpected turn for the better.

If you share these feelings of frustration, regardless of your speciality or stage of training, then you should really consider manual medicine to nurture, expand and enrich your professional life.

What is manual medicine?

Manual medicine is sometimes referred to as physical medicine, and is the practice of providing hands-on treatment to patients. Its applications are wide and diverse. In fact, although its main strength is in treating musculoskeletal (MSK) problems within the locomotor system. It is frequently applied to chronic physical aches, postural problems, functional visceral pains (e.g. IBS), and mental health, particularly stress, anxiety and insomnia. 

It is not a glorified form of “massage”, but a medical practice founded on a solid understanding of anatomy, biomechanics, pain physiology and psychology. The applications of manual medicine therefore span different specialities and settings, and it is relevant to areas such as:

  • MSK medicine
  • Pain medicine
  • Rheumatology
  • Trauma & Orthopaedics
  • Rehabilitation Medicine
  • Sport Medicine
  • Functional and Integrative Medicine
  • Lifestyle Medicine

Why should you consider a career in manual medicine?   

If you are bored by the lack of creativity in the practice of modern medicine, or disillusioned by the drive toward super-specialism and holistic practice in name only, then you must at least consider manual medicine.

First of all, it gives you the unique opportunity to add a truly practical aspect to your clinical work. In fact, except for surgeons and anaesthetists, most doctors use their hands only during brief patient examinations. The lack of practical work is often a source of frustration.

However, there is so much more scope for practical hands-on work for all doctors. Although manual medicine won’t turn you into a “healer”, it will help you and your hands develop manual literacy, which is the skill to assess and treat patients using your hands, adding a new and exciting dimension to your work.

Discovering this untapped resource within your hands, together with your medical knowledge, gives you a new freedom to practice holistically. This is similar to the freedom that learning a new language gives you to explore a foreign country. The additional ability to examine and treat with your hands really helps you better understand the patient’s problem and develop a stronger therapeutic relationship.

In addition, the opportunity to deliver treatment with immediate effects is immensely satisfying, in a way that is unmatched by a drug prescription, an exercise leaflet or a referral to physiotherapy.  

What treatments can manual practitioners provide?

The exciting thing about manual medicine is the variety of treatment techniques that are available. This allows practitioners to tailor treatment to the patient’s needs, often as part of an integrative multi-pronged approach that spans physical, psychosocial and functional spheres. Treatments like joint manipulations, sometimes unfairly called “cracking a joint”, require elements of manual dexterity which makes the practice equally challenging and satisfying.

Techniques that a manual medicine practitioner is able to perform include:

  • Myofascial release
  • High Velocity Low Amplitude (HVLA) joint manipulation
  • Positional release of tender points (Strain/Counterstrain technique)
  • Joint articulation and traction
  • Visceral techniques
  • Craniosacral techniques
  • Exercise prescription
  • Ergonomic and occupational advice

How do I train in manual medicine?

In many western countries manual medicine is a recognised medical speciality, sometimes called “physiatry” or “physical & rehabilitation medicine”. However in the UK it is most often practiced by osteopaths.

European Scientific Society of Manual Medicine (ESSOMM)

The ESSOMM has written the training curriculum for manual medicine and is in the process of having this framework recognised at European level. This will ensure manual medicine is a recognised medical subspeciality by regulatory bodies like the GMC.

However, there are already unique opportunities for UK doctors to train in this field, gain an additional professional qualification and expand their scope of practice. 

London College of Osteopathic Medicine (LCOM)

The LCOM is the oldest osteopathic school in the UK, and was established by a group of American osteopaths in 1937. It is uniquely and solely dedicated to train medical doctors in osteopathy.

The course lasts 18 months on a part-time basis, allowing students to continue their medical practice at the same time. After completing the exit exams, graduates become members of the college (MLCOM) and medical osteopaths. In addition, this professional qualification gives graduates the right to register with General Osteopathic Council (GOsC), the body regulating osteopaths in the UK. 

What are the job opportunities?

Completing the LCOM course allows doctors to practice manual medicine with patients in both NHS and private settings. The qualification also meets the requirements to become recognised by medical indemnity insurers.

As a dually qualified doctor and manual medicine practitioner, you are able to apply your skills in different settings and pursue an alternative medical career.   

Special interest in MSK medicine

The training in manual medicine and osteopathy gives you an enhanced understanding of the MSK and locomotor system. This allows you to diagnose and treat a wide variety of MSK conditions safely and effectively, often without resorting to traditional approaches such as analgesia and injections. This places you in a unique position to work in and lead MSK services, both in primary and secondary care, for example as a GPwER.

Private practice

The dual professional registration as both doctor and osteopath sets you apart from other mainstream medical practitioners and forms a basis to develop a successful independent manual medicine practice. Manual medicine lends itself to an integrated treatment approach. It combines well with complementary medicine areas such as acupuncture, herbal medicine, functional medicine and lifestyle interventions.

Sport Medicine

The medical management of elite and professional athletes is led in a multidisciplinary team, with osteopaths and manual medicine practitioners often playing an integral role in injury rehabilitation. Doctors with expertise in MSK medicine and manual medicine can be an asset to professional sport teams, providing the opportunity to work in football, rugby and other disciplines.

In addition, the MSK and exercise medicine skills gained during manual medicine training, puts you in a prime position to successfully sit the Faculty of Sport & Exercise Medicine membership exam (MFSEM) with the Royal College of Surgeons of Edinburgh.      

 Lifestyle Medicine

The management of chronic and complex conditions warrants an integrated treatment approach. Manual medicine practitioners are trained and versed in holistic care. An enhanced understanding of anatomy, biomechanics and pain physiology is prime position to deliver functional interventions that complements well with lifestyle medicine principles.

Teaching

With MSK conditions comprising 20-30% of GP consultations, there is ample scope to provide and develop MSK medicine teaching resources for doctors across specialities. In addition to manual medicine techniques, the LCOM training confers an in-depth understanding of MSK anatomy, examination skills, ergonomics and exercise prescription. This knowledge provides the unique opportunity to develop courses, teaching material and CPD activities for those attracted to medical education.

Service Development

For those who are inclined toward service management, there is scope to develop novel MSK services that include manual medicine. The Royal London Hospital for Integrated Medicine (RLHIM) recently expanded their MSK & Manual Medicine Department, appointing the first dually qualified osteopath and Sport Medicine consultant.

In addition, Health Education England (HEE) recently published a new framework to increase the number of healthcare professionals with an interest in MSK medicine, including osteopaths. This helps to provide opportunities for entrepreneurial doctors to develop MSK and manual medicine services with CCGs and STPs.

My Experience

Whilst training in general practice and sport & exercise medicine, I became more and more frustrated by the poor teaching of MSK medicine. As well as the unsatisfactory clinical outcomes of patients referred to MSK or pain clinics. I felt I had not only a superficial understanding of the patient’s problem, but also an inability to provide meaningful treatment.

This led me to explore additional sources of training and inspiration, eventually coming across the London College of Osteopathic Medicine (LCOM). I completed its training programme, which exponentially improved my skills in managing patients with MSK problems. As well as instilled a practical element of fun in my practice that was previously lacking.  

Adding manual medicine to my clinical work has enriched my professional life. I have been more effective in my sport medicine roles, improving my ability to contribute to the rehabilitation of athletes and opening the door for more opportunities in elite sport.

I have also taught fellow doctors about manual medicine and developed an interest in back pain. This has allowed me to work at the Royal London Hospital for Integrated Medicine (RLHIM) and be appointed at its first consultant to lead the MSK and manual medicine department.

How do I find out more about a career in manual medicine?

Check out the following sources for more information on manual medicine:

  • LCOM – The London College of Osteopathic Medicine is the only UK institution dedicated to training medical doctors in osteopathy. The course is part-time over 18 months, with 2 days a week (Friday and Saturday). The only other route to qualify in osteopathy is completing a 4-year full-time undergraduate course at a recognised institution.
  • GOsC – The General Osteopathic Council is the GMC-equivalent for osteopaths, regulating the registration, appraisal and practice standards of UK osteopaths. 
  • ESSOMM – The European Scientific Society of Manual Medicine is tasked with the advancement of manual medicine as an independent speciality. It is currently developing the Europe-wide manual medicine training curriculum to establish it as a recognised sub-speciality. The society holds two regular conferences, in Rome in June and Lech (Austria) in December. 
  • RLHIM – The Royal London Hospital for Integrated Medicine is part of University College London Hospitals NHS Trust. It has the only Musculoskeletal and Manual Medicine Department providing NHS services in the UK. The team comprises doctors, osteopaths, psychologists, physiotherapists and naturopaths. Teaching or observership placements are available through its academic office.

Conclusions

Manual Medicine is an exciting and diverse field of medicine, providing the opportunity to practice physical treatments and enhance patient care with a holistic and integrated approach.

The training options in the UK involve an 18-month part-time course leading to dual qualification as a medical osteopath. The training lends itself to doctors interested in expanding their scope of practice and seeking opportunities in private practice, sport medicine, MSK medicine and complementary therapies. 

Keep an eye on our career guides section for a guide to Sports Medicine keeping soon!

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Matteo Bernardotto

Dr Matteo Bernardotto is a consultant in Sport & Musculoskeletal Medicine at the Royal London Hospital for Integrated Medicine (RLHIM), as well as a fully qualified GP and osteopath. He completed the LCOM course in 2019 and integrates osteopathy and manual medicine in his clinical practice. He is also the lead academy doctor at Fulham FC and medical officer for England & GB Boxing.

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