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IAMMM Padua November 2016
by Jacob Patijn

As Science Director of the IAMMM, the 8th 2-days Academy Conference, organised in cooperation with the Department of Anatomy of Faculty of Medicine at the University of Padua, exceeded my expectations both for the scientific content and the ambiance of the Conference. This Academy Conference was perfectly hosted by Professor Raffaele De Caro, Professor Carla Stecco and Dr. Antonio Stecco. The friendly atmosphere during the 2-day conference enabled vivid and fruitful scientific discussions between presenters and audience. Organising an Academy Conference in an historical lecture room (see picture below) as that of the Anatomy Department of one of the oldest universities of Europe, certainly has contributed to the success of this academy Conference.

The many different topics in the field of Manual/Musculoskeletal Medicine of presenters out of many different countries reflected the very aim of the IAMMM to create an international platform for researchers, educationalists and practitioners.

The presentation of Dr. Hermann Locher, about the European Training Requirements for “Additional Competence Manual Medicine” for Physician, reflected that educationalists are an important and vital part of the IAMMM. In present times it essential the scientists and educationalists meet each other in conference such as the Academy Conference.
It helps the mutual understanding of representatives of different schools, medical and non-medical disciplines.

As it is the IAMMM policy to organize Academy Conference in cooperation with universities departments, the 2017 and 9th IAMMM Academy Conference organized in close cooperation with Prof. Radivoje Radić of the Department of Anatomy and Neuroscience of Faculty of Medicine at the J.J. Strossmayer University, Croatia and Professor Marino Rade of the “Martin Horvat" Orthopaedic and Rehabilitation Hospital in Rovinj.

I am looking forward to the Academy Conference in Rovinj (Croatia) with many scientists and educationalists out of the field of musculoskeletal medicine.
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Padua by Michael Hutson
The 8th IAMMM Scientific Conference at the Department of Anatomy, Faculty of Medicine, University of Padua, hosted by Dr. Antonio and Dr. Carla Stecco, was attended by over 80 delegates. By general consent of those delegates who had experience of previous annual IAMMM Scientific conferences in Europe, this was deemed to be “the best yet”! The IAMMM has truly matured – from its inception 10 years previously – into an organisation that understands the need for relevant research in MM/MSK Medicine and the practical application of evidence, based on quality research, to clinicians in their daily practices, to the benefit of their patients.

The dedication of the Executive Board of IAMMM has paid off. At the conference, tributes were paid in particular to the dynamic duo (Professor Jacob Patijn and Professor Olavi Airaksinen) for their past encouragement of a large number of the conference presenters to undertake scientific work and their provision of expert advice on the continuation of research at the highest academic level. Conference attendees were very appreciative of the standard of the papers on a variety of topics. It was clear that university based research has benefited enormously from expert guidance.

At the Executive Board level of IAMMM, a lengthy discussion took place on the most appropriate method of
dissemination of research based evidence presented at the IAMMM Conferences (and elsewhere) and implementation of evidence into clinical practice. Over recent years there has been a move to digital methods of transmission of information, though this is not without practical difficulties, dangers, and costs. The Board is determined to pursue this important issue of keeping its members up to date with relevant information, whether in (paper) journal format or digitally. IAMMM members will be kept informed.

Arrangements are already in hand for the (early November) 2017 Conference in Rovinj, Croatia.

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Helle Borgstrøm, Chairman of DSMM
This was my first participation in the Academy's annual conference.

Academy, or IAMMM, is the international organization of individual members, who are active in the scientific and educational area of ​​Musculoskeletal Medicine. It is obvious that I belong to the last category, the educational field of musculoskeletal medicine. It was my luck that Berit Schiøttz-Christensen, rheumatologist and professor at University of Southern Denmark, participated too. She was able to guide me through the scientific language and set the stage for exciting discussions. I still wonder about her very simple question:
What can IAMMM do for DSMM?" - I now send on the question to you, members of DSMM. Here are some options we have not fully exploited - also for the individual scientific interested members.

The conference took place in Padua, Italy, at the university where Carla and Antonio Stecco have continued their father, Luigi Steccos research around the fascia. Naturally the main topic was the fascia, and Carla Stecco did a very interesting lecture on the role of fascia in proprioception and pain.
Additionally, there was an extensive program with the presentation of large and small projects. All were given 10 minutes for presentation and 5 minutes for discussion. The level was fluctuating, everything from a large Dutch cohort study to a more "lyrical" Finnish study on the fascial manipulation on 8 violin players. The Dutch study followed 599 patients who visited musculoskeletal physicians for treatment. 60% of the patients had symptoms for more than 1 year before treatment, and most were treated with spinal manipulation. 72% of the patients reported an improvement through the first six months after the start of treatment. The effect was generally sustained at one year follow-up. There were still many data back to analyse in this study.

German Wolfgang von Heymann presented a clinical interesting project. The background for the study was the lack of "golden standard" tests for the diagnosis of dysfunctions in the sacroiliac joints. 10 different functional and pain provocation tests was examined for reliability and compared with previously evaluated pain provocation tests. The data collection is not completed yet, but Wolfgang von Heymann expects that the study will lead to a recommendation for a set of mixed both functional and pain provocation tests.

Berit Schiøttz-Christensen reflected about the best way to select patients for treatments. She is seeking questionnaires of more cognitive nature, e.g. what does the pain do for the patients in their daily functioning.
On the general assembly Berit was elected as a member of the Science Board. She will work for a different and more dynamic structure of the conferences.

I noted that the projects do not distinguish between the different musculoskeletal treatments. I think the main focus is on HV-manipulation. An exception was an American project where Larry Steinbeck and others examined Fascial Manipulation compared to standard physical therapy including manipulation. They found a significant improvement in the group of patients who received Fascial Manipulation.
An Italian study has examined fascia with Ultrasound. They couldn’t detect a less densification of the deep fascia after Fascial Manipulation.
Steccos Facial Manipulation works mechanically by breaking the fibres, which has become thickened or placed in inappropriate direction. The treatment triggers an inflammation and is painful. The MFR treatment, as we know it, is very different. It probably works neurophysiological by changing reflex patterns. It would be interesting if it’s possible by Ultrasound to demonstrate a change in the fascial density after a MFR treatment.

My impression of the conference was that the topics for science are endless. Each project opens up new questions to be answered.

DSMM calls for Danish researchers, who have the time and patience to explore the musculoskeletal area for the benefit of the education and the patients we treat.
Berit Schiøttz-Christensen and Finn Johannsen, rheumatologist and sports physician, are willing to give professional support to get started. DSMM has a research award of 15,000 DDK. It hasn’t been given since 2009. We look forward to an application by the right recipient.
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The Roots by Jens Foell
This year the IAMMM community of action convened in the anatomical institute in Padua. This illustrious location set the scene for a trip down autobiographical memory lane for doctors as individuals and for the medical profession as a whole to revisit their roots in morbid anatomy. When we say “morbid” we mean both aspects of the term. The Oxford dictionary describes it as “the anatomy of diseased organs and tissues”, whereas in vernacular language it evokes imaginations of the deceased. We sat in a traditional steep wood-furnished lecture theatre with chalkboard at the front. The AV projector has been only recently superimposed on this setting like satellite dishes as contemporary ornaments on historic buildings. This backdrop of tradition and history focused the attention on the classical way of generating and conveying knowledge for the medical profession as a whole and in particular for the study of tissues. “Fascia”, the soft tissue envelope surrounding and connecting tissues, was the leitmotif of the meeting. We heard that fascia has been intensively studied here in Padua by the anatomist Giuseppe Sterzi in the 19th Century. The local lecturers positioned their research in his legacy (Raffaele de Caro, Carla Stecco, Simon Tomat, Veronica Macchi, Massimo Busato, Andrea Porzionato, Caterina Fede). So we heard about the importance of fascia in its role as connective tissue with mechanical properties, but also about its importance for proprioception (muscle spindles are encased and connected with fascia) and even its properties in relation to neurochemical signalling (hormone-receptors).
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Methodological turn
IAMMM emerged from a schism in the community of medical practitioners of manual/musculoskeletal medicine. Mapping the principles of evidence-based medicine on manual medicine this group of academic practitioners realigned their practices after a methodological turn. The diagnostic procedures (leading the way to therapeutic procedures) were examined.

Led by Professor Patijn, the canon of diagnostic tests has been carefully categorised and the protocol format to “test the test” has been developed. These protocols are available on the website and accessible for all members. They are particularly applicable in the setting where most manual medicine is delivered: in small practices, as opposed to large academic institutions. It was rewarding to see how academy members investigated their diagnostic procedures in their context. We saw a test battery for SI-joint tests being put to the test in Germany (Wolfgang v. Heymann), we saw tests relating to laterality being examined in a single-practice setting (Alain Coiffard) and in an university setting (Sjef Rutte) in line with all recommended quality assurance steps of the academy protocol.

Research genres
We saw a variety of investigations from various settings using various research genres. We learned about the distribution of hormone-receptors in fascial tissue (histopathology studies). We learned about the prevalence of knee pain in Israeli army recruits and their relationship with trigger points in the muscles surrounding the knee (Evgeni Rosenfeld). We learned about high-velocity-low-amplitude thrusts at the atlantooccipital junction to address reflux in infants who struggle with the aftermaths of perinatal trauma to their necks (Heiner Biedermann). We learned about the effectiveness of treating fascial “densities” in musicians troubled by forearm pain and likewise recreational athletes troubled by ankle instability (Kobi Weiss). Fascial manipulation – with the encircled R as registered trademark – has also been presented as promising treatment for persistent low back pain (Larry Steinbeck) We learned about the recovery trajectories including adverse events, plotted as analysis of several influencing variants, in the treatment of neck and backpain in private practice in the Netherlands (Wouter Schuller). The movement of the spinal cord and the vertebral column in people affected by radiculopathic pain has been explored in imaging studies (Marinko Rade). The activation patterns of abdominal muscles under different load constellations has been explored using surface electromyography (Christoph Anders). Altogether the presenters provided us with multiple conceptual lenses to study our subject matter: the locomotor system.
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Issues and tissues
Who pays for the services we provide for the locomotor system of the patients? The patients themselves (musicians)? The parents (infant medicine)? The insurance? The club (sports medicine)? The state? The army? We know that the service arrangements have an effect on the selection of clients/population samples, on contact time, on motivation. Are musculoskeletal services delivered as component of orchestrated multimodal interventions? And if so, what is the relationship between the status of the person delivering these musculoskeletal therapies and the other professionals in the team? These questions appeared throughout these intensive days in Padua. We have been informed about spectacular healing responses to fascial manipulation therapy in the context of breast surgery (anecdotal evidence), also about the effects of soft tissue treatments in small groups of athletes and musicians (small groups of patients), we learned about musculoskeletal matters in large datasets, where individual stories disappeared in the anonymity of stochastic evidence. Berit Schiotz-Christensen investigated how we classify musculoskeletal information as knowledge about function in context and argued for using ICF instead of ICD in order to capture the locomotion system in the interface of activity limitation and restriction in social participation. We have been informed about the careful build-up of larger studies investigating complex interventions, incorporating public involvement and user-involvement (Nefyn Williams).

Can we define what all this is about?
Do we know what “manual/musculoskeletal medicine” is, or what it is not? Working definitions, such as “reversible dysfunction of the locomotor system” appeared from time to time. Lothar Beyer, Physiologist by trade, presented a sophisticated model, “the coordination of coordination”, tracking back to concepts formulated by the Russian Physiologist Sechenov and his Czech disciple Nikolai Vvedenski. This concept integrates the different musculoskeletal sub-systems alongside other organ systems in the paradigm of homoeostasis, reflexes and their central control. It is worthwhile to mention, as it conceptualises the problem in the realm of the regulation of function, not as tissue lesion.
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So where are we now?
And where are we going to? Is it clear who this “we” are, who is included in this community of practice - and who isn’t? One important common characteristic of this group is the link to examination, diagnosis and treatment as a craft, investigated with the tools of science. But here comes the dilemma: therapist-delivered or operator-dependent procedures come in a package with contextual factors. Should we focus on efficacy (the influence of the index modality under perfect conditions) or effectiveness (the sum of all influences in realistic conditions)?
This, alongside other questions of how this craft is represented in a digitalising workplace, delivered by people with various professional backgrounds, applied on an aging population, will certainly debated in the up and coming meeting in Rovinj, Croatia.

Where next?
Where are hands-on practices placed in a digitalised industrial healthcare workplace? How will this work be categorised and negotiated?
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