Scientific Conference Committee
Prof. Jacob Patijn, MD, PhD, University Maastricht, Netherlands (Science Director IAMMM) Prof. Olavi Airaksinen, MD, PhD, University East Finland, Finland (Chairman IAMMM) Prof. Nefyn Williams MD PhD, Department of Health Services Research in the University of Liverpool, Liverpool, United Kingdom
Prof. Berit Schiøttz-Christensen, MD, PhD, Medical Research Department, Spine Centre of Southern Denmark, Hospital Lillebaelt, University hospital of Southern Denmark.

(The abstracts are arranged alphabetically by author)

Conservative treatment and alternative non-invasive treatment options for acute disc prolapse
Olavi Airaksinen1, MD, PhD, 1Professor of Physical and Rehabilitation Medicine. Kuopio University Hospital and University of Eastern Finland
In generally most patients who present with acute sciatica have a good prognosis, with pain and disability usually improving within 2–4 weeks with or without treatment. Conservative treatment is the first-line option and should include an active approach, with patients being reassured and advised to continue their daily activities as much as possible and avoid bed rest.
One high-quality guideline made recommendations for noninvasive management of lumbar disc herniation with radiculopathy. According this guideline spinal manipulation may be on option for symptomatic relief. A limited course of structured exercise for patients with mild to moderate symptoms (consensus opinion of the guideline development group).
Supervised exercise therapy was defined as exercises or physical activities, which had a therapeutic focus, were tailored and adjusted to the individual patient, and delivered by a trained healthcare professional. These included directional exercises, motor control exercise, nerve mobilization, or strength exercises. In systematic review there was a slight benefit of these active treatments for leg pain and local back pain, but no clear difference between the therapies.
One systematic review by Kahne et al 2010 there was shown efficacy as follow: Stabilization exercises over no treatment, manipulation over sham manipulation, and the addition of mechanical traction to medication and electrotherapy. There was no difference among traction, laser, and ultrasound. Adverse events were associated with traction and ibuprofen. Another systematic review with 900 patients concerning manipulation over other treatment modalities there was found, that manipulation had a favorable effect in alleviating pain, and modified oblique pulling manipulation had significant superiority in improving lumbar function when compared with lumbar traction. As a conclusion most high-quality guidelines will recommend education, staying active/exercise, manual therapy and (paracetamol)/NSAIDs as first-line treatments for LBP (radiculopathy included). Lumbar disc herniation with radiculopathy may benefit from spinal manipulation.

Sticky hands – does a specific hands induced posture reliably facilitate trunk and shoulder muscles?
Stefanie Best1, Norman Best2, Christoph Anders3 1 University Hospital Jena, Institute for Physical Medicine 2 University Hospital Jena, Institute for Physical Medicine, Posture and Motion Group 3 University Hospital Jena, Clinic for Hand- Trauma- and Reconstructive Surgery, Dept. of
Experimental Surgery, Motor Research Group
Sensorimotor facilitation according to Janda is applied to improve or restore ones sensorimotor competence. For many but especially lower body handicapped people this method cannot be applied since it requires the activation of foot and lower leg muscles to reach the target position, the so called "Janda short foot exercise" (SFE). The new description of this exercise is proprioceptive sensorimotor facilitation (PSF). Therefore we have developed an alternative approach to facilitate especially upper body muscles.
For this, subjects are positioned about 30 cm in front of a wall in upright position and place their palm extended hands just above their head at 90° abducted and 90° elbow flexed arms at the wall while consciously trying to adduct their arms but keeping their hands on the wall (still sticking on the wall). We asked ourselves i) if this posture meets reliability requirements and ii) if this posture is able to provide the intended facilitation of trunk muscles. For this we have investigated 15 superficial upper body muscles of both sides in 44 healthy subjects (21 females, 23 males) by means of Surface EMG (SEMG). The subjects performed either basic positions (BP) and the hands induce posture (HIP) at identical body postures in an alternating fashion for five times. After a break of at least five minutes the procedure was repeated.
The ICC values ranged between 0.520 and 0.972 for BP and 0.714 and 0.966 HIP independent of the trial number. Between the two trials ICC values were 0.311 to 0.971 for BP and 0.684 to 0.977 for HIP. The SEMG amplitude differences between BP and HIP ranged from 12 % (Trapezius descendens left) to 83 % (Trapezius ascendens left) and were always in favor for the HIP posture for all muscles.
These preliminary results argue for a reliable and considerable facilitation of superficial upper body muscles by applying the HIP posture.

Manual therapy for cervicogenic headache: preliminary observations.
Bakhtadze12 M. A., Kuzminov12 K.O., Bolotov12 D.A.
Russian National Research Medical University named after N.I. Pirogov. Department of Neurology, Neurosurgery, and Medical Genetics. Moscow.
Center for Manual Therapy. Department of Healthcare. Moscow.
Disturbances of spine biomechanics, especially - its cranio-cervical part, is one of the etiological factors in the cervicogenic headache (CGH). Manual therapy (MT), which can improve biomechanics, may, thus, release a CGH in patients with non-specific neck pain.
Forty-four patients (37 female; 7 male) aged from 23 to 59 years (mean age 41.2±9.6) with CGH and non-specific neck pain received both cervical and thoracic manipulations. Treatment consisted of 6-8 sessions, conducted 2-3 times per week. To assess the effect of treatment we used the NDI, the 11-point NRS, and the 7-point Likert scale. To measure the effect size we used Cohen's d.
At the end of treatment, disability improved by 14,5±5,7 points (d = 2.9 ); neck pain decreased by 4,1±1,5 points (d = 3,4); headache - by 3,9±1,9 points (d = 2.3). Thirteen patients (about 30%) estimated the effect of treatment as "better", and thirty-one - as "much better".
Manual therapy is an effective method of treatment CGH in patients with non- specific neck pain.
Key words: manual therapy, cervicogenic headache.

Function, imbalance and functional illness in the movement system – reflection in manual medicine A work report from the taskgroup „functional disease
Beyer, Lothar Prof. Dr. med habil., Niemier, Kay Dr. med., Harke, Gabriele Dr. med. Doctor‘s Association of MM, Berlin (ÄMM)
We suggest, that function in the movement system (motor system - MS) ought to be in the middle of our reflections in MM. Dysbalance and dysfunction in movements may be the cause of complaints and pain. Overestimated in modern branches of medicine, pain of the MS is integrated in a so called “pain medicine”. The knowledge and experience in MM should oppose such opinion and follow the hypotheses that in the MS pain is often a result of functional impairment.
Colleagues from clinics in MM and rehabilitation as well as colleagues from ambulant praxis and teachers in MM in Germany follow this idea and were putting their heads together and analyse the importance of function in movement and poster for MM. We propose a continuum from health to illness with the degree of imbalance - functional disorder – functional illness (restricted function), where we have more clear to differentiate between morphological and functional origin, what’s primarily and what is secondary.
For further work theses were phrased:
  • -  Definition of the term “functional illness” will influence our thoughts sensitize
    our awareness for conservative options in MM treatment according to
    complex symptoms.
  • -  Functional illness is a complexity of dysfunctions in MS, restriction of
    functionality, activity, participation and pain;
  • -  Functional illness has to be analysed and explained by investigation the
    joints, muscles, fascia, nerves, mind and metabolic regulation.
  • -  Verified functional tests have whenever to be completed by objective
  • -  Syndromes in MM build up typical clinical entities (samples), its therapeutic
    reason may be of different multimodal complexity.
  • -  To distribute MM knowledge there are needed discussions based on clear
    function related definitions.

Evaluating a Pain Management Programme ( PMP) in the UK: A case study approach
Dr Angela Clough PhD1 1Clinical Lead Musculoskeletal Physiotherapist, Hull and East Yorkshire NHS Trust Teaching
hospitals, Honorary Senior Lecturer Hull and York Medical School.
A pain management programme (PMP) is a treatment approach which uses education and practice sessions to help people with persistent pain to manage their pain and every day activities better. It offers the potential to help patients that cannot benefit from other medical interventions.
To utilise a case study approach of a patient with chronic pain to reflect on the functionality of a PMP programme.
The Pain Management Programme included a workbook and x10 track Relaxation CD that accompanies up to 6 sessions with a senior Physiotherapist or Nurse experienced in chronic pain management on a one to one consultation. PMP is utilised in many NHS Trusts.
Four pre-screening questionnaires were used:
  • PSEQ Patient self-efficacy questionnaire, which measures how confident a patient is to do a range of activities. The total is a sum of scores from 10 questions which range from ‘not confident at all ‘to ‘completely confident’.
  • PDQ. This looks at patient’s physical health. A score of ‘O’ indicates No physical disability, a score of 1-70 mild disability, 71-100 moderate disability, 101-130 severe disability and score of 131-150 extreme disability.
  • HADS Hospital Anxiety and Depression Scale. A scale of 0-7, indicates a normal case, a scale of 8-10 a borderline case and a score above 11 to be an abnormal case.
  • Bradford HNA. Health Needs Assessment list.
    The principles utilised in the PMP are working with patients to establish realistic

    goals in 3 key areas: Activity; Relaxation & Fun
    The case study illustrates a positive change in the x3 screening questionnaires and bespoke evaluation measure.
    The patient reported specific benefits from developing ‘coping strategies ‘derived from:

1. A private environment of one to one consultation with a clinician experienced in Chronic Pain Management (Physiotherapist or nurse)
  1. Acquiring the skills of relaxation techniques ( Laura Mitchell Physiological method of relaxation), positions of ease and breathing techniques.
  2. An appreciation of ‘Pacing’ of activity and addressing the ‘over activity rest trap’
  3. Feeling ‘listened to’ and having their issues addressed.
  4. An improved ability to ‘cope’ with their pain having acquired more ‘tools’ to add
    to their ‘pain toolkit’
The Pain Management Programme (PMP) can be a beneficial element of a Pain Service in an NHS Teaching Hospital from the perspective of assisting a patient with complex chronic pain to modify their expectations and enhance their coping strategies on an individualised basis. If patients with established chronic pain are appropriately screened and have appropriate level of ‘self-efficacy ‘(e.g. score of 18 or more) they may derive positive self-reported benefit and positive improvement scores from a one to one Pain Management Programme. Those patients with a score of less than 15 may require one to one psychology to potentially modify behaviour.

Is there a 3D relation in the position of the spine between the EOS- system and PMMM. The initiation of an observational study
Alain Coiffard MD DIU MMO1, Hugues Dumez MD2,
1Medical Center, Aix en Provence, France 2Clinic « de l’Etoile » Department Radiology, Aix en Provence, France
In daily practice we observe a relation between the 3D created curvatures of the spine with the EOS system imaging (a quantitative assessment for scoliosis with low radiation impact) and the movement pattern used in Preferential Mass Mechanics Method (PMMM). In this study we tried to objective this clinical relation.
Use of the EOS system, which is a 3D imaging system for the spine in a standing position and the determination of preferential movements as describe by the reproducible tests of the PMMM.
33 subjects from 9 to 71 years old were examined both via the EOS system {retrospective) and the thoracic and lumbar preferential movements tests as described by the PMMM.
1 observer compares the corresponding data in three 1dimensional planes on the level of the thoracic and lumbar region.
The data of the preferential tests (diagram) could not be related with the EOS system because of the poor reconstruction possibilities of the EOS system (diagram).
EOS system is a new low dose imaging system, which gives very good quality images and permits a simultaneous acquisition of upright frontal and sagittal views and is able to cover in the same time the spine and the lower limbs
PMMM determined by Marsman® method permitted to obtain a comprehensive 3D image of the curves, rotations and motilities of the spine.
But because of the present difficulty to obtain 3D results, we just have in the frontal- and sagittal plans EOS-images. That made the comparison with PMMM not possible. In this presentation we show the difficulties and the way, how to obtain the 3D EOS- picture. Further a proposal to continue this study will be suggested.
Vanwylick, Harm. (2004). Voorkeursbewegingen: voorkeur of a eur? NVOM Bilthoven, ed. Ned Tijdschr Man Gen, (2), pp. 16–21. RUTTE S, PATIJN J. (2015). Biomechanics in Musculo- skeletal Medicine: an additional approach? In M. Hutson & A. Ward (Eds.), Textbook of Musculoskeletal Medicine (2nd ed.). Oxford: Oxford University Press.
S. RUTTE, D. FIEVET (2019) Scoliose et latéralité en Marsman, Thérapies Manuelles et Pédiatrie, ed. Sauramps Médical,pp.195-204 G Morvan [1], V Vuillemin, H Guerini, M Wybier, Ph Mathieu, F Zeitoun, Ph Bossard, F Thévenin, F Préaux, S Merran,Imaging of the standing man. EOS system ,e- mémoires de l'Académie Nationale de Chirurgie, 2013, 12 (2) : 006-017.
Skalli W, Vergari C, Ebermeyer E, Courtois I, Dre-vell X, Kohler R, Abelin-Genevois K, Dubousset J. (2016) Early Detection of Progressive Adolescent Idiopathic Scoliosis: A Severity Index. Spine (Phila Pa 1976)

Peroneal nerve schwannoma: a rare cause of lower leg pain in a young individual
Aniek PM van Zantvoort1, Paul M.Cuppen2, Marc R.Scheltinga1
1Department of Surgery, Maxima Medisch Centrum, Veldhoven, Noord Brabant, The Netherlands 2Department of Musculoskeletal Medecine, Cheiron Medisch Centrum Waalre, Waalre, Noord Brabant, Waalre
The differential diagnosis of exercise-induced lower leg pain in young individuals is extensive and includes chronic excertional compartment syndrome, popliteal arterial entrapment syndrome, cystic adventitional disease, medial tibial stress syndrome and tibial stress fractures. Peripheral nerve-related causes for lower leg pain are however unusual.
We present a 35-year-old woman with lower leg pain for more than 2 years. The pain was sharp and burning and was scored 10 on the numerical rating scale . The first symptoms were felt during her pregnancy when crouching. She was referred to the neurologist who diagnosed her with nerve entrapment. No additional investigations, including imaging, was performed.
In addition to mechanical disturbancies of ankle and lower leg rotation we found a retro-fibular swelling. Upon mobilisation and manipulation of the proximal and distal fibula and talocrural joint her complaints decreased to 4 on the numerical rating scale and there were periods the complaints completely dissipated. Nevertheless her symptoms repeatedly recurred. We tried to objectivate the swelling and found by ultrasound a retro-fibular swelling in the common peroneal nerve which suggested the presence of a schwannoma.
During the following years symptoms were greatly interfering daily activities. MRI scanning confirmed a schwannoma of the common peroneal nerve.
The decision was made for curative surgical resection of the schwannoma.
In conclusion, altered lower leg skin sensation due to common peroneal nerve dysfunction combined with a palpable mass along the nerve and a positive Tinel sign may be due to a common peroneal nerve schwannoma.
We present the medical history of the patient and simple diagnostic bedside tools as altered lower leg skin sensation, palpation, and the Tinel sign.

Bupivacaine in cervical segmental test blocks: diagnostic or therapeutic? Maarten van Eerd2, Jacob Patijn12, Maarten van Kleef2
1Department of Translational Neuroscience, School of Mental Health and Neuroscience, Maastricht University, The Netherlands.
2Maastricht University Medical Centre (UPCM), Dept. Anaesthesiology and Pain Management, Maastricht University, The Netherlands
In previous performed double-blind randomized controlled trial, the efficacy of radio frequent denervation of the cervical facet joints nerves combined with bupivacaine in patients with chronic neck was evaluated and compared with group of chronic neck pain patients that was treated with a segmental bupivacaine injection alone.
Patients with chronic neck pain were randomly assigned to radio frequent denervation combined with bupivacaine (intervention group) or bupivacaine alone (control group). The primary and secondary outcomes were measured 6 months after intervention.
76 patients were included. In the intervention group, 54.1% showed a decrease of pain ≥30%. Surprisingly, the control group showed almost the same percentage pain reduction of 51.3%.
In interventional pain management procedures, the main pain reducing action of local anaesthetics is explained by its effect on sodium channels. The long-lasting effect, as was seen in the control group of the RCT, cannot be explained by the effect of the peripheral located sodium channels. Local anaesthetics can influence the nociception in the central nervous system in many different levels.
In RCT’s, local anaesthetics cannot be used as an intervention in the control group, because of their therapeutic properties.

Innervation of fasciae and soft tissues in the hip region: consequences for hip replacement surgery and post-surgical pain
Caterina Fede1*, Carla Stecco1, Chenglei Fan1, Lucia Petrelli1, Carmelo Pirri2, Carlo Biz3, Andrea Porzionato1, Raffaele De Caro1 1Department of Neurosciences, Institute of Human Anatomy, University of Padova, Padova, Italy
2 Physical and Rehabilitation Medicine, University of Rome “Tor Vergata”, Rome, Italy 3Department of Surgery, Oncology and Gastroenterology, Orthopedic Clinic, University of Padova, Padova, Italy
Persistent symptoms, most commonly pain, may remain after otherwise successful hip replacement surgery (total hip arthroplasty or hemi-arthroplasty). Possible causes of the pain include failure of fixation, instability and damage to soft tissues. Innervation of fascia and soft tissues has become increasingly important in etiopathogenesis of pain, but the relative importance of the various anatomical structures is still not known.
In this study authors quantified innervation of skin, superficial adipose tissue, superficial fascia, deep adipose tissue, deep fascia, muscles, capsule, capsule ligament, ligamentum teres and tendon in the hip, aiming to understand their potential roles in nociception and proprioception of the hip joint.
Materials and Methods: Samples from 11 patients (3 males, 8 females, mean age 84.2, 7 right and 4 from left hip joint) at the Padua Orthopedic Clinic according to the approval of the Ethics Committee, and 2 cadavers (both sides, right and left, within the "Body Donation Program" of the Department of Neuroscience, promoted by the University of Padua) were taken following the Watson-Jones procedure. After preparation, sections of 5 μm were used to analyze the distribution of nerve elements by immunohistochemistry with S100 antibody.
All the tissues involved in our study were positive for S100 antibody, with the same innervation’s trend in living patients and cadaver. The skin was the most highly innervated, (0.73±0.37% of positive area in patients; 0.80±0.28% in cadavers); the tendon was the least innervated (0.07±0.01% in patients and 0.07±0.007% in cadavers). The muscles (vasto-lateral and gluteus medius) were the second innervated structure according the percentage (0.31±0.13% and 0.30±0.07% in living humans and cadavers), but with only a few nerves, presumably motor nerves, with large diameters (mean number 12±6.1/cm2, mean diameter 36.4±13.4 μm). Instead, the fasciae had percentages of positive areas of 0.22±0.06% and 0.26±0.05%, in living humans and cadavers respectively, and were invaded by networks of small nerve fibers. The superficial fascia were the second most highly innervated tissue after the skin, with a density of 33±2.5/cm2, but with a mean nerve sizes of 19.1±7.2 μm. Lastly, the capsule turned out to be poorly innervated (0.09%, ±0.03 in living patients, ±0.0 in cadavers).
Our results confirm that capsulectomy in hip replacement surgery does not necessarily lead to painful consequences. On the contrary, the subcutaneous tissue, the superficial fascia, the adipose tissue and the deep fascia have a possible role in pain since the presence of their innervation, which leads us to conclude how important it is to use minimally invasive surgical procedures respect these structures and consequently to reduce post-operative pain. Until now, little importance has been given to the subcutaneous fascial tissues: they are crossed by a dense nervous network and therefore deserve attention and further in-depth studies to understand their role in the autonomic system, in proprioception and in pain.

*Corresponding author:
Caterina Fede, PhD
Institute of Human Anatomy, Department of Neurosciences University of Padova, via A. Gabelli 65, 35121 Padova, Italy. Tel. +39.049.8272308 – E-mail:

Statement of 8 years teaching experience by using the IAMMM scientific protocol in France
Daniel Fievet, MD, France
In April 2011 during the congress « test the test » at the BSO of London I have got an eye-opener of the reliability and reproducibility of my manual tests in my daily professional practice. Since that time, I try, whenever I can to share this instructive experience with my colleagues. I shared it during a congress in Paris in 2012, a pedagogic experience in the Paris XIII University, a course during the Inter University diploma of Medicine Manuel-Ostéopathy (DIU of MMO in french) in University of Montpellier-Nimes. This presentation analyses some of the problems I met to develop the scientific view in Musculo-skeletal medicine using the IAMMM protocol and also how we can change the MMM edudation in the university in France.

"Dazed and Confused”: a case report
Jens Foell, MD1 1Imperial College, London, London
This case study is based in undifferentiated primary care. A patient with chronic vertigo makes an appointment with a randomly chosen GP to get the pharmacological treatment for her diagnosis of vestibular migraine. After a long odyssey through several specialisms over many years a final diagnosis of vestibular migraine has been established by a neurologist and the GP ought to titrate the pharmacological treatment. In the process of reviewing the situation and getting to know the patient better throughout the course of up-titration more and more questions emerge and the doctor steps out from the role of administering treatment in primary care under the instructions of secondary care and starts to unpack together with the patient all previously applied diagnostic labels. He also applies treatment for supposedly reversible functional changes in the upper cervical and lumbar spine and lower limbs. As the story continues, we explore to which extent hands-on interventions are passive or active and deliberate on the intersection and interdependence of central and peripheral factors in this situation of chronic vertigo.

The Challenge of Teaching Manual Medicine in Turkey : a fascinating Experience
Marc-Henri Gauchat, DC, MD, Man Med (SAMM), Sion, Switzerland
Following the demand of the Turkish Association for Manual Medicine for a course fulfilling FIMM criteria of a 300 hours curriculum, a first basic introductory course of 10 ECTS has taken place from April 2018 to February 2019 with 30 participants completing the final examination (MM diagnostics, spinal and peripheral joints mobilization techniques, MET, trigger points, exercises). The logistic has been entirely assured with competence by the Turkish Association for MM. A second basic course is presently in progress.
The program has been based on FIMM and ESSOMM core curricula taking the SAMM scheme of CAS and DAS as a model for the practical aspects. An advanced course (HVLA techniques) of 20 ECTS is programmed in December 2019 for the interested participants having completed the basic course with success.
Among the problems encountered, the problem of language is prominent, the course is given in English but many participants do not master English sufficiently and therefore there is a need for a simultaneous translation in Turkish language with the risk of losing specific details fortunately completed by Turkish professors present. There is no support available in Turkish language although all the slides created in English almost from scratch, a challenge for the teacher, are distributed to the participants. To balance this disadvantage, contrary to what is practiced now in most courses (eg. Switzerland, Germany), the use of smartphones to record the lectures and technical demonstration is authorized and widely used and appreciated. The different cultural and religious backgrounds represent sometimes an obstacle to the active participation in the workshop, the tendency for certain individuals to remain as passive spectators does not promote the acquisition of the manual competences.
There is a great interest in Turkey for Manual Medicine and it is an exciting and fascinating challenge to fulfill. Although there are a few osteopathic books translated from English, they do not correspond to the criteria defined by FIMM and ESSOMM for teaching therefore there is a need for a specific textbook based on the recommended curriculum. The Copyright problematic does not favor the spread of knowledge and should be abandoned.

Recent breakthrough in understanding the immune cause for chronic primary pain (ICD-11) including Fibromyalgia
Andreas Goebels, University of Liverpool, United Kingdom
Chronic primary pain is the new WHO diagnostic category describing a majority of pains seen in clinical practice. Biological contributors are incompletely understood.
We have tested the hypothesis that these pains are caused by autoantibody- mediated autoimmunity and found that passive transfer of patient IgG from two chronic primary pain conditions, Complex Regional Pain Syndrome and Fibromyalgia Syndrome elicit distinct pain-disease phenotypes in rodents which reflect the blood- donor's clinical disorders.
Chronic primary pains are often caused by an autoimmune process. More research is needed to explore this new area of neurobiology and assess the efficacy of immune-modulating treatments.

Pelvic girdle stability and kinetic chain exercise in the treatment of chronic knee complaints
Huétink K1,2, Schuller W1,3 1 Spine Clinic Zaandam, the Netherlands 2 Spine & Joint Centre, Rotterdam, the Netherlands 3 Amsterdam UMC, location VU University, Dept. of Epidemiology & Biostatistics and the Amsterdam
Public Health Research Institute, Amsterdam, the Netherlands Corresponding author, K. Huétink
Chronic knee pain leads to gait adaptations and changes in kinetic chain control. Stabilizing exercise is often exclusively focused on strengthening the muscles of the knee joint. It is unknown whether more extensive training including training of the adjoining joints may be of additional value when standard physiotherapy has not been effective.
The aim was to determine if chronic knee patients with no improvement of knee function or pain after standard physiotherapy could benefit from a kinetic chain exercise treatment, including stability training of the pelvic girdle and correcting gait pattern adaptations.
A pilot study was conducted. Inclusion criteria were: chronic knee complaints for over more than 3 years. Mild to moderate radiographic knee OA. No improvement on standard physical therapy and least one knee pain related visit to an orthopaedic surgeon in the past. All patients received a standardized training program including stability training of the knee and pelvic girdle for a period of eight weeks. The program also included gait pattern training aimed to restore neutral position of the foot, ankle knee and hip. Patients were advised to take adequate rest in order to improve muscle and joint recovery. Standardized knee KOOS and Lysholm questionnaire scores were answered on intake, after 8 weeks, 3 months and one year. Statistical analysis using paired-sample t test was performed.
Six women,aged 23-56 were included. Knee function according to the mean KOOS and Lysholm scores improved during and after treatment. Mean Lysholm scores improved from 39 (n=6) at the start to 83 (n=3) after one year follow-up (SD 2.7, p=0.001). Mean KOOS scores improved from start (n=6) to one year (n=3) follow-up in all subscales. Except for the Symptoms scale, these were all statistically significant differences: Pain: 46-91 (SD 5.3, p=0.006), Symptoms: 58-92 (SD 15.1, p=0.071), ADL: 56-92 (SD 2.5, p=0.004) , Sport/Recreation: 18-16 (SD 12.6, p=0.027) and Quality of Life: (SD 6.0, p=0.005).
A stabilization program that affects the entire kinetic chain may improve long term knee function in chronic knee patients.

Consequences of European Training Requirements of Manual Medicine Wim Jorritsma MD, PhD
Deputy of the Dutch Society of Musculoskeletal Medicine board
After 8 years of consultation the European Union of Medical Specialists (the UEMS) has accepted the proposed Education Model of the European Scientific Society of Manual Medicine (ESSOMM). This European Training Requirements (ETR) for the Additional Competence of MM are of great importance.
The ESSOMM schedule for MM education and the study load of the Diploma MM will be described. After that the UEMS Postgraduate Training structure, which is in accordance to the Bologna process with an integrated Certificate, Diploma and Master route, will be discussed.
Next the consequences of the ETR-MM for trainers and training institutions will be dealed.
At the end of the presentation some challenges for the IAMMM in MM Education will be mentioned.

What is the role of primary care in reducing the decline in physical function and physical activity in people with long-term conditions? A realist evidence synthesis with co-design.
Law, R1; Williams, L1; Langley, J; Burton, C1,3; Hall, B1; Partridge, R2; Hiscock, J1; Morrison, V1; Lemmey, A1; Cooney, J1; Lovell-Smith, C4; Gallanders, J4; Williams, N5
1Bangor University; 2Sheffield Hallam University; 3Canterbury Christchurch University; 4Public research partner; 5University of Liverpool
Corresponding author: Rebecca-Jane Law
Declining physical function and physical activity in people with long-term conditions can cause deteriorating physical, social and psychological health, and reduced independence. In line with the renewed declaration from the World Health Organisation, primary care is well placed to empower individuals and communities to reduce this decline. However, current evidence suggests the best approach is uncertain and the complexities of the needs of people with long-term conditions and of primary care service delivery requires further investigation.
This study aims to unpick this complexity and develop evidence-based recommendations about how primary care can facilitate improved physical function and physical activity for people with long-term conditions.
Realist evidence synthesis combining evidence from varied sources of literature with the views, experiences and ideas of stakeholders. Established realist methods will develop and refine theories about improving physical function and promoting physical activity for people with long-term conditions. In particular, what works (or does not work), for whom and in what circumstances. We have used LEGO® SERIOUS PLAY® as a participatory method for two theory-building stakeholder workshops, enabling expression and creativity through building models and sharing. These included 13 health and social care professionals, 10 people with long-term conditions and the two lead researchers. We have also incorporated expertise and perspectives from the public contributors on our study team as well as members of our international external Project Advisory Group. The initial theory areas have informed the literature review and the programme theories developed from the literature will inform three co-design workshops for a primary care service innovation.
Initial overarching theory areas from the stakeholder workshops include the promotion of physical literacy and organising care according to the International Classification of Functioning. These can be applied at the level of the individual patient, and further sub-divided into physical, psychological and social components, the individual health professional, the practice, and then wider programmes and localities. For example, value and responsibility for physical activity and function, enjoyment and identity, as well as social support have been identified so far. Following initial title and abstract screening of 20,436 articles, the literature search has identified 2069 articles, which are being selected for inclusion according to relevance and theoretical richness. Selected studies are being mapped against our initial theory areas from which we will develop our final programme theories that will be described in terms of contexts, mechanisms and outcomes.
This work is important because shifting the emphasis of long-term condition management away from the diagnosis and categorisation of disease towards the promotion of physical activity has the potential to improve physical functioning and independent living. It will have important implications for practice, primary care education and policy.

Loss of cervical lordosis or cervical kyphosis in neck pain patients. Is it reversible?
Jean-Yves Maigne, Hôpital Cochin. Paris, France
The loss of cervical lordosis is associated with neck pain. In more marked cases, there is a cervical kyphosis and a forward head posture. This reverse cervical curve may accelerate cervical disc degeneration by increasing stresses on the cervical vertebrae. It is supposed to be associated with rather negative clinical outcomes. On the opposite, nothing is known about its natural course and its potential reversibility.
Ambulatory patients with current neck pain (acute or chronic) and a loss of cervical lordosis or a cervical kyphosis on lateral X-ray films taken in the standing position were followed up and X-rayed after partial or full recovery of their neck pain with a single standing lateral film to document the course of their cervical spine postural change.
We enrolled 13 males and 10 females, median age 39. The kyphosis was at C4-5 in 10 cases and C5-6 in 9. In the most severe cases, there was a compensating hyperextension at C0-1 and C1-2 to preserve the horizontality of the gaze (forward head posture).
The repeated x-ray film was taken 1 month to 3 years after the first film and compared with this latter. In 7 cases, no change appeared despite the clinical improvement. The structural change was even worse in 1 case. There was a slight improvement of the structural change in 6 cases, despite the persistence of a cervical kyphosis, and a major improvement or a full reversibility in 10.
At our knowledge, the reversibility of a loss of cervical lordosis and of a cervical kyphosis has never been documented to date. This short case series study shows that there is a weak parallelism between the changes in neck curves and the clinical condition.
The causes of such changes are not known. Theoretically, it could consist in hypertony or hyperactivity of the neck flexors, weakness of the neck extensors, dysbalance between these groups of muscles, separation of the dorsal aspect of the vertebral bodies (due to a disc herniation for example) or approximation of the ventral part of the endplates (due to disc degeneration) at C4-5 or C5-6.

Motor and postural control in patients with chronic non-specific low back pain: a blinded, prospective, and controlled cross-sectional study (Niemier K, Seidel W, Engel)
Niemier K, Emmerich J, Wetterling T, Casser H_R, Marnitz U, Smolenski UC, Menke J, Loudovici-Krug D
Motor and postural control dysfunctions are hypothesized to be important for the development and clinical course of chronic, non-specific low back pain (cLBP).
To compare the motor and postural control deficiencies (MPCD) between patients with cLBP and healthy controls.
Blinded, cross-sectional control study using clinical tests examining motor and postural control between patients and healthy controls.
We compared the motor and postural control of 46 cLBP patients and 36 healthy controls. Patients with cLBP had significantly more positive pathological tests for movement control (one-leg stance, hip extension, and breathing pattern). No significant differences were observed between groups for tests examining postural control. Patients with cLBP had significantly more trigger points in muscles relevant to postural control.
Although we found that, in general, cLBP patients have poorer motor and postural control relative to healthy subjects, not all patients showed poor motor and postural control. Therefore, MPCD might only be relevant for a subgroup of patients with cLBP. Targeted diagnostic and treatment settings as well as preventive interventions for this subgroup should be the aim of further studies.

Development of chronic muscular skeletal pain. Results of a qualitative cross-sectional study. (Niemier K, Schulz HJ)
Niemier K, Emmerich J, Wetterling T, Casser H_R, Marnitz U, Smolenski UC, Menke J, Loudovici-Krug D
There are different clinical models for the development of chronic muscular skeletal pain, most of them suggesting a linear development. In daily clinical praxis we see patients with different pattern of pain development and chronification. This could be interesting, because different development pattern might represent different cause of the disease. So far to the knowledge of the authors there are no studies to examine different pattern in the development of chronic muscular skeletal pain.
To recognize different pattern of disease development and relate them to possible pathogenetic mechanisms.
Qualitative cross-sectional study. Patient admitted to the Westmecklenburg Klinik for chronic muscular skeletal pain (5 inpatients, 5 day-unite -patients) will be examined by a semi-structured interview regarding the development of the pain. Specific prompters will be asked (e.g. life events) and transformed into codes. Two examiners will code the interviews to ensure reliability. Related external data (e.g. functional findings) will be introduced into the evaluation.
Work in progress
We hope to have obtained the data by November 2019 and be able to discuss the results. If not, we would like to discuss the approach to the problem and the issue of qualitative research in Manuel Medicine.

Introduction to a study protocol for the development and validation of a functional orientated clinical examination for patients with muscular skeletal pain syndromes.
Niemier K
Chronic muscular skeletal pain (cMSP) is common and un till now badly diagnosed/treated. The “classification” into specific and non-specific pain has been around since 1992. In Germany national guidelines have been introduced on this “classification”. So far, it has not improved clinical practice nor clinical outcome. Furthermore, the wording “non-specific” seems to lead to the disqualification of somatic dysfunction to non-specific findings and subsequently to the disqualification of functional diagnostic and treatment methods. Over the last years, some data emerged showing the importance of a functional assessment for patients with cMSP. However, there are no validated tools to do a functional assessment so far. The “Deutsche Stiftung Manuelle Medizin” has provided a research fund for the development and validation of a functional assessment. With this presentation we would like to introduce and discuss the study protocol.

Where to apply spinal manipulation? Do clinical outcomes differ when targeting spinal stiffness or pain sensitivity?
Casper Glissmann Nim123, Søren O'Neill23, Gregory Neill Kawchuk4 & Berit Schiøttz- Christensen34
1Corresponding author 2Spine Centre of Southern Denmark, Hospital Lillebaelt, Denmark 3Department of Regional Health Research, University of Southern Denmark, Denmark 4Department of Physical Therapy, University of Alberta, Canada
Low back pain (LBP) is the leading cause of years lived with disability and is notoriously difficult to treat. Spinal manipulative therapy (SMT) is often recommended in clinical guidelines and the effect appears to be similar to other recommended therapies. In an attempt to optimise the clinical effect of SMT, several subgroup analyses have been performed and some evidence is emerging regarding both technique and dose, but where to direct the treatment has not been examined in humans. Arguably, two potential triggers could be targeted: i) spinal stiffness, where a decrease could lead to restoration of segmental mobility, or ii) local pain sensitivity, thereby removing the potential nociceptive trigger. Animal studies have shown that the biomechanics differs when adjusting the contact point. Still, it is currently unknown if this has a clinical impact. Further, the evidence concerning the hypoalgesic effect of SMT is ambiguous and possibly modified by multiple factors, including region application and pain chronicity.
The objective of this randomised experimental trial was to direct spinal manipulation at a lumbar segment characterised by either high stiffness or low pain threshold and determine whether this had an impact on clinical improvement, and whether stiffness and pain sensitivity changed significantly between groups.
Participants with persistent non-surgical LBP were included and for each individual their predominantly i) stiff and predominantly ii) pain sensitive segment were identified using global stiffness (GS) measured by the VerteTracker and pressure pain threshold (PPT) measured with a pressure algometer, respectively. SMT was hereafter provided to either the i) stiff or ii) pain-sensitive segment in a randomized fashion over 4 sessions (2 sessions a week). Subjective low back pain (primary outcome), global stiffness and pressure pain threshold (secondary outcomes) were compared for each of these treatment groups, at the first and fourth treatment as well as after two weeks (follow-up). Data were analysed using linear mixed models.
We included 132 participants and 123 were available at follow-up. Between-group differences from baseline to post treatment were ΔNRS=0.02 (95%CI -0.62;0.66, p- value = 0.9), ΔGS=-0.11 (95%CI: -0.49;0.27, p-value = 0.5) and ΔPPT=-58.8 kPa (95%CI -121.91:-4.31, p-value <0.05).

NRS did not differ between groups and GS did not change significantly over time. However, at post treatment there was a large and significant difference in PPT between groups, favouring the pain group.

University based master programs for M/M Medicine: an utopian dream?
Jacob Patijn, Scientific Director IAMMM
In Manual/Musculoskeletal (M/M) Medicine, the validity of many diagnostic procedures is lacking. Many diagnostic procedures are related to a particular school within M/M Medicine. To elucidate the validity of diagnostic procedures, fundamental research is necessary. However, at present time, hardly any university in Europe performs basic research in the field of M/M Medicine.
The reason for this lack of university related basic research, is the absence of education programs of M/M Medicine in the university. This education is exclusively provided by the national societies of M/M Medicine. University-based education in a particular medical discipline is condition for developing a university-based research policy.
Master M/M Medicine
Basic research as such is indispensable for the development of a medical discipline as M/M Medicine This is the very reason first to try to develop a master M/M Medicine. The second reason will be found in the recognition of M/M Medicine as an additional competence by the EU. In the document “Training Requirements for the Additional Competence of “Manual Medicine” for European Medical Specialists” the competencies are further elaborated.
Particularly in the core competencies for trainers (course leaders and teachers) is mentioned that the has to prepare himself to fulfil the criteria of a “Master of Advanced Studies (MAS)”according to the Bologna criteria, i.e. collecting 60 ECTS in postgraduate education, which includes the presentation of a scientific master-thesis in connection with a university.
Pre-university education of M/M Medicine
The master is only possible if there is a pre-university program for M/M Medicine. This education will be provided by the national societies of M/M Medicine. The content of this education will be according the format developed by the ESSOMM.
Conditions for a Master M/M Medicine
Primary conditions for this master are: 1. Independency of the different schools within M/M Medicine, 2. Related to the content of the pre-university program as defined by the ESSOMM, 3. Pure scientific education program, 4. Main fields: Diagnosis and Treatment in M/M Medicine.
Content Master M/M Medicine
Rough outlines for a content of a master program M/M Medicine will presented for discussion.

Interest Group Master M/M Medicine
An interest group consisting of IAMMM members will further develop the plans for a master M/M Medicine.

Reproducibility of Diagnostic Tests in Manual/Musculoskeletal Medicine: The Overall Agreement reinstated in relation to sample size calculation.
1Jacob Patijn, MD, PhD.
1Department of Translational Neuroscience, School of Mental Health, University of Maastricht, The Netherlands
In previous IAMMM protocols, with respect to the evaluation of the reproducibility of diagnostic procedures in Manual/Musculoskeletal Medicine (M/M Medicine), the kappa value was advocated as the best measure for inter- and intra-observer agreement. In reproducibility studies, evaluating dichotomous date, the kappa value has the advantage to correct for chance, a characteristic that is lacking in the overall agreement (Pobs). However, the kappa value is a relative measure and is dependent of the prevalence of the index condition (Pindex). The same kappa value can be found in relation to a wide variety of combinations with a Pindex and a Pobs. As a consequence, calculation of the sample size for a reproducibility is almost impossible.
Although the overall agreement (Pobs), as measure for inter- and intra-observer agreement, does not correct for chance, the Pobs meets the need of the practitioner in M/Medicine and other clinicians for an absolute measure of reproducibility.
Computerized statistical studies were performed to calculate the sample size for reproducibility studies with the Pobs as primary outcome. Different margins of error (ME) and Pobs values were used for their effect on the final sample size.
Using a ME value ranging from 0.116 to 0.098, the sample size ranges from 40 to 56 with a Pobs of 0.83.
In reproducibility studies, evaluating dichotomous data, the overall agreement (Pobs) is the primary outcome to make sample size calculation possible. The kappa value, as additional outcome remains important, because it corrects for the chance. Accordingly, IAMMM Reproducibility Protocol had to rewritten.

Definition and Interrater Reliability of a Straight Leg Raise Test
Pesonen J1,2, Shacklock M1,3, Mäki J1, Karttunen L1, Kankaanpää M5, Airaksinen O1, Rade M1,3
1Department of Rehabilitation, Kuopio University Hospital, Kuopio, Finland; 2Department of Surgery, University of Eastern Finland, Kuopio, Finland; 3Neurodynamic Solutions, Adelaide, Australia; 4Department of Physical and Rehabilitation Medicine, Tampere University Hospital,
Tampere, Finland; 5Orthopaedic and Rehabilitation Hospital “Prim. dr. Martin Horvat”, Rovinj, Croatia
The research around SLR has focused mainly on its performance to diagnose lumbar intervertebral disc herniation (LIDH), with results showing high sensitivity and heterogeneous or low specificity. When analyzing these results, it is important to acknowledge the high prevalence of asymptomatic LIDHs in MRI, and that radiological lumbar nerve root compression does not always result in a “positive” SLR finding. In other words, the reference standard (MRI) used to confirm the interpretation of SLR provides erroneous results to the studies. In our previous studies, it also has been shown that SLR produces positive/abnormal results when neural movement is restricted regardless whether a LIDH or radiological neural compression is present or not.
In this study we examined the interrater reliability of the SLR test on 40 patients. Our goal was to define both the clinical application and the interpretation of SLR as accurately as possible for it to provide constantly uniform answers.
40 subjects between the age of 18 and 65 were recruited to the study at Kuopio University Hospital Spine Center. 20 patients were included to the symptomatic sciatic patient group (SSG) and 20 to the control group (CG). The sciatic symptoms did not need to radiate below the knee. The patients selected to the CG had LBP, trocantheric pain, hip-joint pain or tightness in the hamstring. Two independent examiners determined the outcome of the SLR and were blinded to each other’s results. The examiners did not speak to the subjects other than needed to determine the possible reproduction or worsening of the sciatic symptoms during the procedure.
The SLR was performed the traditional way until first symptoms were aggravated. At this hip angle, a structural differentiation was performed to confirm whether the symptoms were of neural origin. Based on the location of emerged symptoms, proximal or distal structural differentiation was performed. For subjects whose symptoms occurred in gluteal and/or hamstring area, ankle dorsiflexion was chosen to be the differentiating movement (i.e. distal differentitation), as for patients with symptom reproduction below the knee, internal rotation of the hip was the differentiating maneuver.
To assess interrater reliability, Cohen’s Kappa was calculated.

Κ-score for agreement of the SLR result between the 2 examiners was 0.846 representing almost perfect agreement between the testers for the result of the SLR. The Κ-score between the study controller and Examiner 1 was 0.900, and 0.951 between the study controller and Examiner 2.
In conclusion, SLR with the addition of structural differentiation is a reliable tool in recognition of neural mechanosensitivity in patients with sciatica providing reliable and repeatable results between observers.

Carmelo Pirri1*, Carla Stecco2, Caterina Fede2, Chenglei Fan2, Veronica Macchi2, Calogero Foti1, Raffaele De Caro2
1 Physical and Rehabilitation Medicine, University of Rome “Tor Vergata”, Rome, Italy 2 Department of Neurosciences, Institute of Human Anatomy, University of Padova, Padova,
INTRODUCTION Nowadays, Ultrasound (US) imaging has been used increasingly in Physical and Rehabilitation Medicine (PRM) to assess the abdominal muscles in healthy subjects or with low back pain (LBP). Many parameters are used to assess the muscles in rest and during a dynamic task, but nobody evaluated the thickness of the abdominal fasciae. The purpose of this study was to examine the reliabilities intra and inter- rater of this measurement.
MATERIALS AND METHODS Three raters with different training in muscle skeletal US assessment evaluated one healthy subject. The thickness of abdominal fasciae and muscles were assessed in supine position and during a simple functional task. The standard protocol used included four landmarks that highlighted the abdominal fasciae. Each rater acquired six repeated measurements in two different sessions. Seventeen different anatomical structures were assessed.
RESULTS The relative error of the measurements (intra-rater variability) was slightly higher for the fasciae than for the muscles, and during the dynamic condition than the resting condition. Inter-rater reliability was good under both conditions for the fasciae (Intraclass Correlation Coefficient = ICC = 0.83) and excellent for the muscles (ICC = 0.99).
CONCLUSIONS These findings provide the evidence that US imaging is reliable and useful tool for the study of the fasciae. The variability in the reliability depends on features of the fasciae and on the knowledge of the raters. It is possible to identify these structures with US imaging but it is important to have a fascial knowledge. *Corresponding author:
Carmelo Pirri, MD, PT Physical and Rehabilitation Medicine, University of Rome “Tor Vergata”, Rome, Italy University of Rome Tor Vergata, via Montpellier 1, 00133 Rome, Italy. E-mail:

Mobility of the wrist in relation to preference test of hand clasping: a pilot. Preliminary results.
Sjef Rutte, MD, MSc MSK, Haarlem Netherlands
INTRODUCTION Hand clasping1 is the superposition of each finger of one hand over the corresponding fingers of the opposite hand. When clasping the hands, a person tends to interlace the fingers in one of two ways so the left or right thumb is predominant in the top position. In series of scientific research, hand clasping is related to a part of lateralization functions, to observe the grading of handedness. Mc Manus2 proved that handedness is not related to hand clasping. Several authors3,4 observed that the frequency of asymmetric hand clasping is different between countries. Throughout life, individually asymmetric hand clasping does not barely change. During the position of hand clasping we are used to feel asymmetric position as normal.5 The inverse position of all the fingers during hand clasping are sensed as an abnormal strange non habitual feeling. A logic conclusion is that hand clasping is an asymmetric habitual position as a consequence an asymmetric function by a possible asymmetric mobility fingers and wrist. Little is known about this relation in between hand clasping position and wrist mobility. For diagnostic reasons, knowledge of chain movement, related to preferred mobility, can be very practical. The Marsman-theory based on positioning of lateralization function and mass- mechanics uses hand clasping to examine the mobility of the wrist. In this paper we will describe the lateralization test; hand clasping, the examination- test to indicate which wrist is more mobile in relation to the hand clasping method in between two observers.
In 2 series , n=11 and n=20 patients were included. The patient had no history of wrist and elbow trauma and/or pain. Patients were tested by their hand clasping position and mobility of the wrist. A photo of the hand clasping position was made.
Test procedure: The patient is sitting on the consecutive elbows at the table, forearms vertical united and hands in a clasping position. The blinded observer fixes the both hands of the patients with one hand and covers both wrists with his other hand. During the mobility test, the hands are moved in the direction in between radial abduction and dorsal flexion. The observed site with the most mobility is marked positive. The results were processed in a 2x2 contingency table for kappa statistics as a measure for interobserver agreement
Substantial kappa values (> .60) were found. The photos added no further information in diagnosing wrist mobility disturbances.
The diagnostic test for wrist mobility during clasping is reproducible and can be used in the daily MSK practice. A tendency was found, that hand clasping is one sided more mobile in the direction of radial abduction combined with dorsal flexion. Due to the embracement in hand clasping, the mobility, as an asymmetric factor, is multi-articular dependent, but in-between the hands reciprocal.
  2. I.C. McManus & C.G.N. Mascie-Taylor (1979) Hand-clasping and arm-folding:
    A review and a genetic model, Annals of Human Biology, 6:6, 527-558, DOI:
  3. Reiss, M.. (1997). Does handclasping have a practical significance?. 48. 174-175.
  4. M. Reiss (1999) The genetics of hand-clasping a review and a familial study,
    Annals of Human Biology, 26:1, 39-48, DOI: 10.1080/030144699282967
  5. Imhokhai Ogah, Emily Stewart, Michelle Treleaven & Richard J. Wassersug (2012)
    Hand clasping, arm folding, and handedness: Relationships and strengths of preference, Laterality: Asymmetries of Body, Brain and Cognition, 17:2, 169-179, DOI: 10.1080/1357650X.2010.551126

An overview of European university related (master) education programs manual/musculoskeletal medicine
Sjef Rutte, MD, MSc MSK, Haarlem, Netherlands
For the development of the European MSK (musculoskeletal) Medicine) society for medical doctors, scientific work is needed to serve academic education and development of scientific literature. The MSK education for medical doctors between countries is different. Some countries have a centralised MSK education. Countries have multiple MSK education systems based on different underlying hypothesis and theories. Very few MSK education programs are supported by an academic scientific group and/or are university related. The last ones provide an official university degree.
To get an overview of university related scientific MSK education programs in different countries (recognised by the government) a survey was done by the IAMMM.
A search done by internet with the keywords: manual medicine, musculoskeletal medicine,university MSc. (multiple translations possible) degree, manual therapy, manuelle medizin, medicina manuale, osteopathy, chiropraxy, academic education, terapia manuale, together with the term medical doctor (translated in several languages).
Master degrees in Europe have a definition according to the Bologna Process.1 Bologna Process
there are still a lot of differences in terminology among European countries. The European umbrella organisation ESSOMM developed a European standard for diplomas in basic (pre-university) MSK training. This training is accepted by the UEMS (Union for European Medical Specialists). 15 MSK societies, containing 9 countries, are affiliated but two have till last year an MSC education connection special for medical practitioners. These are the VUB (Free University Brussels) in Brussels and Universidad Complutense de Madrid. The VUB has at this moment also a concentrated MSc course of 45 ECTS but only for IFOMT (International Federation for manual therapists) level students. In England a master of MSK is developed by the SOM (Society of MSK) together with the Queen Margaret University and is open for paramedical and medical practitioners UNIVERSITA’ DEGLI STUDI DI FIRENZE

The is a series of ministerial meetings and agreements between European countries to ensure comparability in the standards and quality of higher education qualifications. However, (QMU) in Edinburgh . In Firenze the year master (first level) for medical practitioners. In France the post-master has a 2-yeareducation as an additional competence is called DIU (diplomeinteruniversitaire). 15 universities in France supported a 3-year diploma leading to a final thesis called "DIU médecine manuel-osteopathie"

An MSK Master after a MD Master degree for medical doctors is not a general concept in Europe. A concentrated one-year course of 45 ECTS offered by the VUB Brussels is perhaps the best concept for MD's as an additional competence after the basic pre-university MSK training as proposed by the ESSOM.
1. Process

The Identity of being a practitioner in Manual/Musculoskeletal Medicine. On behalf of the scientific committee of IAMMM
Berit Schiøttz-Christensen1 1Spine Centre of Southern Denmark, University of Southern Denmark
FIMM defines Manual/Musculoskeletal Medicine as the medical discipline of enhanced knowledge and skills in the diagnosis, therapy and prevention of functional reversible disorders of the locomotor system. IAMMM aims to make the discipline of Manual/Musculoskeletal Medicine a scientifically based medical based discipline. To be able to support future organisation of scientifically based education for M/M M-MD we like to challenge the members' experience of identity as MMM.
To define the identity of being a practitioner in Manual/Musculoskeletal Medicine.
At the annual meeting in Winterthur 2018 we had a broad discussion on the identity of being M/M M-MD. In the scientific committee we have had discussions on the subject before and after the meeting in 2018. The discussions have led to a proposal to be discussed in Liverpool.
The scientific committee: Jacob Patjin, Sjef Rutte, Olavi Airaksinen, Jens Foell and Berit Schiøttz-Christensen. Guest: Wim Jorritsma.
RESULTS As Musculoskeletal Medicine you as physician focus on diagnostics in the locomotor system. You are a medical specialist specifically trained into functional anatomy. You use the MM skills into diagnostics by use of specific tests and you use treatment procedures to support the diagnosis. You may treat patients for some period of time and you have the knowledge to refer patients for follow-up by physiotherapists and chiropractors. As specialist you may be General Practitioner, Orthopedic, Neurologist, Rheumatologist etc. MM is an additional education for a specialist.
To be discussed at the meeting.

Data from the Danish National Spine-Registry including incident back pain patients seen at hospitals on diagnosis, MRI/surgical rates and referral for rehabilitation program.
Berit Schiøttz-Christensen MD PhD1 1Spine Centre of Southern Denmark, University of Southern Denmark
In the Danish population of 5.6 Mio people about half a million patients during the year consult their general practitioner, chiropractor or physiotherapist because of back pain, 100.000 patients are referred to the hospital and 10.000 have surgery. The five Danish regions offers different programs and a system wish can monitor the course is requested. For that purpose at National Spine Registry is develop by use of the organisational registries that are available in Denmark including all services given to the citizens including services given at the private hospitals.
To monitor the course for back pain patients seen at the hospitals in Denmark focusing on use of MRI, surgery and rehabilitation programs in the municipalities.
The Danish National Patient Registry, The Central Person Registry, The Income Statistics Registry at Statistics Denmark and the Danish National Health Service Registry was used to describe the treatment course for the individual patient followed by characteristics and treatment procedures.
In 2018 in total 63.774 incident patients were seen at hospitals in Denmark, 19% diagnosed as having herniated disc in the lower back, 19% spinal stenosis or spondyloarthritis and 39% as having unspecific low back pain. The patients were equally distributed in all age decades. Of the patients diagnosed with a herniated disc 23.4% had surgery, and among those having spinal stenosis 30.6% had surgery; 18.7% were referred for rehabilitation in the communicipality. Patients from each of the 5 regions are offered varying degrees of surgery and longer-term rehabilitation.
A database as the Danish National Spine-Registry is important and informative describing the back pain population seen at hospitals. Data has shown that patients are offered different rates of surgery and rehabilitation programs. Further analyses will estimate whether this difference is important when indicators as continuous use of opioids or departure from the labor market is used as indicators describing the effect of the course for the back pain patients treated at hospitals.

Clinical course and predictors of a favorable outcome in patients with neck pain treated by musculoskeletal physicians in The Netherlands
Wouter Schuller1,2, Raymond W. Ostelo1,3, Daphne C. Rohrich1, Martijn W. Heymans1, Henrica C.W. de Vet1
1 Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics,
2 Spine Clinic, Mahoniehout 10-12, 1507 ED, Zaandam, The Netherlands 3 VU University, Department of Health Science of the Faculty of Science, Amsterdam
Movement Sciences, de Boelelaan 1105, 1081 HV Amsterdam, The Netherlands Corresponding author:Wouter Schuller
A considerable part of the patient population treated by musculoskeletal (MSK) physicians consists of patients with neck pain (NP). At present, hardly any data is available about the clinical course after MSK treatment, or about possible predictors of a favorable course.
The aims of our study were twofold: (1) to describe the pain trajectories of patients with NP after consulting MSK physicians in The Netherlands, and (2) to find possible predictors of a favorable course.
We conducted a prospective, observational cohort study. MSK physicians recorded data about age, gender, type and duration of the main complaint, the existence of concomitant complaints, the type of treatment, and the number of treatment sessions in a web-based registry. Registered patients were recruited to fill in web- based questionnaires at baseline, and at 6 weekly intervals during a follow-up period of six months. Patient questionnaires measured the level of pain, functional status, global perceived effect and the occurrence of side effects. Using Latent Class Growth Analysis (LGCA), patients were classified into different groups according to their pain trajectories. Baseline variables were evaluated as predictors of a favorable pain trajectory using logistic regression analyses.
In a period of two years 334 patients completed the baseline questionnaire and at least one follow-up measurement. LCGA identified three groups of patients with distinct pain trajectories. A first group (N=148) started with high pain levels and showed no improvement, a second group (N=184) with high pain levels showed strong improvement, and a third group (N=102) with mild pain levels showed moderate improvement. The two groups of patients presenting with high baseline pain scores were compared, and a prediction model of a favorable course was constructed. Higher SF6d scores, previous visit to a rehabilitation specialist, higher age, no effect of previous physiotherapy, and additional McKenzie treatment were predictors of a non-favorable course. The prediction model showed an area under the curve of 0.64, and an explained variance R2 of 0.08.
In neck pain patients, three different pain trajectories were identified after consulting a MSK physician in the Netherlands. A prediction model of a favorable course was presented. As the AUC was moderate and the explained variance low, this model will not be very useful in clinical practice.

Clinical course and predictors of a favorable outcome in patients with low back pain treated by musculoskeletal physicians in The Netherlands
Wouter Schuller1,2, Raymond W. Ostelo1,3, Daphne C. Rohrich1, Martijn W. Heymans1, Henrica C.W. de Vet1
1 Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics,
2 Spine Clinic, Mahoniehout 10-12, 1507 ED, Zaandam, The Netherlands 3 VU University, Department of Health Science of the Faculty of Science, Amsterdam
Movement Sciences, de Boelelaan 1105, 1081 HV Amsterdam, The Netherlands Corresponding author: Wouter Schuller
A large part of the patient population treated by musculoskeletal (MSK) physicians consists of patients with low back pain (LBP). At present, hardly any data is available about the clinical course after MSK treatment, or about possible predictors of a favorable course.
The aims of our study were twofold: (1) to describe the pain trajectories of patients with LBP after consulting MSK physicians in The Netherlands, and (2) to find possible predictors of a favorable course.
We conducted a prospective, observational cohort study. MSK physicians recorded data about age, gender, type and duration of the main complaint, the existence of concomitant complaints, the type of treatment, and the number of treatment sessions in a web-based registry. Registered patients were recruited to fill in web- based questionnaires at baseline, and at 6 weekly intervals during a follow-up period of six months. Patient questionnaires measured the level of pain, functional status, global perceived effect and the occurrence of side effects. Using Latent Class Growth Analysis (LGCA), patients were classified into different groups according to their pain trajectories. Baseline variables were evaluated as predictors of a favorable pain trajectory using logistic regression analyses.
In a period of two years 1117 patients completed the baseline questionnaire and at least one follow-up measurement. LCGA identified three groups of patients with distinct pain trajectories. A first group (N=226) started with high pain levels and showed no improvement, a second group (N=578) with high pain levels showed strong improvement, and a third group (N=313) with mild pain levels showed moderate improvement. The two groups of patients presenting with high baseline pain scores were compared, and a prediction model of a favorable course was constructed. Male gender, previous specialist visit, and having work were predictors of a favorable course. The probability of a favorable outcome increased with a shorter duration of the current episode, but also increased with a longer time since the complaints first started. Generally, patients reporting previous treatments as not effective were less likely to show a favorable outcome after consulting musculoskeletal physicians as well. The prediction model showed an area under the curve of 0.68, and an explained variance R2 of 0.09.
In LBP patients, three different pain trajectories were identified after consulting a MSK physician in the Netherlands. A prediction model of a favorable course was presented. As the AUC was moderate and the explained variance low, this model will not be very useful in clinical practice.

A biomechanical model of pelvic displacement
Wouter Schuller 1,2, Jos Noordzij 3, Kasper Huetink 2, Piet Hoogland 4
1 VU University Medical Center, Department of Epidemiology & Biostatistics and the EMGO+ Institute for Health and Care Research, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
2 Spineclinic, Mahoniehout 10-12, 1507 ED, Zaandam, The Netherlands 3 BovenIJ hospital, dept. of radiology, Statenjachtstraat 1, 1034 CS, Amsterdam, 4 VU University Medical Center, dept. of anatomy & neuroscience, van der Boechorststraat
7, 1081 BT, Amsterdam, The Netherlands Corresponding author: Wouter Schuller
In orthomanual medicine bony prominences are palpated to determine the 3-D position of the pelvis. Asymmetries of these structures are thought to be related to alterations in the position of pelvic and spinal joints. These altered joint positions are corrected in a strict sequence of mobilizing techniques. Correction of pelvic unleveling has a major role in the orthomanual treatment of low back pain.
Our aim was to develop a theoretical biomechanical model explaining the empirical findings on the relationship between the position of the pelvic bones and the L4 and L5 lumbar vertebrae, and to explore possible methods for further anatomical study.
In our hypothetical model the spine and the pelvic girdle are viewed as a construction composed of structural bony elements and tensile ligamenteous structures. In an unlevel pelvis the iliac bones rotate around a transverse axis in a ventro-cranial direction on the higher side and a dorso-caudal direction on the lower side. Due to the rotation of the iliac bones, the sacrum rotates around a sagittal axis. Due to the anatomical shape of the sacro-iliac joints, the sacrum shifts laterally from the ventro-cranially rotated ilium, combined with an anterior rotation on the lower side (nutation). Due to stretching forces of the iliolumbar ligaments, L4 and L5 show a similar rotation around the AP axis towards the lower side. We tested whether the clinical observations concerning the 3-D positions of the pelvic bones were visible in anatomical specimen and in 3-D CT imaging, and whether this could be reproduced in a pelvic model.
Rotation of the pelvic bones around a transverse axis could be reproduced in a pelvic model, was visible in 3-D CT imaging and in anatomical specimen. Co-rotation of the sacrum was clearly shown. Co-rotation of the L4 and L5 lumbar vertebrae was visible in the pelvic model and in anatomical specimen.
Our biomechanical model could explain empirical findings on which orthomanual treatment is based. Pelvic models, 3-D CT imaging and anatomical studies are suitable for further study.

Reduction of Force in the Lumbar Nerve Root with Spinal Positioning for Relief of Pain Due to Lumbar Radiculopathy Part 1: Feasibility Study of Transient Foramen Opening Manoeuvres as a Self- Treatment Protocol.
Michael Shacklock1, Marinko Rade2, Anita Marčinko3, Sinisa Posnic4, Heikki Kröger5,Markku Kankaanpää6, Olavi Airaksinen7,
1Neurodynamic Solutions, Adelaide. Corresponding author. 2Director Orthopaedic and Rehabilitation Hospital "Martin Horvat" Rovinj 3Clinical Hospital Sveti Duh, Department of Neurology 4Clinical Hospital Sveti Duh, Department of Physical Medicine and Rehabilitation 5Professor, Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital 6Associate professor, Clinical Director Department of Physical and Rehabilitation Medicine at Tampere University Hospital, Finland 7Professor, Clinical Director Department of Physical and Rehabilitation Medicine at Kuopio University Hospital
Lumbar radiculopathy is a common and debilitating clinical problem for which there is a need to develop drug-free non-surgical treatments for pain relief. Currently, many movement based treatments apply force to the nerve root whose cause is actually excessive force. Hence there is a need for treatments that produce the reverse effect.
This study aimed to test the feasibility of a intervention that transiently reduces force on the lumbar nerve root with positioning the lumbar intervertebral foramen in an open position, for pain relief in patients with painful lumbar radiculopathy due to disc herniation.
The sample consisted of 20 patients who arrived spontaneously at the local hospital emergency department for help with their acute low back pain and sciatica. The attending neurologist evaluated, and a physiotherapist treated, the patients and outcome measures were performed, Oswestry, VAS and EuroQol5D5L instruments.
Included patients were admitted to the neurology ward and given MRI and electrophysiology for verification of diagnosis. Patients were randomly distributed into two groups, A. control or B. treatment. A. Control group patients received medication, walking and flexion activities and B. Treatment group patients received the same as control patients but added was a lumbar positioning manoeuvre for transient opening of the foramen.
Clinical outcomes measured were back and leg pain (VAS), SLR ROM and self- reported disability with Oswestry and EuroQol EQ5D5L.
The treatment (foramen opener) group B exhibited significantly greater improvements than control group A patients in LBP (88.4%, p≤.003), leg pain (73%, p≤.012), SLR (74.6%, p≤.003), and disability (EQ5D5L 194.1 %, p≤.001; EQ-VAS 109.3%, p≤.001; Oswestry 53.7%, p≤.001; ODI 50.5%, p≤.001) at 8 days.
Patients tolerated the exercise protocol well. Whilst one patient in the control group deteriorated, no patients in the treatment group became worse.
Treatment of sciatica due to lumbar radiculopathy and disc herniation with a transient foramen opener protocol was associated with greater improvements than the control group. The protocol was safe, simple, inexpensive and easy to deliver and justifies further investigation on a larger scale in patients with sciatica due to lumbar radiculopathy from intervertebral disc herniation.
Key words: lumbar radiculopathy, spinal position, pain relief

Reduction of Force in the Lumbar Nerve Root with Spinal Positioning for Relief of Pain Due to Lumbar Radiculopathy. Part 2: Validation Experiments on the Mechanism of Reduction of Tension in the Lumbar Nerve Root with the Straight Leg Raise.
Michael Shacklock1, Marinko Rade2, Heikki Kröger3, Markku Kankaanpää4, Olavi Airaksinen5 1Neurodynamic Solutions, Adelaide. Corresponding author. 2Director Orthopaedic and Rehabilitation Hospital "Martin Horvat" Rovinj 3Professor, Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital
4Associate professor, Clinical Director Department of Physical and Rehabilitation Medicine at Tampere University Hospital, Finland 5Professor, Clinical Director Department of Physical and Rehabilitation Medicine at Kuopio University Hospital
A proposal here is that it may be possible to reduce force in the lumbar nerve roots transiently using the contralateral SLR. If this is valid, the contralateral SLR be a useful physical intervention for relief of lumbar radicular pain through reduction of forces in the nerve root.
In three studies, we aimed to investigate the mechanical validity of a new means of transiently reducing mechanical force in the lumbar nerve roots with the SLR.
In a series of three studies, MRI, asymptomatic subjects and cadavers were used to measure displacement of the spinal cord during unilateral and bilateral SLR and ascertain if the proposed mechanism passes contra-laterally and if such reductions in nerve root tension extend to asymptomatic subjects in neuro-dynamic test responses.
Study 1: Using MRI, unilateral and bilateral SLRs were performed in asymptomatic subjects and displacement of the spinal cord in relation to the L1 vertebral body was measured.
Study 2: Movements that reproduce the spinal cord movement in part 1 were used to ascertain if neurodynamic responses in asymptomatic subjects with the slump test followed the mechanics of the spinal cord in study 1.
Study 3: Observations in cadavers were made during simulation of the same mechanism in parts 1 and 2 to ascertain if the nerve roots actually showed a reduction in tension during the contralateral SLR.

Study 1: With the SLR to 60 ̊, the spinal cord displaced 3.5 mm and 7.4 mm caudally with the unilateral and bilateral SLR respectively. This demonstrated that the spinal cord is capable of transmitting forces across the midline to the nerve roots on the opposite side.
Study 2: The slump test in asymptomatic subjects showed consistent reductions in evoked response intensity (3.80, P≤0.001) with the contralateral SLR. The sham (0.62) and control (0.65) groups showed no such changes (P=0.996). Differences between intervention-sham groups and intervention-control groups were significant (P≤0.001)
Study 3: Manual application of caudal tension in the nerve roots on one side produced caudal displacement of the spinal cord as in Part 1 and reductions in tension in the nerve roots, dura on the contralateral side visualised to occur.
In a series of three validation studies, we have demonstrated a new non-invasive positional mechanism for reduction of tension in the lumbar nerve roots.
This mechanism may be applied to patients with lumbar radiculopathy for pain relief. Key words: straight leg raise, lumbar nerve root, force reduction.

Reliability of myofascial trigger-point evaluation in the leg muscles: A modified application of the Pindex-50% -method used in the IAMMM
Asia Strinkovsky1, 2, Evgeni Rozenfeld1, 2, Aharon S Finestone1,3, Leonid Kalichman2
1Israel Defense Force, Medical Corps, Israel. 2Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel. 3Shamir Medical Center, Zeriffin, Affiliated to the Faculty of Medicine, Tel Aviv University, Israel. Corresponding author: A Finestone,
Myofascial trigger point (MTrP) diagnosis is an acquired clinical palpatory skill dependent on the patient’s subjective response. The inter-tester and intra-tester reliability of MTrP palpation in the muscles of the lower leg have rarely been reported.
To evaluate the inter-tester and intra-tester reliability of MTrP recognition in the leg.
Patients aged 18-30 referred for physiotherapy were recruited, 86 were examined by one physiotherapist and 26 subjects with no MTrP’s were excluded, leaving 60 subjects (31 women) in the study group. Demographics and clinical details were collected. Both examiners (physiotherapists experienced in MTrP examination) were blinded to the subjects’ identity. Following the first assessment and exclusion, subjects were examined by the second physiotherapist and then reexamined by the first. Both legs were evaluated, and results were analyzed separately for symptomatic legs (N=89) and for asymptomatic legs (N=31). Dichotomous findings included a palpable taut band, tenderness, referred pain and relevance of referred pain to patient’s complaint. The diagnosis of an MTrP was established when a palpable taut band, tenderness, and referred pain were all present. Muscles evaluated were the medial and lateral gastrocnemius, medial soleus, tibialis anterior (TA) and peroneals.
Intra-rater reliability for active MTrP ranged from 0.36 to 0.84, and inter-rater ranged from 0.41 to 0.75. For the total MTrP (later or active) intra-rater reliability ranged from 0.48 to 0.72, and inter-rater ranged from 0.28 to 0.65. The most reliable MTrP palpation was found in TA (κ =1.00) and in the posterior calf muscles (κ >0.6). MTrP palpation in the peroneal muscles suffered from relatively low kappa scores.
Palpation is a reliable method of MTrP evaluation in the TA and in the posterior calf muscles, but is unreliable for the peroneals, possibly related to difficulty in accurately. identifying or palpating these muscles.

A case of freezing feet
John Tanner MD1 1The Oving Clinic West Sussex
A fit active elderly patient presents with subjective symptoms in the lower extremities, which evolves over 9 months into an obvious case of cervical myelopathy.
To illustrate the necessity of repeated physical assessment and observation over time and the pitfalls of physician blinding by imaging modalities.
Case notes, imaging and reports and correspondence
Clinical outcomes of patient
Delays in diagnosis and surgery may have led to irreversible disability. How can we improve our recognition of a rare condition, which is becoming less rare as population demographics change?

Physical Activity in the management and prevention of disease Dr. Jean Wong, MD MBChB MRCGP MSc (SEM) DTM&H DRCOG PGCE (Med
GP Principal Pinfold Medical Practice Loughborough GPwSI Sports and Musculoskeletal Medicine International Health Rep RCGP Leicester Faculty RCGP Sports and Exercise Medicine Rep
GP Physical Activity Champion Public Health England
Physical inactivity poses a serious and growing threat to our society. It significantly affects musculoskeletal health. On average, an inactive person spends 38% more days in hospital, utilises 5.5% more GP visits, 13% more specialist services and 12% more nurse visits than an active individual. The UK faces an epidemic of physical inactivity. 70% of NHS spend is on long-term conditions. Therefore, tackling sedentary behaviour is emerging as an important target in the prevention and treatment of chronic disease and musculoskeletal health. This lecture considers the evidence for the benefits of physical activity and discusses ways to tackle the barriers to participation.

Putting Function First in Musculoskeletal Practice and Research
Nefyn Williams1 MD PhD, 1Department of Health Services Research in the University of Liverpool, Liverpool, United Kingdom
In the UK 90% of National Health Service (NHS) activity is in primary care, and a quarter of this is musculoskeletal (MSK). A disease centred approach is inadequate for most MSK disorders; a functional approach is better. An important part of improving function is the promotion of physical activity, but how should this be done? Educational booklets and exercise referral schemes have been tried, but are limited in their ability to change behaviour. Educational booklets only influence a proportion of patients because some are already active; others are never going to exercise, whilst others do not read the booklet. Exercise referral schemes are not offered routinely to all patients who might benefit, and there are low rates of uptake and adherence. Rehabilitation programmes have the potential to restore physical function. An enhanced rehabilitation programme following surgical repair of proximal femoral fracture has been developed. It consists of a workbook to improve self-efficacy, a goal-setting diary and additional therapy visits. This intervention was acceptable (with modifications) to patients, carers and therapists in a feasibility study. Randomised controlled trial (RCT) methods were feasible in terms of recruitment, retention and outcome measure completion. A definitive RCT is in progress with concurrent economic and process evaluations. This RCT is in its internal pilot phase.
This rehabilitation approach can be extended to other areas of MSK practice and to the management of other long-term conditions in primary care. A realist review is in progress, which is investigating how physical function can be by the promotion of physical activity. This needs a cultural change in health delivery to integrate ‘physical literacy’ into all aspects of primary care including the management of long-term MSK conditions.