Structural Diagnosis and Manipulative Medicine History

Structural Diagnosis and Manipulative Medicine History


The 20th century has found renewed interest in manual medicine in the traditional medical profession. In the first part of the 20th century, James Mennell and Edgar Cyriax brought joint manipulation recognition within the London medical community. John Mennell continued the work of his father and contributed extensively to the manual medicine literature and its teaching worldwide. As one of the founding members of the North American Academy of Manipulative Medicine (NAAMM), he was instrumental in opening the membership in NAAMM to osteopathic physicians in 1977. He strongly advocated the expanded role of appropriately trained physical therapists to work with the medical profession in providing joint manipulation in patient care.

James Cyriax is well known for his textbooks in the field and also fostered the expanded education and scope of physical therapists. He incorporated manual medicine procedures in the practice of “orthopedic medicine” and founded the Society for Orthopedic Medicine. In his later years, Cyriax came to believe that manipulation restored function to derangements of the intervertebral discs and spoke less and less about specific arthrodial joint effects. John Bourdillon, a British-trained orthopedic surgeon, was first attracted to manual medicine as a student at Oxford University. During his training, he learned to perform manipulation while the patient was under general anesthesia and subsequently used the same techniques without anesthesia. He observed the successful results of non-medically qualified manipulators and began a study of their techniques. A lifelong student and teacher in the field, he published five editions of a text, Spinal Manipulation. Subsequent to his death in 1992, a sixth edition of Spinal Manipulation was published with Edward Isaacs, MD, and Mark Bookhout, MS, PT, as coauthors.

The NAAMM merged with the American Association of Orthopaedic Medicine in 1992 and continues to represent the United States in the International Federation of Manual Medicine (FIMM).


Manual medicine should not be viewed in isolation nor separate from “regular medicine” and clearly is not the panacea for all ills of humans. Manual medicine considers the functional capacity of the human organism, and its practitioners are as interested in the dynamic processes of disease as those who look at the disease process from the static perspective of laboratory data, tissue pathology, and the results of autopsy. Manual medicine focuses on the musculoskeletal system, which constitutes more than 60% of the human organism, and through which evaluation of the other organ systems must be made. Structural diagnosis not only evaluates the musculoskeletal system for its particular diseases and dysfunctions but can also be used to evaluate the somatic manifestations of disease and derangement of the internal viscera. Manipulative procedures are used primarily to increase mobility in restricted areas of musculoskeletal function and to reduce pain. Some practitioners focus on the concept of pain relief, whereas others are more interested in the influence of increased mobility in optimizing joint stability and function of the musculoskeletal system. When appropriately used, manipulative procedures can be clinically effective in reducing pain within the musculoskeletal system, in increasing the level of wellness of the patient, and in helping patients with a myriad of disease processes.


In 1983, in Fischingen, Sweden, a 6-day workshop was held that included approximately 35 experts in manual medicine from throughout the world. They represented many different countries and schools of manual medicine with considerable diversity in clinical experience. The proceedings of this workshop represented the state of the art of manual medicine of the day.12 That workshop reached a consensus on the goal of manipulation: The goal of manipulation is to restore maximal, pain-free movement of the musculoskeletal system in postural balance.

This definition is comprehensive but specific and is well worth consideration by all students in the field.


It is indeed unfortunate that much of the medical thinking and teaching look at the musculoskeletal system only as the coat rack on which the other organ systems are held and not as an organ system that is susceptible to its own unique injuries and disease processes. The field of manual medicine looks at the musculoskeletal system in a much broader context, particularly as an integral and interrelated part of the total human organism. Although most physicians would accept the concept of integration of the total body including the musculoskeletal system, specific and usable concepts of how that integration occurs and its relationship in structural diagnosis and manipulative therapy seem to be limited.

There are five basic concepts that this author has found useful. Since the hand is an integral part of the practice of manual medicine and includes five digits, it is easy to recall one concept for each digit in the palpating hand. These concepts are as follows:

  • Holism

  • Neurologic control

  • Circulatory function

  • Energy expenditure

  • Self-regulation

Concept of Holism

The concept of holism has different meanings and usage by different practitioners. In manual medicine, the concept emphasizes that the musculoskeletal system deserves thoughtful and complete evaluation, wherever and whenever the patient is seen, regardless of the nature of the presenting complaint. It is just as inappropriate to avoid evaluating the cardiovascular system in a patient presenting with a primary musculoskeletal complaint as it is to avoid evaluation of the musculoskeletal system in a patient presenting with acute chest pain thought to be cardiac in origin. The concept is one of a sick patient who needs to be evaluated. The musculoskeletal system constitutes most of the human body, and alterations within it influence the rest of the human organism; diseases within the internal organs manifest themselves in alterations in the musculoskeletal system, frequently in the form of pain. It is indeed fortunate that holistic concepts have gained increasing popularity in the medical community recently, but the concept expressed here is one that speaks of the integration of the total human organism rather than a summation of parts. We must all remember that our role as health professionals is to treat patients and not to treat disease.

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Oct 30, 2018 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Structural Diagnosis and Manipulative Medicine History

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