973 / Training on Manual Medicine

Type of Patient Safety Practice NOT EVALUATED
Clinical Practice (CP)
Related practices from PaSQ database
“Best fit” category of the reported practice


Topic of the reported practice
Professional learning program on quality and safety
Aim and the benefit of the Patient Safety Practice
Our Patient Safety Practice is aiming to train physicians (for the purpose of this paper: surgeons included) to identify minor or major serious conditions that might exclude the patient from some or any manual treatment, in short to train to identify contraindications against any or special manual techniques. Within the framework of a multimodal therapeutic concept, Manual Medicine encompasses the interdisciplinary application of its diagnostic and therapeutic techniques for the diagnosis and treatment of reversible dysfunctions of the locomotor system and the resulting ailments. In addition chain reactions – vertebrovisceral, viscerovertebral and viscerocutaneous – within the locomotor system and psychosomatic influences are also adequately considered.
This training is provided by:
• training to take precise history of the patient, especially related to the painful condition
• training of diagnostic procedures provided by hand (in addition to usual medical diagnostics), in relation to the location of the pain und its regional surroundings
• teaching the graduation of pain intensity and disability (e.g. VAS, SF 12, Roland-Morris Disability Score)
• techniques for precise palpatory investigation in a patient with painful conditions: layer-by-layer palpation: o skin o subcutaneous tissue o fascia o muscle, tendon o ligament o bone, joint
• techniques for evaluation of psychosocial risk factors
• techniques for evaluation of the development of chronification (e.g. to evaluate signs of central sensitization)
• training and education how to use all medical diagnostic procedures to identify minor or more serious contraindication against manual treatment, like o x-ray o CT-scan o MRI-scan o Ultrasound-diagnostics o Biochemical investigation
• training to identify and distinguish painful and pain-free directions of all affected movements of the locomotor system
• training to always use a trial based testing procedure before any treatment and how to do it exactly
• training to provide any impulse manipulation technique (high-velocity-low-amplitude – HVLA) exclusively towards a pain-free direction, i.e. away from any painful barrier within a movement
Description of the Patient Safety Practice
The clinical investigation is provided (in addition to normal procedures of physicians/surgeons) by manual techniques. These special manual diagnostic procedures use:
• palpatory investigation of the pain area the patient describes and its regional surroundings
• functional testing of mobility (range of motion regarding flexion-extension, rotation right and left, sidebending right and left) on a regional level as well as for the individual intervertebral and peripheral joint
• identification of segmental irritation; this irritation is the result of segmental nociceptive afferents (maybe from one tissue, maybe from different tissues: skin, intervertebral joint, peripheral joint, muscle, tendon, bone, visceral organ, and even by psychosocial stress) to the posterior horn of the spinal cord, leading to a nocifensive muscular reaction of the segmentally innervated autochthonous muscles, which then will react by a palpable increase of tonus of the muscle fibers as well as with an increase of pain
• dynamic pain provocation tests to identify a painful as well as pain-free direction during any possible movement, checked at the irritation-tonus; in case of a reversible dysfunction, the patient will describe a release of pain during a movement into a pain-free direction of normal joint mobility.
This technique of segmental functional diagnostics is called “diagnosis in three steps” (mobility – irritation – provocation) and it has to be performed in continuous communication and cooperation with the patient. The results of the diagnostic procedure with identification of a segmental or peripheral dysfunction have to be documented. Typical contraindications to be excluded by any means from special or even any Manual treatment approach are:
• spontaneous dissection of the vertebral artery
• any genetically disease or weakness of the vascular system
• protruded or prolapsed intervertebral disc • segmental hypermobility or instability of intervertebral joints
• fracture or severe osteoporosis of bones
• tumor, metastasis
• bacterial infection
• rheumatoid inflammation
• any other severe structural lesion or abnormality.
This is the essential procedure to identify (for the patient’s safety) the indication respectively the contraindication for fast impulse manipulation techniques, as well as for all other Manual techniques (mobilization, myofascial release, muscle-energy-techniques, visceral, lymphatic and cranial techniques) to treat safely painful dysfunctional conditions of intervertebral joints, peripheral joints and painful conditions due to viscero-somatic reactions (e.g. Head-zones). Our therapeutic procedures and techniques are based on 60 years of experience that showed not a single incident as a result of these techniques. A recent randomized controlled double-blinded trial has proven the efficacy and safety of these techniques especially for acute low back pain. Trials to investigate the safety of other painful conditions as results of segmental dysfunctions will follow. This basic education and training is regulated by the legislation of each federal state of Germany, presented by the respective chamber of physicians. Attachments (please see: 973-Dr.v._Heymann_Additional information_AQuMed.zip, documents 2-4) • FIMM Guidelines on Basic Training and Safety (V 3.1) • Guidelines for the Core Curriculum for Manual Medicine • RCT: Spinal High-Velocity Low Amplitude Manipulation in Acute Nonspecific Low Back Pain.973-Dr.v._Heymann_Additional information_AQuMed.zip
Attachment of relevant written information and/or photos, as appropriate
973-Dr.v._Heymann_Additional information_AQuMed.zip
Effectiveness of the Patient Safety Practice
Degree of implementation of reported practice
Yes, fully
Level of implementation of reported practice
Institution level
Specific and measurable outcome for the reported practice were defined
A baseline measurement before implementation of the reported practice was obtained
Not relevant
A measurement after full implementation of the reported practice was obtained
Evaluation of a “positive” effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Enclosure of a reference or attachment in case of published evaluation’s results
For our institution only german publications are available
2014031109490812064_WP4_2009_complications_vascular_neck manip.pdf
Health care context where the Patient Safety Practices was implemented
Primary care
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Specification of implementation in another health care setting(s)
Primary care
Successful implementation’s level  of this Patient Safety Practice across settings
Yes, across multiple local/national health systems
Involved health care staff
Patient Involvement
Direct service user’s involvement as integral part of this Patient Safety Practice
Specification of the service users or their representatives’ involvement in the implementation of this Patient Safety Practice
Point of time in which service user or their reprasentatives’ involvement takes place
During the application of the Patient Safety Practice
Active seeking of service users’ opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
Short description of the service users’ level of involvement
Collaboration, such as co-designing a Patient Safety Practice or active partnership in implementation
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
List of sources where public information is accessible
www.aerzteseminar-mwe.de www.dgmm.de
Implementation of the Patient Safety Practice
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
There is no specified text here
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
Strong knowledge in implementation
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Not relevant
Costs of the Patient Safety Practices
Completion of cost calculation related to this Patient Safety Practice
Not relevant
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
There is no specified text here