Our treatment is based not just on prescribing pills and delivering injections. Manual medicine focusses on pinpointing the problem and solving the underlying functional imbalance of the musculoskeletal system.
Well trained impulse manipulations are part of manual medicine and can lead to resolving malfunction and to pain amelioration.
Manual medicine is a certified medical degree based on scientifically proven techniques, which originated from osteopathic medicine and chiropractic techniques.

Origin of Osteopathy

Osteopathy was founded by Andrew Taylor Still (1828-1927) who suffered headaches accompanied by nausea as a child. He treated himself by attaching a rope similar to a “slack line“ about 20 cm above ground between two trees. He lied down on his back putting the back of his head on the rope until he felt a relieving stretch in his neck and back. With this method he managed to cure his headaches. He later became a successful physician (MD), surgeon and founder of Osteopathy, influenced by his experience as a child.

Origin of chiropractic

Similarly Chiropractic also originates from a personal story. Harvey Lillard 1895 – as a patient – suddenly noticed cracking sound of his upper back in a hunched over position. This was accompanied by a loss of hearing. 17 years later D.D. Palmer (1845-1913) examined him and noticed an elevation in his upper back. Palmer ventured a forceful rotating move trying to realign Harvey Lillard’s spine. He succeeded, and Harvey Lillard gained back his hearing. Thus D.D. Palmer set the early foundation in the 1890s of what we know as chiropractic today.

Development of Manual Medicine

After World War II physicians got more and more interested in manual techniques, like Osteopathy and Chiroparactic.
Today manual medicine is a widely established form of treating musculoskeletal disorders. The Swiss Society of Manual Medicine (SAMM) currently counts over 1300 members and is a largely, renowned Physicians’ associations in Switzerland.
Also interesting
Manual medicine techniques aren’t always first choice. But when implemented with the right indication and performed carefully by a specialist a controlled impulsive move can be a very powerful tool even for chronic pain conditions.

Quellen:
1.Still A.T., Autobiography. Pulbished by the Author. Kirksville, Mo., 1897, p 192. 
2.https://cranialacademy.org/patients/history-of-osteopathy/
3.Schweizerische Ärztegesellschaft für Manuelle Medizin (SAMM) Modul 1, Einführung, Dr. med. U. Böhni
4.Palmer DD. The Chiropractor’s Adjuster. Portland Printing House Company, 1910:18.

Bad posture

Mother nature has not designed our bodies for sitting long hours behind a desk or in front of a computer – nor are we made for standing at a conveyor belt.
Evolution has much rather programmed us for a setting of diverse movement. If this natural stimulus (diverse movement) is missing, we are prone to experience damage to our joints and misalignment.

Two widespread and harmful incorrect postures as an example
A common type of bad posture is the upper- and lower crossed syndrome (Vladimir Janda, 1928-2002). A sitting posture leads to a lack of stretching stimulus (thus tension/tightness) of certain muscle groups and therefore a shortening of these muscle groups. Counteracting muscles are being overly stretched while sitting, which leads to a weakness of these muscles. The result of this imbalance is a bad posture.

 
Generally speaking, it is a matter of time until bad posture leads to pain symptoms. Posture- associated pain can be the origin of chronically strained muscles containing lots of trigger points.

Bad posture can lead to mechanical overstrain also of facet joints (spinal joints) or impingement of nerves/nerve roots.

Exercise

The most common exercise techniques are the following: stretching of muscles, fascia and nerves, joint mobilization as well as neuromuscular stabilization and strengthening of muscles.

Different cultures of all continents have discovered the healing power of exercise like Yoga, Tai-Chi, Qigong, Pilates, Liebscher & Bracht, and different types of physiotherapy.

An important factor of success is finding the right dose of exercise. A common mistake – especially with chronic pain – is that the amount of beneficial exercise is exceeded, and the pain can exacerbate.

This is why implementing exercise as a therapy is not trivial, but can be like a tightrope walk finding the right balance between excess and effectiveness.

Of course, exercise does not provide a cure for all conditions, but a targeted therapy can be very effective, provided it is tailored to the patients’ needs and repeated with diligence and discipline.

Infiltrations are injections placed at different body structures in order to either diagnose or treat a certain cause for pain.

Diagnostic Infiltrations
Diagnostic infiltrations are a valuable tool in order to pinpoint the cause of pain. A small amount of a local anesthetic is carefully injected at the suspected source of pain.

Therapeutic Infiltrations
Therapeutic infiltrations are used for targeted treatment with a drug (or autologous blood). Depending on the pain origin we infiltrate joints, discs, nerves, ganglions, muscles and fascia. We use local anesthetic, cortisone, hyaluronic acid, Botox or PRP (platelet rich plasma), depending on the underlying cause.

Examples

Trigger point infiltrations and dry needling
Trigger points within the musculature are points of unwanted continuous contraction in certain muscle filaments. They typically originate from overuse or strain due to bad posture. Another common cause for trigger points is muscle strain due to whiplash trauma. Trigger points can range from painless conditions to immobilizing pain – depending on the extent of muscle fibers involved and other cofactors.

According to research there is an acidic milieu with low oxygen values within trigger points. Without oxygen there is no energy source for ATP (Adenosintriphosphate) which is essential for the release of tightly contracted muscle fibers.

Trigger point infiltrations und Dry Needling as therapy
Already in the 1940s physicians discovered that infiltrating trigger points with local anesthetic can lead to long lasting if not permanently pain free conditions. Furthermore, a similar effect was observed when injecting physiologic salt solution (NaCl). Later it was discovered that also needles alone resolve trigger points, at which point the idea of dry needling was “born”: trigger points can be released by puncturing the muscle with a needle alone (dry needling).

Needle puncture can increase the blood flow and thus oxygen concentration within trigger points, leading to a release of contracted muscle fibers.

Advances technique – advantage of ultrasound guided dry needling
With traditional dry needling (without ultrasound guidance) it is safe to treat superficial muscle groups and muscles that can be easily reached. Deep muscles in proximity to the spinal cord or close to the lungs are difficult to treat. Treatment of the erector spinae muscle close to the spine for example is more effective with ultrasound guidance.

Modern ultrasound machines are able to show the structures which need to be treated as well as tissues (i.e. lungs, blood vessels, epidural space) that need to be avoided.
With ultrasound the safety and accuracy is improved which allows for optimal treatment that was previously not possible. Experience and the necessary infrastructure can provide pain alleviation for many patients who have suffered for years.

Autohemotherapy

Definitions
For autohemotherapy two different abbreviations are in use: ACP (autologous conditioned plasma) or PRP (platelet rich plasma).

How does autohemotherapy work?
Platelet rich plasma (PRP) contains messengers which can propagate regeneration and healing in different tissues. Injured tissue goes through complex, intricate healing processes. Blood proteins – originating from platelets and plasma – interact with surrounding cells and are thus responsible für these healing processes. Therefore, these active substances are generated from the patient’s own blood and can be targeted and concentrated where tissue needs healing. This technique has been improved constantly over recent years.
 
When to apply autohemotherapy?
Infiltration with PRP is applied when the main focus is on tissue regeneration and not on suppression of inflammation.

How does autohemotherapy work?
A small amount of blood is drawn from an arm vein. With a special process (centrifugation) PRP is separated and the active regenerating substances are released from cells and now contained within PRP. PRP can be injected directly into injured muscles, tendons and joints. All this is done under sterile conditions and with especially developed syringes.

Onabotulinumtoxin A (Botox))

Botox Injections block chemical signals from nerve endings in the muscles. This prevents the muscle fibers from moving. Botox injections can help reduce migraine attacks when targeted to certain muscle groups. Furthermore Botox infiltrations can also be applied successfully when treating patients who are suffering from muscle dystonia and in cases of unwanted increased muscle tonus.

Another treatment option is using the pain modulating effect of Botox at the nerves (and not the nerve endings). In this case the nerve is located with ultrasound in order to carefully inject Botox round the nerve.

Neural therapy

With neural therapy local anesthetic is injected around the nerve in an attempt to temporarily anesthetize the nerve. Even though the anesthesia is temporary, the procedure can lead to permanently reducing the nerve’s irritation. This effect can be compared to rebooting a computer. The method is especially effective if there is a neuroplastic pain component.

Also through «hydrodissection» – a side effect by separating tissue layers from one another through injecting a solution – can have a therapeutic effect. This treatment is especially effective with nerve compression and fascia are stuck together.

Our goal is to treat the pain at its origin and not to cover up symptoms by prescribing pills. But sometimes pills can be a good solution for pain relief. Migraine patients for example profit from Triptan therapy. Another example are those migraine patients who do not respond well to Triptan therapy, but have experienced migraine-free times after taking a CGRP antagonist. Therefore, it is important to treat each pain individually.

Pain Medication – a critical look

Of course, there are not only positive effects when taking pain medication. Side effects and interactions can not only be uncomfortable, but potentially harmful.

Less is more is the principle when taking medication. It is called polypharmacy when patients are taking several medications (four or more) at the same time and over a longer period of time. Every 3-5th patient over the age of 70 is taking four or more pills simultaneously. The interactions between the different medications are increasing exponentially with the amount of pills taken.

Conclusion

With each treatment the wanted effects need to be weighted against the unwanted side effects. Obviously if unwanted side effects prevail, one should refrain from taken the medication.

If a complete healing of the pain origin cannot be achieved in case of chronic pain, interventional pain treatments can provide an elegant way to interrupt the pain at its origin. Unwanted side effects are often fewer when applying interventional pain procedures and can make medication superfluous. Therefore, taking pills is often not the best choice in chronic pain patients.

Although a workable electrical apparatus was not truly developed until after the Renaissance, ‘natural electricity’ was in use therapeutically in Classical times (Kane and Taub, 1975).
Earliest medical use of electricity dates back to descriptions from Aristotle (384-322 v. Chr.): “an electric ray (torpedo fish, or crampfish) can cause a numbing sensation”.
In the year 46 AD Scribonius Largus describes: “for acute gout an electric ray should be placed underneath the painful leg. The patient should remain standing on top of the fish until the numbness reaches the knee.”

Modern, non-invasive Neuromodulation

Fortunately, the days of treatments with an electric ray are over. But the principle of non-invasive Neuromodulation remains the same: electrical impulses can modulate nerve function and thus modify pain sensations. The exact mechanism of pain modulation is still unknown and is subject to current research.
Non- invasive neuromodulation can be implemented for acute pain and also used as prophylactic treatment (for example in migraine headaches).
Numerous neuro-modulating devices have been developed and are on the market today. For example “Cefaly“ is one widely applied device, which is applied in case of headaches and is a good example of non- invasive neuromodulation of the trigeminal nerve.

How does it work?

“Cefaly” is connected magnetically to a selfadhesive electrode to the forehead of the patient. Microimpulses originating from the electrode are targeted precisely to the top branch of the trigeminal nerve, which can either ameliorate an acute migraine attack of prevent future migraine attacks (prophylactic treatment).

Spinal cord stimulation

Sometimes the underlying cause of the problem cannot be treated directly. In this case altering the nerve activity through targeted delivery of a stimulus, such as an electrical stimulation to specific neurological sites in the body can provide a solution.
One of the most common examples is spinal cord stimulation (SCS). SCS consists of placing an electrical lead (or wires) in the epidural space. The lead is attached to a small generator device that is implanted under the skin.
The devices will deliver electrical impulses to the spine, with subsequent modulation of the pain signals in transit to the brain. These impulses often feel like a gentle tingling which replaces the pain sensation.

There has been significant advancement in technology, so that sometimes complete pain relief can be accomplished even without a tingling.
The patient her/ himself controls the strength and duration of the electrical impulses.

Testing phase before Implantation
Before implanting an SCS system a test stimulation is usually being performed. After thorough examination and explanation of the procedure we carefully implant a test electrode in the target region. Afterwards the effect will be tested for 1-2 weeks, which is done and in an outpatient setting. The patient can test the possible benefit in the comfort of their own home and perform daily chores. Depending on the test result the decision for or against the final implantation of an ACS is made.

Modulation of the autonomic nervous system
With the same spinal cord stimulation (SCS) the sympathetic nervous system can be altered as well.

Indications are:
• chronic regional pain syndrome (CRPS)
• pain in the lower abdomen (interstitial Cystitis)
• chronic abdominal pain (for example pancreatitis)
• arterial occlusion (for example pain in lower extremities, angina pectoris)

Invasive Stimulation of peripheral nerves
The same principal described above can be applied to peripheral nerves. In this case the electrode is implanted near the peripheral target nerve, followed by a test phase. If successful, the final lead and device are implanted.

Radiofrequency neurotomy (RF)

Radiofrequency neurotomy is a minimally invasive procedure using heat to burn (ablate) painful nerves causing chronic pain. Under local anesthesia a specially designed needle is placed at the target nerve, heating the needle tip via electrical radiofrequency to 80 degrees Celsius and thus altering the nerve tissue structurally (Wallerian Degeneration).
As a consequence the nerve can no longer transmit pain signals for a certain period of time, mostly at least one year. After that time period the procedure can be repeated if needed.
Radiofrequency neurotomy is applied to chronic pain symptoms, when the original pain source cannot be eliminated.

Probably the most common indications for radiofrequency neurotomy are painful joints at the spinal level (facet joints, see picture 1).
Other common painful conditions that respond to radiofrequency neurotomy are iliosacral-, hip- or knee- joint pain (see picture 2)

Abbildung 1

Abbildung 2

Radiofrequency neurotomy performed at a nerve plexus/ganglion (sympathetic nerve blockade)
Chronic pain, especially neuropathic and neuroplastic type of pain is often associated with a hyperreactivity of the autonomic sympathetic nervous system.

Signs of this «sympathetically sustained pain» are changes in body temperature and skin consistency, edema, and sensitivity. These symptoms can vary from patient to patient.
Sometimes repetitive infiltrations of the nerve plexus with a local anaesthetic can lead to a drastic and long-term pain reduction.

However, in case local infiltration is only temporary, long-term interruption of pain propagation is needed. In which case radiofrequency neurotomy (or alcohol ablation) targeted to one or two points can interrupt the painful nerve signaling.

Pulsed radiofrequency therapy as an alternative to RF-neurotomy

Pulsed radiofrequency – a less aggressive procedure – can be an alternative to thermal ablation in certain situations.

The relatively low electrical current at the tip of the needle causes reduced heat at the targeted area – only about 42 degrees Celsius. Thus, pain propagation can be curtailed without changing the nerve structurally.

This less aggressive procedure can be compared to a technique called neuromodulation and can only applied effectively to specific regions/nerves of the body.