Book and media reviews

Clinical Reasoning for Manual Therapists

M.A. Jones, D.A. Rivett (Eds.), Butterworth-Heine-mann, 2003, Hardcover 445 pp., price AUD $117.5,RRP £34.99; ISBN 0 750 63906 7.

Clinical Reasoning for Manual Therapists consists of22 chapters, each by a different manual therapist (allphysical therapists, although one teaches at an osteo-pathic college in America). Each chapter describesa patient presentation, and the author’s diagnosticapproach to that patient, from initial thoughts throughto final diagnosis. Management strategies are alsodiscussed. Interposed in each author’s text are commentsand questions by the editors, which elaborate on andhighlight particularly significant material. Cases featur-ing the lower back dominate, but there are also chapterson knee, elbow, shoulder, forearm, hip, groin and cranialpatients. Few presentations are acute (other than thosefollowing a sports injury or car accident), which isappropriate since most practitioners find chronic long-term cases both more interesting and more challenging.

The book is introduced by a chapter outlining recentresearch and development in clinical reasoning in themanual therapies, and closes with two chapters onteaching and improving one’s own skills in clinicalreasoning. This review will give an idea of the strengthsof the book. Apart from the very useful overview of thefield and recent research, and the chapters on increasingone’s own skill and teaching clinical reasoning; thestrength of the book is the concept itself. Most texts andarticles on clinical reasoning describe what has beenlearned about clinical reasoning processes, or try toexplain how to get better at it. There are only a fewmanual therapy books which consist of case studies:none attempts to undertake the task Jones and Rivetthave set for themselves, which, as their title suggests, is toenlarge our understanding of clinical reasoning processesused in practice by a wide range of manual therapists.

The diversity of practitioners and their outstandingcalibre is another strength of the book. Physical therapypioneers including Maitland, Butler, Mackenzie, Sahr-mann, Jull, Kaltenborn and many others each contributea chapter. For those wanting an introduction to theapproach of each of these ‘names’, this is a great place tostart. However, the chapters by the less well known arejust as interestinge in fact there is not one dud case studyin the entire book. Given the distinguished names justcited, it is not surprising that the incorporation of recent

trends in manual therapy by contributors is another greatstrength of the book. Most of the contributors to thebook are aware of Butler’s work on the nervous systemand pain, highly value patient education, integratepsychosocial approaches and use a wide range ofrehabilitation techniques including specific exercise.

The book is outstanding as it is. Nevertheless, I hopethat the next edition of this long awaited text makes thefollowing improvements: Firstly, it would be interesting tosee several different authors dealingwith the same case, anddialoguing out their differences. Secondly, I would like toseemore incorporationof evidence-basedmedicine into thetext and commentary. The idea would not be to use EBMto sledgehammer the text; rather to gain some clarity onwhat has been fairly conclusively established, and to pointout areas where the evidence may be less clear. Thirdly, itwould be interesting for the authors to present cases wherethey have ground to a halt. What do you think when yourapproach, and then another, and then another, fails toproduce the outcomes you expect? Hearing such experi-enced and skilled practitioners share their thoughts onthis topic would greatly illuminate their clinical reason-ing, where sometimes the real challenge lies in managingdifficult and complex patients who do not respond asexpected (and who do not turn out to have an underlyingvisceral condition, systemic inflammatory disease, psycho-social issues or food intolerance as the key to the problem).These, however, are tasks for the future: for now, I think,Jones and Rivett can justly rest on their laurels and receiveour thanks and respect for putting together a unique,exceptionally valuable and ground breaking book.

Christine McCollSchool of Health & Exercise Sciences,

University of Western Sydney, Sydney, AustraliaE-mail address: c.mccoll@uws.edu.au

doi: 10.1016/j.ijosm.2005.04.001

International Journal of Osteopathic Medicine 8 (2005) 75e76

www.elsevier.com/locate/ijosm

Principles of Neuromusculoskeletal Treatment

and Management

N.Petty, Churchill Livingstone, 2004, Softcover, 380 pp.,price AUD $93.50, GBP £27.99; ISBN 0 443 07062 8.

Principles of Neuromusculoskeletal Treatment andManagement by Nicola Petty is an excellent companion

76 Book and media reviews / International Journal of Osteopathic Medicine 8 (2005) 75e76

to her other book, Neuromusculoskeletal Examinationand Assessment (co-authored by Professor Ann Moore).Petty has drawn together a large collection of basicscience literature to develop the concept validity, andtherefore rationale, of a modern and integrated systemof neuromusculoskeletal therapy.

Although the book is targeted towards all professionsinvolved in treating neuromusculoskeletal pain anddysfunction, Petty draws mainly on physiotherapyconcepts. While these concepts are straightforward andoften consistent with an osteopathic understanding offunction, the terminology and descriptors may be un-familiar to those not conversant with the physiotherapyliterature. To help overcome the ‘jargon’ barrier, a glos-sary is provided to define and clarify technical terms.Also, there is a liberal reproduction of figures and tablessourced from original research articles, and over 260 clearline drawings produced specifically for this book.

In order to present the information clearly, the bookhas five general themes: (1) assessment; (2) joint func-tion and dysfunction, and principles of joint treatment;(3) muscle function and dysfunction, and principlesof muscle treatment; (4) nerve function and dysfunction,and principles of nerve treatment; and (5) principles ofpatient management.

As osteopaths, we don’t tend to think in terms oftreating a ‘joint’ or a ‘muscle’ or a ‘nerve’, but rather theintegrated whole. The separation of joints, muscles andnerves might seem reductionist; however the actualinformation is not presented in this way. Petty avoidsartificial separation of body systems by presenting theconcept that one can’t move a joint without alsoaffecting muscle and nerve; one can’t treat a musclewithout also affecting joint and nerve; and one can’ttreat a nerve without also affecting joint and muscle.In reality, one can’t do any of the above without alsoaffecting and interacting with the brain.

The book is not a technique manual, and does notprovide prescriptive treatments for each condition.Instead, the reader is invited to consider the conceptsput forward and use these as a basis for clinicalreasoning. In the foreword, the comment is made thatintegration of the vast amount of knowledge thatinforms this field into a useable text would bea challenging undertaking. Petty has risen to theoccasion, and I feel the book is an excellent resource

for both students and practitioners; however, it doeshave a few subtle weaknesses.

Firstly, the cover of the book states that it is fullysupported by research evidence; however, even thoughthe text is very well referenced, the ideas remain quiteconceptual. We are still left to wonder if many of thebasic science findings cited in support of the conceptspresented actually have clinical relevance. A great dealmore work is needed to determine the answer to thisfundamental question. Secondly, very little attention isgiven to whether or not these treatment and manage-ment approaches are effective. There are lots of reasonsgiven for ‘why’ the approaches ‘should’ work, but littleevidence presented to show that they ‘do’ work. Forexample, some research is cited in regards to what type ofstretch is most effective in producing muscle lengthening,yet no evidence is presented to support the effectivenessof ‘muscle lengthening’ in reducing pain and/or dysfunc-tion. This is a problem faced by all professions involvedin treating neuromusculoskeletal pain and dysfunction,and is most definitely not unique to this book. Lastly,little mention is made of the reliability and validity of thediagnostic methods that precede and determine themanagement strategies outlined in the book. The realityis that there is insufficient research to fully support theconcepts presented, and, to her credit, Petty does ack-nowledge this throughout the text.

Having made these minor criticisms, Principlesof Neuromusculoskeletal Treatment and Managementis still an excellent place to develop an understand-ing of valid contemporary concepts which underliethe management of neuromuscular pain and dys-function. It’s just that, as readers, we should becareful not to extrapolate a list of ‘great ideas’ into‘evidence-based ideas’ before the ideas are confirmedin the clinical setting with appropriately controlledtrials.

Nicholas LucasSchool of Health & Exercise Sciences, University of

Western Sydney, Sydney, AustraliaE-mail address: n.p.lucas@uws.edu.au

doi: 10.1016/j.ijosm.2005.02.004