History of Musculoskeletal Medicine in New Zealand
270 years ago Medical Practitioners were “Bone Setters” and “Healers” largely using manual skills and supported by Churches and Social agencies. In London, at this time, the first “Medical Centres” were established. These were converted houses, initially, which became the first Medical Institutions and now well established Hospitals and Medical Schools (such as London Hospital Medical College and St Batholomews). In these early days of the development of Medicine, a group of practitioners practicing Manual Therapy, which was led by A Still, split off forming a separate group of Osteopathic Physicians. Dramatic advances in Medicine have occurred in the last 100 years. The stethoscope, X-rays, vaccinations and antibiotics have all only been part of medicine in the last century. Medicine has evolved with a progressive loss of the “Art” of medicine. Clinical hands-on skills and manual therapy have been replaced by high-tech investigations and pharmaceuticals. In the 1970s, in NZ, there were only a handful of NZ Doctors who practiced Manual Medicine – mostly Cyriax type techniques.
In the early 1970s a study of patients attending the department of Physical Medicine, at Auckland Hospital, revealed that many patients could have been diagnosed and treated by General Practitioners. Instead, they were referred on to the hospital because of lack of knowledge about musculoskeletal problems. As a result (and with generous support from the Rose Hellaby Medical Scholarships Trust, Drs Johannes Fossgreen and Tobin Pripp) Rheumatologists from Denmark held courses in Manual Medicine, which were located in Auckland, in 1975. Further teaching by Dr James Fisk, Physical Medicine Specialist from Hamilton, was held in 1978.
Formation of the NZAMM
In 1979, a NZ Government commissioned report on Chiropractics delivered recommendations that only Chiropractors and Osteopaths should practice Manual Therapy. The NZ Medical Association, at the time, formed a committee; Dr G Perry (Rheumatologist), Dr J.G.Abercrombie, Dr R Bernau, Dr C.M.Williamson and Dr D Carnachan (General Practitioners interested in Manual Therapy) to respond to this report. They highlighted deficiencies in the report and it was subsequently never enacted. This committee also acknowledged deficiencies in medical training of Doctors to examine and treat common musculoskeletal complaints with manual therapy. They formed the NZ Association of Musculoskeletal Medicine in 1980 with the aim of promoting and teaching Musculoskeletal Medicine in NZ. This new organization with Dr J.G. Abercrombie as President immediately attracted 40-50 members and, over the first year, a further 150 NZ Medical Practitioners. The inaugural conference was held in Rotorua, in 1981, and NZAMM became a member of the International Federation of Manual Therapy (FIMM) in the same year. In 1982, a combined meeting was held with the Australian Association of Manual Therapy (AAMM) in Rotorua and strong links were forged between these two organisations which remain in tact today.
The Relationship Between NZAMM & the AFMM
The academic development of Musculoskeletal Medicine brought the NZAMM and its Australian counterpart, the Australian Association of Musculoskeletal Medicine (AAMM), closer together and, in 1996, a new autonomous body was formed – the Australasian Faculty of Musculoskeletal Medicine (AFMM). This new academic body was specifically formed to develop academic guidelines to Fellowship status and a full specialist training programme in Musculoskeletal Medicine culminating in Fellowship examinations. In 1999, the first Fellowship exams were held. Since then, there have been 69 Fellows (21 NZ Doctors) admitted to the AFMM. Emeritus Professor, Nikolai Bogduk, from the University of Newcastle, Australia was a driving force and a strong influence in the development of the Fellowship curriculum. The academic syllabus and guidelines are strongly evidence-based and are regularly reviewed. The AFMM registrar training programme is still evolving. A recent option is the Masters of Pain Medicine. Further specialised training is now evolving in, for example, high technology injection diagnostics and treatment including procedures such as medial branch blocks for zygapophysial joint pain, provocative discography, sacroiliac joint injections and transforaminal injections for radicular pain. All these are performed under radiological control.
In addition to Fellowship qualifications, Doctors wanting to practice as Specialist Musculoskeletal Physicians in NZ must also complete Accreditation in Musculoskeletal Medicine followed by 3-yearly re-accreditation and Quality Assurance programmes administered by the NZAMM and AFMM.
Recognition by NZ Medical Council
In 2000, the NZ Medical Council recognised Musculoskeletal Medicine as a new Vocational Branch of Medicine. Since then, the Accident Compensation Corporation of NZ (ACC) have recognised Accredited Musculoskeletal Physicians with Fellowship qualifications in their Specialist contracts. A number of private medical insurance companies have also recognised Musculoskeletal Physicians as Specialists in their health policy cover.
Since small beginnings in 1981, Musculoskeletal Medicine in NZ has evolved into a recognised specialist branch of medicine. The NZAMM and Musculoskeletal Medicine in NZ, owe their existence to a small number of visionary, enthusiastic committed Medical Practitioners who have been driven by the need to seek answers and solutions to their patients’ musculoskeletal pain problems. Our organisation, and Musculoskeletal Medicine, will continue to evolve and are driven by this need.
J Fosgren GP Course
Participants left to right standing: John Andrews, Eddie Sang, Philip Barham, Tom Patteson, David Gillingham, Ivor Marsh, Alan Howes, Angus Johnston, Gibbie Abercrombie, Duncan Finlayson, Pater Fettes, Doug Carnachan, Hartley Ferrant, Barrie Tait, Carol Willis
Kneeling and sitting left to right : Simon Cotton, Johannes Forgren, Janet Hoffman, Torben
J Fosgren Specialist Course ( 1980s)
Particpants left to right standing: David Cook, Frank Swan, Jim Fisk, Doug Gordon, Peter Gow, Derek Gallagher, Graham Perry, John Bell, Johannes Fosgren, Whitley otway, Miles Williamson, Ian Broadfoot, Ken Orr, Torben, Gerald Gibb, Peter Moller, Graham Martin
Participants left to right seated/ kneeling: Robin Azariah, Janet Hoffman, Barrie Tait
History of Training Programmes and Courses
From 1982 to 1988 the NZAMM brought out a number of international Physicians who ran courses and taught Manual Medicine and Manual Therapy. These included:
- 1983 Dr Barry Wyke
- 1984 Dr P Goodley Osteopathic Physician, USA who taught muscle energy techniques
- 1985 Dr Robert Burns, UK
- 1986 Prof Philip Greenman Michigan College of Osteopathy, USA, Dr Jiri Dvorak Neurologist, Switzerland and Dr Vladimir Janda, Czechoslovakia
- 1988 Dr Karel Lewit Neurologist, Czechoslovakia
Over 300 NZ Doctors attended these courses. In 1986, the first “Spine in Action” conference was held in Christchurch. From this conference and, with Dr Jiri Dvorak’s input, plans were made to establish formal training programmes for Manual Therapy in NZ which would be similar to the Swiss Association of Manual Therapy training programmes. The NZAMM Manual Therapy training courses commenced in 1987. 4 courses of 1-week training were established and were strongly influenced by the teaching of Dr Philip Greenman, Dr Jiri Dvorak and Dr Karel Lewit.
- Course 1. The Spine – Diagnosis and Manual Therapy
- Course 2. The Peripheral Joints – Diagnosis and Manual Therapy
- Course 3. The Spine – Mobilisation and Neuromuscular Therapy
- Course 4. The Spine – Mobilisation and Impulse Techniques
University of Otago Diploma of MSM
In 1987, the Accident Compensation Corporation of NZ (a national injury insurance scheme) called a meeting of interested parties to address the certification of practitioners with Manual Medicine skills. A working party recommended that:
- The Royal Australasian College of Physicians and the Royal Australasian College of Surgeons define guidelines for Specialist training in Musculoskeletal Medicine.
- A Postgraduate Diploma in Musculoskeletal Medicine be developed at either Otago University or Auckland University. It was envisaged that the PG Diploma MSM would be credited toward the 3 yr Specialist training in Rheumatology.
The University of Otago through the Christchurch Clinical School did take this up. This was largely through the inspirational leadership, and organisation of, Dr Barrie Tait (a Christchurch Rheumatolgist and Pain Medicine Specialist) whose responsibility was to develop the syllabus. Professor Bill Gillespie (Professor of Orthopaedics) was chairman of the working party overseeing the academic programme. Barrie Tait’s vision, energy and commitment saw the formation of the Otago University Postgraduate Diploma in Musculoskeletal Medicine, a 9-module, minimum 2-year, distance teaching diploma and the first intake of 31 students occurred in 1989. Since then, there have been over 200 graduates of the Otago Diploma MSM (which has been taught in Australia as well as in NZ).