Manual medicine (chirotherapy), Arlen’s Atlas therapy, osteopathic medicine, massages, ergotherapy, physiotherapy (Bobath, Vojta, Castillo Morales, PNF techniques, Perfetti, sensorimotor integration (Ayres) etc.), treadmill treatments, extracorporeal shock waves and provision of aids have been combined in the Clinic for Manual Medicine at the Rheintalklinik to form an extensive combination therapy. Originally the concept was developed for the treatment of physically disabled children and to combat pain in children. The governing principle was that the children should not find the treatments with manual medicine and Atlas therapy unpleasant. We therefore developed techniques appropriate for children, and they are also willingly accepted by adults. They are particularly gentle, but just as effective as the techniques that are normally used for adults.

All neurological disorders, pain emanating from joints, muscles, tendons or intervertebral disks, but also headaches and migraines have one thing in common: the musculature gets out of balance. It becomes short, stiff, sometimes doughy, and/or flaccid. This happens when muscles are not properly or adequately controlled by the central nervous system (brain and spinal cord). The changes in the muscles have the tendency to become independent and worsen if the muscular equilibrium cannot be restored. A vicious circle forms from the faulty posture that becomes established and the faulty control that adapts to the altered conditions.

Movements that become very difficult on account of the changes in the muscles are in time no longer carried out and are actually forgotten. This process sometimes takes place so quickly that after a stroke or a spinal injury the perception of the affected limbs disappears more quickly than the partial recovery of the nerve cells that takes place. The result is a physical disability, which at least in theory is not caused by the central nervous system, but must be considered as an independent failure of the muscles. Without correct physical perception, no correct posture or movement is possible. Without correct movements there is no longer proper perception of the body. A vicious circle develops that leads to a gradual increase in physical disability without the damage to the brain itself having increased. In these cases the central nervous system partly or completely “forgets” the planning of postures and movements.

The disturbance in the functions of the muscles also has far-reaching consequences for the connective tissue (fasciae, tendons, etc.). These structures very rapidly shorten with the muscles, so that lasting contractures occur. Faulty positions and abnormal actions occur, which worsen the original paralysis. One causes the other, and vice versa. This vicious circle also causes a gradual increase in the physical disability.

The vicious circles become apparent in a particularly unpleasant way during the child’s growth, because the bones generally tend to grow relatively normally but the muscles do not permit normal growth. The results are distortion of the spine (scoliosis), flat feet, dropped feet and disturbances of maturation, especially of the hip joints, that can lead to dislocation of the hips through hip dysplasia. Most of these malformations and growth faults can worsen to the extent that surgical operations become necessary.

By means of the various techniques of manual medicine (chirotherapy) including Arlen’s Atlas therapy, osteopathic medicine and treatment with extracorporeal shock waves, the disturbed muscle mechanics are brought closer to normality. In many cases this is sufficient for combating pain, but not for the treatment of neurological disorders. The interplay of these forms of treatment with physiotherapy and ergotherapy is necessary in order to show the brain what positions and movements are possible under improved conditions of muscle mechanics. In addition to improving the mechanics of muscles and joints, the extensive combination therapy therefore promotes physical perception so that improved positions and movements can be achieved on this basis.

An important component of the extensive combination therapy is the provision of aids. These include specially adapted wheelchairs, walking aids (wheeled frames, walking sticks), orthotic devices and splints, devices to improve use of the hands and the initiation of non-verbal communication for patients who are unable to speak.

Physiotherapists, ergotherapists, masseurs, orthopaedic technicians and doctors working together as a team provide treatments of absolutely equal value in order to achieve the treatment goal. Only the combination of therapies, carried out in constant and close co-ordination with each other, leads to the desired results.

The way in which the human brain and spinal cord control positions and movements is reminiscent in many respects of how a computer works. Brain damage or damage to nerves and/or the spinal cord is like damage to the hardware. The software programs of movements, which influence each other and in many cases are linked to each other, can no longer operate on the damaged hardware, or at least no longer without malfunction. By improving the biomechanics and making positions and movements as economical as possible, the extensive combination therapy of physically disabled patients is aimed at attaining software programs that take account of the individual patient’s abilities.

Every brain makes the most of its possibilities. Control processes once learned are tenaciously maintained. Therefore it is necessary, in a treatment programme with repeated treatments at short intervals, preferably daily, to give the brain the opportunity to try out and finally learn new, better control processes. For pain patients three, four or five medical treatments with a wide variety of manual medicine procedures may be sufficient. However, that is not the case if the consequences of neurological disturbances are to be improved. In these cases a 2 - 3-week extensive combination therapy is necessary. In rare cases a longer period is necessary.

It might be a great result when a patient who for years has not been able to walk freely learns to walk unaided. However, it is also a great result when an extremely severely disabled child manages to turn in bed independently and thus improve his own quality of life and that of his parents who no longer have to turn him in bed at night. When patients have learned new positions and movements on this basis, they will not forget them providing they are practiced daily.