Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Flawed Methodology
- Bruce M Gray (29 April 2003)
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Do it yourself
- Frank J Leavitt (30 April 2003)
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Gross misrepresentation
- Saravana Kumar (30 April 2003)
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Re: Gross misrepresentation
- Bruce M Gray (1 May 2003)
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Manual Therapy is a Componenet of Physiotherapy
- Deanne M Quartermaine, Graham MacGregor, Lynn Robertson, Keri Graham, Maxene Murdoch, Nicola Anderson, (2 May 2003)
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Overview comment of the study:
- Edward Lai (4 May 2003)
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Comparing like with like
- Anthony V M Morgan (4 May 2003)
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Physiotherapy for neck pain in the UK
- Jane B Greening (11 May 2003)
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Disadvantages of manual therapy
- Anna Alexander (11 May 2003)
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Manual therapy IS physiotherapy
- J. Haxby Abbott (12 May 2003)
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Vertebral manipulations: a beneficial and cost-effective treatment for vertebral pain
- Luigi Gori, Gori L, Firenzuoli F, Corti G, Massai D. (14 May 2003)
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Still Can't Say The "C" Word
- Don Nixdorf, D.C. (19 April 2004)
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Manual Therapy: The example of Cyriax physiotherapy for Lateral epicondylitis
- Dimitrios I. Stasinopoulos, Prof. Mark I. Johnson (30 November 2004)
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What's in a name?
- Nick T L Southorn (27 October 2006)
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Bruce M Gray, Private Physiotherapist in Australia Private Clinic, Brisbane, Australia - 4557
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I have just read Hoving's paper and feel it is pretty pointless to therapists outside and even within Holland. I raise just two immediately apparent issues of political bias in its design. 1. The methodology discouraged physiotherapy treatment from being hands on, hence a big placebo hole, not to mention the lack of muscle relaxation gained from hands on treatment. A more impartial study would have ensured all physios (without the 'special' manual therapy training) did neck massage (not C/S mobes). 2. The cost effectiveness angle is spurious. Manual therapy consisted of 6x45 minute treatments. Physio was 12x30 minute treatments, both over 6 weeks. The cost analysis methodology factored in transport and time away from work. Well gee, 12 appointments are going to take up more total travel time and work time than 6 appts aren't they? A more honest design would have used the same length and number of treatments. Seems a pretty politically motivated study by the manual therapy camp, all things considered. Competing interests: None declared |
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Frank J Leavitt, Chairman, Centre for Asian and International Bioethics Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel. 84105
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I don't understand why the medical profession does not investigate, and consider recommending, simple exercises, which one can do oneself, in order to prevent or relieve neck and similar pain. One can learn the movements in the warmups commonly practiced before martial arts training, as well as in yoga. These exercises may not work for everybody. But they may work for many. Competing interests: None declared |
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Saravana Kumar, PhD student, Centre for Allied Health Research University of South Australia, Adelaide 5000
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I have just completed reading Korthals-de Bos et al paper and am compelled to write to point out the gross misrepresentation of the Physiotherapy profession in their study. While I agree that the issue of cost-effectiveness is seldom addressed, the manner in which this study has been conducted raises many questions. My concerns are (1). The diagnosis: The researchers have stated that the sample group had "neck pain" (along with other inclusion criteria). What the researchers fail to address are, defining the anatomical location of the area they identify as "neck", presence of other symptoms such as radiation to the thoracic spine, suprascapular fossa, upper limbs, co-existing symptoms such as stiffness, headaches etc. As clinicians, very rarely we see purely neck pain alone without other co-existing symptoms especially given the fact that these symptoms have existed for minimal of two weeks. Hence the lack of proper well-defined diagnosis is a major drawback of the study. (2). The intervention: The researchers, by actively discouraging "hands-on" treatment as part of routine physiotherapy management has alienated this study from current clinical practice. Here in Australia and in many other parts of the world, "hands-on" treatment form part of routine physiotherapy management along with plethora of other treatment strategies such as stretching and strengthening exercises, ergonomic and postural advise, and other electrotherapeutic modalities. To specifically state physiotherapy management as purely exercise therapy is misleading and false. To confound this matter further the lack of detail on the intervention further casts doubts over the results of the study (eg: what kind of exercises were prescribed, the number of repetitions, number of sets?) (3). The measures of outcomes: The number of outcomes used to utilise effectiveness of the treatment was, perceived recovery, intensity of pain, functional disability and utility. While they are universal outcome measures and psychometric properties of some of these measures are reported (8-10 in the reference list) , there is no mention of the reliability nor validity of other measures. (4). Cost-effectiveness: By not standardising the treatment (manual therapy 6x45 minutes treatment versus physiotherapy 12x30 minutes treatment), it is expected that the cost would vary due to increased service usage by the physiotherapy profession. Hence it is not surprising to find that there was increased cost associated with Physiotherapy services! Furthermore, in order to identify the methodological quality of this publication, I conducted a critical appraisal using PEDro (http://www.pedro.fhs.usyd.edu.au/CEBP/), a critical appraisal tool for Randomised Controlled Trial. This trial scored quite well for the criteria mentioned within this particular appraisal tool. This is an example where a study of good methodological quality (as per the appraisal tool), which ranks high in the hierarchy of evidence, has exceedingly poor clinical relevance and utilisation due to improper consideration of current clinical practices. Competing interests: None declared |
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Bruce M Gray, Private Physiotherapist in Australia Private Clinic, Brisbane, Australia - 4557
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Saravana, your second criticism needs further context. In Holland, where this study originated, physiotherapists have less education than physios elsewhere in the world. I believe they approach something more like a physio assistant, and I don't believe they are taught mobilizations. Manual therapists are physios who do post grad study of mobes and manips. Competing interests: None declared |
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Deanne M Quartermaine, Senior Physiotherapist Physiotherapy Outpatient Department, Glasgow Royal Infirmary, G31 2ER, Graham MacGregor, Lynn Robertson, Keri Graham, Maxene Murdoch, Nicola Anderson,
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Dear Editor We feel compelled to respond to the article by Korthals-de Bos et al in your journal. We are concerned about the impression given, that physiotherapists are less effective and more costly than manual therapists in the treatment of neck pain. We feel it necessary to emphasise that in the UK manual therapy is a fundamental and integral component of physiotherapy treatment and management of neck pain, where indicated. All physiotherapists at the Glasgow Royal Infirmary outpatient department, who trained at different physiotherapy schools in the UK and Australia, have received manual therapy training. Continuing professional development policy ensures that manual therapy skills are maintained and further developed beyond graduate level for a therapists’ entire career. We also believe this is not a clinically relevant study when “specific manual therapy mobilisations” by a physiotherapist are discouraged for the purposes of comparing physiotherapy and manual therapy treatment groups. Manual therapy is a component of physiotherapy! This is analogous to a respiratory physician treating a patient with pneumonia and asking them not to use anti-biotics. We are concerned this article inaccurately portrays the physiotherapy profession in the UK as ‘ineffective and costly’ in the treatment of neck pain to the medical profession, who make up the majority of your readership. We wish to reassure them that UK registered physiotherapists are indeed proficient in the management of neck pain including the use of manual therapy techniques. Competing interests: None declared |
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Edward Lai, North District Hospital Hong Kong
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I do agree with the comments from Bruce M Gray & Saravana Kumar that the design of the study of Ingeborg B C Korthals-de Bos etal. poses many unanswered questions. However a very simple thing that I can observe from the study is that both so called "manual therapy" and "physiotherapy" are effective in managing the neck pain patients. In Hong Kong context, a neck pain patient will be examined by a physiotherapist for a differentiate diagnosis for neck pain. The possible causes of neck pain may include ligamentous sprain, neck muscle strain, facet joint alignment problem, muscle imbalance, postural problem, or overuse syndrome, etc. will be identified clinically. And the treatment plan will be discussed with the patient. With patient consensus, physiotherapy treatments which may include back exercises, spinal mobilization, spinal manipulation, postural correction exercises, muscle balancing exercise, electrotherapy for sprain or strain, and sometime, Yoga, pilate or progressive stretching exercises may be included for later stage of neck pain rehabilitaition. Our experience and practice are consistant to the comment of Deanne M Quartermaine that manual therapy is one of the components of the physiotherapy services in Hong Kong. May I used this opportunity to thank Ingeborg B C Korthals-de Bos and co-workers in reporting their study in supporting physiotherapy for their neck patients. Further research for neck pain and physiotherapy is beneficial to the public with active participation of multi-disciplinary medical professions in future. Competing interests: None declared |
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Anthony V M Morgan, Senior physiotherapist James Paget Hospital NR31 5BW
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The article "Cost Effectiveness of physiotherapy, manual therapy, and general practioner care for neck pain: economic evaluation alongside a randomised controlled trial" [BMJ 326 pp911-916] has again repeated a serious misconception about physiotherapy and "manual therapy", as if the two were incompatible. As this trial had occurred 5 years ago in Holland, it could give no indication of the skills provided by physiotherapists in this country today. Even a cursory survey of any hospital physiotherapy department or many private practices with Chartered Physiotherapists will show these "manual therapy" skills are provided by physiotherapists, as well as all the other things included as "physiotherapy" in the article. However, these latter skills are often excluded by the sort of "manual therapists" being considered by the article [chiropractors, osteopaths]. That leads me to suggest that the optimum treatment for this group of patients is that provided by physiotherapists rather than anyone else. This is not the first time that the physio vs chiropractor/osteopath discussion within these hallowed pages has misunderstood the depth of skills of Chartered Physiotherapists in this country. To my knowledge there have been no strict comparisons between the physiotherapists with these "manual therapy" skills, and the chiropractic/osteopathic practictioners along the lines of this article. Perhaps when this is done we may see that physiotherapy has unjustly been the poor relative to the more glamorous concept of others, and that one day the true value of physiotherapy and the skills of the practioners will be understood and appreciated Competing interests: None declared |
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Jane B Greening, Consultant Physiotherapist Livingstone Hospital, Dartford,Kent,UK DA1 1SA
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Dear Sir, Re: Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised control trial. Korthals-de Bos I et al BMJ 326;26th April 2003. The Manipulation Association of Chartered Physiotherapists (MACP) welcomes the debate and comment that Korthals-de Bos et al’s paper has stimulated regarding the nature of manual therapy and physiotherapy and their application to the treatment of neck pain. The authors are to be congratulated for undertaking this work and in attempting to be reflective of clinical practice within the Netherlands. However, we feel that some of the comments this paper have attracted are particularly pertinent. As the paper mentions, in the Netherlands, to qualify as Manual Therapists (and to gain recognition from the International Federation of Orthopaedic Manipulative Therapists, IFOMT) Physiotherapist have to undertake extensive postgraduate study. In the UK The MACP is the manual therapy group recognised by IFOMT. While manual therapy examination and treatment is taught at a specialist level by The MACP, the teaching of these techniques is an integral component of all undergraduate physiotherapy courses. In the UK physiotherapy treatment for neck pain is likely to consist of both manual therapy techniques and exercise. While this paper appears to supports specialist postgraduate manual therapy education for Physiotherapists, the MACP feel it is important that the distinction between what the authors define as 'physiotherapy' and what Physiotherapists in the UK consider to be usual / standard physiotherapeutic management of neck pain, is made clear Yours sincerely Jane Greening
Competing interests: None declared |
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Anna Alexander, 3rd year medical student Imperial College London
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It has been shown that manual therapy is more cost effective than physiotherapy and general practitioner care for neck pain. This manual therapy included hands on techniques such as specific articular mobilisation. Manipulation of the muscle will help patient with neck pain. However it must be considered whether excess pressure on the facet joint can cause long term facet joint arthritis. Competing interests: None declared |
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J. Haxby Abbott, Musculoskeletal Research Group, Dept of Anatomy & Structural Biology University of Otago, New Zealand
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Dear Editor, BMJ has, regrettably, joined the ranks of otherwise excellent medical journals that have mislead their readers, and maligned an allied health profession, by failing to exercise adequate editorial oversight regarding the title and terminology of articles published. An April 2003 article (1) purports to compare manual therapy with physiotherapy, however, as defined by countless physiotherapy professional associations and practice Acts around the world, manual therapy is an intervention provided by physiotherapists, as indeed was the case in this study. What the authors called "physiotherapy" was, in fact, a restricted or limited form of physiotherapy, in which manual therapy (an intervention otherwise typically offered when indicated by clinical examination findings [2]), was "discouraged" (1). This highlights an on-going concern regarding editorial responsibility, wherein the profession of physiotherapy is frequently misrepresented and diminished by applying the term to a restricted, and sometimes ill-considered, set of intervention modalities (3). The point has been made by Jules Rothstein, editor of Physical Therapy, that in accordance with Medical Subject Headings (MeSH), "manual therapy" would have been more properly termed "physical therapy techniques" (3), while the "physiotherapy" of the title would have been more fairly described as "restricted physiotherapy". While it is true that national differences in the structure of the physiotherapy profession may explain, in part, the misleading title, it was the responsibility of the editors to ensure that such regional quirks do not venture out of context to confuse their readership. The Netherlands is, to my knowledge, the only country in which physiotherapists with post- graduate training in manual therapy promote themselves as a distinct quasi -profession; in the rest of the world the distinction is a secondary one, within our primary professional role as physiotherapists. The "registered manual therapists" of the article would have been better referred to as "physiotherapists with post-graduate qualifications in manual therapy", or similar. Common sense, and a tide of research evidence, suggests that a multimodal approach is more successful than any one modality in isolation, both in chronic low back pain and chronic neck pain (4, 5). Recent research indicates that manual therapy in combination with other forms of physiotherapy (e.g. specific exercise training and education) is more effective than either modality alone (5, 6). Physiotherapists, at least those with adequate post-graduate training and experience to provide these interventions expertly, are certainly the health professionals of choice to provide such multimodal therapy, in a multidisciplinary team with our medical colleagues (7). References: 1. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. Korthals-de Bos IBC, Hoving JL, van Tulder MW, Rutten-van Mölken MPMH, Adèr HJ, de Vet HCW, Koes BW, Vondeling H, Bouter LM. BMJ 2003;326:911 2. Effectiveness of physical therapy for patients with neck pain: An individualised approach using a clinical decision-making algorithm. Am J Phys Med Rehabil 2003;82;230-218. 3. What we are versus what we do. Rothstein JM. Phys Ther 2002;82(7):646-647. accessed 12/05/03 via http://www.ptjournal.org/July2002/Jul02_EdNote.cfm 4. Combined physiotherapy and education is efficacious for chronic low back pain. Moseley L. Austr J Physiotherapy 2002;48:297-302 5. Manual therapy for mechanical neck disorders: a systematic review. Gross AR, Kay T, Hondras M, Goldsmith C, Haines T, Peloso P, Kennedy C, Hoving J. Manual Therapy 2002;7(3):131-149 6. A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Bronfort G, Evans R, Nelson R, Aker PD, Goldsmith CH, Vernon H. Spine 2001;26(7):788-799 7. Physiotherapy plus medical care is more effective than medical care alone, for low back pain. Abbott JH. (commentary on: Hurwitz et al. A randomized trial of medical care with and without physical therapy and chiropractic care with and without physical modalities for patients with low back pain. Spine 2002;27:2193-2204) New Zealand Journal of Physiotherapy 2003;3(1):48 Competing interests: None declared |
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Luigi Gori, Ambulatory of Chirotherapy, Clinical Center of Natural Medicine (Dir. Dr. F. Firenzuoli); Clinical Center of Natural Medicine,Ospedale S. Giuseppe, via Paladini 40. Az USL 11 , Empoli, Gori L, Firenzuoli F, Corti G, Massai D.
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Dear Gentlemen, We really appreciate the paper of Korthals-de Bos and his group, because it has focused on the important problem of the real effectiveness and costs of treatments for osteoarticular pain, sometimes neglected by health caregivers, but not by patients. Besides manipulative therapy, that is a relative short treatment (in my ambulatory a complete treatment last not more of 20-30 minutes for 3-4 treatments) can also: a. reduce risks of complications due to administration of NSAID’s and
corticosteroids;
We too are conducing a clinical trial on so called hard workers, over forty years of age, undergoing vertebral manipulation for neck, dorsal, lumbar and sciatic pain, quantifying the days of work lost and use of drugs the year before and after treatments. Preliminary data are similar to those of Korthals-de Bos. There is a 40% reduction of absenteeism from work and 70% reduction in drug consumption. My only concerns about the paper are: a. in the general diagnostic assessment of patients at
least the presence or not, of co-existing neurological symptoms, often
associated with neck pain, could be specified;
Clinical Center of Natural Medicine
Competing interests: None declared |
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Don Nixdorf, D.C., Executive Director, British Columbia Chiropractic Association British Columbia Chiropractic Association, 125-3751 Shell Rd. Richmond, B.C., V6X 2W2
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This article provides information that continues the understanding of outcomes and cost effectiveness associated with the treatment of spine related injuries. It is interesting to note the article seeks to classify physical therapist and general practitioner and selectively omits chiropractors in its title and major headings. Chiropractic practitioners are the primary profession the public has historically sought for manual therapy (spinal adjustment)for spine and related conditions. Manual therapy of the spine is a primary core competence during the education and ongoing expertise of chiropractic doctors. It should be noted that there are substantive differances in the core competence and expertise of professions legally permitted to provide this treatment. Applicable health law authorizes professions and its members to provide treatment but does so without regard to the varying competence of the members of the different professions, a matter for informed consent. What value does the omission of chiropractic practitioners provide the reader? Competing interests: None declared |
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Dimitrios I. Stasinopoulos, Ph.D student School of Health and Human Sciences, Leeds Metropolitan University, Prof. Mark I. Johnson
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Dear Editor-Manual therapy is component of physiotherapy. Our experience has shown that almost all physiotherapists receive manual therapy training during their studies. In addition a large proportion of physiotherapists attend courses and seminars to further develop manual therapy "skills". However, the great disadvantage of manual therapy is in research. For example, Cyriax physiotherapy for Lateral epicondylitis (Tennis elbow and / or lateral epicondylalgia) when the affected site is the ECRB tendon consisted of deep transverse friction (transverse friction massage) and Mill's manipulation. When a trial is conducted to investigate the effectiveness (relative or absolute) of Cyriax physiotherapy on LE, apart from possible methodological shortcomings such as small sample size, lack of statistical power and etc, the following issues usually exist: 1) lack of standardisation of the treatment protocol during the treatment course; 2) blinding of patients and therapists is problematic; 3) the one- to-one practitioner-patient relationship cannot be ignored; and 4) the experience of practitioner. The above, individually or in combined, might be overestimated the results of manual therapy-in this case the Cyriax physiotherapy-provided with "problematic" quality studies. However, is it possible to avoid the above four issues in research with manual therapy? It is impossible, in order to maximise the effectiveness of manual therapy. Therefore, in manual therapy high-quality RCTs have to be conducted avoided methodological shortcomings such as small sample size, lack of statistical power, invalid outcome measure and etc. Dimitrios Stasinopoulos Physiotherapist, M.Sc, research student, Cert. Clin Ed., PGCRM, Cert Orth Med (Cyriax) /Rheumatology and Rehabilitation Centre, Athens Greece/ School of Health and Human Sciences, Leeds Metropolitan University, Leeds, U.K. Prof. Mark I. Johnson B.Sc, PhD, PGCHE, Principal Lecturer in Learning, Teaching and Assessment (Human Physiology), School of Health and Human Sciences, Leeds Metropolitan University, Leeds, U.K. Competing interests: None declared |
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Nick T L Southorn, Student Physiotherapist Manchester Metropolitan University
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This article gives the wrong impression about physiotherapy. During physiotherapy treatment the clinician may choose to use, amongst other treatment modalities, exercise and / or manual therapy where indicated. This is standard treatment by physiotherapists in the UK and many other areas of the world. What this article appears to prove is that physiotherapy is a more effective treatment and more cost efficient compared to GP care. Competing interests: None declared |
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