Rapid Responses to:

PAPERS: Helen Frost, Sarah E Lamb, Helen A Doll, Patricia Taffe Carver, and Sarah Stewart-Brown Randomised controlled trial of physiotherapy compared with advice for low back pain BMJ 2004; 329: 708 [Abstract] [Full text]

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Rapid Responses published:

Ooooops, is most treatment unnecessary intervention?

Dr. Herbert H. Nehrlich   (25 September 2004)

What about the early benefits of physiotherapy?

Roderick D D Duncan   (25 September 2004)

NHS physiotherapy systems will not prevent back pain disability

Jeremy G Jones   (25 September 2004)

Important information missing from the published article

Garth Robertson   (27 September 2004)

Good advice is often the best treatment

jon norman   (27 September 2004)

RAPID ACCESS TO PHYSIOTHERAPY

Christopher W IDE   (27 September 2004)

Answer - Refer to Chiropractors

Glenn F. Gumaer   (27 September 2004)

Evidence in the making

Saravana Kumar   (27 September 2004)

Don't throw the baby out with the hydrotherapy!

Rajashekhar M. Reddy, Andrew Severn, Consultant   (27 September 2004)

Re: Answer - Refer to Chiropractors

Mark Potter   (27 September 2004)

"Physiotherapy better to be talked about than not at all"

Malcolm J Philp   (27 September 2004)

Nothing new, but what really are the mechanisms of back-pain?

Jarkko O. Kause,DC   (28 September 2004)

Magnesium deficiency as a cause of back pain

Ellen C G Grant   (28 September 2004)

A complete wash out.

Dr Christopher J McCarthy   (28 September 2004)

What a shame!

John A Mathews   (28 September 2004)

Outcome of physiotherapy, a true reflection of heterogenous data!

Kevin K Wright   (28 September 2004)

Finer measures are required to determine the efficacy of physiotherapy

Venthan J Mailoo   (28 September 2004)

Re: Re: Answer - Refer to Chiropractors

Dr. Glenn F. Gumaer   (28 September 2004)

Good News for Physiotherapists?

David A Jackson   (29 September 2004)

Comparing One Session of Physiotherapy Management Wth Several?

Mary Louise Taylor   (29 September 2004)

Chiropractic biscuits

Richard Bartley   (29 September 2004)

Physios can't cure CHRONIC low back pain.

Dan Doherty   (29 September 2004)

GP-Physio-Team -Methinks we can do better

Dr. Herbert H. Nehrlich   (29 September 2004)

Magnesium is a SUPERNUTRIENT

Dr. Herbert H. Nehrlich   (29 September 2004)

Good study, wrong conclusion

Alfonso Ceccherini-Nelli   (29 September 2004)

Re: Chiropractic biscuits

Jarkko O. Kause,DC   (29 September 2004)

Faster and better results experienced by people who received more physiotherapy

Maria G. Judd   (29 September 2004)

Misleading title biases interpretation

J. Haxby Abbott, University of Otago, Dunedin, New Zealand   (29 September 2004)

Manage or cure?

Christopher Stuart, DC   (29 September 2004)

Re: Good study, wrong conclusion

Dr. Herbert H. Nehrlich   (29 September 2004)

Be careful what you infer

Michael Poling   (30 September 2004)

Physiotherapy for Back Pain

Malcolm IV Jayson   (30 September 2004)

Re: Answer - Refer to Chiropractors

Richard J Nash   (30 September 2004)

Here, have some back treatment - cheers!

adrian wagstaff   (30 September 2004)

Back pain patients and Psychobabble.

Christopher Stuart, DC   (30 September 2004)

Re: Re: Answer - Refer to Chiropractors

James M. Reynaud   (30 September 2004)

Chiropractic v Physiotherapy

Peter J Ward   (1 October 2004)

More chiropractic biscuits

Richard Bartley   (1 October 2004)

Is Physiotherapy effective for the management of LBP?

Fraser Ferguson, Mike McMenemey, LEad Clinician Greater Glasgow Back Pain Service   (1 October 2004)

Treat Underlying Aetiology

Nick D Critchley   (1 October 2004)

Reply to Nash, Ward

Dr. Glenn F. Gumaer   (2 October 2004)

Move on

Martin Jones   (3 October 2004)

Re: Last chiropractic biscuits

Jarkko O. Kause,DC   (3 October 2004)

Politically acceptable research results ?

Tom A Torstensen, B.Sc (Hons), M.Sc., P.T., specialist in manipulative therapy, M.N.F.F.   (4 October 2004)

Chiropractic & Osteopathy

Corey Watts   (4 October 2004)

Alas further confounding appraisal

Brian Sweetnam   (7 October 2004)

Don't dismiss physiotherapy

Neil Watson   (12 October 2004)

A theory that is refutable can still be charming

Dr. Herbert H. Nehrlich   (13 October 2004)

Publishing responsibilities

Neil Watson   (14 October 2004)

Acupuncture for treatment of low back pain

Janet Boaler   (15 October 2004)

Good assessment and advice by a physiotherapist is as effective as traditional physiotherapy.

Abdolkarim Karimi   (15 October 2004)

Back pain treatment is anything but patient centred!

Murray Flett   (18 October 2004)

Low Back Pain and Physiotherapy

Friederike I.M. von Rabenau   (23 October 2004)

Targeting ‘physical factors’ alone is not evidence-based practice

Maureen Simmonds, Anne Daykin, PPA Scientific Officer   (16 November 2004)

Important Oversight

Tom Caumont   (9 December 2004)

Physiotherapy and low back pain

Meir Lotan, Joav Merrick   (23 December 2004)

Proper Title: Trial of NHS Physiotherapy compared with advice for LBP

Brad S Stevens   (10 October 2005)

Ooooops, is most treatment unnecessary intervention? 25 September 2004
Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507 Send response to journal: Re: Ooooops, is most treatment unnecessary intervention?	This paper misses the point in an admirable fashion. First, why would they concentrate on physiotherapy, leaving all other treatment methods for low back pain on the sidelines? If I had low back pain I would, after ruling out the more obvious medical causes, consult with a chiropractor or an osteopath, preferably one who doesn't frequent the 'Practice Management Seminars'. Most low back pain is caused by mechanical stresses and I would think that this, more often than not, would be a mechanical problem. Therefore, physiotherapy would be my last choice. It has been proven beyond any reasonable doubt that chiropractic is the treatment of choice for low back pain but I do see the authors' caution in mentioning the very name 'chiropractic'. Physiotherapy is more politically correct. Another interesting fact (which doesn't enhance the paper) is the fact that the majority of low back pain resolves itself within an average of 8 weeks. The paper describes people who have had a minimum of six weeks' duration for their pain, so a good talking to (remember pain is an emotion after all) by a sympathetic observer may ultimately lead to the status of freedom from pain which would have been reached by then under any circumstances. Does this mean that manipulative treatment is useless? No, not exactly. It means that manipulative treatment would have fixed the problem in much less time, so the patients that endured more than six weeks of misery were not advised as to appropriate treatment.And the disappearance of symptoms does not mean that the illness has been cured. What is useless, it seems to me, is studies like this. I never ceases to amaze me that it is the people who have absolutely no 'hands-on experience' are the ones who conduct and write up studies of hands-on experience. Competing interests: None declared
What about the early benefits of physiotherapy? 25 September 2004
Roderick D D Duncan, Consultant Orthopaedic Surgeon G61 2ER Send response to journal: Re: What about the early benefits of physiotherapy?	This paper is very welcome, and I suspect will be quoted in many an Orthopaedic out-patient clinc for years to come. I accept the need for brevity when publishing in the BMJ, but note that pain relief (as well as mental health) in the treatment group was significantly better at two months than in the control group (noting the findings when the disability scores were analysed). Is this not important and did it lead to a more rapid return to work? Would the authors care to comment on whether they think that the increase in physical function and mental health at two months, and the improved 'role emotional' at twelve months may suggest that the intervention is worthwhile despite the lack of clear difference between the groups at 12 months. The question of whether the intervention is cost-effective not only to the individual, but to society as a whole should not be overlooked. Competing interests: None declared
NHS physiotherapy systems will not prevent back pain disability 25 September 2004
Jeremy G Jones, Consultant Rheumatologist Dept of Rheumatology, Ysbyty Gwynedd, Bangor LL57 2PWedd, Send response to journal: Re: NHS physiotherapy systems will not prevent back pain disability	This study is well worth doing because it assesses the efficacy of physiotherapy as it is served up in the NHS for the treatment of back pain. This does not allow analysis of ideal physiotherapy which is an intervention that should be carried out within a day or two rather than after a few weeks. It should be provided by the same experienced professional with competence in spinal therapy. These ideal conditions can very rarely be met by NHS physiotherapy systems. Thus it is hardly surprising that "pure" physiotherapy which is the NHS's response to back pain has no influence on disability levels at twelve months. I should emphasise that this is not a criticism of the individual NHS physiotherapist for whom I have the highest regard. We should not be surprised that a therapy which is "focussed on physical factors" should fail in low back pain when we look at the evidence. We are appreciating that psycho-social factors are of more importance than medical factors in predicting the disability and chronicity associated with back pain (ref 1). A systemic review of psychological risk factors in back and neck pain has shown level A (two or more good quality prospective studies) evidence for the link between psychosocial variables and the transition from acute to chronic pain disability, and for the presence of cognitive factors as risk factors for pain and disability (ref 2). Practitioners in New Zealand have been aware of this for some years and have methods of identifying those at risk of long term pain and disability using the yellow flag system (ref 3). This system sets out to identify the psychosocial risk factors for long term disability, distress and work loss early in the course of rehabilitation. Such psychosocial predictors of poor outcome include beliefs that back pain is harmful or severely disabling; fear-avoidance behaviours and reduced activity levels to avoid anticipated pain; a tendency to low mood and social withdrawal; and an expectation that passive treatments rather than active participation will help.Of course isolated physical therapy will have no influence on these factors. So to one who has spent much of his career in New Zealand working as a musculoskeletal rehabilitation specialist in a multidisciplinary team, it is no surprise that physiotherapy in isolation for back pain is ineffective; let alone physiotherapy as offered by NHS systems. There is a pressing need for the NHS to stop providing ineffectual care in departmentalised silos which concentrate on outputs rather than outcomes and to identify those patients with musculoskeletal pain who are in danger of long term disability. This is simply done by using the New Zealand Yellow Flag questionnaire(ref 3). It is these patients upon whom the NHS's resources should be focussed and the service should be firmly bio-psycho-socially based, should use a rehabilitation model and must be rapidly accessible. Physiotherapy has a much greater chance of being shown to be effective in this setting than when it is physically focussed and provided in isolation. Jeremy G Jones Ref 1 Cats-Baril WL, Frymoyer JW. Identifying patients at risk of becoming disabled because of low back pain: The Vermont Rehabilitation Engineering Center predictive model. Spine 1991; 16: 605-7. Ref 2 Linton SJ. A review of psychological risk factors in back and neck pain. Spine 2000; 25: 1148-56 Ref 3 Kendall NA, Linton SJ, Main CJ. Guide to Assessing Psychological Yellow Flags in Acute Low Back Pain; risk factors for long- term disabilty and work loss. Wellington. National Health Committee/ACC, 1997. Competing interests: I am a rheumatologist working in a trust which is using innovative ways to provide musculoskeletal services.
Important information missing from the published article 27 September 2004
Garth Robertson, Associate Specialist in Musculoskeletal medicine Andover War Memorial Hospital. SP10 3LB Send response to journal: Re: Important information missing from the published article	Before coming to hasty conclusions, I urge all to read the full un- abridged version of the article. The patients were chronic back pain sufferers: 85% had had previous treatment (details unspecified.) Over 50% had had back pain for more than six years, or put another way, only 26% had a history for less than one year. Little surprise then that "hands on" therapy was a waste of time other than in the early weeks or months. Out of 508 patients assessed for eligibility for the study, 222 were excluded. The reason for exclusion of 178 of these was "not specified." This means that data on 35% of the population used in the study is undocumented. 76 Physiotherapists were involved in the treatment of 286 patients. There is no information given about their professional seniority or level of experience. Any conclusions drawn from this trial must be tempered with caution, and not used to inform management strategies for back pain in Primary Care. Competing interests: Musculoskeletal physician within a multidisciplinary spinal pain assessment and management service in Andover.
Good advice is often the best treatment 27 September 2004
jon norman, SpR anesthetics and pain north manchester general hospital m8 5 rb Send response to journal: Re: Good advice is often the best treatment	EDITOR-Frost et al have managed to produce a well controlled trial on back pain. For this they should be congratulated. I am worried though that the non specialist will conclude that no therapy is effective for back pain other than surgery. Their control group was not a no treatment group. Pain physiotherapists and psychologists will tell you that convincing patients that further pain does not indicate further damage is a powerful, but difficult therapy to administer. Time needs to be set aside to gain patient trust in order to achieve this, which would appear to be exactly what the control group received in this study. The message that hurt does not mean harm needs reinforcing. The mithical dogma that acute back pain equals ruptured disc leading to resting and then on to deconditioning, loss of function, fear of movement, distress and chronic back pain is believed by most patients and some therapists. Encouraging continued movement and patients to be active in thier own rehabilitation is stressed by the authors, but may be missed by readers. Competing interests: None declared
RAPID ACCESS TO PHYSIOTHERAPY 27 September 2004
Christopher W IDE, Medical Adviser Strathclyde Fire Brigade Headquarters, Bothwell Road, HAMILTON, ML3 0EA Send response to journal: Re: RAPID ACCESS TO PHYSIOTHERAPY	Further to the responses of Mr Duncan and Dr Jones, I work in occupational medicine. In 1997, my employers funded a trial of rapid access to a local private physiotherapist who had an interest in sports injuries. The physio agreed to see all referrals within three working days. Using very conservative estimates, we were able to demonstrate that, for every £1.00p invested in the service, we benefitted by almost £2.00p in terms of earlier return to work. The average number of treatments required was 3.8 per patient episode, the range from 1 - 12. Competing interests: None declared
Answer - Refer to Chiropractors 27 September 2004
Glenn F. Gumaer, Chiropractic Physician 97501 Send response to journal: Re: Answer - Refer to Chiropractors	Greetings: There is a real answer. Refer your patients to chiropractic physicians. Chiropractic physicians have significantly better training in the neuromusculoskeletal arena, and provide a unique treatment that physically restores joint function to correct the conditions that create the symptom, instead of masking symptoms, as allopaths do. Your referral will reflect well on your ability to manage such cases, as your patient's satisfaction with the treatment they receive will most certainly be improved. There is much evidence in the medical literature that supports the effectiveness of manipulation (chiropractic adjustment) for lower back pain. After 109 years, chiropractic has become "main stream" and is not an "alternative" therapy by virtue of its proven effacacy. This issue should have been put to bed long ago, but allopaths keep shooting themselves in the foot when they prescribe muscle relaxants and pain killers, and refer to physical therapists for further ineffective therapy. They have created a subculture that has come to realize that medicine does not have the answer for the most common presenting complaint. That subculture is growing...rapidly. So, please do yourselves a favor, and refer to chiropractors. Cordially, Dr. Glenn F. Gumaer Chiropractic Physician References with regard to chiropractic vs. medical education, patient satisfaction, and efficacy are available upon request. Competing interests: None declared
Evidence in the making 27 September 2004
Saravana Kumar, Doctoral candidate School of Health Sciences, University of South Australia, Adelaide, SA 5000 Send response to journal: Re: Evidence in the making	Dear Sir/Madam, Firstly may I take this opportunity to commend the work undertaken by Frost et al in producing and publishing this research? In this era of shrinking funding for health care services, increasing accountability to all the stakeholders in the health care profession and hence the need to justify the services provided, I believe Frost et al have undertaken the first steps in answering some key questions. As Albert Einstein said “The most important thing is not to stop questioning”, and this study has questioned routine treatment program commonly undertaken in many rehabilitation clinics/private practices for low back pain. The authors should also be congratulated for the rigour in the methodology of their research, as proven when critically appraised by PEDro (http://www.pedro.fhs.usyd.edu.au/CEBP/), a critical appraisal tool for Randomised Controlled Trial, their research and its subsequent reporting scoring reasonably well. Nevertheless, I would like to address some key issues as highlighted by this research. My concerns are: (1). Misleading title: The title of the manuscript indicates “Randomised controlled trial of physiotherapy compared with advice for low back pain”. This seems to indicate that the research compared routine physiotherapy care with advice alone. However, in the very next sentence, the authors have highlighted that the study compares “routine physiotherapy” with “advice from a physiotherapist”. Do the authors believe that advice is not part of routine physiotherapy? (2). Information on intervention: This research again has highlighted a commonly encountered problem with most physiotherapy research publications, lack of sufficient information on the intervention programs. The manuscript states that “patients in the advice only group……general advice to remain active” and “patients in the therapy group……a treatment strategy based on their findings”. As a clinician, how am I meant to translate this scanty information to my clinical practice, when all the information I am given is just that the treatment found most effective was “general advice to remain active”? Do I, as a clinician, have enough information to confidently, translate information about the treatment which was ineffective (manipulation, mobilisation, soft tissue techniques and spinal mobility and strengthening exercises) and treatment which was effective (general advise). The answer is NO! (3). Package of care: Physiotherapists, especially in the treatment of musculoskeletal conditions, often undertake a multitude of treatments in one occasion of service. While the composition of the treatment might vary, depending on the subjective and objective findings on each occasion, the treatment will encompass varying treatment techniques within one occasion. This is common Physiotherapy practice and by prescribing a specific regime, the nature of physiotherapy care is varied. Furthermore, I note that, the Therapy group also were provided with “advice”. How was this “advice” different, if at all, to the “advise only” group? Again we cannot come to a conclusion primarily due to lack of adequate information. (4). Insufficient numbers: The researchers note that “30% of the patients failed to provide data for the main outcome at 12 months”. The numbers of non-respondents at 12 months is excessive (statistically it is imperative to have >85% as opposed to 70%) in order to come to an scientifically defensible conclusion. Given that low back pain has a high reoccurrence rate, this lack of information opens sufficient doubts regarding the credibility of the results for the long term. I once again quote Albert Einstein when he said “Insanity: doing the same thing over and over again and expecting different results”. The most difficult step in improving practice is identifying what is best practice. This requires soul searching and questioning theories and practices taught over decades in many schools across the world. These researchers have attempted to do that and hence need to be commended for these first, but important steps. While their research has limitations (which research doesn't?), its results does support many current thought process within the Physiotherapy professions and adds strength to the argument of education and empowerment of the patients in their management of their problem. While these initial steps are arduous and laden with criticisms, I urge the researchers to continue and further improve their work in producing thought provoking and constructive research. Competing interests: None declared
Don't throw the baby out with the hydrotherapy! 27 September 2004
Rajashekhar M. Reddy, Specialist Registrar Dept. of Pain Management, Royal Lancaster Infirmary, LA1 4RP, Andrew Severn, Consultant Send response to journal: Re: Don't throw the baby out with the hydrotherapy!	The trial compares conventional physiotherapy with a single session of advice. It is a trial of two different physiotherapy philosophies rather than a controlled trial. The routine physiotherapy group received only a median number of five sessions, with 82% having six or fewer. The process of "Change of Behaviour" in patients with back pain may take many sessions. A few sessions using conventional techniques of physiotherapy may not change the attitudes of the patients towards promoting exercise. There is a possibility that this study may convince doctors and patients and even journalists that physiotherapy is not beneficial. Surely 'advice' given by a physiotherapist is physiotherapy in the same way that 'advice' given by a doctor is still medicine? The accompanying editorial, in particular the headline and the wording of the summary are misleading. Let us not throw away the baby with the bath water! Competing interests: AS does not want to lose his physiotherapy service.
Re: Answer - Refer to Chiropractors 27 September 2004
Mark Potter, Manipulative Physiotherapist in Private Practice Worthing BN11 1QA Send response to journal: Re: Re: Answer - Refer to Chiropractors	In response to Dr. Gumaer's comments: "Chiropractic physicians have significantly better training in the neuromusculoskeletal arena" - I think it fair to expect all musculo-skeletal therapists should know their specific field in more detail than a general physician. "There is much evidence in the medical literature that supports the effectiveness of manipulation (chiropractic adjustment) for lower back pain." - Manipulation has been practiced for at least 2000 years, chiropractic for 109 years, therefore chiropractic uses manipulation but manipulation is not just carried out by chiropractors. "..........and refer to physical therapists for further ineffective therapy.................... So, please do yourselves a favor, and refer to chiropractors." - I was under the impression that chiropractors were physical therapists, alongside osteopaths and physiotherapists. A good physical therapist (regardless of the "flavour" of training) should be able to help these patients regain functional activity sooner than those who do not receive active treatment. Competing interests: None declared
"Physiotherapy better to be talked about than not at all" 27 September 2004
Malcolm J Philp, Associate Director NMPCT North Manchester Send response to journal: Re: "Physiotherapy better to be talked about than not at all"	The debate and prejeudices expressed in the various rapid responses are almost as entertaining as the article itself. I am not an academic so find it hard to comment on the strengths and weaknesses of the study. However I did see Ceefax the night it hit the press and the message stood out loud and clear. "Physiotherapy does not cure back pain" No detailed explanation of the pros and cons of the study no background analysis, of what was done to who or the history of the population studied. In fact the point that this study explored one physiotherapy intervention being compared to another would have passed me by had I not read the full article in BMJ. We know to our cost in healthcare that shorthand version of medical studies can create all sorts of problems once the popular media pick up on the story.(See MMR, etc etc) Wheter or not this particular study will turn out to have been beneficial for the long term care of those with back problems, time will tell. But at least for once physiotherapy is at the heart of the debate and the profession will be stronger I think for the experience. Competing interests: Manager of a variety of Allied Health and Rehab services including community physiotherapy (Which everyone seems to want a piece of)
Nothing new, but what really are the mechanisms of back-pain? 28 September 2004
Jarkko O. Kause,DC, Health coach, DC-chiropractor, nutritionist, trace mineral specialist, licenced gym instructor Private practice, Tapiolan keskustorni, 1.krs., 02100 Espoo, Finland Send response to journal: Re: Nothing new, but what really are the mechanisms of back-pain?	Sorry for the physiotherapists` public image, but this study in question is perfectly in line with a massive empirical experience that we millions of health-care professionals throughout the world experience every day, while interwieving our new patients. 99% the same story to tell; "physiotherapy was a waste of time". And the few ones, who tell something positive about physiotherapy, probably would have got better just by waiting anyway. Feeling better has so much to do with just time passing on( body`s automatic healing ) and with the feeling that somebody is taking care of me as a patient as well. Here in Finland, as in most other western countries, the situation is based upon general practitioners´ prescription "order" to receive physiotherapy for patients`low back pain. Physiotherapists don`t have the right nor the adequate knowledge to diagnose the cause of low back pain. But do general practitioners have this highly specialised skill to diagnose the complex entity of back pain? - To my opinion, no. How about more educated doctors, e.g. orthopaedic surgeons etc.?- The answer, unfortunately, in the vast majority of cases is still no. This is supported also by numerous medical doctors of whom I know personally, and who are my clients as back pain sufferers. Chiropractors who have a university education for their profession are most highly skilled in diagnosing low-back pain conditions. Their treatment for low-back pain has been shown to be cost-effective in numerous clinical studies. Patient satisfaction scores have beaten the competitors every time as well. We know though, that there are always patients that don`t get better. Usually then the problem is based more or less on a major structural-functional anomaly or degeneration, biochemical imbalance of the body or both. some of these conditions we can alleviate, some not. We know, that most low back pain episodes fade away if not within a few days or weeks, at least within 2-3 months, with no treatment. Some cases tend to remain chronic, though. But is there any sense from tax- payers` view-point to treat pain sufferes with a treatment modality that has not securely been proven cost-effective by any standards?- If one calculates how much time and money has to be spent for a physiotherapy treatment course of e.g. 15 visits, the sum is amazingly high. The psycho- social factors behind back-pain are important, but to my experince, count only for a relatively small group of patients, as a part of a more complex entity of causative agents. What has come more evident with my personal experience of round 12 thousand patients until today, is that there more often are multiple factors behind patients pain. We probably still don`t know all the contributing factors for back pain, but there has been some progress during recent years in understanding this remarkably disabling health- problem. What really is interesting is the realtionship between back pain and psycho-social behaviour, from a biochemical view-point. Numerous recent studies have shown that nutrition plays a vital role in many pain-related conditions. Of course we can not forget all the other possible causes of pain, like genetic predisposition, structural- functional anomalies( of which the disc degeneration is by far the most common cause of inflammatory and acute structural low-back pain ), stress, ergonomy, exercise, the amount of sleep, traumas, repetitive injury etc. What do you think, does the patient have any chance of getting a quick pain relief if his/her inflammatory lab values are exceptionally high?- Does adipose tissue make us more prone to "silent inflammation" in the whole body?-Including the brain. As researchers say today, we may have a situation where our brain is "on fire", as well as the rest of the body, if we eat incorrectly. That is to say we tend to get psychological problems as well as pain conditions more and more in conjunction with each other, if our functional biochemical state is out of line. The use of too much carbohydrates in general is the bad thing. Especially the ones which do have a high glycaemic index(GI). When we eat this food- stuff in excessive amounts, we get a rapid rise in blood sugar level, and a couple of hours later a rapid decrease. Blood sugar going up and down on a regular basis, builds up adipose tissue, which has shown to be a secretory organ, instead of a passive energy store. Fat tissue secretes pro-inflammatory cytokines, namely IL-1, IL-6 and TNF-alfa. This leads to an increased risk of pain conditions anywhere in the body. Logically the inflammatory hot-spot tends to make it`s nest to the weakest or most stressed points in the body. Even slightly degenerated intervertebral disc is a good example of this kind of weak point. If, in addition to degeneration, the patient with low back pain is not exercising or moving in any way, the biochemical state of the intervertebral disc will become more prone to inflammation. This all is true also for slim patients, not surprisingly. Some patients may be suffering from low-back pain of severe intensity, for weeks or months. Many of them may become depressed, angry and hopeless because  they can`t do anything. So they eat sweet biscuits, because "I thought I have to eat at least something; I do not want to eat anything else, don`feel hungry". In fact they are doing harm with this mixture of sugar and wheat/chocolate- biscuit and not eating properly, both to their brain-chemistry( giving rise to depression ) and to their low-back inflammation. In this kind of situation physiotherapy does not help other than what it may give psychologically some support to patients. These kinds of patients usually will be cured most rapidly by a combination of chiropractic manipulation for the verterbrae that may be completely blocked in the low-back to improve lymph and blood circulation in the area, and a complete change in the diet. Patients should stop eating biscuits at once and start eating a balanced Zone-type diet, plus taking high doses of Omega-3-fish-oil-capsules to fight the inflammation off. Patients should get advice to start walking more and more as the condition gets better. In one week the patient may be back to work. Instead of doing this, if these patients would start a course of physiotherapy, they would be still having their low-back-pain for weeks if not months to come. There is no doubt about it. I have seen this thousands of times during my career. These kinds of positive therapeutic examples of other than physiotherapy treatment are numerous, but still in the mainstream health- care are mostly overlooked and sometimes even ridiculed. We still have, unfortunately, a big problem with how the health-care-sector works in the first place. Medical industry wants their part as well, being by far the strongest financial leader in the health-market. That is something we have to think about: what is also financially reasonable and what is not?- Do we have too much money to throw it out of the window, or are we missing something? Physiotherapy is, to my opinion at it`s best in rehabilitating trauma -patients, e.g. after a car-accident or some other trauma. Rehab for handicapped people as well is a superb treatment of choice in many cases. Working with athletes is well worth doing, as they need constant care in trying to manage their career in the jungle of injuries. But in treating acute or chronic low-back pain( or other musculo-skeletal pain ), unfortunately it is completely useless. Competing interests: None declared
Magnesium deficiency as a cause of back pain 28 September 2004
Ellen C G Grant, physician and medical gynaecologist 20 Coombe Ridings, Kingston-upon-Thames, KT2 7JU, UK Send response to journal: Re: Magnesium deficiency as a cause of back pain	EDITOR- One of the main causes of chronic idiopathic back pain appears to be magnesium deficiency which would not necessarily respond quickly to either general advice or physiotherapy. Deficiency of this essential bulk mineral can be related to impaired muscle function by the use of a myothermogram. This test, first described by Dr John McLaren Howard in 1989, uses sensitive temperature recording equipment in a clinical test of muscle action.1 Dr Howard wrote that in the subcellular events responsible for muscle contraction the biochemical energy utilized must equal the energy output of the system and this is essentially the external work done plus the heat energy produced. The external work can be limited so that a plot of the heat produced during contraction and relaxation should reflect the subcellular chemistry. The limiting factors are the difficulty of detecting very small temperature changes and the efficient way in which muscle heat is conducted away by the circulation. The myothermogram demonstrates abnormalities of potential diagnostic significance in deficiencies of magnesium, calcium, iron (in children),manganese and folate. The test also detects reduced oxygenation or perfusion and abnormal results are seen in thyroid disorders. It shows that muscle damage can result from exercise during magnesium deficiency,which can also be diagnosed by analyses of magnesium levels in sweat and red blood cells. It is easy to imagine how mechanical back problems can occur when muscle are contracting irregularly, as demonstrated by irregular patterns on a myothermogram. In some patients magnesium may be difficult to replete, especially if the patient has absorption problems, hypochlorhydria or selenium deficiency. However, verified successful repletion of magnesium is usually accompanied by resolution of idiopathic back pain in my experience and that of others.2 1.Howard J. Muscle Action, Trace Elements and Related Nutrients: The Myothermogram. In: Chazot G, Abdulla M, Arnaud P, eds. Current Trends in Trace Element Research: Proceedings of International Symposium on Trace Elements. Paris, 1987, Smith-Gordon, London, 1989, pp79-85 2. Vormann J, Worlitschek M, Goedecke T, SilverB. Supplementation with alkaline minerals reduces symptoms in patients with chronic low back pain. J Trace Elem Med Biol. 2001;15(2-3):179-83. Competing interests: None declared
A complete wash out. 28 September 2004
Dr Christopher J McCarthy, Research officer for the Manipulation Association of Chartered Physiotherapists The Centre for Rehabilitation Science, Manchester Royal infirmary, Manchester, M13 9WL Send response to journal: Re: A complete wash out.	Dear Sir, It is a shame that another low back pain study has failed to address a primary recommendation in the field of low back pain research, namely the problem of washed out effects due to the heterogeneity of low back pain(1). Again, we are left with decidedly under whelming results. Patients with low back pain and low back and leg pain are a hugely heterogeneous group. The biopsychosocial characteristics of patients with non-specific low back pain (NSLBP) are so disparate that there has been the strongest recommendation to address the issue of the sub- classification of low back pain(1). It is well recognised that in clinical trials with heterogeneous samples treatment effect sizes can be reduced as the large effects evident in some patients are countered by the small effects in others. By establishing homogenous sub-groups of patients within NSLBP it has been suggested that this “wash-out” effect will be reduced and more effective treatments for certain “types” of NSLBP established(2). This study made no attempt to address the issue of heterogeneity within the study sample and compounded the wash out effect by providing an extremely heterogeneous intervention. As a result we can only be left to conclude that in NSLBP patients in general, spending an additional hour and a half in the company of a physiotherapist leads to no additional improvement in disability 12 months after the cessation of contact. I don’t think many of us would be that surprised at that outcome. There is the most urgent need for physiotherapists to accept that treatment effect sizes in this field will continue to appear small unless trial design includes the sub-grouping of NSLBP into valid sub-categories. Until these sub-categories are established we will continue to see under whelming findings reported in the literature. Whilst this study has shown some benefit for these two interventions, with subjective and short-term improvements, it is only a matter of time before the resources needed to produce such small effects will be strongly questioned. Physiotherapists spend many years developing specialised skills in the assessment of patients with NSLBP. Expert clinicians, such as members of the Manipulation Association of Chartered Physiotherapists have been shown to identify patterns of presentation quickly(3;4) and accurately and consider this process of clinical reasoning to be vital. Let us recognise that this process of sub-categorisation occurs and develop valid sub- categories within NSLBP before more under whelming research is reported. Reference List (1) Borkan J, Koes B, Reis S, Cherkin D. A report from the second international forum for primary care research on low back pain. Spine 1998; 23(18):1992-1996. (2) McCarthy CJ, Arnall FA, Strimpakos N, Freemont AJ, Oldham JA. The bio -psycho-social classification of non-specific low back pain: A systematic review. Physical Therapy Reviews 2004; In Press. (3) King CA, Bithell C. Expertise in diagnostic reasoning: a comparative study. British Journal of Therapy and Rehabilitation 1998; 5(2):78-87. (4) Doody C, McAteer M. Clinical reasoning of expert and novice physiotherapists in an outpatient setting. Physiotherapy 2002; 88(5):258- 268. Competing interests: None declared
What a shame! 28 September 2004
John A Mathews, Physician, Musicians' Clinic, Department of Rheumatology, St. Thomas' Hospital, London SE1 7EH Send response to journal: Re: What a shame!	Another paper has appeared whose title gives an unequivocally negative message about physiotherapy for back pain. It omits mention of sub-groups where physiotherapy has shown to be helpful. e.g. twice as many patients with back and leg pain are , other things being favourable, back at work the week after manipulation than are controls. John Mathews ref:Mathews J. A. et al. British Journal of Rheumatology,1987. 26, 416 - 423 Competing interests: None declared
Outcome of physiotherapy, a true reflection of heterogenous data! 28 September 2004
Kevin K Wright, clinical specialist in spinal conditions (Physiotherapy) Pennine acute hospitals NHS Trust, OL12JH Send response to journal: Re: Outcome of physiotherapy, a true reflection of heterogenous data!	As both a clinician with 10 years practical spinal experience at a senior level and being involved in acute back pain research I agree with the paper on the following points. The sample reflects the mixed group we see in the NHS. Helen Frosts research included a subacute group (6 - 12 weeks), with 23% in the therapy group and the 25.5% in the advice only group. The majority were chronic 77% of the therapy group and 74.5%of the advice only group. 90% of patients recover spontaneously within 6 weeks, thus this research avoided this group but the question evaluated also the most chronic group. The many subgroups of physiotherapy treatment in the therapy group along with the mixed experience and training that the large physiotherapy population is common in the NHS. Alessandro (2004) in a recent review indicated that even with specific subgroup of chronic discogenic patients where they are assessed and treated by a direction of preference used by experienced and trained mckenzie practioners produced a centralisation effect in 52% of chronic patients distal symptoms. As a clinical specialist clinical effectiveness is promoted but outcome measures are difficult for most clinicans to intrepretate. To identify the sub group in clinical practice reaching a high level of clinical effectiveness would require a multitude of predictive and outcome measures to formulate a possible indication of clinical outcome with experience. In practice mild or moderate back pain is difficult to define as there are differing components of their problem i.e. psychosocial, disability or pain. I consider it positive that despite variable levels of professional experience and type of back pain that there was patient perceived benefits for either intervention on the NHS. This paper will encourage through its debate professionals to review their current practice. Alessandro A, The centralization phenomenon of spinal symptoms—a systematic review. Manual Therapy, 2004 Aug, Vol:9(3), 134-43. Competing interests: None declared
Finer measures are required to determine the efficacy of physiotherapy 28 September 2004
Venthan J Mailoo, Student Occupational Therapist Brunel University, Borough Road, Isleworth, Middlesex TW7 5DU Send response to journal: Re: Finer measures are required to determine the efficacy of physiotherapy	In my opinion the Frost el al (2004) paper is not a valid indication of the efficacy of physiotherapy for back pain in general for the following reasons: - 26 patients from the advice group were given extra sessions, in some cases because the physiotherapists felt it was unethical to withhold treatment(Frost el al 2004). If these people had been given one session of advice only, they may have altered the statistics - 74% of the sample had had back pain for more than a year (Robertson 2004). Psychosocial interventions are more important for chronic samples like this. - The median number of sessions in the physiotherapy group was 5 (Frost el al 2004). Perhaps this is not realisitic for people who have had back pain for over a year. - The Oswestry disability index is a subjective measure of function relative to pain (Fairbank and Pynsent 2000). The influence of psychosocial interventions is therefore likely to appear far greater when this measure is used. It is a valid measure of function but not of impairment. The absence of pain does not indicate a person has fully recovered from an injury, and similarly, persistance of pain does not indicate total absence of recovery. - The research methodology was not sensitive to speed of recovery within the first two months of treatment (Duncan 2004). In short, the study carried out by Frost et al (2004) only suggests that chronic low back pain patients that physiotherapists are prepared to advise but leave otherwise untreated are likely to show recovery if checked at a two-month period, similar to those who have received physical treatments. I do not believe any other conclusions are valid. The national press should therefore be ignored. References Duncan R.D.D. (2004) What about the early benefits of physiotherapy? Rapid Responses http://bmj.bmjjournals.com/cgi/eletters/329/7468/708#75668 Fairbank JC, Pynsent PB. (2000) The Oswestry Disability Index. Spine 25:2940-2953 Frost H., Lamb S.E., Doll H.A., Carver P.T., Stewart-Brown S. (2004) Randomised controlled trial of physiotherapy compared with advice for low back pain BMJ; 329: 708-0 Robertson G. (2004) Important information missing from the published article. Rapid Responses http://bmj.bmjjournals.com/cgi/eletters/329/7468/708#75668 Competing interests: None declared
Re: Re: Answer - Refer to Chiropractors 28 September 2004
Dr. Glenn F. Gumaer, Chiropractic Physician Medford, OR 97501 Send response to journal: Re: Re: Re: Answer - Refer to Chiropractors	In response to Mark Potter: Mr. Potter writes: - I think it fair to expect all musculo-skeletal therapists should know their specific field in more detail than a general physician. Answer: The general physician, as gatekeeper, needs better training in NMS conditions, and better understanding about chiropractic care, so that more appropriate referrals may be made. Chiropractors receive 3,768 classroom hours of graduate-level education and 894 hours of internship in outpatient clinics. The physical therapists’ total class hours are 1,356, with an internship of 1,080 hours. Physical therapists are not trained in diagnosis. The diagnosis is provided to them by referral from general physicians. The reality is that the vast majority of referrals from general physicians, who have a total of about two weeks training in neuromusculoskeletal conditions, go to physical therapists. Mr. Potter writes: - Manipulation has been practiced for at least 2000 years, chiropractic for 109 years, therefore chiropractic uses manipulation but manipulation is not just carried out by chiropractors. Answer: No, chiropractic adjustments have only been performed for the past 109 years. There is a distinct difference between an adjustment and manipulation, as performed by physical therapists and cave dwellers 2,000 years ago. Yes, chiropractors use manipulation and chiropractic physiological therapeutics as part of their arsenal to treat lower back pain. However, chiropractic adjustments and manipulations are distinctly different. Physical therapy manipulations are performed about a joint over a longer duration, allowing fluids to escape muscle compartments as the joint capsule is slowly stretched into the paraphysiological joint space. A chiropractic adjustment moves the joint into the paraphysiological space with a specific amplitude, velocity and direction. The short duration of the adjustive thrust into that space compacts the fluids so that the joint capsule is distracted and cavitation occurs. The therapeutic effect is distinctly different as well. It is unfortunate that the two terms are used interchangeably by some medical researchers, much to the glee of physical therapists, who are not aware of the distinction, but lay claim to its positive outcomes. Chiropractic physicians perform the vast majority of adjustments, or manipulations, that cavitate joint capsules. Besides the 160 hours of training received by osteopathic physicians as elective coursework, Chiropractors are the only physicians trained to perform adjustments. Mr. Potter writes: - I was under the impression that chiropractors were physical therapists, alongside osteopaths and physiotherapists. Answer: A chiropractic physician is trained as a generalist, primary care practitioner during the four year graduate-level coursework of 3,768 hours. Osteopathic physicians and Medical Doctors receive 1,936 and 2,465 hours of graduate-level classroom education, respectively. Mr. Potter writes: - A good physical therapist (regardless of the "flavour" of training) should be able to help these patients regain functional activity sooner than those who do not receive active treatment. Answer: I agree, but please don’t blur the difference between a chiropractic physician and physical therapist by the “flavour” of their training. There is a vast difference. Respectfully, Dr. Glenn F. Gumaer Competing interests: None declared
Good News for Physiotherapists? 29 September 2004
David A Jackson, Research Facilitator The Institute of Rehabilitation HU3 2PG Send response to journal: Re: Good News for Physiotherapists?	One might be led to believe from this paper that physiotherapy is of no value at all in the management of back pain. However, this research is good news for physiotherapists if it encourages them to evaluate practice in order to make the best use of their skills and target them more effectively. These findings are similar to previous work which has arrived at similar conclusions for the management of whiplash injuries (refs 1, 2), namely that a brief intervention, consisting of an assessment plus relevant advice given by a physiotherapist, can be effective in producing long term improvement. A biopsychosocial assessment carried out by a physiotherapist is important in order to expose patient’s fears and beliefs about their pain, which can then be dealt with by giving appropriate evidence-based information. It is also an opportunity to reassure the patient that they have no serious pathology, and to explain that the research evidence suggests that an active self-management approach is most effective (refs 3, 4). Rather than producing a gloomy prognosis for physiotherapists in the NHS, this research should encourage their appropriate use. Perhaps open access to physiotherapists should be the norm, and indeed this is currently being rolled out more widely across the country. This should result in fewer visits to GP’s together with fewer hospital referrals; also, in the long term, fewer visits to physiotherapists. References 1. McKinney, L. A. (1989). "Early Mobilisation and Outcome in Acute Sprains of the Neck. (Whiplash)." British Medical Journal 299: 1006-1008. 2. McKinney, L. A., J. O. Dornan, et al. (1989). "The Role of Physiotherapy in the Management of Acute Neck Sprains Following Road- Traffic Accidents." Archives of Emergency Medicine. 6: 27-33. 3. Klaber Moffett, J. and H. Frost (2000). "Back to Fitness Programme." Physiotherapy 86(6): 295-305. 4. RCGP (1999). Clinical guidelines for the management of acute low back pain (first revision). London, Royal College of General Practitioners. Competing interests: None declared
Comparing One Session of Physiotherapy Management Wth Several? 29 September 2004
Mary Louise Taylor, Orthopaedic Physiotherapy Practitioner North Deon Primary Care Trust, North Devon District Hospital Barnstaple EX31 4JB Send response to journal: Re: Comparing One Session of Physiotherapy Management Wth Several?	This article looks at patients over 6 weeks LBP but doesn't break that down, most LBP patients in their catchment of mild/moderate LBP will start to settle in 6-8/52 so one might expect their functional scores not to be significant after a year. If many of the referrals come in that 6- 8/52 interval they would undoubtedly do as well with advice and reassurrance, however, the more severe patients didn't seem to be caught by this paper and indeed it wouldn't seem ethical to deny those people, who clinically we see derive most benefit from being allocated treatment, to purely advice, indeed the paper did give extra sessions to 26 patients. The paper is thus showing a biased picture, nevertheless, patients did demonstrate a perceived benefit which we shouldn't ignore. If patients don't feel a benefit they will continue to make demands on services. The huge benefit of early and consistent advice on keeping active etc is again highlighted by this article and is one I hope all experienced physiotherapists endorse and as such is integral in their physiotherapy management. The paper is therefore comparing one session of management with several sessions of physiotharapy management and so is only confirming the importance of good advice and reassurrance for optimum management. We recognise that the development of chronicity in low back pain has been evidenced as a reflection of their psychosocial reaction and is therefore predictable through the presence of 'yellow flags'. These are factors that we need to address in low back pain management To this end in North Devon we are setting up a web site readily accessible to all GPs with early evidence based patient advice and education that GPs can print off and give to their patients during consultations to encourage early consistent advice and reduce development of chronicity and dependence. Thus hopefully only those patients that symptoms and signs won't settle will need treatment. Competing interests: None declared
Chiropractic biscuits 29 September 2004
Richard Bartley, Chartered Physiotherapist Denbigh Infirmary LL16 5BQ Send response to journal: Re: Chiropractic biscuits	I think the reponses from the chiropractors to this paper provide an interesting insight into their work and their approach to health care in general. Competing interests: None declared
Physios can't cure CHRONIC low back pain. 29 September 2004
Dan Doherty, Extended Scope Musculoskeletal Physiotherapist Maldon and South Chelmsford PCT CM9 6EG Send response to journal: Re: Physios can't cure CHRONIC low back pain.	As a qualified physiotherapist with post-graduate training in manipulative therapy, I feel it is time for physiotherapists, chiropractors and osteopaths to quit their squabbling and appreciate that each field is extremely valuable in its own right. We are all autonomous, first contact practitioners. We are all adept at assessment and diagnosis, and we can all provide patients with safe, effective, valuable treatment. Having been trained by chiropractors in the use of manipulative techniques, I understand how powerful these techniques can be when applied correctly to appropriate patients. Additionally, I have no doubt that more traditional physiotherapeutic techniques such as, mobilisations or exercise therapy can also be effective when used appropriately. However, the Frost et al study confirms what most therapists (physios, chiropractors etc.) already know. That is, it is extremely difficult to effectively manage chronic low back pain. 77% of patients in the Frost et al study would be categorised as chronic back pain patients, with 35% of these having had pain for a year or more. As an NHS physiotherapist it is often frustrating attempting to help this patient group. GPs often manage early back pain with advice, exercises, analgesia and NSAIDs. If this approach fails the next step is usually a referral to a physiotherapist, chiropractor or osteopath. If this treatment fails to ‘cure’ the problem what then? Consultants are rightly reluctant to intervene in all but the most severe cases of back pain and the wait to see a Consultant only adds to the likelihood of chronicity. The patient often ends up in a loop of repeat referrals for further ineffective treatment. A number of respondents have identified the need to encourage a more self-orientated approach to management of chronic back pain. We are now (more than ever) aware that socio-economic, emotional and cognitive factors have a huge influence on chronic pain and are increasingly realising the value of expert patient and chronic pain management programmes empowering patients to manage their chronic pain. Personally, access to clinical psychologists has been a huge advantage in this area. The Frost et al study simply supports this type of management approach. Constant referrals for physical ‘hands-on’ treatment are not the way to manage chronic low back pain – biopsychosocial approaches are. The cost of low back pain to society is enormous. If GPs and 1st contact therapists can use yellow-flag prognostic indicators to identify patients with a high likelihood of chronicity, these patients can be referred to the appropriate form of management early. Not only does this result in more efficient management of these patients, it decreases the number of inappropriate Consultant referrals (freeing up their time), and frees up valuable therapist time allowing us to treat the more acute problems the evidence suggests we can actually help. Competing interests: None declared
GP-Physio-Team -Methinks we can do better 29 September 2004
Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507 Send response to journal: Re: GP-Physio-Team -Methinks we can do better	Dr Gumaer's comments are to the point. If we, for a moment, let the voice of anecdotal evidence (also known as patient experience) speak we will realise that the public at large have accepted that Chiropractors are the ones to see if you have a back problem. After taking a good hard look at Physiotherapy (known in the USA as Physical Therapy)I must admit that the typical, all-to-common scenario of GP to Physio is a recipe for a suboptimal outcome most every time. Insufficient training in both camps, outmoded theories about causation and effective treatment are the reasons that the practice of Chiropractic is much more cost-effective. David Jackson talks about "biopsychosocial assessment to expose the patient's fears and beliefs about their pain.." He follows with my old favourite :"Appropriate evidence-based information", and "re-assurance of the patient that they have no serious pathology..." Give me a break, please! Who has the skills to perform these procedures (BIO-PSYCHO-SOCIAL hints at additional psychological skills) and did I miss the evidence for the statement of reassurance that the patients do not have serious pathology? Surely, great expertise is required to fit the shoes that would be needed for the outlined tasks. One should not expect to find this in your GP/Physio team. Competing interests: None declared
Magnesium is a SUPERNUTRIENT 29 September 2004
Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507 Send response to journal: Re: Magnesium is a SUPERNUTRIENT	Yes, tireless Dr. Ellen Grant again with very pertinent information. Adding to this, for the practitioner of any persuasion, magnesium deficiency is very common. In Australia, the soil in general is lacking Magnesium, in New Zealand it is Selenium, Kiwi immigrants may run into a compound problem. The first sign of a possible Mg deficiency is usually cramps, and a patient presenting with significant back pain (especially recurrent, and especially in summer*) and intermittent calf muscle cramps needs to be considered for MG 'repletion'. I have seen countless sufferers of back pain and a similar number of hypertensives completely and quickly overcome their conditions. Since there is a definite interaction between Magnesium and Pyridoxine one ought to look for a lack of B 6** and, as the suspicion for nutritional imperfection grows, a thorough evaluation for nutrients is indicated. It has been my experience that the vast majority of Chiropractors will not be lacking in this, their interest and competence in matters nutritional is legendary. Sadly, this does not apply to the average 'allopathic' physician or his even less informed specialist colleague. Nutrition is still not a priority in medical schools, if it exists there at all. *In addition to excess coffee, alcohol or diuretics, sweating also depletes magnesium ** A B 6 deficiency (as compared to a dependency) can often be diagnosed by finding very poor dream recall in the patient."I don't dream doc because my pyridoxine is low!" Competing interests: None declared
Good study, wrong conclusion 29 September 2004
Alfonso Ceccherini-Nelli, Consultant Psychiatrist The Cardinal Clinic - Reading RG30 4EL - UK Send response to journal: Re: Good study, wrong conclusion	I found this paper very useful, at least in view of the rich debate it stimulated. The only criticism I would like to raise is that, if I had been the author of this study, I would have interpreted the results differently and reached the opposite conclusion, ie: "Routine physiotherapy is more effective than one session of assessment and advice from a physiotherapist". It is my opinion that the authors failed to adequately appreciate the importance of the statistically significant improvement of the mental health domain of SF-36 at 2 months follow-up. This failure is quite surprising as it is common knowledge of the importance of the interaction of mind and body. In this week issue of Newsweek (October 4, 2004), J.Bakalar has written: "Every child knows that a scraped knee can bring tears as well as blood. Physical pain always has emotional overtones, and we now know that emotional distress can be physically painful. Depressed people suffer three times their share of chronic pain and people in pain are at high risk of depression." This common sense statement is supported by a substantial medical literature. Just to cite one recent contribution, McWilliams et al (2004) investigated of the relationship between pain conditions and psychopathology. The odds ratios for patients with back pain of suffering from depression, panic attacks, and generalised anxiety were 1.87, 2.69, and 2.54, respectively. Therefore my belief that patients with back pain can benefit from physiotherapy was further strengthened by the data provided by Frost and colleagues. References McWilliams LA. Goodwin RD. Cox BJ. Depression and anxiety associated with three pain conditions: results from a nationally representative sample. [Journal Article] Pain. 111(1-2):77-83, 2004 Sep. Competing interests: My employer offers a physiotherapy service
Re: Chiropractic biscuits 29 September 2004
Jarkko O. Kause,DC, Health coach, DC-chiropractor, nutritionist, trace mineral specialist, licenced gym instructor Private practice, Tapiolan keskustorni, 1.krs., 02100 Espoo, Finland Send response to journal: Re: Re: Chiropractic biscuits	In response to mr. Richard Bartley`s comment on chiropractors I would like to point out: understandably it is very difficult to admit that the hard work physios do, amongst others, with patients has been again proven scientifically invalid. Other thing is how the physiotherapist sees his or her role: surely one feels also important. Unfortunately today we live in the world where cost-efficacy has become one of the leading terms in health-care, as well as elsewhere in the society. The reason is clear: we don`t have too much money to spend it blindly. There is no way that the traditional physiotherapy treatment( with no manipulation ) would pass business-analysts tests of cost-efficacy. There is no scientific evidence anywhere in the world to justify widespread use of physiotherapy in treating low-back pain conditions. Why then do some physiotherapists educate themselves to chiropractic or osteopathic manipulation?- Many of them get their education from chiropractors. Why is the number of chiropractors increasing throughout the world very rapidly?- The answer is clear: because it has been shown to be effective in treating low-back pain. It works much better than the traditional physiotherapy. Still, some claims about physiotherapists being skilled manipulative specialists, are bizarre, because the number of these " orthopaedic manipulative therapists"( i.e. physios with s.c. short lever manipulative skills ), is still very small. In Finland there are about 8000 physios, of which only 2-300( 2,50-3,75%) are using short lever joint manipulation( creating joint cavitation, i.e. "cracking" sound from the joint). So it is not correct to say that physiotherapists are generally skilled in manipulation, when ca. 97,50% of them are not skilled in it. Vast majority of physios are still doing what I call traditional physiotherapy every day while working with patients. That means other methods than joint manipulation. Positive changes may often arise from uncomfortable experiences. Physiotherapy`s special position in the NHS of western countries is now inevitably getting more and more under jeopardy, and correct me if I´m wrong, for obvious reasons. My suggestion is, that let us all try to limit our scope of practice to the best know-how we have, in conjunction with evidence-based practice guide-lines. NHS funding should be directed to treatment protocols that are being supported by scientific proof, instead of some senseless and stubborn traditions. Many health-care professionals have a role to play in the treatment and prevention of back-pain, but let`s do it accurately, wisely, and cost- efficiently. Competing interests: None declared
Faster and better results experienced by people who received more physiotherapy 29 September 2004
Maria G. Judd, Best Practice Program Coordinator Canadian Physiotherapy Association, Ottawa, Canada K1J 9B8 Send response to journal: Re: Faster and better results experienced by people who received more physiotherapy	Re: Randomised controlled trial of physiotherapy compared with advice for low back pain – Frost et al. BMJ September 25, 2004 The Canadian Physiotherapy Association (CPA) affirms the importance of and is encouraged to see studies that examine the effectiveness of how physiotherapy interventions are delivered. Examining current approaches to physiotherapy practice and reflecting on the results informs best and evidence based practice. A number of important points are highlighted by this research study: (1) The role and effectiveness of physiotherapy in treating low back pain is supported by this study. Both study groups benefited from the intervention of physiotherapy - this is not a comparison of treatment vs. no treatment. The researchers examined two broad physiotherapy approaches to treating mild to moderate lower back pain and found that both approaches were as effective after one year. It is important to note that physiotherapists provide specific advice to patients about how to remain active. This advice is tailored to the individual and based on the results of the physiotherapist’s physical examination. (2) Early benefits experienced by those in the “routine physiotherapy” treatment group are important. The study showed that after two and six months the patients receiving additional physiotherapy intervention reported feeling better and had returned to greater function compared to those who only received one visit with the physiotherapist. The impact of earlier and greater improvements in mental health and physical functioning on patients’ ability to participate in family and social activities, intimate relationships, and work should not be so quickly overlooked. Quality of life and participation in daily activities is important to all patients at all time points – 2, 6, 12 months included. (3) The strength of the study conclusions were not supported by the study findings. First, as the authors note on page 711 in the first paragraph "patients perception of treatment benefit was, however, in conflict with the validated outcome measures, and the clinical significance of this finding needs further investigation”. They also note that the “internal validity of our study is limited because 30% of patients failed to provide data for the main outcomes at 12 months”. Reasons for this are not known. (4) Caution is needed however against making broad generalizations about practice based on the results of one study. Clinical research continually produces new findings that can contribute to effective and efficient patient care and health policy. It is critical to examine the broader evidence base (all relevant high quality studies on a topic). Well conducted systematic reviews are increasingly seen as providing the best evidence to inform clinical decisions and practices. Before drawing hurried conclusions, CPA encourages readers to read the full un-abridged version of this article. We also encourage those seeking the evidence on treatments for low back pain to consult existing reviews such as the two listed below. For acute low back pain the available evidence suggests that reassurance, advice about how to stay active, and spinal manipulative therapy are effective treatments. For chronic low back pain (i.e. duration greater than three months) interventions found to be effective include exercise, behavioral therapy, multi-disciplinary rehabilitation and spinal manipulative therapy. References: 1)Waddell G, McIntosh A, Hutchinson A, Feder G, Lewis M, (1999) Low Back Pain Evidence Review London: Royal College of General Practitioners Available at URL: http://www.rcgp.org.uk/clinspec/guidelines/backpain/ 2) Australian Physiotherapy Association Low Back Pain Position Statement © August 2002. Available at URL: https://apa.advsol.com.au/staticcontent/staticpages/position_statements/mpa/LOWBACKsummary.pdf Competing interests: I am a physiotherapist and am the Best Practice Program Coordinator for the Canadian Physiotherapy Association.
Misleading title biases interpretation 29 September 2004
J. Haxby Abbott, PhD candidate & assistant lecturer Dept of Anatomy & Structural Biology, University of Otago, Dunedin, New Zealand Send response to journal: