Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Ooooops, is most treatment unnecessary intervention?
- Dr. Herbert H. Nehrlich (25 September 2004)
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What about the early benefits of physiotherapy?
- Roderick D D Duncan (25 September 2004)
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NHS physiotherapy systems will not prevent back pain disability
- Jeremy G Jones (25 September 2004)
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Important information missing from the published article
- Garth Robertson (27 September 2004)
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Good advice is often the best treatment
- jon norman (27 September 2004)
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RAPID ACCESS TO PHYSIOTHERAPY
- Christopher W IDE (27 September 2004)
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Answer - Refer to Chiropractors
- Glenn F. Gumaer (27 September 2004)
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Evidence in the making
- Saravana Kumar (27 September 2004)
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Don't throw the baby out with the hydrotherapy!
- Rajashekhar M. Reddy, Andrew Severn, Consultant (27 September 2004)
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Re: Answer - Refer to Chiropractors
- Mark Potter (27 September 2004)
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"Physiotherapy better to be talked about than not at all"
- Malcolm J Philp (27 September 2004)
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Nothing new, but what really are the mechanisms of back-pain?
- Jarkko O. Kause,DC (28 September 2004)
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Magnesium deficiency as a cause of back pain
- Ellen C G Grant (28 September 2004)
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A complete wash out.
- Dr Christopher J McCarthy (28 September 2004)
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What a shame!
- John A Mathews (28 September 2004)
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Outcome of physiotherapy, a true reflection of heterogenous data!
- Kevin K Wright (28 September 2004)
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Finer measures are required to determine the efficacy of physiotherapy
- Venthan J Mailoo (28 September 2004)
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Re: Re: Answer - Refer to Chiropractors
- Dr. Glenn F. Gumaer (28 September 2004)
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Good News for Physiotherapists?
- David A Jackson (29 September 2004)
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Comparing One Session of Physiotherapy Management Wth Several?
- Mary Louise Taylor (29 September 2004)
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Chiropractic biscuits
- Richard Bartley (29 September 2004)
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Physios can't cure CHRONIC low back pain.
- Dan Doherty (29 September 2004)
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GP-Physio-Team -Methinks we can do better
- Dr. Herbert H. Nehrlich (29 September 2004)
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Magnesium is a SUPERNUTRIENT
- Dr. Herbert H. Nehrlich (29 September 2004)
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Good study, wrong conclusion
- Alfonso Ceccherini-Nelli (29 September 2004)
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Re: Chiropractic biscuits
- Jarkko O. Kause,DC (29 September 2004)
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Faster and better results experienced by people who received more physiotherapy
- Maria G. Judd (29 September 2004)
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Misleading title biases interpretation
- J. Haxby Abbott, University of Otago, Dunedin, New Zealand (29 September 2004)
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Manage or cure?
- Christopher Stuart, DC (29 September 2004)
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Re: Good study, wrong conclusion
- Dr. Herbert H. Nehrlich (29 September 2004)
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Be careful what you infer
- Michael Poling (30 September 2004)
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Physiotherapy for Back Pain
- Malcolm IV Jayson (30 September 2004)
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Re: Answer - Refer to Chiropractors
- Richard J Nash (30 September 2004)
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Here, have some back treatment - cheers!
- adrian wagstaff (30 September 2004)
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Back pain patients and Psychobabble.
- Christopher Stuart, DC (30 September 2004)
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Re: Re: Answer - Refer to Chiropractors
- James M. Reynaud (30 September 2004)
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Chiropractic v Physiotherapy
- Peter J Ward (1 October 2004)
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More chiropractic biscuits
- Richard Bartley (1 October 2004)
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Is Physiotherapy effective for the management of LBP?
- Fraser Ferguson, Mike McMenemey, LEad Clinician Greater Glasgow Back Pain Service (1 October 2004)
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Treat Underlying Aetiology
- Nick D Critchley (1 October 2004)
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Reply to Nash, Ward
- Dr. Glenn F. Gumaer (2 October 2004)
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Move on
- Martin Jones (3 October 2004)
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Re: Last chiropractic biscuits
- Jarkko O. Kause,DC (3 October 2004)
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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)
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Chiropractic & Osteopathy
- Corey Watts (4 October 2004)
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Alas further confounding appraisal
- Brian Sweetnam (7 October 2004)
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Don't dismiss physiotherapy
- Neil Watson (12 October 2004)
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A theory that is refutable can still be charming
- Dr. Herbert H. Nehrlich (13 October 2004)
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Publishing responsibilities
- Neil Watson (14 October 2004)
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Acupuncture for treatment of low back pain
- Janet Boaler (15 October 2004)
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Good assessment and advice by a physiotherapist is as effective as traditional physiotherapy.
- Abdolkarim Karimi (15 October 2004)
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Back pain treatment is anything but patient centred!
- Murray Flett (18 October 2004)
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Low Back Pain and Physiotherapy
- Friederike I.M. von Rabenau (23 October 2004)
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Targeting ‘physical factors’ alone is not evidence-based practice
- Maureen Simmonds, Anne Daykin, PPA Scientific Officer (16 November 2004)
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Important Oversight
- Tom Caumont (9 December 2004)
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Physiotherapy and low back pain
- Meir Lotan, Joav Merrick (23 December 2004)
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Proper Title: Trial of NHS Physiotherapy compared with advice for LBP
- Brad S Stevens (10 October 2005)
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Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
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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 |
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Roderick D D Duncan, Consultant Orthopaedic Surgeon G61 2ER
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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 |
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Jeremy G Jones, Consultant Rheumatologist Dept of Rheumatology, Ysbyty Gwynedd, Bangor LL57 2PWedd,
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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. |
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Garth Robertson, Associate Specialist in Musculoskeletal medicine Andover War Memorial Hospital. SP10 3LB
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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. |
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jon norman, SpR anesthetics and pain north manchester general hospital m8 5 rb
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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 |
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Christopher W IDE, Medical Adviser Strathclyde Fire Brigade Headquarters, Bothwell Road, HAMILTON, ML3 0EA
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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 |
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Glenn F. Gumaer, Chiropractic Physician 97501
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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
References with regard to chiropractic vs. medical education, patient satisfaction, and efficacy are available upon request. Competing interests: None declared |
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Saravana Kumar, Doctoral candidate School of Health Sciences, University of South Australia, Adelaide, SA 5000
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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 |
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Rajashekhar M. Reddy, Specialist Registrar Dept. of Pain Management, Royal Lancaster Infirmary, LA1 4RP, Andrew Severn, Consultant
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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. |
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Mark Potter, Manipulative Physiotherapist in Private Practice Worthing BN11 1QA
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In response to Dr. Gumaer's comments: "Chiropractic physicians have significantly better
training in the neuromusculoskeletal arena" "There is much evidence in the medical literature that
supports the effectiveness of manipulation (chiropractic adjustment) for lower
back pain." "..........and refer to physical therapists for further
ineffective therapy.................... So, please do yourselves a favor,
and refer to chiropractors." 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 |
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Malcolm J Philp, Associate Director NMPCT North Manchester
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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) |
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Jarkko O. Kause,DC, Health coach, DC-chiropractor, nutritionist, trace mineral specialist, licenced gym instructor Private practice, Tapiolan keskustorni, 1.krs., 02100 Espoo, Finland
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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 |
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Ellen C G Grant, physician and medical gynaecologist 20 Coombe Ridings, Kingston-upon-Thames, KT2 7JU, UK
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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 |
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Dr Christopher J McCarthy, Research officer for the Manipulation Association of Chartered Physiotherapists The Centre for Rehabilitation Science, Manchester Royal infirmary, Manchester, M13 9WL
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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 |
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John A Mathews, Physician, Musicians' Clinic, Department of Rheumatology, St. Thomas' Hospital, London SE1 7EH
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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 |
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Kevin K Wright, clinical specialist in spinal conditions (Physiotherapy) Pennine acute hospitals NHS Trust, OL12JH
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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 |
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Venthan J Mailoo, Student Occupational Therapist Brunel University, Borough Road, Isleworth, Middlesex TW7 5DU
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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 |
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Dr. Glenn F. Gumaer, Chiropractic Physician Medford, OR 97501
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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 |
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David A Jackson, Research Facilitator The Institute of Rehabilitation HU3 2PG
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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 |
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Mary Louise Taylor, Orthopaedic Physiotherapy Practitioner North Deon Primary Care Trust, North Devon District Hospital Barnstaple EX31 4JB
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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 |
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Richard Bartley, Chartered Physiotherapist Denbigh Infirmary LL16 5BQ
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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 |
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Dan Doherty, Extended Scope Musculoskeletal Physiotherapist Maldon and South Chelmsford PCT CM9 6EG
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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 |
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Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
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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 |
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Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
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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 |
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Alfonso Ceccherini-Nelli, Consultant Psychiatrist The Cardinal Clinic - Reading RG30 4EL - UK
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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 |
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Jarkko O. Kause,DC, Health coach, DC-chiropractor, nutritionist, trace mineral specialist, licenced gym instructor Private practice, Tapiolan keskustorni, 1.krs., 02100 Espoo, Finland
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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 |
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Maria G. Judd, Best Practice Program Coordinator Canadian Physiotherapy Association, Ottawa, Canada K1J 9B8
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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. |
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J. Haxby Abbott, PhD candidate & assistant lecturer Dept of Anatomy & Structural Biology, University of Otago, Dunedin, New Zealand
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Dear Editor, BMJ has, regrettably, yet again mislead their readers by failing to exercise adequate editorial oversight regarding the terminology used in the titles of articles. A Septembter 2004 article (1) purports to compare physiotherapy with advice, however, as defined by countless physiotherapy professional associations and practice acts around the world, physiotherapy is defined as any intervention provided by physiotherapists, as indeed was the case in both intervention arms of this study. What the authors called "advice" was, in fact, a form of physiotherapy, an intervention that physiotherapists use routinely, which is supported by the panels of the major clinical practice guidelines (2). 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 (3,4). The point has been made by Jules Rothstein, editor of Physical Therapy, that in accordance with Medical Subject Headings (MeSH), the "advice" of the title (of 1) could be described as "physical therapy techniques" (3). Equally, the "physiotherapy" of the title could also have. They were both provided by registered/licensed physiotherapists. Recent research evidence suggests that referral to physiotherapy is more successful than management by a general practitioner only, for chronic low back pain (5,6). The present BMJ paper (1) offers no refutation of that. Accurate, well structured advice and education, provided by a health professional who is able to schedule the 1-1/5 hour appointments necessary, in combination with other forms of physiotherapy (e.g. specific exercise training and manual therapy) is more effective than GP care 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. In the present study (1) the idiosyncratic, unstructured manner in which physiotherapy was provided by a very heterogeneous sample of physiotherapists, within the NHS system, demonstrated little added benefit from forms of intervention in addition to the advice component, for most (not all) of the outcomes measured. Other respondents have commented on the importance of the benefits that were significant, and the potentially important outcomes that were not measured, such as time off work, recurrences, and total economic cost. This study only demostrates that a lengthy and structured advice session provided by a physiotherapist was almost as beneficial as advice plus a fairly small few other unstructured, heterogeneous interventions, for people with quite longstanding chronic low back pain. While this indicates that the NHS should be, and is, improving its provision of physiotherapy services (for example by the introduction of Extended Scope Physiotherapy Practitioners and Consultant Physiotherapists into challenging areas such as chronic low back pain), this result should come as no surprise. Had the additional interventions been as structured and comprehensive as the education, the result would likely have been very different (6,7). I hope that the editorial team at BMJ will, in future, exercise a little more care, and a little less sensationalism, in their oversight of titles used in this respected journal. References: 1. Randomised controlled trial of physiotherapy compared with advice for low back pain. Frost et al. BMJ 2004; 329: 708-0 2. Clinical guidelines for the management of acute low back pain. 1999. Royal College of General Practitioners 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. Manual therapy IS physiotherapy. Abbott JH 2003. http:// bmj.bmjjournals.com/cgi/eletters/326/7395/911#32197 5. 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 6. Combined physiotherapy and education is efficacious for chronic low back pain. Moseley L. Austr J Physiotherapy 2002;48:297-302 7. Comparison of Classification-Based Physical Therapy With Therapy Based on Clinical Practice Guidelines for Patients with Acute Low Back Pain. Fritz et al. Spine 2003;28(13):1363–1372 Competing interests: None declared |
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Christopher Stuart, DC, chiropractor Mays Landing, NJ
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I think the question is: What are appropriate first tier, second tier, and third tier interventions (and so on). Let's face it - chronic pain is difficult to deal with as a practicioner. As a chiropractor, I have had successes (many in fact) but I have had failures too. When I fail on chronic LBP, I then list a few providers a patient can consult - a PT is included among them. And despite the results of this study, they will still be there. Empirically, when I follow-up with these patients, I must admit my observations jive with the study discussed. I don't say this with any pleasure, beleive it or not, as I would personally prefer a PT to handle my failures vs. let's say a neurosurgeon. But. . .I don't see PT's trumping me or doing extremely well in the area of chronic, outpatient LBP. Maybe we are all passing around the same failures. Ultimately, many of these patients are just managed passively. I know "passive" is passe (ha, no play on words intended) in today's world of "active care rules the day in rehab" but for some reason, it appears you can't exercise chronic pain away (a lot of the time). Or e-stim it away. Or ultrasound it away. The right "cocktail" for a lot of patients seems to be a maintenance dose of spinal adjustments and a Cox-2 inhibitors. In that, we aren't getting to the "cause" as some DC's would suggest, just managing what God handed the patient or what has developed over a lifetime in their spine/back. There has been some original chiropractic research demonstrating extension tractioning in the lumbar spine in hypolordotic patients having an effect on chronic pain levels (Archives of Physical Medicine and Rehab) but this was admittedly only one study and the study group was rather small. Still, it was interesting, and again, empirically, I have found it a useful intervention in my office for chronic pain patients. Anyway, my post is some random thoughts on this matter, as probably 80% of my practice is chronic pain. I never much care for these studies that structure chiropractic/PT/whatever against a pamphlet or something. There seems something inherently flawed in the logic on such a design but I'll admit I can't put my finger on what I find wrong. Competing interests: Educated and practice as a chiropractor |
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Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
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I agree with Dr. Ceccherini-Nelli. Pain is an EMOTION. Without going into the ramifications of the pandemic of depressive illness, it probably needs to be said for the benefit of those who have forgotten it, or never ever knew it: Kissing a scraped knee, a bruise or other hurt is good therapy for the simple reason that it works. And it works for children because LOVE makes it better. What makes anyone think it wouldn't work for adults? Competing interests: None declared |
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Michael Poling, Physiotherapist Outpatient Orthopaedics, Thunder Bay P7A 1R4
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Ok, I read the study and most of the responses and I am amazed that people put this much credence in a single article. First, the article fails to identify the best practice method of physiotherapy for low back pain. TENS, Ultrasound, heat packs, etc are ineffective but are often called "physiotherapy". This is NOT physiotherapy. Someone commented on seeking a chiro for treatment of mechanical pain. That's fine and a good option, but don't think for a second that physiotherapists don't treat mechanically. We treat EXTREMELY mechanically! Many of us, anyway. Just like any profession, we have our members that sit on their thumbs, refusing to change treatment methods with the literature and refusing to improve their skills...JUST LIKE ANY PROFESSION. Mechanical treatment for low back pain is EXTREMELY effective as evidenced by studies by Van Tulder (a SYSTEMATIC REVIEW, not a mere semi-RCT like this study), Jull, McKenzie, Bogduk and many others. "Abdominal Exercises" are poorly defined as well. Core stability training, ala Jull et.al, is quite effective, whereas standard rectus abdominus, EO and IO training is quite the opposite, even harmful. "Low velocity Mobilization" implies manual therapy, which has been shown by Van Tulder, in a SYSTEMATIC REVIEW to be of moderate benefit. "Lumbar Spine Mobility" is completely non-specific as well. McKenzie is a good source here. A direction needs to be established for pain control and reduction. If simple mobility is given, the anatomical structure responsible for the pain (assuming there is one) will become inflamed or irritated. Physiotherapy is not a definition...there are many activities under that umbrella, many of which are ineffective for LBP, but MANY of which are VERY effective. The quality of this study is not high, according to Sackett's methodology for analyzing study quality (the most widely regarded method). Let's be real here. This study is of questionable quality at best. Any intervention may, or may not, be effective for certain patients. For example, an article in Spine in 1999 estimated that over 85% of spinal surgeries were performed unnecessarily as the patients did not meet a surgical criteria of compressive pathology. Yet some patients responded to the surgery. Be careful how you use this literature and of the advice you give to patients. Information like this can be dangerous and harmful. Michael Poling, M.Sc.(Kin.), M.Sc.(PT). Competing interests: None declared |
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Malcolm IV Jayson, Emeritus Professor of Rheumatology, Chairman Research Committee BackCare Manchester M20 2TY
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Dear Sir A careful controlled study of physiotherapy compared with advice for low back pain by Frost et al (1) is welcome but the conclusion they have drawn and the accompanying editorial (2) appear unduly pessimistic. In a chronic relapsing condition such as back pain it is not to be expected that physiotherapy treatment will provide long-term benefit. The prime objective of treatment is to enable patients to recover from the acute episode more rapidly and indeed this was demonstrated at the two and six month assessments. Indeed this seems to be the overall conclusion from a number of controlled studies of physiotherapy treatments including one from my own group which concluded that the benefits of treatment are restricted to hastening recovery in patients likely to improve spontaneously (3). Yours sincerely Malcolm IV Jayson
Competing Interests: None declared. 1. Frost F, Lamb S E, Doll HA, Carver PT and Stewart-Brown S. Randomised Controlled Trial of Physiotherapy Compared with Advice for Low Back Pain. BMJ, 2004; 329:708-11. 2. MacAuley D, Back Pain and Physiotherapy. NHS Treatment is of Little Value. BMJ, 2004; 329:694-695. 3. Sims-Williams H, Jayson MIV, Young S M S, Baddeley H and Collins E. Controlled Trial of Mobilisation and Manipulation for Low Back Pain: Hospital Patients. BMJ 1979;2:1318-20. Competing interests: None declared |
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Richard J Nash, Chartered Physiotherapist in Private Practice Marlow, UK
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I read with interest Dr Glenn F Gumaers response to the above piece of research. Unfortunately, he has failed to appreciate one of the most important elements of the article, namely that the research looks at NHS Physiotherapy provision for Low Back Pain ie: the availability of treatment within the public health sector, to which most patients within the UK are referred. Access to specialist private medical care is beyond the means of many of the population, whether that be a specialist Physiotherapist, Osteopath or Chiropractor. More interestingly, he betrays a complete lack of understanding of how Manipulative Physiotherapists work, and of the techniques that are employed. Finally, whilst the inference that Physiotherapists and 2000 year old cave dwellers (surely the species had moved on by then, at least in Europe) are one and the same, one wonders when on the evolutionary timescale Chiropractors arrived on the scene? With reference to the original article, I can only endorse the views stated by Dr Christopher McCarthy as to the validity of the results. Competing interests: None declared |
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adrian wagstaff, Senior MS Physiotherapist Leighton Hospital, Crewe
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I read with great intrigue, amazement and amusment at the comments made following this study. It is however quite interesting. The simple fact is that we do not really know any one thing that can help 'cure' back pain. This is because every single case is different. For example; a patient presents with a spondylolisthesis (vertebral fracture with instability). What would be the best treatment here? Manipulation? Ultrasound? Traction? - no, none of them would be a logical choice. Such a patient would require stability training. However, outcome would largley depend on the quality of training and specificity of treatment that the practitioner applied. I dont think the results would tarnish the reputation of physiotherapists. Lower-back pain is a complex issue and needs speialist training to administer effective management. This could be given by GP, Chiropractor, Physiotherapist, or osteopath - it really depends on the diagnosis. Without empirical support I can say that I have treated back pain on many occasions with great success. The successful ones are those that responded because I have developed a treatment regime suited to that clnical impression. The patients that I have not been able to assist have been so because 1) I may have lacked the clinical expertise - if I were to say I knew everything I would be a very poor practitioner 2) the patient has had a problem that requires further investigation 3) bio-psychosocial factors exist, and I am not a psychologist. I have not scoured the archives of journals for answers to my questions, but with this study in mind why cant we produce a study that examines the various methods of treatment when placed appropriately against a clinical impression/diagnosis. Competing interests: None declared |
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Christopher Stuart, DC, chiropractor, private practice Mays Landing, NJ
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I'm going to admit right up front I have no research to support my position. In fact, my position actually contradicts the research. I have read many of the studies outlining that back pain patients have pscyhosocial issues and differences from the general population. But. . .I just don't see it. In my 7 years of practice, I feel I learned to size up what motivates people and even read their minds to a certain extent. Someone distant to the chiropractic profession said that DC's have an uncanny ability to size up a person in a very quick amount of time. I always accepted that compliment freely. Maybe that's what makes us so popular and survivable. To the topic, I don't see that chronic low back pain patients are psychosocially any different from the next Joe Schmoe down the street. Again, I know I contradict the research and I am forever immersed in biased observational error as I say this but I feel strongly about this. Chronic back patients are teachers, lawyers, ditchdiggers, politicians, football coaches, and textile mill workers. They are normal and abnormal as the rest of us here complete with dysfunctional families and functional families. Of course, psychosocial factors need to be considered in the care of the chronic back pain patient. I would never deny that. But from a public health standpoint, I think policymakers are using the wrong compass here in gaining direction. I don't think they are trusting their senses and instead trusting the research too much. Okay, I said my peace/piece. Competing interests: Practice as a DC |
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James M. Reynaud, Chiropractor Total Insight Chiropractic, 95008
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Dr. Mr. Nash, Having read both yours and Dr. Gumaers' rapid response editorials I too would agree that there could be more said to the differences between the two terms, "manipulation" and "chiropractic adjustments." One glaring distinction lies not so much in the skill or the technique so much as in the reason for doing either. The premise originally put forth by the founder of the "Chiropractic adjustment", Dr. D.D. Palmer, was to restore normal nerve function to what he perceived was an impinged nerve. His motive had nothing to do with back pain, neck pain or "segmental dysfunction" whatsoever. He applied his "adjustment" to affect the nervous system. I have heard it said that Chiropractors deal with the nervous system, the bones merely get in the way. Given that less than 10% of our nervous system deals with those senses which we can perceive or control, how far reaching can an "adjustment" really be? When one considers this premise one realizes that Chiropractic "adjustments" are initiated to re-establish normal nerve function, not relieve back pain. Recent studies in brain mapping have clearly demonstrated that sections of the brain hyopertrohy with somato-stimulation and atrophy with somato-inactivity/immobilization. Whether one believes in the "pinched nerve" theory or, the ability for Chiropractors to remove such impingements, the evidence is becoming more and more clear that neural stimulation occurs with the Chiropractic "adjustment" that does not with mere random "manipulation." Competing interests: None declared |
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Peter J Ward, Superintendent Physiotherapist Tameside General Hospital, Ashton under Lyne, OL6 9RW
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My response to those correspondents who are using this research as a basis for claiming that chiropractic is superior to physiotherapy in the treatment of low back pain is - look at the evidence. 1. "A Comparison of Physical Therapy (Mckenzie Therapy), Chiropractic Manipulation, and Provision of an Educational Booklet for the Treatment of Patients with Low Back Pain." Cherkin et al: The New England Journal of Medicine, Oct8,1998 Vol.339. Conclusion: "We found that physical therapy and chiropractic manipulation had similar effects on symptoms, function, satisfaction with care, disability, recurrences of back pain, and subsequent visits for low back pain." (tested at 1,4,12 and 52 weeks). 2. "One year follow-up comparison of the cost and effectiveness of chiropractic and physiotherapy as promary management for back pain." Skargren et al:Spine 1998 Sep 1 Vol: 23(17). Results: "No differences were detected in health improvement, costs, or recurrence rate between the two groups." Key messages from the Warwick University research are that both groups of patients improved with physiotherapy, and that education is a vital physiotherapy skill in the treatment of low back pain. If we can give the patient the confidence and the knowledge to manage their own back pain effectively, it is far better for them than becoming dependent on passive treatment, whether delivered by a physiotherapist, chiropractor or anyone else. Competing interests: None declared |
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Richard Bartley, Chartered Physiotherapist Denbigh Infirmary LL16 3AS
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Having once been a lecturer at a chiropractic college affiliated to the University of Westminster, I can testify to the high quality of training of chiropractors and their dedication to providing high quality of care for patients with musculo-skeletal problems. However, I never cease to be amazed at their ignorance of my own profression. This study was not a comparison between chiropractic and physiotherapy intervention (that has been done before), but rather a comparison between two different physiotherapy approaches to managing patients with chonic low back pain. The study was conducted very well and it is therefore a shame that a combination of sloppy editorial input and sensational articles in the press have put physiotherapists in a vulnerable postion. Effective communciation and dissemination of information is an essential core skill of physiotherapy. As other contributers have commented, this study highlights the potential benefits of encouraging patients to self-manage their back pain. Short-term pain relief, whether provided by a physiotherapist or chiropractor has its merits, but to suggest that physiotherapy is inferior to chiropractic intervention on the basis of this study is a nonsense. Competing interests: None declared |
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Fraser Ferguson, Clinical Specialist Physiotherapist Greater Glasgow Back Pain Service, Clydebank Helth Centre, Kilbowie Rd Glasgow G81, Mike McMenemey, LEad Clinician Greater Glasgow Back Pain Service
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01/10/04 Dear Sir Re Frost H, Lamb S, Doll H, Carver P, Stewart-Brown S. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ 2004;329:708-714. MacAuley D. Back pain and physiotherapy (Editorial). BMJ 2004;329: 694-695 We are writing in response to the above paper and preceding editorial as representatives of the Greater Glasgow Back Pain Service (GGBPS). We are a physiotherapy led service working across acute and primary care sites in Glasgow. The 13 Clinical Specialist Physiotherapists act as gatekeepers for orthopaedic and imaging referrals for all acute back pain. Our service is partly responsible for helping to almost abolish plain film x-rays in Glasgow and greatly reducing orthopaedic waiting times for back clinics. We regularly see around 90% of acute LBP patients within our 2 week standard. The introduction of patient self-referral in most areas of Glasgow means patients have to wait little time to speak with a physiotherapist at all. In the ever-increasing number of cases the GP is not involved in the referral of patients with LBP thereby reducing the need for GPs taking “the easy option” and referring their LBP sufferers to physiotherapy. The study by Frost et al is well-constructed controlled trial. The authors' objectives were to measure the effectiveness of routine physiotherapy for patients with low back pain, compared to an assessment session and advice from a physiotherapist. To help show this they employed recognised and valid outcome measures. Unlike many studies, which attempt to compare benefits of physiotherapy, this particular study takes great care in spelling out exactly what it perceives as ‘routine physiotherapy.’ The authors’ conclude a standard course of physiotherapy is no more effective than an advice session with a physiotherapist for people with moderate to low back pain of more than 6 weeks duration. After 12 months the authors report there was no statistically significant difference in the disability index between the two groups. However, throughout the study patients in the physiotherapy group were significantly more likely to report benefits from treatment. There were no statistically significant differences between the groups on any items of a validated measure of general health. Although these statistics are reported as being significant enough to draw the conclusion that routine physiotherapy seems to be no more effective than one session of assessment and advice from a physiotherapist, a few questions should be raised to these findings. Research to date has been insufficiently rigorous to give clear indications of the value of treatment for non-specific LBP patients. No treatment has been shown beyond doubt to be effective. Where there is reasonable evidence to suggest an intervention is effective, issues including the optimal timing and duration of treatment need to be explored. Research has previously shown that the majority of LBP is self limiting and will improve within 6 weeks with physiotherapy more effective in that time Pinnington et al (2004) and Pengel et al (2003) being among the more recent papers . The study group in Frost’s paper only included patients with LBP over 6 weeks with 77% of the therapy group having symptoms for greater than 3 months. Unfortunately allowing the therapy group to “include any combination of joint mobilisation and manipulation; soft tissue techniques, including stretching; spinal mobility and strengthening exercises; heat or cold treatment; and advice,” adds multiple variable factors to compare. Although not wholly conclusive the research published in the area does show that manual therapy is less effective in non-acute low back pain Assendelft (2004) Koes (1996) (Evans et al, 1996). The authors openly reference papers, which suggest management considered to be routine physiotherapy. One is 10 years old and another from a Dutch perspective. The Foster et al (1999) was UK review of amongst other things the most common treatment modalities used by physiotherapists in the treatment of LBP. This paper was chosen by the authors as a means to employ a standardised treatment protocol. Worryingly this paper highlights the fact that many physiotherapists would choose passive, clinically ineffective modalities as a first choice. Many more recent LBP guidelines build on these older references. They promote active exercise general advice and return to normal function (Accident Compensation Corporation: New Zealand, 2003; European guidelines for the management of acute non-specific low back pain in primary care, 2001). These respected guidelines also discourage the use of the passive modalities ‘allowed’ in the trail group. The ethical considerations of a physiotherapist offering these less clinical effective modalities is another discussion topic altogether, but using them in the trail group as a means of ‘proving’ the ineffectiveness of physiotherapy is an error. Previous studies have shown the effectiveness of good advice booklets being given to patients (Burton et al, 1999; Burton et al, 2000). This would constitute ‘routine physiotherapy’ within Greater Glasgow NHS Board as patients who receive physiotherapy from the GGBPS all receive a copy of ‘The Back Book’ (1996)) referred to in these articles. The chosen journal for publishing the study has raised the role of physiotherapy in the management of LBP. For years the physiotherapy profession could have accused of being negligent at times in at not showing through well-structured research that it can offer an effective means of managing LBP. Unfortunately having this paper appear in arguably the most widely read of medical journals has meant it has been picked up by non-medical texts. Like a game of Chinese whispers this message has changed and become diluted. What can stimulate a worthwhile discussion amongst likeminded medically orientated professionals can cause confusion and dissatisfaction amongst patients. How much will a patent value or respect their GPs judgement when it is suggested they are going to be referred to physiotherapy. How will they value this physiotherapy too, if they have read these headlines created from the Frost et al article? “Physiotherapy doesn't work for back pain.” (The Guardian, 24 September 2004, p3. “Why going to a physio won't fix that bad back.” (Daily Mail, 24 September 2004, p31). The authors even touch on the importance of the patients’ perception as being crucial to the overall management “The patients’ perception of treatment benefit was, however, in conflict with the validated outcome measures.” As physiotherapists continue to strive to work hard throughout the country these mis-represented studies cause confusion to patients, medical staff, service managers and budget holders. The conclusions drawn from the study can only be applied to the population area included in the study and not to widespread attribution of the lack of benefit fro physiotherapy on a nationwide basis. We would similarly not be able to respond that all other physiotherapy areas offer different treatment, with the exception of our own GGBPS, but such wide- ranging conclusions about the profession are primed with problems. The authors’ should be applauded if the study is trying to say many of physiotherapy modalities offered in the management of LBP are still practised even though they have been shown in many cases not to be clinically effective. They should also be praised if they are suggesting these modalities are less effective than an thorough examination which excludes any serious red flags and offers advice on how to self manage the condition. Unfortunately it seems the good intentions of the study have been lost in the reactionary aftermath and the demedicalisation of the story by the popular media. With the ongoing suffering of LBP patients and the vast financial expense laid out in an often futile and ineffective overall management of the condition the Frost et al paper is highly relevant in the present economic climate. If nothing else it should encourage the physiotherapy profession to keep re-evaluate its role in the management of LBP and rather than allow other papers to stir a professional defence outcry, encourage physiotherapists to show through a good quality research that they are effective in the treatment of many musculoskeletal conditions. As an autonomous profession there still seems a worrying misconception amongst other professions that referring patients to physiotherapy is ”an easy option” even though the referrers are unsure as to the effectiveness of the treatment the patient will receive. It should also make the physiotherapy profession proud of its role in the management of LBP. There are many numerous areas of excellence sprouting up throughout the country that are showing that patients referred to physiotherapy are receiving a multi-disciplinary service unparalleled anywhere, where highly skilled clinicians work within the bio psychosocial model to empower patients to self-manage their condition. Perhaps in future the authors will re-examine the effects of some of these services. FRASER FERGUSON, CLINICAL SPECIALIST PHYSIOTHERAPIST, GREATER GLASGOW BACK PAIN SERVICE MIKE MCMENEMEY, LEAD CLINICIAN, GREATER GLASGOW BACK PAIN SERVICE REFERENCES Accident Compensation Corporation (2003) New Zealand Acute Low Back Pain Guide, incorporating the guide to assessing psychological yellow flags in acute low back pain. www.nzgg.og.nz/guidelines/0072/albp_guide_col.pdf Assendelft WJJ, Morton SC, Yu Emily I, Suttorp MJ, Shekelle PG Spinal manipulative therapy for low-back pain (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd Burton, A. K.; Waddell, G.; Tillotson, K. M.; Summerton, N. Information and advice to patients with back pain doees have a positive effect : an RCT of an educational booklet in primary care. Journal of Bone & Joint Surgery - British Volume. 82-B Supplement I:38-39, 2000. Burton, A. Kim PhD, DO Waddell, Gordon DSc, MD, FRCS; Tillotson, K. Malcolm CStat; Summerton, Nick MA, MPH, MRCGP Information and Advice to Patients With Back Pain Can Have a Positive Effect: A Randomized Controlled Trial of a Novel Educational Booklet in Primary Care. Spine. 24(23):2484, December 1, 1999. Daily Mail, 24 September 2004, p31’Why going to a physio won't fix that bad back.’ European guidelines for the management of acute non-specific low back pain in primary care (2002) Acta Orthop Scand Suppl;73(305):20-5 Evans G, Richards S. (1996) Low back pain: an evaluation of therapeutic interventions. . 176. Bristol: University of Bristol, Department of Social Medicine, Health Care Evaluation Unit. NHS Centre for Reviews and Dissemination Foster N Thompson K Baxter JM (19990 Management of non-specific low back pain by therapists in Britain and Ireland Spine 1999;24:1332-1342 Frost H, Lamb S, Doll H, Carver P, Stewart-Brown S. (2004) Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ;329:708-714. Koes B W, Assendelft W J, van der Heijden G J, Bouter L M. Spinal manipulation for low back pain: an updated systematic review of randomized clinical trials. Spine. 1996. 21(24). 2860-2871 MacAuley D. Back pain and physiotherapy (Editorial) (2004); BMJ 329: 694-695 The Back Book (1996) The Stationary Office. Norwich The Guardian, 24 September (2004), p3. ‘Physiotherapy doesn't work for back pain.’ Pengel, LHM; Herbert, RD Maher, CG; Refshauge, KM (2003) Acute low back pain: systematic review of its prognosis. BMJ. 327(7410):323, August 9,. Pinnington, MA; Miller.J Stanley, I (2004) An evaluation of prompt access to physiotherapy in the management of low back pain in primary care. Family Practice. 21(4):372-380. Competing interests: None declared |
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Nick D Critchley, Director Health and Fitness Solutions, City of London Medical Centre, 11-13 Crosswall, London EC3N 2JY
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When I first read the article in the Times newspaper (UK)about this study I was initially very disappointed that another poorly controlled an ill thought out piece of research had been conducted that added fuel to the debate of how to treat low back pain. On reflection though it fully supports the clinical philosophy that I and my colleagues adhere to. We are all experienced physiotherapists working in private practice. What we call ourselves though is of little relevance when considering effective practice. We are happy to manipulate spinal joints just as our colleagues in chiropractic and osteopathy do. What is different though is that we see this as a very small part of a client's treatment - like injections, massage, surgery, electrotherapy etc it is merely a way to achieve better joint movement and tissue compliance and hopefully reduce pain levels which it often does very well (IN THE SHORT TERM). Other comments in this feedback forum have suggested that chiropractic is clearly the treatment option that is preferred with low back pain treatment. I would contest this by drawing these clinicians attention to the overwhealming amount of evidence that suggests that low back pain, in the LONG TERM, is treated far more effectively with postural correction through exercise therapy, ergonomic intervention and lifestyle change. Manipulation or any other passive treatment intervention does not improve ones ability to hold their skeleton with optimal segmental alignmant against gravity and yet they correctly state that most spinal pain has mechanical overload as its major cause. Motor skill learning not strength training is required and so the traditional gym environment is often not the best place for most people. The reality is that most chiropractors, osteopaths and physiotherapists still merely treat peoples symptoms with passive modalities and largely ignore the underlying lifestyle causes of their client's problems. Treating peoples symptoms is still the first stage of any treatment approach but too many people start and finish their care plan with these passive therapies. For these reasons I can well imagine that the outcomes in the study alluded to are a fair reflection of the "traditional" but outdated physiotherapy approach as well as other professions claiming to effectively manage this lifesyle condition. Competing interests: None declared |
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Dr. Glenn F. Gumaer, Chiropractic Physician Medford, OR 97501
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In reply to: Richard J. Nash General Practitioner, Domhnall MacAuley’s editorial regarding this research concluded: “…For one of the most common and debilitating conditions in the community, we have no real answer.” I was responding to his comments and not to this research article. He suggested that I post my comments here. I apologize for not making that clear. You are correct to assume that I am unaware of how Manipulative Therapists work outside of the USA. In my comments, I revealed that my training included 3,768 hours of graduate-level instruction, including 660 hours in biomechanics, palpation and adjustive technique training, plus 894 hours of internship. Perhaps you might enlighten me on how Manipulative Therapists gained their expertise in manipulative procedures? In Mark Potter’s response to my comment, he implied that manipulations performed for the past 2000 years are equivalent to the chiropractic adjustment. I apologize if you were offended by my glib remark. I meant it half in fun, after all, he made the original inference, and I was merely attempting to highlight the absurdity of his statement. In reply to: Peter J. Ward I did not intend for my comments to be construed as wholesale support of this research, or that physical therapists are inferior in any way. But please, don’t quote from discredited studies by Cherkin et al. as evidence to suggest that physical therapy and chiropractic adjustments are equally ineffective in treating lower back pain. His paper takes a portion of each therapy out of context, and when he gets his expected result, comes to the grand pronouncement that patients are as well off reading a brochure, as seeking care from either practitioner. Not unlike giving cancer patients aspirin, and after they die, concluding that medical care is totally ineffective. His research belongs in the junk science file. It failed to provide any meaningful insight into therapy for lower back pain. Dr. Anthony Rosner published a critical review of that paper, if you care to check it out…http://www.fcer.org/html/news/cherkin1.htm. Competing interests: None declared |
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Martin Jones, Senior 1 Physiotherapist Cheshire, UK
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For heaven's sake. Let's not loose sight as to what we are actually here for. It is not to belittle each other's profession or to slap other professionals on the back (or ourselves) in some kind of sickening self- gratification. We are all trying to help the poor individual who is in pain, and/or has a biomechanical insufficiency. Whether or not you think the Frost paper is a well written piece of research or not is open for academic debate and will probably be so for some time, specially in Physio schools. What we should be doing is accepting the paper for what is has done and that is to create debate. The problem is that some individuals have seized upon the marketing potential for whatever personal or financial satisfaction they aspire to. What we should be doing is seizing the momentum this debate should be creating to help promote the best care we can all give for our shared patients. Personally, I could not care who has the best treatment approach or how many hours you have spent coming to that approach, as long as it works. None of us should be so retentive as to thnk that our own profession holds the best approach to helping with back pain. Stop criticising the paper (no matter how well deserved) and certainly, stop criticising each other, you are doing yourselves no good by doing so. Move on, grow up and let's see how we can help others. After all, that's why were are here. Competing interests: None declared |
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Jarkko O. Kause,DC, Health coach, DC-chiropractor, nutritionist, trace mineral specialist, licenced gym instructor Private practice, Tapiolan keskustorni, 1.krs., 02100 Espoo, Finland
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Why some chiropractors may have a certain attitude towards "traditional" physiotherapy, is something that could be a topic for further research, perhaps? This study in question has not compared physiotherapy to chiropractic. Nor does it suggest anything about the cost-efficacy between physiotherapy and other treatment protocols. But is there a reason why in this discussion personal opinions and comments on a closely related treatment to low-back pain should be forbidden?- If I understand it correctly, openness and honesty are good values, whether in personal life or related to professional matters. Just to let some readers know, chiropractic treatment includes multiple methods, not only manipulation. Mobilisation, numerous muscle relaxing techniques, nutritional and ergonomic advice, rehabilitation programs( including muscular stretching/exercises ), patient education towards prevention, biopsycho-social councelling to mention a few. I speak as a practising chiropractor, being proud of what chiropractic is today. I feel more pleased to be able to help the patient much quicker and with longer-lasting results than what they usually have been used to with physiotherapy. Having had the opportunity to work together with MDs and PTs for more than 10 years in 2 different multidisciplinary clinics, I have seen the results more than closely for different treatments. Unfortunately, from day one, I was amazed of how poor the physiotherapy worked for low-back pain. These PTs were experienced, not newly graduated as I was. During the first 2 months 2 of these PTs came to present with their particular back-problems, perhaps to test what chiropractic is. Both of them got a rapid and complete recovery of a long-term back-problem, the other one low-back pain and the other one thoracic chronic pain condition. Since that day PTs came to consult me occasionally, and referred patients to me regularly. I referred patients to them as well, but mostly in cases where patients needed rehabilitation after an injury or car-accident. This kind of co-operation improved the clinical outcome of low-back pain sufferers. This is just one example of how things have happened on a personal level. But I am sure, I am not the only one who has got exactly similar experiences. I strongly support, on the other hand, co-operation between chiropractors, PTs and MDs as has been the case during my 13,5-year career as a chiropractor. We all are needed in trying to improve patients´ condition. Patients are satisfied and will remember the positive treatment experience for the rest of their life. That is why most of chiropractors are fully booked all the time. Let us all be open to discussion and criticism as well. If there is none of these, there will be no progress in treatment protocols or prevention of that common medical nuisance of low-back pain. Competing interests: None declared |
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Tom A Torstensen, B.Sc (Hons), M.Sc., P.T., specialist in manipulative therapy, M.N.F.F., Physiotherapist Holten Institute AB, Box 6038, 18106 Lidingö, Sweden
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Frost et.al study published in BMJ 2004;329;708 concludes that routine physiotherapy was no more effective than one session of assessment and advice given by a physiotherapist. Their conclusion should have been: There is today good evidence that routine physiotherapy is effective for patients with low back pain. Because of inadequate research design we could not confirm results from other high methodological quality studies. And the methodological problems for Frost et al.are: 1. The number of treatments (median of one (range 1-22) versus a median of 5 treatments (range 1-12) are too few to expect a statistical change or clinical interesting change. With so few treatments a follow up (12 months) is too long to be able to expect any difference between groups. 2. In fact two very similar physiotherpy interventions were compared. One intervention consisting of an assessment with information about back pain including a booklet. The comparison group received also an assessment from a physiotherapist and information about back pain. In addition the physiotherapist saw the patient another 4 ??? (median of 5 including the assessment) times combining other physiotherapy methods. 3. It is fascinating that researchers design a study expecting that a median of 4 treatments should make a difference in outcome. And it is even more fascinating when the authors focus on the ONE year follow up, and not the 2,and 6 months follow ups, when they report that the routine therapy group had greater improvements for mental health and physical functioning than the advice group at 2 months follow up. 4. Even so, this is a brilliant design to make sure that the end results will give no difference between the intervention groups. 5. The chance of finding a difference between groups become even slimmer when as many as 30% dropped out at 12 months follow up. And even slimmer again when the researchers use an intention to treat analyses of their data. 6. Frost et al. discussion and use of references is biased. There is no reference to other studies of high methodological quality showing that routine physiotherapy is an effective treatment resulting in less pain and improved function. Thus, the authors discussion and use of references is biased towards information and advice about staying active. There is good evidence today for routine physiotherapy: We published in Spine in 1998 a study; Torstensen TA, Ljunggren AE, Meen HD, Odland E, Mowinckel P, Geijerstam S. Efficiency and costs of medical exercise therapy, conventional physiotherapy and self-exercise in patients with chronic low back pain. A pragmatic, randomized, single-blinded, controlled trial with 1-year follow up. Spine 1998;23:2616-24. We found that the group receiving information about back pain and maintaining a normal activity (modified Indahl intervention) had significantly more pain, poorer function and higher number of days on sick leave compared to both routine physiotherapy and physiotherapy as medical exercise therapy. Due to less days on sick leave both physiotherapy groups saved thousands of pounds compared to the information and self exercise group. Our conclusions have been confirmed by other similar studies of high research methodology and also through the systematic review published by Van Tulder et al. Spine 2000;25:2781-96. Where do we go from here? There has over the last 10 years been a negative attitude towards physiotherapy generally and a positive attitude towards information about back pain and staying active. However, many physiotherapists use this approach combining active exercise therapy with information and a cognitive approach focusing on improved function and returning to work. Additional methods are also incorporated such as different manual techniques, massage, stretching, traction and electrotherapy. Frost et al. should be careful with their conclusions because randomized controlled trials (RCTs)give us only information about effect on a group level. In daily practise we work on an individual level, thus information from RCTs only give a us a very rough idea about what method to apply on an individual level. Clinical reasoning needs to be incorporated including knowledge from RCTs and clinical experience working with individual patients. An example of such an approach was published in 2004; Torstensen TA, A software programmer and sportsman with low back pain and sciatica. In: Jones MA and Rivett DA, Clinical Reasoning for Manual Therapists, pages 275-311, 2004, Elsevier Ltd, ISBN 0750639067. In conclusion: the modern physiotherapist has an extensive tool box where the mostly used tools are active graded exercise therapy with a cognitive approach where other methods/tools are combined to meet the need of the patient. Frost et al. study is in many ways similar to the Meade study published in BMJ 1990;300:1431-1437, where private chiropractic therapy was compared to NHS out patient physiotherapy. The study was flawed resulting in a massive critigue. However, the chiropractors used the study politically for all it was worth. And rightly so! I am afraid that Frost et al. study will be used for the same purpose, and there is already one recent example of this published in one of Norways major newspapers. When research results is used in media for personal or political purposes there is never the time nor the space for thoughtfull discussions about design or results. Nor is it time to evaluate the usefulness of the study results to give patients a better understanding of-, and treatment for their back pain. To avoid this, if possible, researchers have a moral obligation to design, perfom and publish studies of the highest quality. The external validity or generalization for this study is low and implies to the British NHS only. But, if it is correct that the study is a mirror image of how English physiotherapists in the NHS treat their patients with long lasting back pain, they need to change their practise using higher treatment dosages incorporating active progressive exercise therapy with a cognitive approach. Then there is a greater possibility to get a clinically positive respons. And finally, I would like to meet the therapist that treats a patient with long lasting back pain 5 times and still expects that the treatment is effective one year later. Competing interests: None declared |
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Corey Watts, non-medical Melbourne, Australia
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Several issues in this discussion require clarification: To begin with, an important distinction needs to be made between the American and International models of osteopathic medicine. US osteopaths are qualified medical physicians and surgeons almost indistinguishable from their 'conventional' counterparts and hold equal practice rights. On the other hand, osteopaths trained elsewhere receive minimal education in pharmacotherapy and surgery, and very little, if any hospital -based training. Non-US osteopaths, however, receive in the order of three to ten times the number of hours of training in diverse manual therapies ('Osteopathic Manipulative Medicine/Therapy' or OMT) as compared to their American cousins. Their education emphasises the diagnosis and treatment of neuromusculoskeletal (and related) syndromes, and is complementary to physiotherapy and mainstream medicine. Both the American and International schools emphasise an holistic, patient-centred approach to medicine. Except for certain specialists, most US osteopathic physicians employ OMT only minimally. Whilst it is true that most chiropractic teaching institutions in Europe, North America and Australasia train their students in a variety of basic physiotherapies and manual therapies in addition to the high- velocity-low-amplitude thrust technique (HVLA, or 'adjustment'), the fact is that the vast majority chiropractors rely very heavily, if not solely on this technique. The chiropractic patient window is often less than fifteen mintues, and a high level of dependence on the therapist seems to be encouraged. Non-US osteopaths (at least) tend to spend upwards of twenty minutes with each patient and place great emphasis on self-care. A further important difference between chiropractors and most other manual therapists is that the frequency and number of treatments offered by the former tends to be substantially greater. Both chiropractors and osteopaths effectively aim to treat a range of (apparently) non-musculoskeletal disorders via manipulative therapy. There is a body of evidence of variable quality to suggest that at least some of these disorders are amenable to treatment or at least co-treatment with different manual therapies. However, it is for the management of joint, muscle and head pain syndromes that people most often consult both sets of professionals. To the best of my knowledge, the efficacy of a combinatory manual therapeutic approach vs a HVLA-centred approach, the influence of the time spent with the patient, and the potential for co-treatment (with the medical profession) of certain disorders are areas that remain largely under-explored in the literature. Competing interests: I hold no medical or paramedical qualifications. |
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Brian Sweetnam, consultant rheumatologist Morriston Hospital, Swansea SA6 6NL
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EDITOR- For decades the many assessments of back pain therapy that have been undertaken have resulted in confusion, and all for the same reason. Though the statistical analyses may have been adequate, the study designs have invariably fallen short. MacAuley (1) has drawn attention to some of the problems in the recent editorial in this journal relating to the study in general practice published in the same issue (2). Firstly, it is often enough assumed that the common presentation of low back pain cannot readily be subdivided into meaningful sub categories or distinctive diagnoses. It is no doubt that it was for this reason that Frost and co-workers state that they did not “stratify” their cases for the purposes of analysis. Despite the fact that they undertook a detailed assessment of each patient they did not include the very simple clinical tests that are distinctive (3). Secondly, as mentioned by MacAuley, the prospective element of study design was not fully embraced as the components of the active treatments were not determined in advance, and indeed no single treatment modality was given a real chance of showing its colours. However it is important to mention that diagnosis specific response to a given treatment has been demonstrated which was not apparent when all and sundry were evaluated together (4). Thirdly, there are specific outcome criteria available that reflect changes in impairment that are probably far more responsive to changes in back pain status than the indirect indices of disability and handicap that they and so many others have used (5). It is therefore no wonder that MacAuley concludes that, as yet we have no real answers! Brian Sweetman 1 MacAuley D. Back pain and physiotherapy. NHS treatment is of little value, an editorial. BMJ 2004; 329: 694-5. 2 Frost H, Lamb SE, Doll HA, Carver PT, Stewart-Brown S. Randomised controlled trial of physiotherapy compared with advice for low back pain. BMJ 2004; 329:708-11. Competing interests: Industrial and clinical back pain research previously funded by the Arthritis Research Council. |
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Neil Watson, Former orthopaedic surgeon San Francisco
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Dear Sir I do not know who refereed the paper by Frost et al in the BMJ of 25 September (about physiotherapy and back pain) or who approved the leading article by Dr. MacAuley with which it is associated, but whoever or whomever did has, or have, a great deal to answer for. In one fell swoop the whole credibility of the BMJ has been seriously questioned, the profession of physiotherapy ridiculed and millions of patients probably deprived of valuable help in dealing with their back pain; a widespread, debilitating problem which costs the country millions, if not billions of pounds each year, and for which conventional medicine has contributed almost nothing. Why such sweeping comments? In Frost’s paper it is stated that 1.3 million people see physiotherapists each year about back pain. Their paper describes what they felt were the outcomes of treatment in 144 patients (0.01% of the total back pain population undergoing treatment by physiotherapists nationwide). At least 6 different treatments were mentioned, though apparently each of the 76 physiotherapists involved chose their own regimen, and so there was no standardisation whatsoever. If the workload was evenly distributed each therapist saw 1.59 patients (0.0001% of the nationwide back pain population). To derive the conclusion that physiotherapy is no better than advice on the basis of these numbers, and the nature of the ‘trial’ is absolutely ridiculous. If this is science then I am a Dutchman. To go on and write in a headline on the front of the BMJ that ‘Physiotherapy for back pain no better than advice’ and then have a, supposedly, authoritative opinion on ‘Back pain and physiotherapy’ based on this sort of nonsense is irresponsible to say the least. You owe it to your readers to publish a well-reasoned refutation of what you allowed to be printed. If there is any good that may result from this paper, and one can only hope that there may be some, it is that the physiotherapy profession might see fit to carry out some more trials in which methodology is more standardised, and numbers raised to meaningful levels. That way some sense might emerge. Neil Watson, MA, MD, FRCS
(Lean, fit oarsman and kayaker currently receiving tremendously effective physiotherapy, in the form of a carefully supervised exercise programme, in the management of OA of the lumbar spine and an MRI-proven sequestrated disc at the L5/SI level) Competing interests: None declared |
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Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
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Dr. Watson scolds the BMJ as follows: "To go on and write in a headline on the front of the BMJ that 'Physiotherapy for back pain no better than advice' and then have a, supposedly, authoritative opinion on 'Back pain and physiotherapy based on this sort of nonsense is irresponsible to say the least. You owe it to your readers to publish a well-reasoned refutation of what you allowed to be printed." Well, Dr. Watson, what better way could you think of or dream up to allow an entire 'gaggle' of refutations, laudatios and other comments to be presented to the world than the institution of the Rapid Response section of the BMJ? If I didn't dislike the word 'Democracy' almost as much as Evidence Based Medicine I would have mentioned it. A medical journal could never equal the distribution of so many diverse opinions by editorials or papers or other comments - thus, the Rapid Response section of the BMJ plays a vital role in the dissemination of knowledge through informal discussion on an open stage. It is being copied by others and must be the envy of many . Competing interests: None declared |
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Neil Watson, Artist and Writer California 94801
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Dr. Nehrlich's response to my response seems to me, in the circumstances, to be flippant, at best. As a teacher/facilitator in the world of art and creativity I am all too familiar with 'charming theories'; indeed the entertainment of such theories is an important part of 'thinking outside the envelope'. Such theories could properly be posted in some whacky, off-beat, fringe journal. But the BMJ is none of those. It is, in effect, the serious voice of British Medicine, and, as such, is heard around the world, as this correspondence confirms. And so when the BMJ publishes something that will likely have significant consequences for at least 1.3 million patients per year in Britain alone, it does so with a considerable degree of responsibility. In my opinion the conclusion that 'physotherapy is no better than advice', what Dr.Nehrlich calls a 'charming theory', was not based on solid ground; in fact it was pretty flimsy ground. It might turn out, that, in the fullness of time, this 'charming theory' proves to be true. But, as of now, there are not sufficent grounds to say that it is. Like Dr. Nehrlich, I commend the BMJ for having this forum in which diverse opinions, including strongly contrary opinions, may be heard. However it is my belief that much damage has been done already by the publication of this article; damage which will be very hard to rectify, especially if, as I suspect to be the case, the 'charming theory' proves to be false. Neil Watson, MA, MD, FRCS Artist and Writer Formerly Consultant Hand Surgeon Competing interests: None declared |
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Janet Boaler, Retired Anaesthetist current acupuncturist specialising in chronic pain management.BMAS member Wessex Healthy Living FoundationBournemouth
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It is of interest to note, in the paper by Frost et al., an RCT on the use of physiotherapy in the management of low back pain, that acupuncture did not appear to have been included in the treatment options. This is surprising as a high proportion of physiotherapists use acupuncture, some having undergone training by the British Medical Acupuncture Society. Acupuncture is the one of the more successful and simple treatments for low back pain once the 'red flag 'signs have been discounted. In those who can be described as 'good responders', about 40% of the population, an almost immediate improvement can result from trigger point de-activation of the lumbo-sacral spine, particularly, in acute flare ups if combined with ear acupuncture. Endorphine raising 'needling' at strategic distal points can boost the effect resulting in an early return to normal activity. It is crucial to start acpuncture early in the disease process to avoid the development of chronicity which carries the risk of invalidity and 'chronic pain behaviour'. Frequently, in acute cases, no more than 1-3 treatments are needed. I encourage patients to walk and swim gently but avoid special exercise programs. Weight should be kept within the mormal range for height. THe use of a 'back friend' to correct posture while sitting is advisable particularly on long car journeys. I also recommend the use of a special frame to lie on for 5 minutes , two to three times daily, which provides a gentle stretch along with acupressure along the whole spine. It is of interest to note that this frame was designed by a physiotherapist. Recurrent episodes of low back pain can be avoided by these simple aids. What is required is more availability of specialist acupuncture clinics within the area of a PCT so that low back pain and many other pain problems can be successfully treated. The initial funding might stretch the budget but the savings to the NHS of prompt and effective treatment of low back pain, for instance, would more than compensate for the inital outlay. Competing interests: None declared |
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Abdolkarim Karimi, PhD student School of Allied Health professions (AHP)- University of East Anglia (UEA)- Norwich NR4 7TJ
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A very interesting topic to discuss. In particular it looks that the authors have left the discussion to the readers as the paper is suffering from a comprehensive discussion. They did not discuss the significant benefit of physiotherapy in short term (two months). They did not highlight the patients' perception of treatment benefit and why it was in conflict with the outcome measures. As we know when the perception of patient is positive, then it is more likely to return to normal activity and work as a common goal in treatment of low back pain. Furthermore, the treatment in this study is traditional and routine physiotherapy which is not necessarily the optimal physiotherapy intervention, therefore, I don't agree to generalise the findings to all physiotherapists in NHS. The sample is not a good represetative of chronic low back pain population because the mean of Oswestry disability index (ODI) at baseline is low in both groups (21.12 and 21.60) in compare with nomative data for ODI (43.3 for chronic low back pain) (Ref. 1) In general that is a good paper which cause us (as physiotherapist) to re-evaluate our practice more critically. According to literature and guidelines, when chronic back pain is a concern, psychosocial factors should be addressed and more than 70% of the sample in this study are chronic. That is surprising that the authors did not discuss about biomedical and biopsychosocial approaches and their role in obtaining such a result. The reader would like to know why there was not a difference between two groups and what is the authors suggestion about it but the athours keep silence about these important subjects. Traditional medical model is mostly tissue oriented and focuses on pain, it does not consider the factors involved in development and persistence of the problems such as psychosocial factors (Ref 2). It has been emphasised that physiotherapists will not be successful in their treatment unless they address the patient's fear avoidence beliefs (Ref. 2). It has also been shown that physiotherapist's beliefs may have an influence on management of chronic low back pain (Ref. 3). Frost et al pushed the physiotherapists to choose a "standard protocol reflecting routine practice in NHS" but it has been recommended in the lierature to choose an individual problem solving approach, individual plan with personal goals and individual monitoring of progress by physiotherapists (Ref 2). How to integrate and implement the evidence and clinical guidelines into practice is another issue that should be taken into account (Ref 4) and the gap between research results and actual practice should be closed (Ref 5). Koes et al (2001)clarified that there is a need for systematic implimentation strategies to change the behaviour of health care providers (Ref 6). Still it looks better to entitle the study in this way: Good assessment and advice by a physiotherapist is as effective as traditional physiotherapy. By this title the article does not mislead the media and the media do not mislead the patients and health care professionals. Abdolkarim Karimi-Physiotherapist References Ref 1 Fairbank, J. C. T. & Pynsent, P. B. 2000, "The Oswestry Disability Index", Spine, vol. 25, no. 22, pp. 2940-2953. Ref 2 Watson, P. 2000, "Psychosocial predictors of outcome from low back pain," in Topical Issues in Pain 2: Biopsychosocial Assessment and Management: Relationships and pain, L. Gifford, ed., CNS Press, Falmouth, pp. 85-109. Ref 3 Daykin, A. R. P. & Richardson, B. P. 2004, "Physiotherapists' Pain Beliefs and Their Influence on the Management of Patients With Chronic Low Back Pain", Spine, vol. 29, no. 7, pp. 783-795. Ref 4 Muncey, H. & Watson, P. 1999, "Efficacy of a Unidisciplinary Outpatient approach for patients with musculoskeletal pain. Abstracts, Annual Scientific Meeting of The Pain Society, Edinburgh". Ref 5 van Tulder, M. W. P., Koes, B. W. P., & Bouter, L. M. P. 1997, "Conservative Treatment of Acute and Chronic Nonspecific Low Back Pain: A Systematic Review of Randomized Controlled Trials of the Most Common Interventions.", Spine September 15, vol. 22, no. 18, pp. 2128- 2156. Ref 6 Koes, B. W. P., van Tulder, M. W. P., Ostelo, R. M., Kim Burton, A. P., & Waddell, G. D. M. F. 2001, "Clinical Guidelines for the Management of Low Back Pain in Primary Care: An International Comparison.", Spine, vol. 26, no. 22, pp. 2504-2513. Competing interests: None declared |
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Murray Flett, Researcher LS1 3EX
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I commend the authors Frost et al, for taking the time to do this study. The NHS as a whole is highly inefficient and along this theme this study is welcome because for the first time someone has proven that the NHS physiotherapy we deliver is no more effective that advice. Despite the perception that many of the respondents to this article seem to have this does not mean physiotherapy does not work. Having read through the rapid responses, I am saddened by the mob style approach that the Chiropractors seemed to have adopted in trying to jump on the wave of bad news for physiotherapists. There is no reliable nor credible data to support the benefits of chiropractic treatments. Having visited a number of Chiropractors I was left with quite a negative impression of the chiropractic profession. My perception is that they are Osteopaths who are licensed to take Xrays and because they can, they do. In four visits to four different chiropractors I never left without an Xray of something. I happen to be a radiologist and so I found it difficult not to question the indications and findings. On every occasion I have been less than impressed with the skills and knowledge of the therapist. Yet through behaviour modification for some reason, perhaps in the spirit of being a good patient, I let them continue to manipulate me, both physically and financially in the hope of a much wanted cure. A cure that sadly has not yet surfaced. I once stood up in a Spinal conference and confronted both an osteopath and a chiropractor as to what the difference was between them. Expecting a response along the lines of "£20", and was therefore a bit thrown when they simultaneously replied "Im better". Looking at this through the eyes of a patient, I think it is very sad to see such animosity and competition between therapists, in particular physiotherapists and chiropractors. After all, the patient has one diagnosis and needs a cure and any diagnostic or treatment modality must revolve around them and no one else. Surely it is about time that you all got together and started to find an integrated solution rather than concentrate on territorial and skill based superiority. Competing interests: None declared |
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Friederike I.M. von Rabenau, Physiotherapist Al Khobar, Dhahran 31932 Saudi Arabia
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Due to the delay in my husband receiving his British Medical Journal (BMJ) here in Saudi Arabia I am afraid this is a ‘not-so-rapid’ response. Randomised controlled trial of physiotherapy compared with advice for low back pain (BMJ Vol 329, pp 708-711) Hoping that Dr Domhnall MacAuley’s editorial (BMJ Vol 329, 25 Sept 2004, pp 694-695) had a facetious rather than serious character, it nevertheless filled me with concern about how most of his colleagues were going to interpret and use the results of this study. I hope that with my letter, even without going into the statistics of the paper, I may give some of the readers food for thought and would like to take the opportunity to recommend Trisha Greenhalgh’s excellent book on the basics of evidence based medicine “How to Read a Paper”, in which the questions presented here can be found. While I recognize that Helen Frost et al’s paper has not been published in its entirety I would like to limit my reply to the article in the BMJ because this is what I presume to be the literature (and maybe the tool for decision making) of the larger number of the subscribers. I was surprised to see that the paper had been published without the usual reviews and requests for alterations and corrections with subsequent re-submissions being declared. These reviews are frequently announced as footnotes in other journals and serve to prevent a publication of the standard that I wish to discuss here. As a physiotherapist I firstly have to take issue with the terms ‘routine’ and ‘standard’ physiotherapy treatment. I understand the term ‘routine medical check-up’ to be used in a scenario where patients attend assessments in regular intervals that contain exactly the same components (eg. blood pressure, weight, height, certain lab tests, ECG etc), every time for all attendees. While physiotherapy treatments contain standard techniques (mobilizations, manipulations, various soft tissue techniques etc) and modalities such as ultrasound, interferential, shortwave I would like to think that any Physiotherapist worth his/her salt will baulk at the term ‘standard treatment’. Following careful assessment we should decide on a specific approach in response to the problem posed by a particular patient. I also disagree with the dissection of physiotherapy treatments that the authors have undertaken in their paper, separating electrotherapy from advice and those two from ‘routine physiotherapy’ without giving a definition of what exactly constitutes 'routine physiotherapy'. I would like to stress here that advice and education are integral tools of physiotherapy in long-term management, especially of low back pain. I suggest that the research presented in the article has various flaws, some of which I endeavour to point out in the following to the doctors who may want to use the article in their decision making where the use of physiotherapy in the management of their patients with low back pain is concerned. When we read a research paper we need to ask certain pertinent questions in order to allow us to judge whether this particular paper is relevant to us in our clinical practice and whether the information given in it has been derived in a scientifically acceptable way. In the following I would like to cover some of the questions that I asked myself when I read the article and then leave the reader to draw his/her own conclusions 1. Did the authors formulate a problem? Did they define the desired outcome? Even though the paper states the objective of the study it neither formulates any actual problem, which would have made the investigation necessary nor is a motivation (such as cost saving in the NHS) made known. The tentative literature review of management of low back pain only insufficiently familiarizes the reader with the topic. 2. Was a hypothesis formulated and was it tested by the study? No hypothesis or null hypothesis is stated so we are left in the dark as to what the researchers were actually trying to prove or disprove. In good research a hypothesis should be formulated, which the researchers then set out to disprove. If it withstands the rigours of good research it can be regarded as not wrong. According to Richard Feynman (The Character of Physical Law, 1965) the key to science lies in initially guessing a new law, computing the consequences of the guess, comparing the result of the computation to nature and if the guessed law disagrees with experiment it is wrong. He warned that experimentation must be checked for errors and oversights, which can easily creep into research at all stages. 3. With the information given, could the study be reproduced? Is there any information (a table or paragraph) that allows for sufficient comparison of the two groups? The methods section of this paper is extremely short and sketchy in that insufficient information has been given about the exact conditions admitted and excluded, not enough has been said about the exact instructions given to physiotherapists or about the precise nature of the advice given to patients. For example, we do not know whether patients with spondylolisthesis were admitted to the study and if the handout covered advice for this condition. Further, no information has been given about how the deviations from the original protocol were handled. We also have very little information about the therapists, that is to say if all therapists were of comparable standard. Their qualifications and years of experience are not stated in the study. 4. Was this the best study design for the patients or for the outcome? Was appropriate treatment given to all cases? Despite having received ethical approval I am wondering whether this study is entirely ethical. Should treatment be withheld from patients? Even though the researchers would like to make us believe that their research concludes that their protocol of ‘routine’ physiotherapy treatment is not superior to ‘advice only’ this was not known beforehand. This means that effectively NHS approved treatment was withheld from half their subjects. My own doubts are reflected in the fact that some of the participating patients complained about not getting treatment and some participating therapists failed to adhere to the protocol for ethical reasons. 5. Did difficulties compromise the study design? Because neither all the patients nor all the therapists were satisfied with the protocol, significant changes over which the researchers had no control were undertaken while the study was in progress. Out of 142 patients in the ‘advice only’ group 14 ended up having hands on treatment of varying intensity. This makes up almost 10% of the sample. We are neither informed about how the researchers handled deviations from their protocol nor how they dealt with the results of those deviations. The study design is therefore severely compromised. 6. Was a sample size calculation given in the paper? Was the sample size sufficient? No calculation was given but commonsense must tell us that, if annually 1.3 million people receive treatment for low back pain in the UK, a sample size of 144 and 142 subjects for each group over a period of about three years cannot be sufficient to make a clinically or statistically significant statement. Also only 70% of all patients provided follow-up at 12 months. Trisha Greenhalgh states in her book that this is at the bottom end of the scale before a study becomes invalid. Hence the power of the study is low. And would not ‘last value carried forward’ in lieu of actual data give a distorted view, especially if there is only a 70% follow up for the final value? 7. Was the study performed under real life circumstances? Was the design appropriate and sensible? Trisha Greenhalgh warns that if a study has not been conducted under real life circumstances (ie shorter waiting time for subjects, interventions that are not normally available) this may cast doubt on the applicability of the study to our own clinical practice. The first deviation from a real life scenario is that in the trial the patient- information leaflets differed from those usually given. However, the main issue here is that patients were randomly assigned to the two groups while in reality physiotherapists should carefully select which patients are to be given hands-on treatment (as well as education and advice) and which patients are suitable for advice only. Due to the random assignment of the patients to the groups the result of this paper is not really applicable to our clinical practice. 8. Did the analysis include only predefined ‘objective’ endpoints, which may exclude other important aspects of the intervention? What outcome was measured and how? Have the authors drawn justified conclusions from their paper? In my opinion the study failed to look at some of the important objectives of hands-on physiotherapy, some of which are: faster pain relief, quicker return to work, sport and activities of daily living, in short reduced morbidity. As they are short-term outcomes they were not considered since the main outcome measure of the study was the status of patients at 12 months post intervention (with 2 and 6 months as secondary outcome measures). In the ‘therapy group’ 118 patients had six or fewer sessions. There is no explanation as to the reasons, apart from adherence to the study design. However, considering that some of the therapists used their discretion and did not adhere to the protocol by giving more treatments if they deemed it necessary this could also be interpreted as: no more than six treatments were needed to achieve satisfactory immediate results in 82% of the patients of the ‘therapy group’. This falls in line with the paragraph which states that patients from the ‘therapy group’ were more likely to report benefits at two and six months as well as in the 0-10 rating scale at all time points than the 'advice only' group. Further, the fact that both groups were given advice as part of the protocol diminishes the difference between the two groups and thus between the expected outcomes of the two groups. In my opinion we therefore should not expect any significant difference in the outcomes of the two groups at 12 months. My interpretation of the result here is that both groups adhered equally to the advice given. I will leave the decision whether the authors drew correct conclusions from their paper up to the reader. 9. Is the evidence given in this article politically desirable? Without wanting to sound cynical I have to ask whether this paper can be regarded as evidence of anything but I suppose that the answer to this question would depend on where one stands. Apart from the fact that the outcome is in my opinion not clinically relevant for the reasons stated above we still do not know about the motivation of the study and about who commissioned it. If one wished to save cost in the NHS it certainly seems that what the authors regard as the outcome of this study is politically desirable as it would support an argument in favour of abandoning Physiotherapy in the NHS. One statement that Trisha Greenhalgh made in her book, and which I have come across many times during my own clinical practice is: “What is important for the doctor may not be important for the patient and vice versa”. This is why I do not understand the discrepancy in the result as reported and the statement made regarding reported benefits. It seems as if noone was listening to what the patients really reported. At the end of the day we should ask ourselves what we as clinicians are trying to achieve. As a physiotherapist I regard myself as accountable to my patients first and foremost and strive to act in their best interest to my best knowledge and ability. Friederike von Rabenau MSc Physiotherapist Al Khobar Saudi Arabia Phone: ++ 966 3 8827711x 2221 Competing interests: None declared |
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Maureen Simmonds, Chair PPA, Professor & Head of School of Health Professions and Rehabilitation Sciences University of Southampton, Anne Daykin, PPA Scientific Officer
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We should not be too surprised at Frost et al’s conclusion that ‘routine physiotherapy’ based on physical factors was no more effective than one session of assessment and advice from a physiotherapist. What is surprising is the defensive nature of the responses to this research and this is partly due to the perceived rivalry between health care professions managing low back pain and the attention grabbing headlines with which it was reported. In recent years the evidence base has highlighted that low back pain (LBP) is a multifaceted phenomenon incorporating physical impairment, psychological distress and social interruption and thus the effective biopsychosocial management of LBP should reflect its multifaceted nature and not just focus on the ‘physical factors’ as was done in Frost et al’s study. Epidemiological studies have consistently pointed to psychological and social risk factors being important in the development of persisting pain and its associated disability. It is worth noting that Frost et al’s study was commenced prior to the emergence of Yellow Flags in 1997 and that outcome measures targeting psychosocial risk factors were not included in the evaluation of the treatment and control arms. Being an evidence-based practitioner should involve the identification and management of our patients’ risk factors. The rationale being that risk factors are clinical predictors of outcome and that efforts to mange them may reduce the burden of LBP for those who consult physiotherapists. Due to the recurrent nature of LBP, talk of a ‘cure’ is unrealistic. This is why the Physiotherapy Pain Association (PPA) has been tireless in emphasising that patients should be taught skills to self-manage their low back problem so that long-term they are less likely to experience pain- related disability and depression thus improving their quality of life. Receiving passive treatments focusing on ‘physical factors’ which show only slight short term benefits is not in the personal or economic interest of the patient with low back pain. As is highlighted by the responses to Frost et al’s study, beliefs regarding treatment preferences for LBP vary across professions and can be traced to beliefs about the cause of the problem. The PPA is committed to facilitating the physiotherapy profession’s move away from a traditional biomedical view of LBP to a more evidence-based biopsychosocial approach. The PPA’s education programme is available on our web-site www.ppaonline.co.uk . Reference Frost et al (2004). Randomised controlled trial of physiotherapy compared with advice for low back pain. British Medical Journal 329-708. Competing interests: None declared |
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Tom Caumont, Student Physiotherapist (3rd Year) Brunel University, Middlesex
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Despite my limited clinical experience in this particular area, I think there is one fundamental fact that is missing from the article in question. Whether we are providing a full-on, multiple-treatment service to a patient with back pain, or a simple one-off consultation of assessment and advice, surely we as physios are one of the ideal healthcare professions to provide either or. This is what we spent three years at university for, after all... Initial physiotherapy assessment should provide the revevant information about each patients condition, so the clinician can make the right decisions about both the nature of each individual case, as they arise, as well as how is best to go about solving the problem. Having written a 3rd year literature review about how is best to combat lower back pain, I think a more relevant question we need to ask is not whether physiotherapy treatment/advice is effective or not, but rather is the resource well-managed by 'the people upstairs', so that it is cost- effective and readily available when it is needed? Competing interests: None declared |
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Meir Lotan, Director of Therapeutics Zvi Quittman Residential Center, The Millie Shime Campus, Elwyn Jerusalem, Joav Merrick
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EDITOR--- Frost et al (1) have managed to produce a controlled trial on back pain using a large group of participants. For this they should be congratulated. The faults of this study have been introduced by other readers. Doing a very organized job at locating those faults was done by Friederike IM von Rabenau from Saudi Arabia (2). This enquiry and the responses that followed are the beginning of a surge of interest. Such an interest can go both ways: It could be distorted and manipulated by headlines seeking newspapers and gloated by chiropractors. But those responses are hopefully over and done with. It could start a positive professional interest by other physical therapists and researchers. If the results of the article are feared, then a wide spread debate should be conducted among physical therapists on how to treat LBP (Low Back Pain) patients. Thus within this brain-storming turbulence, insights into the profession will benefit our expertise and our patients. This is good enough for us. If such results will enhance employment of better "therapeutic" techniques than commonly used; then this is good enough also. If it will bring better and unified team work within the public health services then the system will benefit and our patients will benefit – and this is good enough. If somewhere around the globe enough concern over this article will lead to performing more pinpointed intervention, enhancing our knowledge and improving our skills this is good enough for me. If by any chance some hi-ranking public servant will take those results and use them to establish a specialist committee to improve and better present public care for patients (like the NHS)… than we all have gained. If by any chance all those therapists responding so furiously to the results of Frost et al (1) will pick up the glove and perform better investigations. Than the future looks promising. Let us hope that for the professionalism of manual therapy (including: physical therapists, chiropractors, osteopaths) some of those wishes will come true then our costumers have really won. Let us hope that all those good things will come in 2005 – then we will have a happy (and wiser) New Year. AFFILIATION Meir Lotan, MScPT, is a physiotherapist working at the Zvi Quittman Residential Center, The Millie Shime Campus, Elwyn Jerusalem with special interest in physiotherapy aspects on intellectual disability, Snoezelen and physical activity for children and adults with intellectual disability. He lectures on assistive technology at Department of Physical Therapy, Haifa University and Ben Gurion Univeristy. E-mail: ml_pt_rs@netvision.net.il Joav Merrick, MD, DMSc is professor of child health and human development, director of the National Institute of Child Health and Human Development and the medical director of the Division for Mental Retardation, Ministry of Social Affairs, Jerusalem, Israel. E-mail: jmerrick@internet-zahav.net. Website: www.nichd-israel.com REFERENCES 1. Frost H, Lamb SE, Doll HA, Carver PT, Stewart-Brown S. Randomised controlled trial of physiotherapy compared with advice for low back pain BMJ 2004;329:708-13. 2. von Rabenau FIM. Low back pain and physiotherapy. BMJ Rapid Response at http://bmj.bmjjournals.com/cgi/eletters/329/7468/708#80667 Competing interests: None declared |
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Brad S Stevens, Physiotherapist Australia
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Dear Frost H. et al, Happily this paper has evoked the appropriate responses, and support the need for heavy scrutiny of research purporting to provide evidence where in fact the methods show something else entirely. I suggest: - Stronger scrutiny of research titles. - A better NHS system for the UK. Certainly this research goes a long way toward proving how inadequate it really is with respect to providing physical therapy (using Mr Potter's definition) for LBP. Brad Stevens Physiotherapist (without any NHS experience). Competing interests: None declared |
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