Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Same pain, no gain!
- james m noon (1 November 2006)
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evidence based sustainable interventions.
- Peter B Hadfield (11 November 2006)
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Re: Same pain, no gain!
- Dina Ralt (11 November 2006)
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opioids and knee osteoarthritis
- hussam m, ammar MD, ashok K, malani MD FRCS (12 November 2006)
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Re: evidence based sustainable interventions.
- Neha S. Godre (13 November 2006)
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Rotational Field Quantum Magnetic Resonance
- Neha S. Godre (13 November 2006)
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Message to the authors and responders
- Richard Bartley (14 November 2006)
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Paranoia over paper
- david c Hartley, Dr Johanna Lowther GP Kippax Leeds (15 November 2006)
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Management of Knee Pain in Primary Care
- Caroline Anne Mitchell (18 November 2006)
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Re: Rotational Field Quantum Magnetic Resonance
- Sukhbindar S Sibia (6 October 2007)
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Re: Rotational Field Quantum Magnetic Resonance
- G S Nayar (2 November 2007)
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Re: Rotational Field Quantum Magnetic Resonance
- Raghav Kumar (12 December 2007)
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Re: Re: Rotational Field Quantum Magnetic Resonance
- Sukhbindar Singh Sibia, Harpreet Kaur Sibia (15 February 2008)
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Newsweek International - Something Less Than a Miracle
- Sukhbindar S Sibia, Kaur Harpreet (13 March 2008)
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james m noon, clinical health psychologist treliske hospital, truro, cornwall, tr1 3lj
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The conclusions of this study can be paraphrased as:
It follows from the above that:
Bottom line? There is no net gain! I fully support the profession of physiotherapy and admire the high levels of skill demonstrated by my colleagues from this profession. However, in my opinion, the profession is done no favours by presenting these findings as 'evidence' of anything. Certainly there would be no grounds to commission a service based on these findings. Competing interests: None declared |
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Peter B Hadfield, gp principal pe12ra
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The only valid conclusion from this study is that community physiotherapy and pharmacy intervention produce a statistical improvement in pain and function scores at 3 months that is not sustained for 6 or 12 months compared to no treatment. Unsurprisingly those receiving no treatment had to come back and see their GP whilst those in a treatment programme did not, and so to conclude that community physio effected a shift in care away from the traditional GP led model is baseless. Yes we would all like to have rapid access to community physiotherapy for musculoskeletal problems. However we need to consider the cost effectiveness of an intervention that the evidence shows only provides short term benefit that is not sustained. Perhaps the traditional gatekeeper GP still has a role to play. Competing interests: I am a GP with a desire to deliver evidence based interventions. |
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Dina Ralt, Scientific editor Internet - http://www.nrg.co.il/online/HP_0.html
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Dear James, If you look at the details you could see that physiotherapy was scheduled for 10 weeks...for that period of time it helped... so maybe you should have titled your comment as: same pain, no gain if you stop physiotherapy... Competing interests: None declared |
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hussam m, ammar MD, attending physician Heartland Regional Medical Center, 5325 Faraon Street, St Joseph, MO 64506, USA., ashok K, malani MD FRCS
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In their interesting study, Professor Hay and her colleagues proposed an algorithm for pharmacy intervention for the management of osteoarthritic knee pain. They offered non responders to acetaminophen weak narcotics like codeine and those who didn’t respond to codeine were offered Non- Steroidal anti- inflammatory drugs (NSAIDs). This approach is not supported by the current guidelines, The European League Against Rheumatism (EULAR) recommended for the management of knee osteoarthritis that opioid analgesics are useful alternative in patients in whom NSAIDs, including COX 2 selective inhibitors, are contraindicated, ineffective, and/or poorly tolerated, the American College of Rheumatology(ACR) issued similar recommendations. The EULAR graded the evidence for opioid use as 1b while the evidence supporting the use of (NSAIDs) as 1a, this was partially because of the paucity of randomized controlled trials supporting the use of opioid. (2,3) In a recent meta-analysis of the effectiveness of opioids in non cancer pain, weak and strong opioids were more effective than placebo for relieving pain and improving functional outcomes, but they were less effective than other analgesics for improving functional outcomes.(4) Professor Hay and her colleagues stated that ( NSAIDs are the most common cause of iatrogenic disease) we believe that there is no evidence to support this conclusion, even though the current guidelines were released before the publication of widely publicized cardiovascular adverse effects of COX 2 inhibitors and (NSAIDS). Sedation, confusion and constipation are well known side effects of opioid use in the geriatric population who are mostly affected by knee osteoarthritis. Prescription narcotics accounted for most of the increase in non-illicit drug- poisoning deaths of unintentional or undetermined intent in the United States.(5) We believe based on the current evidence and potential side effects that opioids should be prescribed only after failure of trial of acetaminophen and (NSAIDs). references 1- Elaine M Hay, Nadine E Foster, Elaine Thomas, et al. Effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in people aged over 55 presenting to primary care: pragmatic randomised trial. BMJ. 2006 Nov 11;333(7576):995. Epub 2006 Oct 20. 2-Jordan KM; Arden NK; Doherty M; et al. EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis 2003 Dec;62(12): 1145-55. 3-American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. Arthritis Rheum 2000;43:1905-1915 4-Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ. 2006;174:1589-94. 5-Caravate EM, Grey T, Nangle B, et al. Increase in poisoning deaths caused by non-illicit drugs. MMWR. 2005;54:33-6. Competing interests: None declared |
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Neha S. Godre, intern India
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Dear Dr. Hadfield, I completely agree with your view about the general practitioners having the potential to provide something more. I belong to a nation where patients still put in a lot of faith in the GPs and most dont find it cost effective to visit myriad of specialists for their problems. Such a thing might infact lead to patients not following up anywhere and finally returning with a far worse condition. A GP, if well trained, can provide physiotherapy support too to the patient, thus not only improving the patient's physical condition and functional capacity, also ensuring that his patients are well followed up. Competing interests: None declared |
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Neha S. Godre, intern India
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Knee osteoarthritis [OA] for the patients is mainly pain and loss of function which is most often managed symptomatically- analgesics and physiotherapy. But as the studies show hitherto, OA management is inadequate, providing short term, temporary relief, with progressive resurgence of symptoms soon after. And what about the patients living a debilitated life due to severe OA? Rotational Field Quantum Magnetic Resonance [RFQMR] is a noninvasive technique to improve cartilage thickness by normalising the cell membrane resting potential and stimulating cartilage regrowth. It is an upcoming mode of knee OA management in India with long term relief as compared to conventional therapy. Competing interests: None declared |
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Richard Bartley, Physiotherapist Denbigh LL16 3ES
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Physiotherapy is a profession, not a treatment. Until this clearly understood we'll continue to measure the wrong things, on the wrong conditions, on the wrong patients, at the wrong time, for the wrong reasons. Competing interests: None declared |
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david c Hartley, GP York YO1 7NP, Dr Johanna Lowther GP Kippax Leeds
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reading this paper produced a defensive paranoia in us as it attempts to show that other professionals provided better care then GPs. This is a recurring theme that fails to take account of the polypathology dealt with in most general practice consultations, something most other professionals cannot deal with. The study encourages a move away from standard general practice care when the control group used bore no resemblance to what we as General practitioners(GPs) offer our patients with knee pain i.e. exercises,dietary advice,analgesia,acupuncture & injections. It will in our opinion be used as evidence by the politicians to support their attempts to fragment general practice by claiming that Physiotherapists & pharmacists reduce contact with GPs when in reality this only happened for the first three months of the trial. we were not surprised to see no GP authors involved in the trial. we would certainly be surprised to see our local pharmacist giving individual patients six sessions of twenty minutes over ten weeks to discuss their medication. we need more physiotherapists but please do not try to make the case that they can replace Gps Competing interests: None declared |
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Caroline Anne Mitchell, General Practitioner. Senior Lecturer Primary Medical Care University of Sheffield, Division of Primary Care, S5 7AU, UK
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The prevalence of chronic knee pain is rising, not least due to increasing obesity and diminishing activity levels in western populations (1). It is imperative that the research community evaluate primary care approaches which encourage safer analgesic prescribing, sustainable increased activity, weight loss and non-pharmacological interventions to manage pain (2) . This well conducted pragmatic randomised controlled trial of complex physiotherapy and pharmacy interventions in primary care is a welcome contribution to an evidence base dominated by pharmacological interventions, which is at odds with the information needs of patients and the multidisciplinary primary care team (3). Evidence based exercise treatments for OA knee are not widely available in primary care and referral to community physiotherapists is inconsistent (4). The new Musculoskeletal Framework (MSF) announced by Andy Burnham (Health Minister) will extend physiotherapist roles in the management of musculoskeletal problems from presentation and treatment in primary care to screening orthopaedic referrals (5). The challenge to evidence based commissioners of primary care services is to provide a coherent and cost effective integrated care pathway for knee pain which can reconcile patient choice, increase capacity using alternative non-NHS providers of musculoskeletal services, explore ‘expert patient’ initiatives, work with charitable and voluntary bodies and provide an overview of the public health issues. The general practitioner gatekeeper role may well diminish along the way, although we will still provide continuity of care for those patients who require prescribed analgesics, fail to respond to physiotherapy interventions or are unfit for knee replacement. General practitioner expertise in chronic pain and co-morbidity management including timely steroid injection and recognition and treatment of the psychological impact of significant disability is still important (6). (1)M.Underwood, Community managememt of knee pain in older people: is knee pain the new back pain?, Rheumatology 2003 42:2-3) (2)Dieppe P. Evidence-based medicine or medicines-based evidence? Ann Rheum Dis 1998;57:385-6. (3)Tallon D, Chard J, Dieppe P. Relation between agendas of the research community and the research consumer. Lancet 2000;355:2037-40. (4)Jordan KM; Arden NK; Doherty M; et al. EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis 2003 Dec;62(12): 1145-55. (5)http://www.gnn.gov.uk/Content/Detail.asp?ReleaseID=238864&NewsAreaID=2 (6)Managing osteoarthritis of the knee’, MacAuley,D, BMJ2004,329:1300 -1301 Competing interests: I have co-authored a paper on maangement of shoulder pain in primary care with Professor Elaine Hay |
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Sukhbindar S Sibia, Consultant Physician Ludhiana (India) 141001
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Based on our experience of over one hundred osteoarthritis (OA) Knees treatment with Rotational Field Quantum Magnetic Resonance (RFQMR) we conclude that RFQMR has good result in most patients but the role of physiotherapy cannot be undermined even when there is evidence of increased thickness of joint cartilage. Also necessary is to take care of the patient's psychology as most of these patients having tried various treatments unsuccessfully and have some degree of depression and biased negativity against all therapy modes. Competing interests: Using Cytotron to generate RFQMR since March 2006 to treat patients having Osteoarthritis and cancer. |
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G S Nayar, Consultant (Medicine) Pristina 38000
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Rotational Field Quantum Magnetic Resonance (RFQMR) technology is being used to treat advanced osteoarthritis following successful Phase 2 clinical trials in India using the medical device Cytotron (TM). Significant improvements in all Knee Society parameters have been consistently achieved. There is also MRI evidence of regeneration of articular cartilage. The technology is also being used in clinical trials in various malignancies, especiallly of brain, lungs and pancreas. The hypothesis of this nanotechnology application, using radio and sub-radio frequencies of electromagnetic spectrum, is to normalise the altered transmembrane potentials of the degenerated or rapidly multiplying cells in osteoarthritis and cancer respectively, in order to re-establish the normal command and control of cellular function resulting in the gene expression of HSP or p53 groups of proteins to promote or arrest mitosis as applicable. Competing interests: None declared |
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Raghav Kumar, interested party EC4
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Since last couple of days only, I have come across the miraculous work thatjhas been done using RFQMR (cytotron) . Such is the impact on me that : - I have now already read the published paper from 2004 and noted the initial scores (which are very promising) on 30+ subjects on standard knee measures in the Indian Aerospace Journal for Mediac Research - I have also read about several testimonials (including one from a close relative), and reported success in 70% patients (good), 20% (fair) and 10%(poor i.e. presumably meaning no notable improvement) but in no cases, any adverse effect from the Ludhianan centre. I think the figures quoted from Bangalore are even higher (90% good) - I have also come read about reported cartilage growth which substantiates above claims even further, well beyond claimed improvements over 21 day treatment days which medics can often regard as due to built- up expectations although they cannot deny physical aspects of it i.e. improved movements. Although I have not seen any clinical data around cartilage growth What I am still trying to put my arms around is : 1 how come no (literally zero) Eu/NA media or medics have commented on this at all, given osteoarthritis is such a big issue ? Is this some sort of vested interest, plain ignorance, or simple rejection of anything that seems to come from the East ? Not one comment from/any where is a real surprise, given the potential this shows By any stroke of imagination, the kind of results demonstrated in the paper above, and ever since is much more than simply 'significant' in statistical terms or when compared to any type of medical research. In the papers I have come across, if only 5-10% of subjects would report improvements - it will be considered a major breakthrough. It is only sligthly short of a 'a complete cure'. The only issue was a small sample size in this paper - hwoever ever since as I understand that over 500 people have been treated and am sure evidence will have been recorded. Therefore, according to me, unless either of the two situations apply, this is a sure winner: a) the improvements are temporary (although no evidence on this account) b) the treatment is not safe (again, no evidence on this account, infact, on the contrary this is a no side effect treatment) I wonder what the inventors have to say about the lack of any media or peer coverage in the West 2 I am sure that the inventors are pushing for even more evidence and approvals, but I dont know what exacatly is the next step and when is it targetted to be completed ? Or do they feel completely handicapped by the lack of process patent laws in India ? Do they believe there is any hope of this reaching the West ? Or are they limiting your ambition (which is still very large and noble) to providing relief (and may I submit 'near cure') to millions of Indians I would appreciate any views, as I am passionate about not only bringing cure and relief, but also about the inventors getting their due credit for their invention - and especially if they happen to come from India, my native land Competing interests: None declared |
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Sukhbindar Singh Sibia, Consultant Physician Ludhiana Punjab India 141001, Harpreet Kaur Sibia
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I have been practicing non surgical and non-invasive treatments for kidney stones since 1991, for Coronary Artery Disease and Peripheral Artery Disease since 1994, for osteoarthritis since 2006 and for cancer since 2007. My experience that mental block holds back the development and spread of many effective treatments. We have faced the same delima for every treatment. Most doctors comment - it is useless and when probed furthur they say we have not heard about it and know nothing about it. This same story has been repeted for Extracorporeal Lithotripsy and External Counter Pulsation when we introduced them in our region in 1991 and 2002. Now history is repeating itself with Cytotron since 2006. I would love to interact with anyone who say I have studied the technique and then comment that it good or bad. Another common comment is that if it was so good it would be FDA approved - exposing the rejection of anything that comes from the East without applying the mind. The attidude seems to be that anything not from the west is useless and anyting not FDA approved is fake and quack. The only western media I know that has written about Cytotron is the Red Herring in its April 24, 2006 issue titled Cancer: India’s New Treatments - A new device offers patients hope. To get its due place Cytotron has to fight vested comercial interests of large TKR, pain killers and chemotherapy lobby and with its weak financial muscle this will grow only if good hands support it. We are ready to participate in any research for this purpose for public / patient benefit. Competing interests: Providing Cytotron therapy since 2006 |
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Sukhbindar S Sibia, Consultant Physician Sibia Medical Centre, Ludhiana, Punjab, India, 141001, Kaur Harpreet
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As a rejoinder to the last response we will like to add that Cytotron / RFQMR has also been written about in Newsweek International edition, 20 December, 2004 issue under thge heading "Something Less Than a Miracle" This can be viewed on the internet website http://www.msnbc.msn.com/id/6700298/site/newsweek/ and the details mentioned is as follows:One day last month, Dr. V. G. Vasishta and Dr. Rajah Vijay Kumar were confronted by a 35-year-old woman suffering from ovarian cancer. After three operations, her cancer had returned, but she couldn't afford the extra chemotherapy treatments her doctors prescribed. She had heard rumors that a new cancer treatment was being tested at Scalene Cybernetics, a biomedical firm in Bangalore working with researchers from the Indian Air Force. She traveled 2,000 kilometers by train from her home in the northern state of Haryana to beg the doctors to treat her. "Please admit me," she pleaded. The lack of affordable treatments is one reason why half of the 700,000 to 900,000 Indians who come down with cancer each year wind up dying—a survival rate half that of developed nations. Kumar thinks he's discovered a low-cost solution. In this month's issue of the Indian Journal of Aerospace Medicine, Vasishta and Kumar describe a device which bombards tumors with electromagnetic radiation, applying a voltage to the membranes of cancer cells. The beams, they think, activate a protein in the cells that kills them. During clinical trials on 33 cancer patients, each given 28 one-hour sessions, the device stopped the growth of tumors in 20 patients, while six others had improved enough after exposure to the beams to undergo successful operations. A 5-year-old boy at Hosmat Hospital in Bangalore receiving treatments for a brain tumor has also shown improvement. Competing interests: Using Cytotron / RFQMR since 2006 |
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