Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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A more informed choice
- Neil A Tuttle (23 October 2009)
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Response to Tuttle
- Richard Bartley (24 October 2009)
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Never mind the treatment - what about the tests?
- Andrew N Bamji (3 November 2009)
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Neil A Tuttle, Lecturer and Physiotherapist in private practice School of Physiotherapy and Exercise Science, Griffith University, Gold Coast Campus, Australia 4222
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Cassidy (BMJ 339;2009:b3952) in his editorial subtitled “let the patient decide” provides some thought provoking material on the choice of treatments not only for patients with cervical but also lumbar radiculopathy. Physiotherapy is more expensive than immobilisation, but the patient and clinician might make a different choice with a little more information. In a study including some patients with cervical radiculopathy, we found that an improvement (particularly in active range of movement) in the first treatment predicts lasting change 1 and improvement within the first two treatments predicts end of treatment outcomes 2. Similarly in the lumbar spine, response to one physiotherapy treatment predicts lasting change 3 and for treatment based on a McKenzie model, response within two treatment sessions predicts the effectiveness of treatment for patients with both cervical and lumbar symptoms 4. By all means let the patient decide, but ensure their decision is fully informed and that the patient as well as the clinician know that if results are to occur with active treatment, they should be expected to commence within two or three treatment sessions. 1. Tuttle N. Do changes within a manual therapy treatment session predict between-session changes for patients with cervical spine pain? Australian Journal of Physiotherapy 2005;51(1):43-8. 2. Tuttle N, Laakso L, Barrett R. Change in impairments in the first two treatments predicts outcome in impairments, but not in activity limitations, in subacute neck pain: an observational study. Australian Journal of Physiotherapy 2006;52(4):281-5. 3. Hahne AJ, Keating JL, Wilson SC. Do within-session changes in pain intensity and range of motion predict between-session changes in patients with low back pain? Australian Journal of Physiotherapy 2004;50(1):17-23. 4. Werneke M, Hart DL. Discriminant validity and relative precision for classifying patients with nonspecific neck and back pain by anatomic pain patterns. Spine 2003;28(2):161-6. Competing interests: None declared |
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Richard Bartley, Physiotherapist Wales, UK
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The papers quoted refer to cervical (and lumbar) pain in general. In the case of radiculopathy, where the limb pain is worse than axial pain, great care should be taken not to exacerbate mechano-chemical triggers. This is ideally achieved by avoiding treatments that are no better than doing nothing. Letting the patients with radiculopathy decide whether to maintain normal activities, immobilise or do exercises seems reasonable, but simple advice on pain control, posture and what to expect is perhaps the most helpful. Competing interests: None declared |
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Andrew N Bamji, Consultant Rheumatologist Queen Mary's Hospital, Sidcup, Kent DA14 6LT
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Cassidy's editorial makes oblique reference to the usual timescale of cervical root irritation - which is, in over 90% of cases, measured in days or weeks. Perhaps the relative similarity of outcome for both treatments examined reflects the possibility that neither actually does much to alter the normal natural course of recovery. That is helpful to have proved. However, a worrying trend of overinvestigation is emerging following the introduction in some areas (including my own) of open-access GP-initiated MRI scanning. This results in patients being scanned unnecessarily, and often causes more alarm than benefit. Some patients have clearcut MRI scans of root compression (some with symptoms do not, and I have several cases myself where persistent symptoms are investigated only to find trouble on the wrong side) but there is no point whatever in doing a scan if it will not alter the outcome. I suggest that any patient with symptoms persisting over 6 weeks, or 4 weeks with motr signs, requires investigation but it is pointless to scan all when only 1% will actually require surgery. The NHS is stretched enough without indulging in unnecessary and expensive tests; sadly, however, it appears that some PCTs have paid for block contracts, which is hardly conducive to sensbile, practical and economical decision-making. I believe that all such contracts should be terminated. Competing interests: None declared |
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