Randomised controlled trial of physiotherapy compared with advice for low back pain
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.38216.868808.7C (Published 23 September 2004) Cite this as: BMJ 2004;329:708
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Proper Title: Trial of NHS Physiotherapy compared with advice for LBP
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
Competing interests: No competing interests