Two eminent academics, both with backgrounds in clinical practice – one as a practicing neurologist, the other as a general practitioner proffer their comments in the following discussion article:

Commentary on the United Kingdom evidence report about the effectiveness of manual therapies. Chiropractic & Osteopathy, 2010, 18:4. Haldeman, S. Underwood, M.    doi:10.1186/1746-1340-18-4

Some key points made by Prof. Haldeman in this commentary stand out. In particular, the idea that it is not acceptable to claim that treatment is effective in helping patients when there is no evidence to support such a claim. On the positive side, Haldeman points out that there is now little dispute amongst knowledgeable scientists that manipulation is of value in the management of back pain, neck pain and headaches. His key exhortation to practitioners is to ensure attendance at scientific meetings in which the latest clinical studies are presented and discussed, and that they keep up with the latest research.

Prof. Underwood also highlights the utility of manual intervention (massage, joint mobilisation, manipulation) though avoids maintaining a particular focus on any specific manual discipline. As indeed I have stated elsewhere, individual manual disciplines are quick to opportunistically point out the usefulness of manual intervention – irrespective of the source of the research – if it helps their own case and yet, in a curious double standard, get quite coy with each other in the political or funding arenas.

Refreshingly, academic research and evidence based practice highlight the spuriousness of maintaining philosophical and historical discipline differences that originate in the late nineteenth and early twentieth centuries. The intellectual focus is shifted to what is actually done -  including ideas that embrace a more contemporaneous biopsychosocial model of healthcare practice. Evidence based practice importantly will inevitably move patient expectations steadily away from the more esoteric conceptualisations of a mystical woo-woo process that some practicing in manual therapy appear to foster, and dare I say it, not a few of their willing patients appear to enjoy.

Prof. Underwood states that manual therapists need to indicate to their patients the risk of minor and major adverse events, particularly in the context of the presenting complaint and mechanism of injury. He concludes his commentary by highlighting the popularity of manual intervention for some non-musculoskeletal disorders. In this instance, without evidence being available for such intervention he urges that there is a real need for new trials to produce evidence of effectiveness / ineffectiveness and it is incumbent on manual practitioners to be aware of non-manual treatment, to be able to consider the comparative evidence and to be able to explain this to a patient who may then make an informed treatment decision.

Prof. Underwood observes that the majority of osteopaths and chiropractors in the UK  (and equally in Australia and in New Zealand) are in private practice. He suggests that this could lead to the concern that unproven treatments are being inappropriately offered for short term commercial gain. This statement by Prof. Underwood goes directly to the heart of a rarely spoken about issue amongst osteopaths and chiropractors that centers around what I might less delicately describe as an Integrity Conflict -  a potential conflict between the commercial imperative and professional integrity. One possible way of characterising aberrant osteopathic or chiropractic practice is through over-servicing. This is usually self-evident to the informed patient who will unilaterally terminate continuing treatment as they improve. They understand natural history and risk, instinctively or otherwise. The less aware may unfortunately become ongoing practice cash flow and capital. Regrettably, the concern that  unproven treatment is inappropriately offered for short term commercial gain is not only limited to the osteopaths and chiropractors but as Prof. Underwood states, ‘might be raised for my medical colleagues who work in private practice’.

In New Zealand, where the Accident Rehabilitation Compensation Insurance Corporation – known by the contracted acronym – ‘ACC’  funds a model of practice that in no small part, it could be argued, drives practitioner behaviour. No where is this so well seen but in the ‘management’ and treatment of musculoskeletal ‘strains and sprains’. Inevitably, and as we have recently seen, this practice funding model is apt to eventually be caught up by reality, leading to Ministerial intervention. In the truest sense it is unsustainable. The predictable hiatus associated with reduced funding has, in this particular instance, been rather muted. Unsurprising really, as the evidence shows that outcomes have not been usefully influenced by unfettered grazing at the funding trough.

We may all, patients and practitioners alike, live in hope for a future where evidence based practice increasingly guides and informs clinical practice, and contributes to professional ethics. Brontfort et al (2010) – Effectiveness of manual therapies: the UK evidence report – together with the comments of Professors Haldeman and Underwood, have undeniably raised the bar in the manual healthcare professions and in time, this will also be felt in patient expectations.