Here in New Zealand, our friendly Accident Rehabilitation, Compensation and Insurance Corporation, colloquially and widely known as the ‘ACC’ is a health-premium-tax funded organisation that provides the funding for treatment and rehabilitation after accidents. The ACC is presently endeavouring to control the fiscal results of previous political decisions that saw an expansion of expenditure to hitherto unimaginable levels, which in turn has led to the most recent political decision to adopt a more economically sustainable business model. The see-saw of the political landscape wreaks its own unintended consequences in health care, exerting a measured pressure on case management broadly consistent with the evidence but definitively consistent with fiscal goals. ‘Managed care’, which may utilise clinical guidelines born out of the highest ethical desire to see best practice,  remains primarily concerned with a financial imperative. It is serendipitous when the goals of ‘managed care’ coincide perfectly with the goals of evidence based practice (EBP).

When considering the evidence based health care management of an episode of acute back pain it has been of longstanding interest to me that the message ACC promulgates as evidence based is to remain active – and most preferably, at work. The financial imperative here is evident. The costs associated with income related compensation are very substantial. In addition, the risk of chronicity associated with disengagement from normal everyday activities including work, escalates. So the Corporation puts out the following EBP advice:

In most cases, the patient can be advised to continue working normally. Communication with the patient must include clear statements like ‘working heals rather than harms the back’. The patient should also be reassured that while there may be some temporary increase in pain, the physical activity is beneficial to their rehabilitation, (Non-specific acute low back pain: Return to work – Issue 10; May 2004. http://www.acc.co.nz/for-providers/clinical-best-practice/acc-review/WCMZ003162)

Staying active and continuing usual activities, even though there may initially be pain and discomfort, usually results in a faster recovery from symptoms, less chronic disability and less time off work. NZ Acute Low Back Pain Guide Oct 2004, p12.

The evidence suggests that in the absence of ‘red flags’ – indicators of potentially significant or serious pathology, most individuals improve quite quickly from an episode of acute low back pain. It should be pointed out here that this does not mean they ‘get better’ or make a ‘full recovery’. The implication also exists that as the condition is not diagnosable (at least without expensive, sophisticated imaging or invasive diagnostic tests – and, so it goes, there’s no point anyway as most patients get better)………then it follows that there’s nothing really wrong, which is another subtle reinforcement of the keep moving, stay at work message. The trouble is that the literature also suggests that there is a 50% chance of recurrence within a year after an acute episode which leaves one in little doubt that for a significant proportion of acute low back pain sufferers, an injury of consequence has been incurred -  MRI studies suggest that 35 – 40% of the population have intervertebral disc bulges.

When an injury occurs it requires a period healing. The healing process takes a period of time but it will permit the progressive resumption of pain free activity in a manner that is physiologically consistent with the degree of injury and the role of the structure involved.  In addition, the neurological recovery from a episode of acute pain may arguably take longer – pain pathways are sensitised and some central expansion of related central somatosensory areas may ensure and importantly, the pain experience will not be forgotten.

Now, there is little doubt if one were to fall over, hands outstretched, in a manner that results in the forcible over extension of a knuckle joint, the joint is likely to swell and become painful. It was sprained. More than likely, one will limit the amount of movement until the pain and swelling subsides. Almost certainly, one will not actively wiggle the joint in order to promote a more rapid recovery. In this instance, such behaviour is both inconsistent with a speedy physiological recovery and a pain free life .

A patient experiencing an acute episode of low back pain will sometimes barely be able to walk, let alone think of working. Usually and fortunately, this period is short – days. In most cases individuals do press on as best they can but they will instinctively limit their activities commensurate with their pain. Moving may not be of therapeutic use. And indeed, this is what the evidence now tells us. The ACC Acute Low Back Pain (2004), which refers to the Cochrane Collaboration as a source of data, does not appear to reflect recent Cochrane Collaboration findings.

The Cochrane Collaboration has quite recently withdrawn advice to stay active as a single treatment for low back pain and sciatica (Hilde et al. Cochrane Collaboration, Issue 4, 2009) and highlights the idea that remaining active and engaged in daily activities as normally as possible is the best EBP advice. This stands in notable contrast to the ACC statement that ‘working heals rather than harms the back’ or  ‘In most cases, the patient can be advised to continue working normally’. Such statements are incorrect generalisations that may inadvertently encourage unintended consequences.  They may inhibit rapid physiological recovery by promoting the notion that activity per se is useful – which it clearly isn’t – and they may result in a prolongation of injury and increased risk of chronic back pain. The new evidence however, is consistent with the physiological requirement for recovery from injury, although the Corporation may view it as a fiscally risky recommendation. We’ll see. I suspect fiscal risk will win out.

So the take away message to patients and practitioners, having clinically excluded ‘red flags’, is to pay attention to the symptoms, listen to your body and move about in a manner consistent with managing your discomfort at a tolerable level. Exercise (remember wiggling the knuckle) and acute back pain do not enjoy some secret inverse relationship. In fact, they are not related at all. However, you will find that if you move about in a manner you can tolerate and you stay engaged with life, friends and work you’ll recover with less struggle and potential complication, and you’ll remain saner. I sometimes frame such advice in the following way; number one rule is to stay comfortable and engaged and number two is to move, but not in a manner that compromises number one rule. Needless to say this advice is not only patient specific but also takes into account other potential risk factors associated with the development of a chronic condition.

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.

An important and thorough review of the scientific evidence surrounding the use of manual intervention for a variety of common conditions has recently been published and is seriously recommended reading for both the professional and the public – indeed in the case of the former, hopefully the subject for compulsory continuing professional education points and in the case of the latter, leading to a better understanding of the therapeutic benefits and limitations associated with manual intervention – despite what a practitioner or your friends might tell you.

Irrespective of the discipline of practice eg. osteopath, chiropractor, manipulative physiotherapist, musculoskeletal general practice, the key message from a substantive and recently published report, which provides a comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal condition is that effective utility resides in manual intervention.

Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy, 2010, 18:3. Bronfort G et al.    doi:10.1186/1746-1340-18-3

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

The study concludes the following:

‘Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain.’ (Bronfort et al. 2010).

The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension- type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults.’ (Bronfort et al. 2010).

‘Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.’ (Bronfort et al. 2010).

‘Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic’. (Bronfort et al. 2010).

A more detailed analysis of the report is underway and you can read it here in the next week.

So, the humble and ubiquitous fibroblast whose normal role is to manufacture the material of the body structure – collagen proteins – may be persuaded to turn into a functioning nerve cell or neuron – and not with stem cell technology but instead with three transcription genes!

The advance article published online in the prestigious scientific journal Nature, 27 January 2010, doi: 10.1038/nature08797 – Direct conversion of fibroblasts to functional neurons by defined factors – Vierbuchen, T. and colleagues highlights this work of such tremendous potential. The researchers took embryonic and postnatal mouse fibroblasts and identified a combination of three genes that were capable of inducing these fibroblasts to become functional neurons capable of generating action potentials and forming synapses.

It is known that fibroblasts may be genetically re-programmed to a pluripotent state using a number of genetic transciption factors but it was unknown whether they could be persuaded directly into another defined somatic cell. Vierbuchen et al. have shown that this is feasible by their work on mouse fibroblasts. The implications are huge for the treatment of disease, the regeneration of compromised, traumatised or aged nerves and the therapeutic intervention in development, to name a few.

2010: welcome to a brighter future as we enter the new year; now is one time to affirm a truly positive outlook, so here is one very good idea……reject the tedious, ultimately indigestible diet of fear, gloom and desperation that characterises the biased mainstream media (MSM). As you satisfy your addiction into what selectively passes for ‘news’, you risk jeopardizing your mental and emotional health, because you’re literally quite helpless to respond. In truth, look to your own community, the one that you know and can influence. This is where you can see and do good – literally. On the other hand the MSM news reinforces your sense of helplessness -  and that is indescribably unhealthy. We know ‘fear mongering injures civil society’ and we persist in battering ourselves into states of insensibility and cynicism, needing ever more disasters, cataclysms and news of ‘the end is nigh’. Such is one modern day addiction. Make no mistake; the more fearsome, the more sensational, the more troubling, the more you’re likely to listen, buy the paper, and see the ads. Instead, use your intelligence and wit to select, assess and evaluate the news. Go to the net. Look at different sources. Select, assess and evaluate. Once or possibly twice a week is perfectly sufficient to grasp the essentials.

The world is a fabulous place, full of opportunity and joy. Develop the habit of looking for positive things, surrounding yourself with positive people and projects, doing something new and interesting, rediscovering some of your passion and enthusiasm for life. Take one day, one moment, one hour, one step at a time. This is one of many routes leading to better health and well being.

Dunedin Osteopathic Clinic positively and distinctively offers you focused osteopathic care. The clinical goal is to have you diagnosed, comfortably functional and as pain free as possible within the shortest possible time. Our treatment is informed by research, evidence, experience and qualifications second to none. We think positively and we aspire to have you doing the same. Our pre-eminent aim is to save you time and therefore money; not to over-diagnose, over-treat or over-service your condition or indeed to foster clinical ‘dependence’. We believe in delivering the minimum amount of treatment for your maximum benefit, and providing you with the ability to manage future risk. And we believe in doing this collaboratively with you.

We wish you a positively prosperous and healthy 2010!