‘The object of life is not to be on the side of the majority, but to escape finding oneself in the ranks of the insane….’

Marcus Aurelius Antoninus Augustus (121 – 180)

Current evidence that best guides manipulative intervention is recently described in the work of Bronfort et al. 2010, ‘Effectiveness of manual therapies: the UK evidence report’ and discussed by Haldeman and Underwood 2010 in: ‘Commentary on the United Kingdom evidence report about effectiveness of manual therapies’. Both articles should really be considered mandatory reading for practitioners, regulators and educators occupying whichever flavour of manual health care. Be advised however that Journal reading is not an endorsed continuing professional development (CPD) choice for osteopaths. It is not an activity sanctioned by the statutory body, the Osteopathic Council of New Zealand. Regrettably therefore, in New Zealand it may take considerably longer to breach a threshold of wider professional awareness.

Reading the UK evidence report (Bronfort et al. 2010) might quickly be followed by a purging dose of Hartman 2009, ‘Why do ineffective treatments seem helpful? This brief review provides helpful insight into practitioner and patient perceptions that believe therapeutic benefit may be occurring clinically. Hartman 2009 states:

“Independent of direct, effective, therapeutic support, patients often come to feel better. This is not trivial, but ethics of all healing professions demand that such effects not be falsely credited to specific treatments.”

Based on the UK evidence report (Bronfort et al. 2010), Haldeman (Haldeman and Underwood 2010) echoes this stating:

“It is however a serious mistake to try to attack or disagree with the evidence when treating patients. It does not serve patients to provide treatment that has been shown to be ineffective or where there is insufficient evidence to reach a conclusion when there are other options available that have been demonstrated to be beneficial. It is not acceptable today to claim that a treatment is effective in helping patients when there is no evidence to to support these claims.”

Underwood (Haldeman and Underwood 2010) continues by underlining the key message:

“There is evidence to support the use of manual therapies for a range of, primarily musculoskeletal, disorders for which it is biologically plausible that they might have a specific effect. There is not evidence for their use for a range of other disorders for which a biologically plausible mechanism for a specific effect is unclear.”

Today a potential exists for legislative pressure to develop that would seek to ensure a formalised presence of evidence based practice in regulated health care. Hunt and Ernst (2009) describe the UK House of Lords Select Committee advising that the “ethos of evidence based practice should extend to alternative and complementary medicine.” Their study highlighted that only the British Osteopathic Council, Chiropractic Council and General Regulatory Council for Complementary Therapies oblige their members to adopt evidence based practice.

It remains a matter of deep interest to this writer to observe how long it is before the regulators in New Zealand step up to the practical and ethical challenge of instigating a code of evidence based practice in osteopathic and wider manual health care. It would obviously be far better were the professions to pre-empt a directed development of this nature. In a sense the process has started elsewhere through AMSEC (Australian Musculoskeletal Education Competencies), which has sought to establish defined core competencies in musculoskeletal medicine for the implementation into the curricula in all Australian medical schools.

For osteopaths, the implementation of evidence based practice is not only feasible but a vitally important project. Much of the necessary expertise in tertiary education exists to provide an Australasian expert guidelines group. All that is required is for the regulatory boards to wake-up to the reality that almost all osteopathic academic and clinical expertise resides in tertiary institutions, in spite of a persistent and unspoken denial that this is the case – as evidenced by a bizarre and inexplicable reluctance to acknowledge substantial professional and clinical development accruing to those in tertiary osteopathic and related manual medicine education and research.

A suggestion made to the New Zealand Osteopathic Council in the form of a ‘Terms of Reference’ document in February 2009, described  ‘A possible role for evidence assimilation explicit in the scope of practice’ (McGrath MC 2009) was greeted by deafening silence. To quote a salient passage:

“The development of an osteopathic guidelines process may offer a dynamic way in which to assimilate current research and practice paradigms with distinctiveness. This could also offer a responsive and evolutionary way to modify scope of practice. Extant scopes of practice might reflect specific professional guidelines developed by a professional guideline group. Consideration of the possibility that some of the scope of practice be represented by current guidelines (developed by osteopaths) for the treatment of common conditions.

Such an approach would require the establishment of a formal guidelines group charged with a review of evidence and the synthesis of professional guidelines that are show osteopathic distinctiveness. Made available to the profession, the maintenance of currency in professional guidelines maybe considered a feature of currency of scope of practice (SOP). In this way, the SOP would assist moving usual practice towards best practice, assimilating evidence based guidelines.”

Nevertheless, an acknowledgment of evidence based practice continues to remain on the fringes of statutory perception as does the development of a professional mechanism to assist and support a ‘species specific’ guidelines group – surely a tremendous opportunity and practical first step in drawing all the professions involved in manual musculoskeletal practice closer together.

A recent paper hot of the press, so to speak (Murphy DR 2010), suggests that the current evidence shows that cervical (neck) manipulative treatment is associated with but may not be causally related to vertebral artery dissection and stroke (VADS). The article points out that VADS is rare but potentially serious and that some of the initial symptoms of this disorder can mimic more common and relatively benign neck and headache problems. The article goes on to indicate that diagnosis may be difficult so that some individuals and their health care providers are not always aware that they are experiencing VADS. The important thing is the recognition of subtle signs and symptoms (derived from an appropriate physical examination and history). This nicely written article is very well worth reading critically. It is available through BMC open access.

Anyone interested in having a look at evidence based medicine/practice might check out the following helpful links:

http://library.ncahec.net/ebm/pages/learning.htm#online

http://www.cebm.net/index.aspx?o=1014

http://www.nice.org.uk/

http://www.sciencebasedmedicine.org/

http://www.patient.co.uk/guidelines.asp

http://library.umassmed.edu/EBM/index.cfm

And finally, to quote directly from a recent article by Goldstein M (2010):

‘Modern medicine now requires that OMT’s present and future clinical application be evaluated utilizing methodologies that are reliable and reproducible. The randomised controlled trial (RCT) is a critical methodology for meeting that objective. It is a methodology that the osteopathic profession must foster so that its identifying characteristics of patient care become part of conventional medicine rather than continuing to be considered complementary medicine’.

Goldstein (2010) goes on to raise the crucial issue of funding for contemporary osteopathic research, stating that it is only through research expertise that the osteopathic profession will address its responsibility to be ‘active participants in what is rapidly becoming the basis for modern clinical care — evidence-based medicine’. This is precisely the same issue that requires intelligent and urgent attention from the osteopathic profession in New Zealand and Australia. Indeed, it is imperative that the relevant statutory bodies recognise, promote and support a tertiary based culture of research and teaching expertise. Without such recognition and support it is sad and likely that the profession will continue a progressive slide toward irrelevance, unable to define meaningful clinical distinctiveness.

Thank you for your engagement.

Bibliography

Bronfort G et al. 2010. Effectiveness of manual therapies: the UK evidence report. Chiropractic and Osteopathy, 18:3. Biomedcentral.

Haldeman S and Underwood M, 2010. Commentary on the UK evidence report about effectiveness of manual therapies. Chiropractic and Osteopathy, 18:4 Biomedcentral.

Hartman SE, 2009. Why do ineffective treatments seem helpful? A brief review. Chiropractic and Osteopathy, 17:10. Biomedcentral.

Murphy DR, 2010. Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession? Chiropractic and Osteopathy, 18:22. Biomedcentral.

Hunt K and Ernst E, 2009. Evidence based practice in British complementary and alternative medicine: double standards? J Health Res Serv Policy 14(4):224 – 5.

McGrath MC, 2009. Proposed terms of reference for the development of a discussion document relating to a requirement for a scope of practice for osteopaths by the Health Practitioners Competence Assurance Act (2003)’. Commissioned by the Osteopathic Council of New Zealand.

Goldstein M, 2010. Osteopathic manipulative treatment for pneumonia. Osteopathic Medicine and Primary Care 4:3. Biomedcentral.

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.