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.