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Manipulation Issues
97
Manipulation Issues MADAM --It was heartening to find a response to the article ‘Manipulation and back school in the treatment for back pain’ (Ross, 1997) by a chiropractor. I have read with great interest Mr Gregory Parkin-Smith’s long letter in the November 1997 issue of Physiotherapy and along with many others share his interest in this area of our practice. However, I was surprised by some of the issues he grappled with in his well-referenced letter. Mr Parkin-Smith states that manipulations are a highly-skilled intervention which while very beneficial in the hands of the experts can do more harm than good when used by ill-trained practitioners. The author uses this argument to suggest that manipulations should be left to the experts - chiropractors. Needless to say, I whole-heartedly agree with the argument though not with the conclusion.The Manipulation Association of Chartered Physiotherapists (MACP) for one has worked incessantly to safeguard and maintain the very high standards of assessment, clinical reasoning and application needed for this treatment approach. This has resulted in effective and safe practice by the many trained manipulative physiotherapists. The fact that most of this education lies firmly embedded within postgraduate continuing professional development (and hence has been validated by independent universities) reaffirms this point. Mr Parkin-Smith goes on to state the possibility of cerebrovascular accidents being caused by manipulation by ill-trained practitioners. Figures derived from a company providing malpractice insurance to US chiropractors suggest though that in 1990 alone the company paid approximately 140 claims to patients who had suffered a stroke after spinal manipulation (Consumer Report, 1994). This survey not only concentrated on safety with regard to strokes but also quoted delayed medical care when appropriate as one of the worst dangers in chiropractic. The over-reliance of often repeated whole spine X-rays is another criticism of chiropractic in this report. Safety is clearly an important issue for all manipulators and I therefore share the author’s concern. This has led us
to pursue the very highest standards in our manipulative education, continualty re-evaluating our procedures against newly-published research. Another point made by Mr ParkinSmith is the Manga Report (Manga et a/, 1993) which was funded by the Ontario Ministry of Health and undertaken by the economist Dr Pran Manga and colleagues. The aim of this review study was to determine the effectiveness and cost-effectiveness of chiropractic management for low back pain. The reported outcome of this report appeared to strongly support the efficacy of chiropractic, assuming that all the manipulations performed in the reviewed studies had been done by chiropractors alone - something most of the studies’ designs did not make clear (Butcher, 1994). It therefore concluded that chiropractic was the effective ingredient. Koes et a / (1991) examined 35 world-wide randomised clinical trials of spinal manipulation and mobilisation; this showed that 24 of these produced positive results from manipulation. Of these though only four could be attributed to chiropractors while the remaining 20 were done by physiotherapists and others. The Manga Report basically re-affirmed the validity of manipulation but did not have the data allowing for comparisons between chiropractors, physiotherapists or osteopaths in its review. As many readers will know the report’s findings have come under criticism for its weak methodological design as well as its interpretation of the available data. Even some contributors to the Manga Report seem to have distanced themselves from its published outcomes (Butcher, 1994; Consumer Reports, 1994). To conclude, I welcome the inter-professional exchange with Mr Parkin-Smith and thank him for initiating it. The problems with the quoted evidence in favour of chiropractic manipulation have demonstrated the need for all of us with an interest in this area to continue in our efforts to improve our research base, particularly with regard to methodology and relevance to practice. The different philosophies underlying chiropractic and physiotherapy could help both professions to contribute to a more all-encompassing insight into the
effects and outcomes within this specialist area of practice. At present there is certainly nothing in the literature to suggest that a manipulation by a physiotherapist trained in these approaches is anything but a safe, skilled and very effective technique.
Anne-Marie Hassenkamp MSc MCSP PRO, MACP
References Butcher, D (1994).‘Professional Association Report to the Manga Report‘, Journal of Manual and Manipulative Therapy,
22,4,143-148. Consumer Report (1994).‘Chiropractors: Can they help? Do they harm?’ Consumer Reports, June, 383-390. Koes, B W, Assendelft, W J J, van der Heijden, G J M G, Bouter, L M and Knipschild, P G (1991).‘Spinal manipulation and mobilisation for back and neck pain: A blinded review’, British Medical Journal,
303,1298-1303. Manga, P, Angus, D E, Papadopoulos, C and Swan W R (1993).‘A study to examine the effectiveness and cost-effectiveness of chiropractic management of low back pain’, The Manga Report, www.mbnet.mb.ca. Ross, M (1997).’Manipulation and back school in the treatment for low back pain’, Physiotherapy#83,4,181-183.
Exercise Software MADAM - How delighted I was to see that a review of a software package was included in Physiotherapy (November 1997, page 605). This muchwelcomed inclusion of such reviews could help to bridge the current void. Presenting reviews of computerised software suitable for physiotherapy use will assist many members desperately seeking help with this issue. I was even more interested to read that the software under review was one of the Physio Tools Compatible Collection. I have been a user of the Physio Tools main programme for three years and extended the programme by adding the Back Care and Incontinence ‘add-ons’ last year. Although not wholly familiar with the package under review - Home Care for the Stroke Patient - I was still most interested to read the reviewer’s comments. 1 was, however, somewhat disappointed with the overall inference of the report which came over quite
Physiotherapy, February 1998, vol84, no 2
Manipulation Issues MADAM --It was heartening to find a response to the article ‘Manipulation and back school in the treatment for back pain’ (Ross, 1997) by a chiropractor. I have read with great interest Mr Gregory Parkin-Smith’s long letter in the November 1997 issue of Physiotherapy and along with many others share his interest in this area of our practice. However, I was surprised by some of the issues he grappled with in his well-referenced letter. Mr Parkin-Smith states that manipulations are a highly-skilled intervention which while very beneficial in the hands of the experts can do more harm than good when used by ill-trained practitioners. The author uses this argument to suggest that manipulations should be left to the experts - chiropractors. Needless to say, I whole-heartedly agree with the argument though not with the conclusion.The Manipulation Association of Chartered Physiotherapists (MACP) for one has worked incessantly to safeguard and maintain the very high standards of assessment, clinical reasoning and application needed for this treatment approach. This has resulted in effective and safe practice by the many trained manipulative physiotherapists. The fact that most of this education lies firmly embedded within postgraduate continuing professional development (and hence has been validated by independent universities) reaffirms this point. Mr Parkin-Smith goes on to state the possibility of cerebrovascular accidents being caused by manipulation by ill-trained practitioners. Figures derived from a company providing malpractice insurance to US chiropractors suggest though that in 1990 alone the company paid approximately 140 claims to patients who had suffered a stroke after spinal manipulation (Consumer Report, 1994). This survey not only concentrated on safety with regard to strokes but also quoted delayed medical care when appropriate as one of the worst dangers in chiropractic. The over-reliance of often repeated whole spine X-rays is another criticism of chiropractic in this report. Safety is clearly an important issue for all manipulators and I therefore share the author’s concern. This has led us
to pursue the very highest standards in our manipulative education, continualty re-evaluating our procedures against newly-published research. Another point made by Mr ParkinSmith is the Manga Report (Manga et a/, 1993) which was funded by the Ontario Ministry of Health and undertaken by the economist Dr Pran Manga and colleagues. The aim of this review study was to determine the effectiveness and cost-effectiveness of chiropractic management for low back pain. The reported outcome of this report appeared to strongly support the efficacy of chiropractic, assuming that all the manipulations performed in the reviewed studies had been done by chiropractors alone - something most of the studies’ designs did not make clear (Butcher, 1994). It therefore concluded that chiropractic was the effective ingredient. Koes et a / (1991) examined 35 world-wide randomised clinical trials of spinal manipulation and mobilisation; this showed that 24 of these produced positive results from manipulation. Of these though only four could be attributed to chiropractors while the remaining 20 were done by physiotherapists and others. The Manga Report basically re-affirmed the validity of manipulation but did not have the data allowing for comparisons between chiropractors, physiotherapists or osteopaths in its review. As many readers will know the report’s findings have come under criticism for its weak methodological design as well as its interpretation of the available data. Even some contributors to the Manga Report seem to have distanced themselves from its published outcomes (Butcher, 1994; Consumer Reports, 1994). To conclude, I welcome the inter-professional exchange with Mr Parkin-Smith and thank him for initiating it. The problems with the quoted evidence in favour of chiropractic manipulation have demonstrated the need for all of us with an interest in this area to continue in our efforts to improve our research base, particularly with regard to methodology and relevance to practice. The different philosophies underlying chiropractic and physiotherapy could help both professions to contribute to a more all-encompassing insight into the
effects and outcomes within this specialist area of practice. At present there is certainly nothing in the literature to suggest that a manipulation by a physiotherapist trained in these approaches is anything but a safe, skilled and very effective technique.
Anne-Marie Hassenkamp MSc MCSP PRO, MACP
References Butcher, D (1994).‘Professional Association Report to the Manga Report‘, Journal of Manual and Manipulative Therapy,
22,4,143-148. Consumer Report (1994).‘Chiropractors: Can they help? Do they harm?’ Consumer Reports, June, 383-390. Koes, B W, Assendelft, W J J, van der Heijden, G J M G, Bouter, L M and Knipschild, P G (1991).‘Spinal manipulation and mobilisation for back and neck pain: A blinded review’, British Medical Journal,
303,1298-1303. Manga, P, Angus, D E, Papadopoulos, C and Swan W R (1993).‘A study to examine the effectiveness and cost-effectiveness of chiropractic management of low back pain’, The Manga Report, www.mbnet.mb.ca. Ross, M (1997).’Manipulation and back school in the treatment for low back pain’, Physiotherapy#83,4,181-183.
Exercise Software MADAM - How delighted I was to see that a review of a software package was included in Physiotherapy (November 1997, page 605). This muchwelcomed inclusion of such reviews could help to bridge the current void. Presenting reviews of computerised software suitable for physiotherapy use will assist many members desperately seeking help with this issue. I was even more interested to read that the software under review was one of the Physio Tools Compatible Collection. I have been a user of the Physio Tools main programme for three years and extended the programme by adding the Back Care and Incontinence ‘add-ons’ last year. Although not wholly familiar with the package under review - Home Care for the Stroke Patient - I was still most interested to read the reviewer’s comments. 1 was, however, somewhat disappointed with the overall inference of the report which came over quite
Physiotherapy, February 1998, vol84, no 2