220
Grantham CJ, Cannell MB. Kinetics, stoichiometry and role of the Na-Ca exchange mechanism in isolated cardiac myocytes. Nature 1990; 345: 618-21. 6. Bridge JHB, Smolley JR, Spitzer KW. The relationship between charge movements associated with ICa and INa-Ca in cardiac myocytes. Science 1990; 248: 376-78. 7. Noble D. Mechanism of action of therapeutic levels of cardiac glycosides. Cardiovasc Res 1980; 14: 495-514. 8. Sheu S-S, Lederer WJ. Lidocaine’s negative inotropic and antiarrhythmic actions. Circ Res 1985; 57: 578-90. 5.
Crespo LM,
CHIROPRACTERS AND LOW BACK PAIN The medical profession and chiropracters have not enjoyed an easy relationship. Does the publication1 of a "pragmatic" trial of chiropractic vs conventional hospital treatment of patients with back pain deemed safe for manipulative treatment, that showed a strong and clear advantage for patients treated with chiropractic, necessitate revision of the conventional medical view of chiropracters? In 1979 the Cochrane Commission report on back pain2 made several recommendations, one of which was that clinical trials should be established to test the value of "alternative" methods of management. Chiropracters persuaded the Medical Research Council to establish first a pilot trialand then the clinical trial that has now been reported by Meade et al*—an act of courage on both sides, because there was considerable medical and chiropractic resistance to the venture. The lapse of nearly 15 years from conception to completion should be a lesson to all involved in the funding of research who expect instant answers. This latest trial was devised and completed by the MRC Epidemiology and Medical Care Unit at the Clinical Research Centre in Harrow; twelve hospital centres with nearby chiropractic clinics were recruited. After the pilot study,3 a slight modification of the Oswestry disability index (ODI) was identified as a reasonably reliable outcome measures.The main study accepted 741 patients, sufficient to show a 3-point difference in outcome on the ODI scale. The researchers found at least a 7-point advantage for chiropractic treatment over conventional hospital management. This is not a trivial amount, because it reflects the difference between having mild pain, the ability to lift heavy weights without extra pain, and the ability to sit for more than an hour, compared with moderate pain, the ability to lift heavy weights only if they are conveniently positioned, and being unable to sit for more than 30 minutes. This highly significant difference occurred not only at 6 weeks, but also for 1,2, and even (in 113 patients followed so far) 3 years after treatment. Surprisingly, the difference was seen most strongly in patients with chronic symptoms. This result is not easy to explain away. The trial was not simply a trial"of manipulation but of management. 72% of the hospital-managed patients had Maitland manipulations, and 12% had Cyriax manipulations. The very strong result this trial has produced needs to be confirmed by other studies, which should attempt to dissect the causes of the observation. Future studies should also address a major criticism that has not been answered satisfactorily by the trial’s organisers-whether it is good enough to compare treatment given in a busy physiotherapy department with that administered in the relatively unhurried atmosphere of a chiropracter’s clinic. It should be possible to define clearly those patients who will respond to chiropractic and to identify those in whom this approach is
dangerous. Presumably some of this information is already chiropracters but it is not available in the conventional medical literature. Classification of back pain syndromes remains a contentious issue which no-one, including the chiropracters, has solved. Second, chiropractic treatment should be taken seriously by conventional medicine, which means both doctors and physiotherapists. Meade and co-workers recommend that chiropractic be available in the UK on the National Health Service, a view that is probably too extreme to be absorbed at this stage. Although cogent arguments can be made for such a policy on financial grounds alone,’ other aspects of chiropractic care have not faced stringent analysis. Physiotherapists also need to come under the spotlight. Doctors generally believe that these carefully trained and well-educated health workers make an important a contribution to management of many conditions. However, they have a poor record of initiating and responding to research, and numerous treatment techniques are used with little, if any, scientific backing. For example, 10 years ago it known to the
shown that Maitland’s mobilisation was no more effective than control treatment for patients with back pain,s yet 72% of the patients entering the hospital arm of this latest trial received this therapy. Physiotherapists need to shake off years of prejudice and take on board the skills that the chiropracters have developed so successfully. Special training is clearly needed in manipulative techniques because back pain is one of the most frequent reasons for referral for physiotherapy. Third, if their skills are to be adopted by mainstream medicine, chiropracters must put their own house in order. This trial was conducted with chiropracters who had been trained at the Anglo-European College of Chiropractic, or at one of its North American parent colleges-institutions that award a qualification of Doctor of Chiropractic (DC) after 4 years’ training. In the UK, anyone can set himself up as a chiropracter (or for that matter as a physiotherapist) by nailing up a brass plate and advertising in the local media. In the first instance the British Chiropractic Association might follow the example of the Chartered Society of Physiotherapists and circulate general practitioners with a list of their members, perhaps with a brief account of their qualifications. The Government will have to decide how to cope with regulation of practitioners offering both mainstream and alternative paramedical treatment. Lastly the MRC (which managed to fund this trial, including payment of the chiropracter’s fees, in a period of unprecedented financial stringency) and other agencies must look to develop this fmding through the support of back pain research, which for too long has received very little academic attention, out of all proportion to the frequency of this complaint in the adult working population. was
TW, Dwyer S, Browne W, et al. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J 1990; 300: 1431-37. 2. Department of Health and Social Security Working Group on Back Pain. Report to Secretary of State for Social Services. London: HM Stationery Office, 1979. 3. Meade TW, Browne W, Mellows S, et al. Comparison of chiropractic and hospital outpatient management of low back pain: a feasibility study. J Epidemiol Commun Hlth 1986; 40: 12-17. 4. Fairbank JCT, Davies J, Couper J, O’Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy 1980; 66: 271-73. 5. Sims Williams H, Jayson MIV, Young SM, Baddeley H, Collings E. Controlled trial of mobilisation and manipulation for patients with low back pain: hospital patients. Br Med J 1979; ii: 1318-20. 1. Meade
Grantham CJ, Cannell MB. Kinetics, stoichiometry and role of the Na-Ca exchange mechanism in isolated cardiac myocytes. Nature 1990; 345: 618-21. 6. Bridge JHB, Smolley JR, Spitzer KW. The relationship between charge movements associated with ICa and INa-Ca in cardiac myocytes. Science 1990; 248: 376-78. 7. Noble D. Mechanism of action of therapeutic levels of cardiac glycosides. Cardiovasc Res 1980; 14: 495-514. 8. Sheu S-S, Lederer WJ. Lidocaine’s negative inotropic and antiarrhythmic actions. Circ Res 1985; 57: 578-90. 5.
Crespo LM,
CHIROPRACTERS AND LOW BACK PAIN The medical profession and chiropracters have not enjoyed an easy relationship. Does the publication1 of a "pragmatic" trial of chiropractic vs conventional hospital treatment of patients with back pain deemed safe for manipulative treatment, that showed a strong and clear advantage for patients treated with chiropractic, necessitate revision of the conventional medical view of chiropracters? In 1979 the Cochrane Commission report on back pain2 made several recommendations, one of which was that clinical trials should be established to test the value of "alternative" methods of management. Chiropracters persuaded the Medical Research Council to establish first a pilot trialand then the clinical trial that has now been reported by Meade et al*—an act of courage on both sides, because there was considerable medical and chiropractic resistance to the venture. The lapse of nearly 15 years from conception to completion should be a lesson to all involved in the funding of research who expect instant answers. This latest trial was devised and completed by the MRC Epidemiology and Medical Care Unit at the Clinical Research Centre in Harrow; twelve hospital centres with nearby chiropractic clinics were recruited. After the pilot study,3 a slight modification of the Oswestry disability index (ODI) was identified as a reasonably reliable outcome measures.The main study accepted 741 patients, sufficient to show a 3-point difference in outcome on the ODI scale. The researchers found at least a 7-point advantage for chiropractic treatment over conventional hospital management. This is not a trivial amount, because it reflects the difference between having mild pain, the ability to lift heavy weights without extra pain, and the ability to sit for more than an hour, compared with moderate pain, the ability to lift heavy weights only if they are conveniently positioned, and being unable to sit for more than 30 minutes. This highly significant difference occurred not only at 6 weeks, but also for 1,2, and even (in 113 patients followed so far) 3 years after treatment. Surprisingly, the difference was seen most strongly in patients with chronic symptoms. This result is not easy to explain away. The trial was not simply a trial"of manipulation but of management. 72% of the hospital-managed patients had Maitland manipulations, and 12% had Cyriax manipulations. The very strong result this trial has produced needs to be confirmed by other studies, which should attempt to dissect the causes of the observation. Future studies should also address a major criticism that has not been answered satisfactorily by the trial’s organisers-whether it is good enough to compare treatment given in a busy physiotherapy department with that administered in the relatively unhurried atmosphere of a chiropracter’s clinic. It should be possible to define clearly those patients who will respond to chiropractic and to identify those in whom this approach is
dangerous. Presumably some of this information is already chiropracters but it is not available in the conventional medical literature. Classification of back pain syndromes remains a contentious issue which no-one, including the chiropracters, has solved. Second, chiropractic treatment should be taken seriously by conventional medicine, which means both doctors and physiotherapists. Meade and co-workers recommend that chiropractic be available in the UK on the National Health Service, a view that is probably too extreme to be absorbed at this stage. Although cogent arguments can be made for such a policy on financial grounds alone,’ other aspects of chiropractic care have not faced stringent analysis. Physiotherapists also need to come under the spotlight. Doctors generally believe that these carefully trained and well-educated health workers make an important a contribution to management of many conditions. However, they have a poor record of initiating and responding to research, and numerous treatment techniques are used with little, if any, scientific backing. For example, 10 years ago it known to the
shown that Maitland’s mobilisation was no more effective than control treatment for patients with back pain,s yet 72% of the patients entering the hospital arm of this latest trial received this therapy. Physiotherapists need to shake off years of prejudice and take on board the skills that the chiropracters have developed so successfully. Special training is clearly needed in manipulative techniques because back pain is one of the most frequent reasons for referral for physiotherapy. Third, if their skills are to be adopted by mainstream medicine, chiropracters must put their own house in order. This trial was conducted with chiropracters who had been trained at the Anglo-European College of Chiropractic, or at one of its North American parent colleges-institutions that award a qualification of Doctor of Chiropractic (DC) after 4 years’ training. In the UK, anyone can set himself up as a chiropracter (or for that matter as a physiotherapist) by nailing up a brass plate and advertising in the local media. In the first instance the British Chiropractic Association might follow the example of the Chartered Society of Physiotherapists and circulate general practitioners with a list of their members, perhaps with a brief account of their qualifications. The Government will have to decide how to cope with regulation of practitioners offering both mainstream and alternative paramedical treatment. Lastly the MRC (which managed to fund this trial, including payment of the chiropracter’s fees, in a period of unprecedented financial stringency) and other agencies must look to develop this fmding through the support of back pain research, which for too long has received very little academic attention, out of all proportion to the frequency of this complaint in the adult working population. was
TW, Dwyer S, Browne W, et al. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J 1990; 300: 1431-37. 2. Department of Health and Social Security Working Group on Back Pain. Report to Secretary of State for Social Services. London: HM Stationery Office, 1979. 3. Meade TW, Browne W, Mellows S, et al. Comparison of chiropractic and hospital outpatient management of low back pain: a feasibility study. J Epidemiol Commun Hlth 1986; 40: 12-17. 4. Fairbank JCT, Davies J, Couper J, O’Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy 1980; 66: 271-73. 5. Sims Williams H, Jayson MIV, Young SM, Baddeley H, Collings E. Controlled trial of mobilisation and manipulation for patients with low back pain: hospital patients. Br Med J 1979; ii: 1318-20. 1. Meade
