In a prospective study of 640 consecutive hospital and clinic deliveries at Jane Furse Memorial Hospital, Lebowa, South Africa, in 1988 the perinatal mortality rate was 60/1000 births. One third of these deaths were considered easily avoidable: they were associated with failure to detect and treat severe anaemia and syphilis and the failure to refer patients with pre-eclampsia in the early stages. After these defects in care were identified it proved fairly easy to design and implement intervention strategies to try to prevent such deaths. Antenatal care was reorganised, standing orders for the management of antenatal problems were issued, the midwives were trained, and village clinics were supported. A comparative prospective study of 2193 consecutive deliveries in the seven months after implementation of the strategies found that the perinatal mortality rate had fallen to 40/1000 and deaths considered easily avoidable had been eliminated (ninth conference on priorities in perinatal care in South Africa, University of Witwatersrand, March 1990). The general standard of care improved appreciably. With an annual delivery of 4000, 80 perinatal deaths are prevented each year. The value of such work is that it proves that preventive measures can measurably reduce mortality. Health workers battling under enormous workloads should take heart and ensure that their curative and preventive strategies are balanced. I agree with Dr Fauveau and colleagues that much can be done while awaiting improved socioeconomic conditions. D WILKINSON
Newquay TR7 IDA 1 Fauveau V, Wojtyniak Bn Chakraborty J, et al. The effect of maternal and child health and family planning services on mortality: Is prevention enough? Br Med J 1990;301:103-7. (14 July.)
Low back pain: comparison of chiropractic and hospital outpatient treatment SIR,-It is perhaps surprising that despite the recent correspondence regarding their paper on back pain' Dr T W Meade and colleagues continue to assert that their results "make it necessary to consider the availability of chiropractic to NHS patients now."' Their study shows that one of the two treatment groups derived more long term benefits.2 The fact, however, that there were other important variables in addition to the availability or otherwise of chiropractic seems to have been largely ignored in the conclusions. The consequence of this is that the media have transmitted the simplified message that chiropractic heals backs without the necessary caveats that should have been more clearly presented in the original paper. This, I believe, has not helped the cause of manipulation. As a doctor trained in medical manipulation I am well aware of its potential benefits in treating musculoskeletal pain. It is not, however, a universal cure, and there already exist several competing schools of manipulative technique, each laying claim for special consideration. The specialty oforthopaedic medicine, which integrates manipulation into a structured medical framework, offers a sensible way forward. A department of orthopaedic medicine, run by Dr Cyriax, existed for many years at St Thomas's Hospital. It acquired a good international reputation, and its work is still recognised and quoted. Similar centres currently exist in Europe and North America. If manipulation is to be introduced into the NHS it should be properly planned. The ideal would be through departments of orthopaedic medicine set
BMJ
VOLUME 301
1 1 A'UGUST 1990
up in a few key centres, with suitable research facilities.3 To give precedence on the basis of this paper to one particular school of manipulation is unwarranted; nor is it helpful to the future development of a therapeutic technique that has much to offer prospective patients. ADAM A WARD
Royal London Homoeopathic Hospital, London WC IN 3HR 1 Correspondence. Low back pain: comparison of chiropractic and hospital outpatient treatment. Br Med J 1990;300:1647-50. (23 June.) 2 Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J 1990;300:1431-7. (2 June.) 3 Ward A. A limited role for manipulation? Br Med J 1987;294: 311.
SIR,-There can be no satisfaction gained in any quarter from the correspondence generated by the paper by Dr T W Meade and colleagues.' In April 1981, on behalf of the British Chiropractic Association, I approached Dr Meade, as the director of a prestigious Medical Research Council unit, about the possibility of a randomised controlled trial of our treatment for low back pain. The association's motives for doing this should be known and are as follows. Firstly, the association was unhappy with the legislative safeguards for the standards of practice and found the medical profession's representatives unwilling to undertake any dialogue about this because the effectiveness of chiropractic treatment was unproved. This impasse had to be overcome before initiatives towards obtaining statutory backing for standards of care and professional competence could hope to overcome medical opposition. Secondly, it was clear that growing public interest in heterodox medicine would make a clinical trial inevitable at some stage. The difficulty in designing such a trial made it necessary that it be approached with absolute evenhandedness and by someone with the ability to follow a close argument. In short, a flawed trial would have been worse than no trial at all. It was on the advice of the then chief scientist to the Department of Health and Social Security in the light of this that an approach to the Medical Research Council was made. Thirdly, at the time considerable pressure was being applied by groups of patients, who felt certain that if chiropractic could only "prove itself' all would be well for their interests. During the trial the chiropractors had many anxious moments, not least of which was when an article was published in The Times in 1985 quoting Dr Meade as listing as a possible consequence of an unfavourable outcome for chiropractic the restriction ofits practice. In the event chiropractors and patients with back pain can take no comfort from the response to the trial as it appears in your columns. Most of those commenting seem to have done so with irritation and apparently on impulse. Thus after eight years of work and many thousands of pounds spent on research few besides the authors themselves have so far exhibited a constructive attitude to the results. Surely a paper with such socioeconomic implications deserves to be read more carefully. A BREEN Anglo-European College of Chiropractic, Bournemouth BH5 2DF 1 Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J 1990;300:1431-7. (2 June.)
SIR,-I would like to take issue with Dr T W Meade and colleagues over their trial of treatment for back pain. The results do not bear the conclusion they wish to make,' and it is those conclusions
rather than the results that have captured the attention of the media. I pointed out to Dr Meade at the beginning of the trial that they were in danger of promoting chiropractic instead of a treatment modalityhigh velocity manipulation. This treatment is performed by many therapists but only chiropractors were included in the trial. It is also available in many hospital departments; I run such a clinic in one of the chosen centres, but again this was excluded from the trial. As "opponents" for the chiropractors Dr Meade and colleagues chose the hard pressed physiotherapists, who do not specialise in back treatments or necessarily use manipulation. They have many other priority groups to deal with and physiotherapy is only one of the many departments available in hospitals to treat back pain. Once again, none of these were included. That the chiropractors were working in the private sector, with funding, and had a vested interest in a positive result and that they were compared with physiotherapists working within the much more restrictive conditions of the NHS is further evidence of bias. I believe that the results from such a protocol cannot be taken seriously. Even with this favourable loading the chiropractors' results were only marginally better than those of the physiotherapists, and they gave their patients almost twice as many treatments. There is, however, a need for a properly constructed trial of manipulative treatment as the questions about it remain largely unanswered. BRIAN GURRY Plympton, Plymouth PL7 3DE I Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J
1990;300:1431-7. (2 June.)
AUTHORS' REPLY,-Dr Ward has misrepresented our results and provides a good example of the need, referred to by Mr Breen, for more careful consideration of what we actually said. We made it very clear that the trial was a comparison of two policies: chiropractic and hospital outpatient management. We ourselves pointed out that both (particularly hospital management) consist of several components. In each case one of these was manipulation. The relative effectiveness of different manipulative techniques is certainly a high priority for further trials. Until these have been carried out, however, it is premature for Dr Ward to suggest particular methods or administrative arrangements. Meanwhile, patients who cannot afford chiropractic privately can reasonably claim that they are being denied an effective treatment through the NHS. Provision of this treatment does not need to await full and detailed knowledge of which component is responsible for its value. Dr Gurry suggests lack of specialisation by physiotherapists as a possible explanation for the superiority of chiropractic, and earlier correspondents have made similar comments. ' Clearly, the role of general practitioners and others with special interests and skills should be taken into account in planning further studies. There was no question of actively excluding Dr Gurry's clinic from our trial, which was concerned with chiropractic in chiropractic clinics and with hospital management. In considering the extent to which chiropractic was more effective than hospital management, we should reiterate the distinction between the percentage point nature of the Oswestry scale and comparison of the two approaches expressed in percentage terms. By the last method at two and three years the benefit due to chiropractic was about 70% and 100% respectively more than the sum of spontaneous improvement and of any treatment effect in the
341
Newquay TR7 IDA 1 Fauveau V, Wojtyniak Bn Chakraborty J, et al. The effect of maternal and child health and family planning services on mortality: Is prevention enough? Br Med J 1990;301:103-7. (14 July.)
Low back pain: comparison of chiropractic and hospital outpatient treatment SIR,-It is perhaps surprising that despite the recent correspondence regarding their paper on back pain' Dr T W Meade and colleagues continue to assert that their results "make it necessary to consider the availability of chiropractic to NHS patients now."' Their study shows that one of the two treatment groups derived more long term benefits.2 The fact, however, that there were other important variables in addition to the availability or otherwise of chiropractic seems to have been largely ignored in the conclusions. The consequence of this is that the media have transmitted the simplified message that chiropractic heals backs without the necessary caveats that should have been more clearly presented in the original paper. This, I believe, has not helped the cause of manipulation. As a doctor trained in medical manipulation I am well aware of its potential benefits in treating musculoskeletal pain. It is not, however, a universal cure, and there already exist several competing schools of manipulative technique, each laying claim for special consideration. The specialty oforthopaedic medicine, which integrates manipulation into a structured medical framework, offers a sensible way forward. A department of orthopaedic medicine, run by Dr Cyriax, existed for many years at St Thomas's Hospital. It acquired a good international reputation, and its work is still recognised and quoted. Similar centres currently exist in Europe and North America. If manipulation is to be introduced into the NHS it should be properly planned. The ideal would be through departments of orthopaedic medicine set
BMJ
VOLUME 301
1 1 A'UGUST 1990
up in a few key centres, with suitable research facilities.3 To give precedence on the basis of this paper to one particular school of manipulation is unwarranted; nor is it helpful to the future development of a therapeutic technique that has much to offer prospective patients. ADAM A WARD
Royal London Homoeopathic Hospital, London WC IN 3HR 1 Correspondence. Low back pain: comparison of chiropractic and hospital outpatient treatment. Br Med J 1990;300:1647-50. (23 June.) 2 Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J 1990;300:1431-7. (2 June.) 3 Ward A. A limited role for manipulation? Br Med J 1987;294: 311.
SIR,-There can be no satisfaction gained in any quarter from the correspondence generated by the paper by Dr T W Meade and colleagues.' In April 1981, on behalf of the British Chiropractic Association, I approached Dr Meade, as the director of a prestigious Medical Research Council unit, about the possibility of a randomised controlled trial of our treatment for low back pain. The association's motives for doing this should be known and are as follows. Firstly, the association was unhappy with the legislative safeguards for the standards of practice and found the medical profession's representatives unwilling to undertake any dialogue about this because the effectiveness of chiropractic treatment was unproved. This impasse had to be overcome before initiatives towards obtaining statutory backing for standards of care and professional competence could hope to overcome medical opposition. Secondly, it was clear that growing public interest in heterodox medicine would make a clinical trial inevitable at some stage. The difficulty in designing such a trial made it necessary that it be approached with absolute evenhandedness and by someone with the ability to follow a close argument. In short, a flawed trial would have been worse than no trial at all. It was on the advice of the then chief scientist to the Department of Health and Social Security in the light of this that an approach to the Medical Research Council was made. Thirdly, at the time considerable pressure was being applied by groups of patients, who felt certain that if chiropractic could only "prove itself' all would be well for their interests. During the trial the chiropractors had many anxious moments, not least of which was when an article was published in The Times in 1985 quoting Dr Meade as listing as a possible consequence of an unfavourable outcome for chiropractic the restriction ofits practice. In the event chiropractors and patients with back pain can take no comfort from the response to the trial as it appears in your columns. Most of those commenting seem to have done so with irritation and apparently on impulse. Thus after eight years of work and many thousands of pounds spent on research few besides the authors themselves have so far exhibited a constructive attitude to the results. Surely a paper with such socioeconomic implications deserves to be read more carefully. A BREEN Anglo-European College of Chiropractic, Bournemouth BH5 2DF 1 Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J 1990;300:1431-7. (2 June.)
SIR,-I would like to take issue with Dr T W Meade and colleagues over their trial of treatment for back pain. The results do not bear the conclusion they wish to make,' and it is those conclusions
rather than the results that have captured the attention of the media. I pointed out to Dr Meade at the beginning of the trial that they were in danger of promoting chiropractic instead of a treatment modalityhigh velocity manipulation. This treatment is performed by many therapists but only chiropractors were included in the trial. It is also available in many hospital departments; I run such a clinic in one of the chosen centres, but again this was excluded from the trial. As "opponents" for the chiropractors Dr Meade and colleagues chose the hard pressed physiotherapists, who do not specialise in back treatments or necessarily use manipulation. They have many other priority groups to deal with and physiotherapy is only one of the many departments available in hospitals to treat back pain. Once again, none of these were included. That the chiropractors were working in the private sector, with funding, and had a vested interest in a positive result and that they were compared with physiotherapists working within the much more restrictive conditions of the NHS is further evidence of bias. I believe that the results from such a protocol cannot be taken seriously. Even with this favourable loading the chiropractors' results were only marginally better than those of the physiotherapists, and they gave their patients almost twice as many treatments. There is, however, a need for a properly constructed trial of manipulative treatment as the questions about it remain largely unanswered. BRIAN GURRY Plympton, Plymouth PL7 3DE I Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J
1990;300:1431-7. (2 June.)
AUTHORS' REPLY,-Dr Ward has misrepresented our results and provides a good example of the need, referred to by Mr Breen, for more careful consideration of what we actually said. We made it very clear that the trial was a comparison of two policies: chiropractic and hospital outpatient management. We ourselves pointed out that both (particularly hospital management) consist of several components. In each case one of these was manipulation. The relative effectiveness of different manipulative techniques is certainly a high priority for further trials. Until these have been carried out, however, it is premature for Dr Ward to suggest particular methods or administrative arrangements. Meanwhile, patients who cannot afford chiropractic privately can reasonably claim that they are being denied an effective treatment through the NHS. Provision of this treatment does not need to await full and detailed knowledge of which component is responsible for its value. Dr Gurry suggests lack of specialisation by physiotherapists as a possible explanation for the superiority of chiropractic, and earlier correspondents have made similar comments. ' Clearly, the role of general practitioners and others with special interests and skills should be taken into account in planning further studies. There was no question of actively excluding Dr Gurry's clinic from our trial, which was concerned with chiropractic in chiropractic clinics and with hospital management. In considering the extent to which chiropractic was more effective than hospital management, we should reiterate the distinction between the percentage point nature of the Oswestry scale and comparison of the two approaches expressed in percentage terms. By the last method at two and three years the benefit due to chiropractic was about 70% and 100% respectively more than the sum of spontaneous improvement and of any treatment effect in the
341
