Letters
of less than 0.7 conveys poor discrimination. However, in the multivariable analysis, the standard uptake value was associated with survival. It is not surprising that no difference was detected in survival between groups because the major role of PET is to detect metastatic disease that would preclude hepatic resection. Hofman and colleagues correctly observe that 90% of patients in both groups had surgery, which also argues against routine performance of PET-CT.
aggressive approach, and the basis for using this intervention on end-stage disease is not well supported in the literature.3 The title of the article and the abstract conclusion are overly broad and misleading. Physical therapy is not an intervention. Physical therapeutic management of hip osteoarthritis involves not only the interventions studied but also diagnostics, counseling, collaboration with other medical professionals, and interventions not studied.
Carol-Anne Moulton, MB, BS Karen Gulenchyn, MD Mark N. Levine, MD
Douglas M. White, DPT Michael T. Cibulka, DPT Judith Woehrle, PhD
Author Affiliations: University Health Network, Toronto, Ontario (Moulton); McMaster University, Hamilton Health Sciences, Hamilton, Ontario (Gulenchyn, Levine).
Author Affiliations: Milton Orthopaedic and Sports Physical Therapy PC, Milton, Massachusetts (White); Physical Therapy Program, Maryville University, St Louis, Missouri (Cibulka); Physical Therapy Program, Midwestern University, Glendale, Arizona (Woehrle).
Corresponding Author: Mark N. Levine, MD, Juravinski Hospital and Cancer Center, 711 Concession St, Hamilton, ON L8V 1C3, Canada ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Corresponding Author: Douglas M. White, DPT, Milton Orthopaedic and Sports Physical Therapy PC, 191 Blue Hills Pky, Milton, MA 02186 ([email protected]).
1. Delbeke D, Coleman RE, Guiberteau MJ, et al. Procedure guideline for tumor imaging with 18F-FDG PET/CT 1.0. J Nucl Med. 2006;47(5):885-895.
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
2. Boellaard R, O’Doherty MJ, Weber WA, et al. FDG PET and PET/CT: EANM procedure guidelines for tumour PET imaging: version 1.0. Eur J Nucl Med Mol Imaging. 2010;37(1):181-200.
1. Bennell KL, Egerton T, Martin J, et al. Effect of physical therapy on pain and function in patients with hip osteoarthritis: a randomized clinical trial. JAMA. 2014;311(19):1987-1997.
3. Evans WK, Laupacis A, Gulenchyn KY, Levin L, Levine M. Evidence-based approach to the introduction of positron emission tomography in Ontario, Canada. J Clin Oncol. 2009;27(33):5607-5613.
2. Bennell KL, Egerton T, Pua YH, et al. Efficacy of a multimodal physiotherapy treatment program for hip osteoarthritis: a randomised placebo-controlled trial protocol. BMC Musculoskelet Disord. 2010;11:238.
4. Wiering B, Krabbe PF, Jager GJ, Oyen WJ, Ruers TJ. The impact of fluor-18-deoxyglucose-positron emission tomography in the management of colorectal liver metastases. Cancer. 2005;104(12):2658-2670.
3. Hoeksma HL, Dekker J, Ronday HK, et al. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Rheum. 2004;51(5):722-729.
5. Hosmer DW, Lemeshow S. Applied Logistic Regression. 2nd ed. New York, NY: John Wiley & Sons; 2000.
Physical Therapy and Hip Osteoarthritis To the Editor Dr Bennell and colleagues1 examined some interventions used by physical therapists in the management of patients with hip osteoarthritis. Fifty-one percent of the patients in the active intervention group had moderate to severe hip osteoarthritis. In our experience, this subset of patients typically is less likely to respond favorably to most conservative treatment, particularly given the low dose and types of interventions in the study. It would be valuable to conduct a study with a severityadjusted intervention protocol with adequate dosage to likely result in measurable physiological change, excluding individuals with end-stage hip osteoarthritis, or to report results of subsets of individuals by disease severity. Bennell et al1 observed that their active intervention may not have adequately targeted and changed physical impairments. We believe this may be the case. The exercise consisted of 4 to 6 exercises.2 Only 1 strengthening exercise was specific to the hip. The lack of a comprehensive strengthening program precludes any generalized conclusions on the effects of strengthening for hip osteoarthritis. In the active group, 41% of participants had adverse events. A significant number of these individuals may have sustained adverse events from hip thrust manipulation. Joints with advanced degenerative changes are not likely to respond to this
In Reply Dr White and colleagues raise 4 issues. First, they are concerned about differential treatment effects according to disease severity given that half of our participants had moderate to severe hip osteoarthritis and that their experience shows that those with moderate to severe hip osteoarthritis do not respond as favorably to most conservative treatment. This is a possibility although an exploratory post hoc analysis of the data showed no significant differences in the amount of improvement in pain (P = .76) and function (P = .38) comparing disease severity subgroups with active and sham treatment. Second, White and colleagues question the dose and content of the active intervention. We evaluated a program that was designed to match common clinical practice parameters in Australia and internationally. Whether a more intensive program with a greater number of exercises and greater supervised contact time would be more effective remains to be tested. However, given that longer-term adherence is problematic, the feasibility of such a program needs to be considered in the context of a chronic disease such as osteoarthritis. Third, the authors speculate that the adverse events may have been sustained from hip thrust manipulation. We cannot ascertain the cause of the adverse events given the multimodal nature of the program. However, few adverse events were noted from this same technique in another trial of hip osteoarthritis.1 Fourth, the authors thought that the title of the article and abstract conclusion based on the term physical therapy was
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Copyright 2014 American Medical Association. All rights reserved.
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1257
Letters
broad and misleading because physical therapy is not an intervention. However, the multimodal protocol was designed to encompass all the elements these authors mention2 so this was the most representative title and conclusion possible within the word limit. Kim Bennell, PhD J. Haxby Abbott, PhD Author Affiliations: Department of Physiotherapy, University of Melbourne, Melbourne, Australia (Bennell); Centre for Musculoskeletal Outcomes Research, University of Otago, Dunedin, New Zealand (Abbott). Corresponding Author: Kim Bennell, PhD, Centre for Health, Exercise and Sports Medicine, School of Health Sciences, University of Melbourne, Melbourne, Victoria 3010, Australia ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Bennell reported receiving royalties from an educational DVD on knee osteoarthritis and from a commercially available shoe from ASICS Oceania; being a consultant for Physitrack; and receiving grants from the National Health and Medical Research Council. Dr Abbott reported receiving a grant from the Health Research Council of New Zealand. 1. Hoeksma HL, Dekker J, Ronday HK, et al. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Rheum. 2004;51(5):722-729. 2. Bennell KL, Egerton T, Pua YH, Abbott JH, Sims K, Buchbinder R. Building the rationale and structure for a complex physical therapy intervention within the context of a clinical trial: a multimodal individualized treatment for patients with hip osteoarthritis. Phys Ther. 2011;91(10):1525-1541.
Euthanasia for Minors in Belgium To the Editor In their Viewpoint, Dr Siegel and colleagues1 reflected on the recent extension of the Belgian euthanasia law to include competent minors. As members of the Belgian Endof-Life Care Research Group, we think it is necessary to respond to their views to provide a more nuanced context and explain the prevailing perspective in Belgium. The authors claimed that minors cannot possess the capacity for “a sophisticated preference” or “the experiential knowledge and sense of self” necessary to entertain the choice of euthanasia.1 The question is whether this is true for all minors. In the experience of pediatricians, terminally ill minors tend to mature more rapidly than their healthy peers as a consequence of their illness.2 This finding is reflected in the legislator’s rationale: in a context of legal euthanasia under criteria of strict due care, the age barrier for euthanasia is perceived as arbitrary. The prime qualifier for a valid, wellconsidered and competent request should not be chronological age but mental age and maturity. These views were supported by the Belgian Royal Academy of Medicine in a unanimous recommendation to government. Evidently, this capacity only develops at a certain age, but this age differs from individual to individual. The stipulations in the law extension ensure rigorous procedures for evaluating this capacity, including psychiatric consultation. Although the law now theoretically applies to Belgians of all ages, in reality, euthanasia for minors will be limited to preadolescents owing to the requirement for “capacity of discernment.” The extension of the euthanasia law has been an issue of principle, not necessarily of immediate necessity—in terms of numbers of patients. In a recent Belgian study of deaths of mi1258
nors, not one euthanasia request had been made.3 As the authors mentioned, “palliative care is generally adequate…”1 to relieve terminal pain. Belgian pediatric palliative care—a legal patient right since 2002—is among the best in Europe4 and adequately addresses extreme physical suffering in the vast majority of dying children. The claim by Siegel et al1 that “children seem to be asked to choose between unbearable suffering on the one hand and death on the other” represents a crude and flawed view of the matter. The Dutch Groningen protocol, also cited by the authors, only applies to neonatal intensive care units and has no overlapping characteristics with euthanasia for competent minors, and thus has no place in a criticism of patient-requested assistance in dying. Kenneth Chambaere, PhD Marc Roelands, PhD Luc Deliens, PhD Author Affiliations: End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium. Corresponding Author: Kenneth Chambaere, PhD, End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Siegel AM, Sisti DA, Caplan AL. Pediatric euthanasia in Belgium: disturbing developments. JAMA. 2014;311(19):1963-1964. 2. Pousset G, Mortier F, Bilsen J, Cohen J, Deliens L. Attitudes and practices of physicians regarding physician-assisted dying in minors. Arch Dis Child. 2011;96 (10):948-953. 3. Pousset G, Bilsen J, Cohen J, Chambaere K, Deliens L, Mortier F. Medical end-of-life decisions in children in Flanders, Belgium: a population-based postmortem survey. Arch Pediatr Adolesc Med. 2010;164(6):547-553. 4. Centeno C, Lynch T, Donea O, Rocafort J, Clark D. EAPC atlas of palliative care in Europe 2013—full edition. http://issuu.com/universidaddenavarra/docs/atlas _europa_full_edition. Accessed July 10, 2014.
To the Editor Dr Siegel and colleagues1 commented on the recent approval of the Belgian Act on Euthanasia to allow euthanasia for chronically ill children. We would like to enrich this commentary with findings from research in the Netherlands, a country where the law, since 2002, allows euthanasia for patients who are at least 12 years old, provided that a number of specific criteria are met. Siegel and colleagues stated that euthanasia is usually performed for existential reasons that go beyond pain and that children lack the intellectual capacity and experience to make a balanced request for euthanasia. This seems to be reflected in the fact that euthanasia for children in the Netherlands is very rare.2 In the past 10 years, 5 cases of euthanasia in minors have been reported to the euthanasia review committees.3 Four of these cases concerned a 16- or 17-year-old person; 1 case concerned a child aged 12 years. Although euthanasia for children is a heavily debated topic, its actual scope is limited. However, the fact that the Dutch law does allow euthanasia for minors stems from the assumption that it cannot be precluded that in rare cases severely ill children may suffer unbearably and without hope of relief, despite the best
JAMA September 24, 2014 Volume 312, Number 12
Copyright 2014 American Medical Association. All rights reserved.
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of less than 0.7 conveys poor discrimination. However, in the multivariable analysis, the standard uptake value was associated with survival. It is not surprising that no difference was detected in survival between groups because the major role of PET is to detect metastatic disease that would preclude hepatic resection. Hofman and colleagues correctly observe that 90% of patients in both groups had surgery, which also argues against routine performance of PET-CT.
aggressive approach, and the basis for using this intervention on end-stage disease is not well supported in the literature.3 The title of the article and the abstract conclusion are overly broad and misleading. Physical therapy is not an intervention. Physical therapeutic management of hip osteoarthritis involves not only the interventions studied but also diagnostics, counseling, collaboration with other medical professionals, and interventions not studied.
Carol-Anne Moulton, MB, BS Karen Gulenchyn, MD Mark N. Levine, MD
Douglas M. White, DPT Michael T. Cibulka, DPT Judith Woehrle, PhD
Author Affiliations: University Health Network, Toronto, Ontario (Moulton); McMaster University, Hamilton Health Sciences, Hamilton, Ontario (Gulenchyn, Levine).
Author Affiliations: Milton Orthopaedic and Sports Physical Therapy PC, Milton, Massachusetts (White); Physical Therapy Program, Maryville University, St Louis, Missouri (Cibulka); Physical Therapy Program, Midwestern University, Glendale, Arizona (Woehrle).
Corresponding Author: Mark N. Levine, MD, Juravinski Hospital and Cancer Center, 711 Concession St, Hamilton, ON L8V 1C3, Canada ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Corresponding Author: Douglas M. White, DPT, Milton Orthopaedic and Sports Physical Therapy PC, 191 Blue Hills Pky, Milton, MA 02186 ([email protected]).
1. Delbeke D, Coleman RE, Guiberteau MJ, et al. Procedure guideline for tumor imaging with 18F-FDG PET/CT 1.0. J Nucl Med. 2006;47(5):885-895.
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
2. Boellaard R, O’Doherty MJ, Weber WA, et al. FDG PET and PET/CT: EANM procedure guidelines for tumour PET imaging: version 1.0. Eur J Nucl Med Mol Imaging. 2010;37(1):181-200.
1. Bennell KL, Egerton T, Martin J, et al. Effect of physical therapy on pain and function in patients with hip osteoarthritis: a randomized clinical trial. JAMA. 2014;311(19):1987-1997.
3. Evans WK, Laupacis A, Gulenchyn KY, Levin L, Levine M. Evidence-based approach to the introduction of positron emission tomography in Ontario, Canada. J Clin Oncol. 2009;27(33):5607-5613.
2. Bennell KL, Egerton T, Pua YH, et al. Efficacy of a multimodal physiotherapy treatment program for hip osteoarthritis: a randomised placebo-controlled trial protocol. BMC Musculoskelet Disord. 2010;11:238.
4. Wiering B, Krabbe PF, Jager GJ, Oyen WJ, Ruers TJ. The impact of fluor-18-deoxyglucose-positron emission tomography in the management of colorectal liver metastases. Cancer. 2005;104(12):2658-2670.
3. Hoeksma HL, Dekker J, Ronday HK, et al. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Rheum. 2004;51(5):722-729.
5. Hosmer DW, Lemeshow S. Applied Logistic Regression. 2nd ed. New York, NY: John Wiley & Sons; 2000.
Physical Therapy and Hip Osteoarthritis To the Editor Dr Bennell and colleagues1 examined some interventions used by physical therapists in the management of patients with hip osteoarthritis. Fifty-one percent of the patients in the active intervention group had moderate to severe hip osteoarthritis. In our experience, this subset of patients typically is less likely to respond favorably to most conservative treatment, particularly given the low dose and types of interventions in the study. It would be valuable to conduct a study with a severityadjusted intervention protocol with adequate dosage to likely result in measurable physiological change, excluding individuals with end-stage hip osteoarthritis, or to report results of subsets of individuals by disease severity. Bennell et al1 observed that their active intervention may not have adequately targeted and changed physical impairments. We believe this may be the case. The exercise consisted of 4 to 6 exercises.2 Only 1 strengthening exercise was specific to the hip. The lack of a comprehensive strengthening program precludes any generalized conclusions on the effects of strengthening for hip osteoarthritis. In the active group, 41% of participants had adverse events. A significant number of these individuals may have sustained adverse events from hip thrust manipulation. Joints with advanced degenerative changes are not likely to respond to this
In Reply Dr White and colleagues raise 4 issues. First, they are concerned about differential treatment effects according to disease severity given that half of our participants had moderate to severe hip osteoarthritis and that their experience shows that those with moderate to severe hip osteoarthritis do not respond as favorably to most conservative treatment. This is a possibility although an exploratory post hoc analysis of the data showed no significant differences in the amount of improvement in pain (P = .76) and function (P = .38) comparing disease severity subgroups with active and sham treatment. Second, White and colleagues question the dose and content of the active intervention. We evaluated a program that was designed to match common clinical practice parameters in Australia and internationally. Whether a more intensive program with a greater number of exercises and greater supervised contact time would be more effective remains to be tested. However, given that longer-term adherence is problematic, the feasibility of such a program needs to be considered in the context of a chronic disease such as osteoarthritis. Third, the authors speculate that the adverse events may have been sustained from hip thrust manipulation. We cannot ascertain the cause of the adverse events given the multimodal nature of the program. However, few adverse events were noted from this same technique in another trial of hip osteoarthritis.1 Fourth, the authors thought that the title of the article and abstract conclusion based on the term physical therapy was
jama.com
JAMA September 24, 2014 Volume 312, Number 12
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Yale University User on 05/14/2015
1257
Letters
broad and misleading because physical therapy is not an intervention. However, the multimodal protocol was designed to encompass all the elements these authors mention2 so this was the most representative title and conclusion possible within the word limit. Kim Bennell, PhD J. Haxby Abbott, PhD Author Affiliations: Department of Physiotherapy, University of Melbourne, Melbourne, Australia (Bennell); Centre for Musculoskeletal Outcomes Research, University of Otago, Dunedin, New Zealand (Abbott). Corresponding Author: Kim Bennell, PhD, Centre for Health, Exercise and Sports Medicine, School of Health Sciences, University of Melbourne, Melbourne, Victoria 3010, Australia ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Bennell reported receiving royalties from an educational DVD on knee osteoarthritis and from a commercially available shoe from ASICS Oceania; being a consultant for Physitrack; and receiving grants from the National Health and Medical Research Council. Dr Abbott reported receiving a grant from the Health Research Council of New Zealand. 1. Hoeksma HL, Dekker J, Ronday HK, et al. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Rheum. 2004;51(5):722-729. 2. Bennell KL, Egerton T, Pua YH, Abbott JH, Sims K, Buchbinder R. Building the rationale and structure for a complex physical therapy intervention within the context of a clinical trial: a multimodal individualized treatment for patients with hip osteoarthritis. Phys Ther. 2011;91(10):1525-1541.
Euthanasia for Minors in Belgium To the Editor In their Viewpoint, Dr Siegel and colleagues1 reflected on the recent extension of the Belgian euthanasia law to include competent minors. As members of the Belgian Endof-Life Care Research Group, we think it is necessary to respond to their views to provide a more nuanced context and explain the prevailing perspective in Belgium. The authors claimed that minors cannot possess the capacity for “a sophisticated preference” or “the experiential knowledge and sense of self” necessary to entertain the choice of euthanasia.1 The question is whether this is true for all minors. In the experience of pediatricians, terminally ill minors tend to mature more rapidly than their healthy peers as a consequence of their illness.2 This finding is reflected in the legislator’s rationale: in a context of legal euthanasia under criteria of strict due care, the age barrier for euthanasia is perceived as arbitrary. The prime qualifier for a valid, wellconsidered and competent request should not be chronological age but mental age and maturity. These views were supported by the Belgian Royal Academy of Medicine in a unanimous recommendation to government. Evidently, this capacity only develops at a certain age, but this age differs from individual to individual. The stipulations in the law extension ensure rigorous procedures for evaluating this capacity, including psychiatric consultation. Although the law now theoretically applies to Belgians of all ages, in reality, euthanasia for minors will be limited to preadolescents owing to the requirement for “capacity of discernment.” The extension of the euthanasia law has been an issue of principle, not necessarily of immediate necessity—in terms of numbers of patients. In a recent Belgian study of deaths of mi1258
nors, not one euthanasia request had been made.3 As the authors mentioned, “palliative care is generally adequate…”1 to relieve terminal pain. Belgian pediatric palliative care—a legal patient right since 2002—is among the best in Europe4 and adequately addresses extreme physical suffering in the vast majority of dying children. The claim by Siegel et al1 that “children seem to be asked to choose between unbearable suffering on the one hand and death on the other” represents a crude and flawed view of the matter. The Dutch Groningen protocol, also cited by the authors, only applies to neonatal intensive care units and has no overlapping characteristics with euthanasia for competent minors, and thus has no place in a criticism of patient-requested assistance in dying. Kenneth Chambaere, PhD Marc Roelands, PhD Luc Deliens, PhD Author Affiliations: End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium. Corresponding Author: Kenneth Chambaere, PhD, End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Siegel AM, Sisti DA, Caplan AL. Pediatric euthanasia in Belgium: disturbing developments. JAMA. 2014;311(19):1963-1964. 2. Pousset G, Mortier F, Bilsen J, Cohen J, Deliens L. Attitudes and practices of physicians regarding physician-assisted dying in minors. Arch Dis Child. 2011;96 (10):948-953. 3. Pousset G, Bilsen J, Cohen J, Chambaere K, Deliens L, Mortier F. Medical end-of-life decisions in children in Flanders, Belgium: a population-based postmortem survey. Arch Pediatr Adolesc Med. 2010;164(6):547-553. 4. Centeno C, Lynch T, Donea O, Rocafort J, Clark D. EAPC atlas of palliative care in Europe 2013—full edition. http://issuu.com/universidaddenavarra/docs/atlas _europa_full_edition. Accessed July 10, 2014.
To the Editor Dr Siegel and colleagues1 commented on the recent approval of the Belgian Act on Euthanasia to allow euthanasia for chronically ill children. We would like to enrich this commentary with findings from research in the Netherlands, a country where the law, since 2002, allows euthanasia for patients who are at least 12 years old, provided that a number of specific criteria are met. Siegel and colleagues stated that euthanasia is usually performed for existential reasons that go beyond pain and that children lack the intellectual capacity and experience to make a balanced request for euthanasia. This seems to be reflected in the fact that euthanasia for children in the Netherlands is very rare.2 In the past 10 years, 5 cases of euthanasia in minors have been reported to the euthanasia review committees.3 Four of these cases concerned a 16- or 17-year-old person; 1 case concerned a child aged 12 years. Although euthanasia for children is a heavily debated topic, its actual scope is limited. However, the fact that the Dutch law does allow euthanasia for minors stems from the assumption that it cannot be precluded that in rare cases severely ill children may suffer unbearably and without hope of relief, despite the best
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Copyright 2014 American Medical Association. All rights reserved.
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