Journal of Manipulative and Physiological Therapeutics
Volume 29, Issue 6 , Pages 502-503, July 2006

In Reply: Response to Letter to the Editor

Sense Technology Inc, Pittsburgh, PA

Article Outline

 

Survival analysis is more than an important tool for understanding the treatment course of conditions such as low-back pain.1, 2 The study discussed hereinabove by Triano and McGregor was preceded by a pilot study3 using the same methodology and, like the study of van den Hoogen et al,4 which used the same criterion and served as a historic control, is prospective and designed to document clinical practice rather than a simple research construct. We reported the results of treatment of 8 homogenous groups of patients.

The authors hypothesized in the pilot study that if a treatment were effective, there would be no observed effect of chronicity. This hypothesis was supported.

The major finding of Collins et al for low-back pain was that 50% of the patients reported symptom resolution in 9 to 16 days, and the average number of visits required to achieve that status was 4. We compared these results in this and previous work not with just 1 but with 4 studies of back pain, including a study of osteopathic manipulation,5 where the results were indistinguishable from the van den Hoogen study (hazard ratio = 1) and 2 studies of neck pain. These comparisons are an alternative to subjective peer review of the literature and expert ranking as exemplified by Gatterman et al.6 These results were noted in the Discussion section of the report as is common practice, for example, a study by Hurwitz et al.7 We did not claim any causality.

We have found no basis in the literature for the writers' opinion regarding the usefulness of severity. As far as we are aware, no measure of severity has been found to provide clinically useful prediction of treatment outcomes.

In the van den Hoogen study where predictive value is claimed for “pain intensity,” careful reading of the study reveals that the prognostic factor reported was the pain component of the Nottingham Health Profile, a series of “yes” and “no” answers to 8 pain-related questions accounting for 1% lower probability of recovery (hazard ratio = 0.99 for pain). This pain component has a negative correlation with the SF-36 bodily pain scale8 and did not contribute significantly to the model.

Our results may be due to severity or some other unknown factor. However, this assumption requires that we believe that patients with this factor selectively flock to the Collins Clinic rather than to other sites.

We know of no studies in the literature that report an effect size close to the achievement of pain-free status in half the time of other treatments (hazard ratio = 0.5 for no treatment). These results are not simply “interesting,” they are potentially revolutionary.

As we stated in our article, causal relationship cannot be inferred from this research; however, the results suggest a treatment effect and support the need for further research to explain and expand upon these results.

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References 

  1. Evans JM. The use of survival analysis for the evaluation of musculoskeletal therapy. J Manipulative Physiol Ther. 2005;28:374
  2. Evans JM. A proposed method for estimating the efficiency and effectiveness of techniques of musculoskeletal therapy. J Manipulative Physiol Ther. 2005;28:206–210
  3. Evans JM, Collins DL, Grundy RH. Pilot study of patient response to multiple impulse therapy for musculoskeletal complaints. J Manipulative Physiol Ther. 2006;29:51.e1–51.e7
  4. van den Hoogen HJ, Koes BW, Deville W, van Eijk JT, Bouter LM. The prognosis of low back pain in general practice. Spine. 1997;22:1515–1521
  5. MacDonald RS, Bell CM. An open controlled assessment of osteopathic manipulation in nonspecific low-back pain. Spine. 1990;15:364–370
  6. Gatterman MI, Cooperstein R, Lantz C, Perle SM, Schneider MJ. Rating specific chiropractic technique procedures for common low back conditions. J Manipulative Physiol Ther. 2001;24:449–456
  7. Hurwitz EL, Morgenstern H, Kominski GF, Yu F, Chiang LM. A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study. Spine. 2006;31:611–621[discussion 22]
  8. Von Korff M, Jensen MP, Karoly P. Assessing global pain severity by self-report in clinical and health services research. Spine. 2000;25:3140–3151

PII: S0161-4754(06)00166-7

doi:10.1016/j.jmpt.2006.06.014

Refers to article:

  • The Efficiency of Multiple Impulse Therapy for Musculoskeletal Complaints

    John J. Triano, Marion McGregor
    Journal of Manipulative and Physiological Therapeutics July 2006 (Vol. 29, Issue 6, Page 502)

Journal of Manipulative and Physiological Therapeutics
Volume 29, Issue 6 , Pages 502-503, July 2006

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