BMJ, Manipulating the manipulators!

BMJ Manipulating the manipulators!

What fun the BMJ are having. Take three authors will little or no track record in the field, get them to review a few 'Cherry picked' papers, write a non-peer reviewed opinion/debate article (http://www.bmj.com/content/344/bmj.e3679) add a press release (http://www.bmj.com/press-releases/2012/06/07/should-spinal-manipulation-neck-pain-be-abandoned) and light the touch paper! 

Enter the 'Daily Mail' (http://www.dailymail.co.uk/health/article-2156179/Letting-chiropractor-crack-neck-ease-pain-trigger-stroke.html), fan the flames and watch the manipulators eat themselves. Nice . . . Or is it? 

We learnt a lot in Physiotherapy about the haemodynamics of the cervical spine and risk assessment over the last decade or so. We had seen the limitations of our own 'bad science', the vertebral artery test and IFOMPT will this year provide guidance to those who treat the cervical spine in a well thought out attempt to limit risk.

Wand et al (2012) have been manipulated themselves, and whilst they clearly enjoy the spotlight (#abandonneckmanipulation on Twitter "woohoo") their argument is weak and badly thought out (see the considered respondents on the BMJ site) and furthermore is harmful to the profession. My last two (expert witness) medico-legal cases involving stroke post manual therapy, were in fact not manipulation cases, but rather ASSESSMENT CASES . . . Oh, I hear the wolves call, perhaps we should call a halt to assessment and movement too? Then we truly can stick to handing out leaflets (http://rogerkerry.posterous.com/should-cervical-manipulations-be-abandoned).

So unwittingly we (as a profession) fall into the trap set by the BMJ, we antagonise the Chiropractors/osteopaths and call our own profession into question. We have more to learn about haemodynamics and risk in the cervical spine I have no doubt . . . but is this the way to operate in what is already a challenging and hostile environment? There really is no strong scientific case for calling a halt to manipulative therapy, any more there is many components of conventional medicine. You can read the debate yourself and I would invite you to make up your own mind.

In the mean time take the opportunity to vote on the BMJ website . . . Have your say, they did . . . in the most manipulative way.

1. Kerry R, Taylor AJ, Mitchell, JM, McCarthy C. Cervical arterial dysfunction and manual therapy: A critical literature review to inform professional practice. Manual Therapy 2008;13: 278-288
2. Bowler N, Shamley D, Davies R. The effect of a simulated manipulation position on internal carotid and vertebral artery blood flow in healthy individuals. Manual Therapy 2011; 16: 87-93
3. Kerry R, Taylor AJ. Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists. Journal of Orthopaedic and Sports Physical Therapy 2009; 39:378-387
4. Vogel S, Mars T, Keeping S et al 2012 Clinical Risk Osteopathy and Management (CROaM) project: national cross-sectional survey. BSO, London.
5. Carnes D, Mars TS, Mullinger B, Froud R, Underwood M. Adverse events and manual therapy: A systematic review. Manual Therapy 2010;15: 355-363
6. Taylor AJ, Kerry R. A systems based approach to risk assessment of the cervical spine prior to manual therapy. International Journal of Osteopathic Medicine 2010;13:85-93

Government hit from behind on whiplash injury claims

David Cameron out of touch with contemporary evidence say University of Nottingham academics!

David Cameron’s pledge to cut car whiplash claims has been challenged by University of Nottingham academics and physiotherapists Roger Kerry and Alan Taylor. Backed by leading USA researcher James Elliott, they have called into question the Government’s exposé of the whiplash injury industry in the UK.

Whilst accepting the critique of the unethical and corrupt practices within the ‘whiplash injury industry’ and a justified call for an end to so called referral fees. Kerry, Taylor and Elliott who have written extensively on neck issues and teach evidenced based practice in whiplash injury, have called into question the second layer of the broadside.  Here there is a suggestion that “all whiplash injuries are artificially contrived”, therein casting doubt on the medical legitimacy of the diagnosis at all levels. They contend that challenging the current argument is not difficult. The suggestion for instance, that ‘whiplash Injury’ is not a clinical entity is both ill informed, irresponsible and not up to date with contemporary research on the subject. They are able to draw attention to high quality objective evidence from internationally recognised MRI studies demonstrating changes in neck muscle properties in people who have suffered whiplash (e.g. Elliott et al 2010, Spine).  Furthermore, they highlight trial and experimental evidence has demonstrated that chronic whiplash associated disorder (WAD) can be reliably indentified. WAD is thus, for some a very real physical problem.

The Government’s diatribe unfortunately, calls into question the genuineness of all whiplash injury claims. This notion has, according to some, been supported further by recent media reports of a Physiotherapist winning a so called “landmark case” proving that ‘whiplash injury’ doesn’t exist (Daily Mail Jan 29^th 2012).  These reports do of course champion the proposals, but are a predictable, inaccurate spin of the facts of the quoted case, i.e. Robinson Vs Hussain, which was not technically a ’whiplash injury’ case (in fact the exact opposite of such).

For many involved in front line care delivery, the unfortunate part of this politicised rhetoric is that the proposed actions could easily lead to an irretraceable stigmatisation of the percentage patients who genuinely suffer following road traffic accidents. If wholesale changes to the industry are undertaken, there is genuine fear that evidence-based health interventions will be withdrawn for patients who have genuine, demonstrable WAD. It is important that before politically fuelled knee-jerk reforms are made, that dialogue takes place between MPs and health care practitioners such as Chartered Physiotherapists, who have been at the forefront of clinical practice and research in this area.

Government rhetoric may well be designed to galvanise public opinion and has clearly been taken up with typical emotional aplomb by tabloids such as the ‘Daily Mail’. However, it only serves to generalise and then stigmatise those patients who have genuine complaints affecting their day-to-day function. Such patients may now, in the light of this important new research, be identified by appropriate evidence based scientific tests, which the Government appear to have conveniently overlooked.

Roger Kerry (University of Nottingham, UK)

Alan J Taylor (University of Nottingham, UK)

James M Elliott (Northwestern University, USA)

References;

Elliott J, Jull G, Noteboom JT, Darnell R, Galloway G, Gibbon WW. (2006) Fatty infiltration in the cervical extensor muscles in persistent whiplash-associated disorders: a magnetic resonance imaging analysis. Spine;31(22): pp 847-55

Elliott JM, O'Leary S, Sterling M, Hendrikz J, Pedler A, Jull G. (2010) Magnetic resonance imaging findings of fatty infiltrate in the cervical flexors in chronic whiplash. Spine;35(9): pp 948-54


http://feeds.myptsd.me/are-there-implications-for-morphological-changes-in-neck-muscles-following-whiplash-injury/


http://www.nottingham.ac.uk/physiotherapy/index.aspx

https://twitter.com/#!/TaylorAlanJ