606

letters Manipulation for L MADAM - I am a chiropractor prac- tising in South Africa and I must commend you on an excellent journal which I read regularly.

I felt both excited and wary when I read the article ‘Manipulation and Back Pain (Ross, 1997) - excited, because finally manipulation is becoming recognised by all health care professions as a safe, reliable and effective treatment protocol for the treatment of mechanical low back pain; but wary, because the science and skill of manipulation is still seen by medical doctors and physiotherapists as a simple, mech- anical treatment process.

When it comes to the skill of manip- ulating the spine and extremity joints, chiropractors spend a good two to three years in their training on devel- oping their skills and knowledge in palpation and manipulation. There is far more to manipulation than a sim- ple, mechanical procedure, and in the hands of ill-trained or inexperienced practitioners it may do more harm than good, and in certain cases even cause cerebrovascular accidents (Haldeman, 1997). Furthermore, in the USA certain States have legisla- tion that prohibits practitioners who have insufficient training from per- forming manipulative procedures (grade V). It has also been suggested by Atchison et a1 (1 995) that there is a need for increased instruction for physical therapists wanting to perform manipulation. It has been suggested by educators in the field of manipula- tion that a full-time postgraduate programme of six months’ theory and 12 months’ practical, under supervi- sion, is required for such training to be sufficient. My suggestion is: leave manipulation to the experts - skilled chiropractors.

The chiropractic profession has used manipulation (called an ‘adjust- ment’ because of its specific, high- velocity, low-amplitude application) since its inception in 1895, and there are a number of studies (more than 45 since the 1970s) showing its effectiveness (Manga et a/, 1993; Aker et al, 1997 [155]; Haldeman, 1992 [422]; US Department of

ow Back Pain Health and Human Services 1994 [34]; reliability and safety (Terret and Kleynhans, 1992) and cost-effective- ness (Stano and Smith, 1996; Stano, 1993; Sawyer and Kassak, 1992), not only for low back pain, but also for conditions such as mechanical cervi- cal pain (Cassidy eta/, 1993, Hurwitz et a/, 1996; Parkin-Smith and Penter, 1997; Bronfort et a/, 1997; Mior et al, 1997), headaches (Nilsson, 1997; Tuchin, 1997; Penter and Liebenberg, 1997) and extremity joints. The chi- ropractic studies listed below are just a few examples of the latest peer- reviewed research. I assume that the science, skill and effectiveness of manipulation are not widely known because health care professionals are not reading chiropractic literature! Even the Journal of Manipulative and Physiological Therapeutics, a peer- reviewed chiropractic journal listed in Medline and Index Medicus, is sel- dom referenced.

It seems that recognition is not, and never has been, given to the profes- sion that has done more research in terms of manipulation than all the other health care professions put together - Chiropractic. In my institute, chiropractic students undergo a six- year programme which includes a full master’s degree by research, at an undergraduate level. Therefore a number of studies are done on manipulation every year!

In fact, chiropractic research into manipulation has progressed so rapidly that research is now being conducted in terms of neuropatho- physiology and kinesiopathology (Sato, 1997; Budgell and Sato, 1997; Yamashita et a/, 1997; Balon et al, 1997), as well as the relationship between joint dysfunction (with asso- ciated radicular neuropathophysi- ology) and visceral disorders. This is to investigate whether chiropractic is a viable additional modality (in con- junction with medical treatment) in disorders such as asthma (Balon et a/, 1997), infantile colic, primary dysmenorrhoea (Bromfield and Till, 1997) and blood pressure (Masato, 1997).

It is obvious that the effectiveness

of manipulation for low back pain is no longer an issue; we already know it is one of the best, if not the best, treatment for mechanical low back pain.

I recommend the following texts and journal on chiropractic:

Haldeman S (1992). Principles and Prac- tice of Chiropractic, Appleton and Lange, USA, page 641 (ISBN 0 8385 6360 0).

Gatterman, M (1995). Foundations of Chi- ropractic, Mosby-Year Book, USA, page 487 (ISBN 0 8151 3543 2).

Journal of Manipulative and Physiological Therapeutics.

Gregory F Parkin-Smith MTechChiro CFI Lecturer, Research Supervisor

Technikon Natal Durban South Africa

and Clinic Director

References NB: The Proceedings of the Scientific Symposium, World Chiropractic Congress, Japan, contains the latest research infor- mation and will soon be published formally by the World Federation of Chiropractic, 3080 Yonge Street, Suite 3002, Toronto, Ontario, Canada M4N 3N1. They are abbreviated in this list to ‘Proceedings’.

Aker, P, Bombadier, C, Jansz, G, Keyes, W and Bressler, H (1 997). ‘Chiropractors’ management of low back pain’, Proceed- ings, page 155.

Atchison, J W, Newman, R Land Klim, G V (1995) ‘Interest in manual medicine among residents in physical medicine and rehabilitation: The need for increased instruction’, American Journal of Physical Medicine and Rehabilitation, 74, 6, 429- 443.

Balon, J W, Aker, P, Crowther, E R , Cox, G, Danielson, C, O’Shaughnessy, A D, Walker, C M, Duke, E K, Goldsmith, C H and Sears, M R (1997). ‘A randomised controlled trial of chiropractic spinal manipulation in asthma in children’, Proceedings, page 156.

Bromfield, B and Till, A G (1997). ‘Chiro- practic management of primary dys- menorrhea’, Proceedings, page 159.

Bronfort, G, Aker, P, Evans, R, Goldsmith, C R, Nelson, B and Vernon, H (1997). ‘A randomised controlled clinical trial of rehabilitation exercise and chiropractic spinal manipulation for chronic neck pain’, Proceedings, page 161.

Budgell, B and Sato, A (1997). ‘Reflex cardiac responses to noxious and innocu- ous stimulation of interspinous tissue’, Proceedings, page 139.

Cassidy, J D, Lopes, A A and Yong-Hing, K (1993). ‘The immediate effect of manip- ulation versus mobilisation on pain and range of motion in the cervical spine: A randomised controlled trial’, Journal of Manipulative and Physiological Therapeu- tics, 16, 4, 279-280.

Physiotherapy, November 1997, vol83, no 11

607

Haldeman, S (ed) (1 992). Principies and Practice of Chiropractic, Appleton and Lange, USA, page 641 (ISBN 0 8385 63670 0).

Haldeman, S (1 997). ‘Cerebrovascular complications of cervical manipulation: Our current level of understanding’, Pro- ceedings, page 58.

Hurwitz, E L, Aker, P D, Adams, A H, Meeker, W C and Shekelle, P G (1996). ‘Manipulation and mobilisation of the cervical spine: A systematic review of the literature’, Spine, 21, 15, 1746-60.

Manga, P, Angus, D E, Papadopoulos, C and Swan, W R (1993). ‘A study to exam- ine the effectiveness and cost-effective- ness of chiropractic management of low-back pain’, The Manga Report, www.mbnet.mb.ca.

Masato, A C (1997). ‘An observation on the effectiveness of cervical chiropractic treatment on blood pressure’, Proceed- ings, page 174.

Mior, S, Bales, S, Gauthier, M and Difinney, J (1997). ‘Chiropractic manage-

ment of neck pain in children: A retro- spective study’, Proceedings, page 166.

Nilsson, N (1 997). ‘Spinal manipulation in the treatment of headaches: The clinical trials’, Proceedings, page 12.

Parkin-Smith, G F and Penter, C (1997). ’The efficacy of spinal manipulative therapy in the treatment of mechanical neck pain’, Proceedings, page 168.

Penter, C and Liebenberg, H S (1 997). ‘Determining the role chiropractic plays in the treatment of tension-type headache’, Proceedings, page 231.

Ross, M (1997). ‘Manipulation and back school in the treatment of low back pain’, Physiotherapy, 83, 4, 181-183.

Sato, A (1997). ‘A neurophysiological rationale for the treatment of visceral disorders’, Proceedings, page 50.

Sawyer, C E and Kassak, K (1992). ‘Patient satisfaction with chiropractic care’, Journal of Manipulative and Physiological Therapeutics, 16, 25-32.

Stano, M (1993). ‘A comparison of health care costs for chiropractic and medical patients’, Journal of Manipulative and Physiological Therapeutics, 16, 5, 291- 299.

Stano, M and Smith, M (1996). ‘Chiro- practic and medical costs of low back care’, Medical Care, 34, 3, 191-204.

Terret, A G J and Kleynhans, A M (1992). ‘Complications of manipulation of the low back’, Chiropractic Journal of Australia,

Tuchin, P (1997). ‘The efficacy of chiro- practic spinal manipulative therapy in the treatment of migraine with aura’, Proceed- ings, page 172.

US Department of Health and Human Ser- vices (1994). ‘Acute Low Back Problems in Adults’, Public Health Service, USA, page 160, AHCPR Publication no 95-0642.

Yamashita, T, Minakik, Y, Takebayashi, T, Sakamato, N and Ishii, S (1997). ‘Electro- physiological studies of the joint mechanoreceptors’, Proceedings, page 151.

22,129-140.

Walking after Lung Reduction MADAM -We were interested to read the article on ‘Lung volume reduction surgery’ (LVRS) in the September issue of Physiotherapy (Grant, 1997) as we too are keen to undertake a randomised controlled trial.

Unfortunately Cooper’s work has been misquoted by Grant. Grant gives the six-minute walk test (6MWT) improvement in metres whereas the actual measurements are in feet (Cooper et a/, 1995). This typograph- ical error has emphasised the ‘flurry of misleading, exaggerated and frankly dishonest’ claims about LVRS (Cooper and Lefrak, 1996). Therefore although the improvement is substan- tial, patients were not walking one mile (1,600 metres) in the 6MWT six months after operation, but actually 1,600 feet (about 487 metres).

We await with interest any further developments of a United Kingdom- based randomised controlled trial.

R R Jeffrey FRCS Consultant Cardiothoracic Surgeon

Jackie Wattie GradDipPhys MCSP Superintendent Physiotherapist Aberdeen Royal Hospitals NHS Trust

References Grant, A (1997). ‘Lung volume reduction surgery - Clarification of the controversy’, Physiotherapy, 83, 9, 491-494.

Cooper, J D and Lefrak, S S (1996). ‘Is vol- ume reduction surgery appropriate in the treatment of emphysema? Yes’, American Journal of Respiratory and Critical Care Medicine, 153, 1201 -04.

Cooper, J D, Trulock, E P, Triantafillou, A N, Patterson, G A, Pohl, M S, Deloney, P A, Sundaresan, R S and Roper, C L (1 995). ‘Bilateral pneumectomy (volume reduction) for chronic obstructive pul- monary disease’, Journal of Thoracic and Cardiovascular Surgery, 109, 106-1 19.

The author of the article in the Sep- tember Journal replies: MADAM - May I thank Mr Jeffrey and Ms Wattie for highlighting the typographical error in the recent LVRS article (Grant, 1997). Although acknowledging that the error does greatly alter evaluation of walking dis- tance outcome in this group, Cooper’s conclusions on LVRS outcome still cannot be substantiated on the basis of a single non-randomised study (Cooper et a/, 1995). Therefore, the call for a randomised controlled trial of LVRS must again be emphasised in evaluation of a procedure that has potential long-term benefit to emphy- sematous patients (Holohan and Handelsman, 1996; Lomas et a/, 1997; Snider, 1996; Weinmann and Hyatt, 1996).

Alistair Grant MCSP Papworth Hospital NHS Trust

References Cooper, J D, Trulock, E P, Triantafillou, A N, Patterson, G A, Pohl, M S, Deloney, P A, Sundaresan, R S and Roper, C L (1 995). ‘Bilateral pneumectomy (volume reduction) for chronic obstructive pul- monary disease’, Journal of Thoracic and Cardiovascular Surgery, 109, 106-1 19.

Grant, A (1997). ‘Lung volume reduction surgery - Clarification of the controversy’, Physiotherapy, 83, 9, 491-494.

Holohan, T V and Handelsman, H (1 996). ‘Health Technology Assessment: Lung- volume reduction surgery for end-stage chronic obstructive pulmonary disease’, US Department of Health and Human Ser- vices; Agency for Health Care Policy and Research, HTA No 10, AGCPR Pub No

Lomas, D A, Caine, N and Wells F C (1 997). ‘Health technology assessment: Time for a randomised controlled trial of the role of lung volume reduction surgery in the treatment of emphysema’, Thorax,

Snider, G L (1996). ‘Health care technol- ogy assessment of surgical procedures: The case of reduction pneumoplasty for emphysema’, American Journal of Respi- ratory and Critical Care Medicine, 153,

Weinmann, G G and Hyatt, R (1996). ‘Evaluation and research in lung volume reduction surgery’, American Journal of Respiratory and Critical Care Medicine,

96-0062.

52,755-756.

1208-1 3.

154, 1913-18.

Wide Research on Pain MADAM - The book Bad Backs and Painful Parts, which describes how stress can make muscles tense, and how muscles which remain tense overstimulate the Golgi tendon organs and result in pain, was based on research on 224 patients, and not just a few anecdotal cases as your reviewer thought (August 1997, page 437). The cases mentioned in the book are simply illustrative.

Jenny Draspa MCSP Chester

Physiotherapy, November 1997, vol83, no 11