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REPLY
Effects of Three Therapies for Neck Pain
Jan Lucas Hoving, PT, PhD;
Bart W. Koes, PhD; and
Henrica C.W. de Vet, PhD
15 April 2003 | Volume 138 Issue 8 | Pages 685-686
IN RESPONSE:
The question at hand is the way in which one should interpret statistically nonsignificant results. Should one take the common point of view that without statistical significance there is no effect, or the more Bayesian view that combines new evidence of the magnitude and statistical significance of the effect with its prior probability (1)? In the latter case, the P value is less sacrosanct and the results of other outcome measures are taken into account. It is clear that we took the latter viewpoint in our paper. Although we agree with Drs. Kwan and Friel that our conclusion did not specifically refer to the size and potential uncertainty of the effect, we hold to our conclusion that manual therapy appears to be more effective than general practitioner care and probably than physiotherapy.
We can reassure Drs. Kwan and Friel that the effect of manual therapy persists after 6 weeks. Our recent cost-effectiveness analysis (2) shows that the total costs of manual therapy over 12 months were statistically significantly lower than the costs of physiotherapy and general practitioner care, confirming that manual therapy is a cost-effective intervention in the long term.
In our trial, we chose perceived recovery as a primary outcome for the very reason that it is a multifactorial scale, summing the effects of pain and function and other aspects that patients may consider important. Drs. Posner and Glew (3), in their accompanying editorial, equated perceived recovery to satisfaction and to nonspecific effects. We strongly disagree. Patients include in their perceived recovery score specific effects, such as pain reduction and functional improvement. Our trial was designed as a pragmatic trial, comparing three frequently applied interventions in primary care, because we were interested in the total effect (both specific and nonspecific) of these interventions. To study only specific effects, a placebo therapy is required. A double-blind trial of these interventions for neck pain would be extremely difficult to perform and has no relevance for primary care.
We have no idea why Drs. Posner and Glew consider us to be advocates of manual therapy. We are independent scientific researchers with epidemiologic backgrounds and a tradition of studying the effectiveness of frequently used primary care interventions for musculoskeletal disorders (4, 5).
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Author and Article Information
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Cabrini Medical Centre; 3144 Victoria, Australia (Hoving)
Erasmus Medical Center Rotterdam; 3000 DR Rotterdam, the Netherlands (Koes)
Vrije Universiteit Medical Centre; 1081 BT Amsterdam, the Netherlands (de Vet)
1. Burton PR. Helping doctors to draw appropriate inferences from the analysis of medical studies Stat Med. 1994;13:1699-713. [PMID: 7997704].[Medline]
2. Korthals-de Bos IB, Hoving JL, Van Tulder MW, Rutten-van Mölken MP, Adèr HJ, De Vet HC, et al. Cost-effectiveness of physiotherapy, manual therapy and GP care for neck pain: an economic evaluation alongside a randomised controlled trial. In: Korthals-de Bos IB. Economic Evaluations in Musculoskeletal Disorders [Thesis]. Amsterdam: VU University; 2002.
3. Posner J, Glew C. Neck pain [Editorial] Ann Intern Med. 2002;136:758-9. [PMID: 12020144].[Free Full Text]
4. Koes BW, Bouter LM, van Mameren H, Essers AH, Verstegen GM, Hofhuizen DM, et al. Randomised clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: results of one year follow up BMJ. 1992;304:601-5. [PMID: 1532760].
5. Smidt N, van der Windt DA, Assendelft WJ, Deville WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial Lancet. 2002;359:657-62. [PMID: 11879861].[Medline]
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Articles
Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain: A Randomized, Controlled Trial
Jan Lucas Hoving, Bart W. Koes, Henrica C.W. de Vet, Danielle A.W.M. van der Windt, Willem J.J. Assendelft, Henk van Mameren, Walter L.J.M. Devillé, Jan J.M. Pool, Rob J.P.M Scholten, AND Lex M. Bouter
- Annals 2002 136: 713-722.
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