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Effects of Three Therapies for Neck Pain
- Jan Lucas Hoving, PT, PhD;
- Bart W. Koes, PhD; and
- Henrica C.W. de Vet, PhD
- 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)
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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).
Jan Lucas Hoving, PT, PhD
Cabrini Medical Centre; 3144 Victoria, Australia
Bart W. Koes, PhD
Erasmus Medical Center Rotterdam; 3000 DR Rotterdam, the Netherlands
Henrica C.W. de Vet, PhD
Vrije Universiteit Medical Centre; 1081 BT Amsterdam, the Netherlands
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
