Bouter, L.M.

Knipschild, P.

Koes, B.W.

Vanmameren, H.

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332 Journal of Manipulati%e and PM.siological Therapeutics
Volume 15 • Number 5 • June 1992
LETTERS TO THE EDITOR
A BLINDED RANDOMIZED CLINICAL TRIAL OF MANUAL
THERAPY AND PHYSIOTHERAPY FOR CHRONIC BACK
AND NECK COMPLAINTS: PHYSICAL OUTCOME
MEASURES
To the Editor:
B. W. Koes et al.'s trial on manual therapy (Koes BW et
al. A Blinded Randomized Clinical Trial of Manual Therapy
and Physiotherapy for Chronic Back and Neck Complaints:
Physical Outcome Measures. J Manipulative Physiol Ther
1992: 15(1):16-23) seems to suffer from "double vision." This
study has appeared in two forms (1. 2). In the Spine version,
there was no advantage to manual therapy over physical
therapy at 3 wk. However, in the .1.14PT version. manual
therapy results were statistically better than the physical ther-
apy results at 3 wk. If one looks at the tables published in the
two articles, it is obvious that the data are different (Table 5
in Spine vs. Table 6 in J.IIPT). although all other aspects of
the reports are identical.
How do the authors account for these differences? Which
set of results should we believe? In the Spine version. the
effects of manual therapy and physical therapy are explained
by the effect of referral and giving the patient extra attention.
In the J.IIPT version, manual therapy is extolled as a treat-
ment that shows a faster and larger improvement than the
other therapies.
In addition, the authors of this study have failed to differ-
entiate between manipulation and mobilization. Previous
trials comparing these two treatments have shown that they
are not equivalent (3). This means that the treatment applied
in their trial was some mix of manipulation and mobilization
as defined by the Dutch Society for Manual Therapy. Future
trials should differentiate between these two different types of
manual therapy.
J. David Cassidy, D.C.
Research Associate
Department of Orthopaedics
Royal University Hospital
Saskatoon, Saskatchewan
Canada S7N OX0
REFERENCES
I. Koes BW et al. The effectiveness of manual therapy, physiother-
apy, and treatment by the general practitioner for nonspecific
back and neck complaints: a randomized clinical trial. Spine
1992; 17:28-35.
2. Koes BW, Bouter LM, van Mamerren H et al. A blinded ran-
domized controlled trial of manual therapy and physiotherapy
for chronic back and neck complaints: physical outcome meas-
ures. J Manipulative Physiol Ther 1992; 15(1):16-23.
Journal of Manipulative and Physiological Therapeutics 333
Volume 15 • Number 5 • June. 1992
LETTERS TO THE EDITOR
Hadler NM et al. A benefit of spinal manipulation as adjunctive
therapy for acute low back pain: a stratified controlled trial. Spine
1987: 12:703-5.
Miearau DR, Cassidy JD. et al. Manipulation and mobilization
of the third metacarpophalangeal joint: a quantitative radio-
graphic and range of motion study. Manual Med 1988; 135-40.
In Reply:
We hereby enclose a copy of our reply with respect to the
letter of D. Cassidy'.
Although Cassidy has identified two publications of our
study (1, 2), he has failed to notice that in each article we
report differe	 itcome measures, and consequently, it is
not strange at all that the data differ. In the article published
in Spine. we have reported the results of our principal out-
come measures (severity of the complaint and perceived ben-
efit) (I). whereas in the one published in the J.IIPT, we have
reported the results of the physical outcome measures (phys-
ical functioning and spinal mobility). as is mentioned in the
subtitle of the article (2). We believe that the results of our
principal outcome measure (severity of the complaint and
perceived benefit) have more relevance for evaluating the
treatment effect in patients with hack and neck complaints.
Readers who are interested in the long-term results (12 mo
follow-up) of our study are referred to a recent publication in
the British Medical Journal (3).
The scientific evidence that manipulation and mobilization
have different effects (with respect to relevant outcome meas-
ures) is not convincing (4). We agree with Cassidy that to
resolve this issue, future trials are needed to separate their
effect in specific subgroups of patients with back and neck
complaints.
B. Koes
L. Bouter
P. Knipschild
H. van Mameren
University of Limburg
Department of Epidemiology
P.O. Box 616
6200 MD Maastricht
The Netherlands
REFERENCES
Koes BW et al. The effectiveness of manual therapy, physiother-
apy, and treatment by the general practitioner for nonspecific
back and neck complaints: a randomized clinical trial. Spine
1992; 17:28-35.
Koes BW. Bouter LM, van Mamerren H et al. A blinded ran-
domized clinical trial of manual therapy and physiotherapy for
chronic back and neck complaints: physical outcome measures.
J Manipulative Physiol Ther 1992; 15:16-23.
Koes BW et al. Randomised clinical trial of manipulative therapy
and physiotherapy for persistent back and neck complaints:
results of one year follow-up. Br Med J 1992; 304:601-5.
Koes BW et al. Spinal manipulation and mobilisation for back
and neck pain: a blinded review. Br Med J 1991; 303:1298-1303.


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