Thai Journal questioning Maitland approach

[Katie-Lou]

Hi

I have just read an RCT Journal from Thailand and they have disproved Maitlands approach of doing a unilateral PA pressure on the side of the symptoms for treating patients presenting with unilateral neck pain. By comparing them to a random group receiving either central PA, Ipsilateral PA or contralateral unilateral PA pressure.

However in the random group the therapist was able to change treatment technique regarding pt symptoms. But if the therapist was able to change treatment technique in the random group is this not slightly biased and assumptions could be made they are doing a treatment technique on the opposite side to the symptoms.

I have just read Maitlands book and they all have pain relieving qualities.

I would really like anyone thoughts on this please as I am confused by it all and now my practice.

This is the journal.. its very convincing

Arch Phys Med Rehabil. 2009 Feb;90(2):187-92.
The immediate effects of mobilization technique on pain and range of motion in patients presenting with unilateral neck pain: a randomized controlled trial.
Kanlayanaphotporn R, Chiradejnant A, Vachalathiti R.


Similar Threads:

• Which Maitland Mob??
• Journal club
• Paediatric Journal
• Best journal
• Pediatric Journal (from archives)

[sarahleeandrews]

Hi, we are critiquing this article for one of our 2nd year physiotherapy degree courseworks, and we don't think it is that good. It seems like they haven't even read maitland properly at all.

[gcoe]

Hi Katie-Lou

I was intrigued by this study. However have you really appraised the article for quality and applicability? It seems to me you haven’t. Your comments seem a bit confusing. May I ask do you know how to appraise a clinical trial?

sarahleeandrews - did your group appraise the article? Your only comment seems to be about whether they understood what “Maitland protocol” would be for unilateral neck pain.

I had a bit of a look at the article and to me it has some good points, but a number of limitations. I think the study should be taken seriously.

The article It is a well respected peer-reviewed journal.

Quality:

• Reasonable description of inclusion and exclusion criteria

• Random allocation: Yes = sound method of randomisation

• Concealed allocation: Yes by envelopes

• Baseline comparability: Yes; Well described for age, gender, symptomatic side ( L vs R) Direction of worst movement, Duration of neck pain, Neck Disability Index, Pain intensity at rest on the most painful movement, and cervical ROM. The groups were very much comparable

• Outcome measures chosen have demonstrated reliability and validity with limited data on responsiveness.

• Blinding: the study claims to be a triple blind study which is of course rubbish. It is impossible to blind subjects and as the same therapist carried out both interventions it is impossible to blind the therapists in way or form. However assessors were well blinded which is often the best you can do in a physiotherapy intervention.

• Adequate follow-up: Yes, although the effect was measured immediately (5 minutes) after the session. It would have been interesting to know if there was any longer term benefit – however this was not the aim of the study

• Intention-to-treat analysis: No not stated although flow chart implies people were analysed according to the group they were originally allocated to;

• Between-group comparisons: Yes; However the statistical analysis is limited in that doesn’t indicate the clinical significance of the change in pain level

• Point estimates and variability: Yes. However difficult to interpret, Better if they had give the mean differences and confidence intervals for each outcome measure

• This means it scores about 7/10 on the PEDro scale which is quite a good score. Certainly it indicates the study is worth taking note of.



Applicability

• sarahleeandrews, I think you have to be realistic what in a single RCT can achieve. You have to simplify things in order to standardise the treatment; The question is whether the simplification (in such a complex system of identification and selection of the most appropriate treatment technique as Maitland) is clinically meaningful. The authors decided to tackle unilateral vertebral joint unilateral PAs as a therapeutic technique so this isn’t the whole of Maitland’s array of techniques for a unitlateral problem. For example it excluded the use of rotation mobilisations. I think this is justified because the whole treatment group have to get a similar treatment. They adjusted the grades based on whether predominant impairment was pain or hypomobility – this was in accordance with Maitland’s principles

• Katie-Lou, I agree that the control group treatment was a bit odd. However the therapist couldn’t choose the treatment in anyway as they had to deliver what was randomly selected between the three available techniques. There seemed no sensible rationalisation for this “randomisation” .Some would be allocated a unilateral PA on the same side so some would presumably get a treatment that could have been similar to the active treatment. A more sensible choice might have been to offer a standard sham treatment to all in the control group such as unilateral PAs on the contralateral side or a general massage.

• The outcome measures were appropriate for the clinical problem and for assessing the treatment. Pain and ROM were highly relevant to the technique, particularly as the time frame is immediately after one treatment.

• It was hard to interpret the data analysis (2-way ANOVA). It would have been more useful if the mean difference (along with the 95% Confidence Intervals) between the two groups post treatment was reported for both pain and most painful movement.

• In fact the treated group gained more range of motion than the comparison group. However it was clinically relatively small improvement and as no confidence intervals are given it is hard to say how much we can rely on these results

• The Global Perceived Effect indicates there was no difference in benefit between the groups

• It is a not a large study so this far from “disproves” or proves the efficacy of unilateral PAs as a technique

• It only examined one treatment as far as I could see. And the authors make this clear. So usually one would treat a patient a few times with such a technique or progress the technique/change the technique. So this is a limitation

• It seemed this group was quite chronic (although variable). 800-900 average days since the onset means the patients had these symptoms for years 2-3 years. Given what we know about the value of manual techniques to date such techniques may be more warranted in the acute/subacute presentation. One reason there wasn’t much of a response is that a chronic pain patient may not be expected to respond to such a modality.

In summary

This study was of reasonable quality and does cast some doubt over the immediate effectiveness of the unilateral PA for treating unilateral neck pain. The protocol for the comparison group treatment is a design flaw. The control group didn't get a consistent treatment and I would wonder if if was a true placebo in some cases. It may not have really separated definitively what the two treatment groups got and this could have made the treatment look more useless than it may have been.

The study certainly doesn’t “disprove” Maitland’s approach to unilateral neck pain. One would want to see the study replicated and it may be more useful now to see what a course of treatment produces – as this maybe more clinically meaningful.

And finally I wonder if in such a chronic group of patients starting with a passive modality like mobilisations is really good practice anyway.

[sarahleeandrews]

Hi gcoe thanks for your cirtique!! I am right in the middle of writing my essay, and i thought your comment about chronic pain was interesting and something I had not noticed and probably very important.

I do believe that they have not read maitland properly though. I wonder whether they wrote it in english themselves, or it was translated.

Maitland talks about using certain techniques relating to where the pain is, but he says these are in relation to a recongnised pattern of symptom history. Traumatic accidents, such as whiplash do not tend to apply, but back pains which suddenly start from something like a small twist fit. He calls these regular patterns. The traumatic ones are refferred to as irregular. He does say that these are only guidlines though, and it is also quoted in his book, which the article references, that manipulative therapy is not an empirical treatment.

Also the authors do not give a p value for the 20% more females in the study, and a question i would like to know, is how many people actually only follow Maitland? We are learning his technique as a key text on our course, but I have not had lots of clinical experience yet. I have just read a 2006 Misner book, and she notes down quite a few different techniques, with only a small part being Maitland.

[gcoe]

Hi sarahleeandrews

Thanks for your response. I can see now you clearly have given considerable thought about the study in pursuit of your education.

I do believe that they have not read Maitland properly though.

we might just disagree about this. Just so you know where I am a coming from: I am a very experienced practitioner who was exposed to Maitland's ideas and approach at the outset of my career. However I am certainly not not an expert MSK therapist - my chief area of interest being in rehabilitation. So it might be a really worthwhile question to pose to your MSK educators (or manual therapist might on this discussion site might contribute) about there opinion on the protocol used for selecting the treatment. To me the researchers achieved an adequate protocol. According to Maitland's chapter on technique selection in Verterbal Manipulation 5th ed (pp116-117) along side rotation mobs, PA unilateral vertebral pressures are recommended as the first technique to try in the case of unilaterally distributed symptoms in the neck and are particularly indicated if middle or upper cervical in origin. In order for the authors to provide a relatively consistent treatment in the case of the active intervention so all patients received a standard treatment the had to simplify Maitland's approach. They did this by selecting one of the most appropriate techniques and then adjusted the grades according to the primary impairment identified on testing (pain or hypomobility) and they standardised a dosage. The question is: is this like real practice? My answer would be yes and no. Because the study is only looking at a one off treatment and the immediate effect this is not unlike the initial choice of a technique. Obviously in real life, one then alters the technique, grade and dosage according to the immediate response and the response at the second session. So for what the authors were setting out to do I think this has good ecological validity - but I accept other therapists may not agree.

Maitland talks about using certain techniques relating to where the pain is, but he says these are in relation to a recognised pattern of symptom history. Traumatic accidents, such as whiplash do not tend to apply, but back pains which suddenly start from something like a small twist fit. He calls these regular patterns.

. Maitland offers a highly rational but highly sophisticated approach. The fact that his book is 390 pages long is a testament to that. No doubt in your training you are learning many of the nuances of this approach such as the concept of regular patterns. However I would consider the most important factors in the selection of a technique are that the 1) presentation is mechanical in nature 2) the level of the symptoms and 3)signs and the distribution of the symptoms. The main inclusion criteria was "Patients suffering from mechanical neck pain that was unilaterally distributed for at least 1-week duration"; Although they have excluded severe trauma the fact that they haven't been specific about the condition in the inclusion criteria seems ok to me and is consistent with this approach

Also the authors do not give a p value for the 20% more females in the study,

do you mean 20% more females in the study overall or do you mean 20% more females in the intervention group?

If you mean the former I don't quite get your point - why would you be looking at a p value? Isn't this an issue of applicability - Is this like what you would see in your clinic? I wouldn't be too concerned about this. I think the prevalence of women with neck pain is higher anyway.

If you mean the latter - then you are right - this is an issue of the relative comparativeness of the groups. However given the relatively small sample size of the study these differences are bound to arise in a block randomisation procedure and given the number of "prognosticators" analysed between the two groups I still think the randomisation procedure produced a result that is suggestive of good distribution of these factors.The question is would you expect female vs male to be prognostically different? ie would you expect males and females to respond differently to manual therapy? Gener is am important prognosticator for many treatments but I would not expect that males and females would respond in a very different way to unilateral PAs

One final thing I would say about evidence like this. You clearly are developing good critical skills when appraising evidence and being as critical as you can when developing these skills is all good. However Prof Rob Herbert from the St George Institute (Sydney Uni and PEDro fame) makes an important point: we are not looking for perfect evidence. We would never find it. trials are always riddled with problems and tradeoffs. The question is whether the evidence is good enough for the purpose of influencing our decisions. This means the quality of the study must of adequate quality and relevant to the patient's we see. If we are too picky we can end up not paying attention data that may be valid and this can be a costly mistake. This sort of research does not come cheaply. Personally I feel this study meets that criteria and I would tend to take the results seriously enough to put into doubt the value of unilateral PA's in unilateral neck pain. But as I said in my previous post I would want to see the study replicated and I would be more interested in seeing what happens in a course of Unilateral PAs rather than just one immediate effect.

and a question i would like to know, is how many people actually only follow Maitland?

. Yes this is a good point. This approach is just one of an array of different approaches. In my part of the world many therapists are very McKenzie oriented and these proponents offer a completely different approach. Likewise Brian Mulligan gets a lot of air play with his techniques. But there is also Kaltenborn, osteopathic approaches , chiropractic techniques, Myosfascial pain approach, movement impairment approaches and so on. Gregory Grieve was from England and his approach is very similar to Maitlands - so I think he was very influential in your part of the world. One great thing about Maitland/Grieve is that it is very rational and the history/examination very detailed - not a bad place to start out as you acquire your MSK skills.

All the best with your assignment