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