Dear Howard,
You wrote: "Although I am only a clinician, from a methodology standpoint,
it seems to me that that reproduction of technique would be essential to
prove or disprove effectiveness."
Yes I agree.
You also wrote: "Having those adequately trained in research protocol is
critical to broadening the reach of podiatric medicine worldwide. However,
being unnecessarily critical of those of us who practice and publish from
the perspective of a clinical practice, needs to be carefully thought
through."
I hope I have not been unnecessarily critical of anyone due to their
background, whether it be clinical practice or research. I admire greatly
those who run busy clinical practices yet have time to dedicate themselves
to research in an attempt to improve the lives of their patients and of
other clinicians. I hope I never become biased towards a paper because of
the author's name, although it is known to be a problem which is why some
systematic reviews go through the enormous task of removing author's names
from articles before the reviewers look at the trials. The comments I have
made are because I am hoping to promote better quality trials and thereby
help clinicians such as yourselves to provide high quality evidence for your
treatments and thereby improve patient's lives worldwide. Obviously we are
both in this game for the same reason.
You also wrote "(It should be noted that Jenna was quite sceptical about the
effects of manipulation prior to the completion of this study.)"
I'm afraid that acknowledging that someone is sceptical about the results of
the trial is not necessarily a good thing. In fact this acknowledges that
the measurer was indeed biased, but in the opposite direction to what you
yourself would be biased towards. Unfortunately, all researchers are
subject to bias. We have our theories that an intervention is very
effective and want to see our theories confirmed. However, we have an
ethical responsibility to work at removing such bias from our research and
one of the ways of effectively doing this is by blinding the outcome
assessor to which group a participant belongs to.
You also wrote: "As for the control, I have never seen ankle joint range of
motion spontaneously change other than for ankle fracture."
Trials including a control group and looking at the effect of calf muscle
stretches on ankle ROM have indeed found increases in ROM for the control
group (Williford, East et al. 1986; Grady and Saxena 1991; Bohannon, Tiberio
et al. 1994; Zito, Driver et al. 1997; Fryer, Mudge et al. 2002). The Fryer
paper also reports increases in ROM for the control group. So it appears
that a participant's ROM may change spontaneously, although these changes in
the trials were indeed small.
You also wrote: "I have no problem with having my work, thoughts and ideas
questioned. I do have difficulties with those who would "throw the baby out
with the bathwater" because in their eyes, methodology was imperfect.
Building from works such as these is important. Knocking them down without
providing anything else to build upon, should be frowned upon by the entire
profession."
I have no doubt that your work has definitely made a contribution to the
literature by suggesting that manipulation may increase ankle ROM. Case
studies and non-randomised trials are usually the first to suggest that a
new intervention may be useful. Hopefully, you have scraped the tip of the
iceberg with your trial and now a good quality RCT is required to confirm
your findings. I should comment that even so, one RCT is not enough to
usually confirm any intervention's effectiveness, several good quality RCTs
combined into a systematic review and meta-analysis is the highest form of
evidence and is what we need for every intervention. Therefore, your trial
on its own is not enough. Your work makes a good start to suggesting that
ankle manipulation has potential to be an effective treatment and is
obviously a grounding for researchers like Craig to build on. You should be
congratulated on your enthusiasm to see this treatment accepted and I hope
you will continue to research its effectiveness.
Kind regards,
Joel.
Bohannon, R. W., D. Tiberio, et al. (1994). “Effect of five minute stretch
on ankle dorsiflexion range of motion.” Journal of Physical Therapy Science
6: 1-8.
Fryer, G. A., J. M. Mudge, et al. (2002). “The effect of talocrural joint
manipulation on range of motion at the ankle.” Journal of Manipulative and
Physiological Therapeutics 25(6): 384-390.
Grady, J. F. and A. Saxena (1991). “Effects of stretching the gastrocnemius
muscle.” The Journal of Foot Surgery 30(5): 465-469.
Williford, H. N., J. B. East, et al. (1986). “Evaluation of warm-up for
improvement in flexibility.” The American Journal of Sports Medicine 14(4):
316-319.
Zito, M., D. Driver, et al. (1997). “Lasting effects of one bout of two
15-second passive stretches on ankle dorsiflexion range of motion.” Journal
of Orthopaedic & Sports Physical Therapy 26(4): 214-221.
-----Original Message-----
From: A group for the academic discussion of current issues in podiatry
[mailto:[log in to unmask]]On Behalf Of [log in to unmask]
Sent: Saturday, 25 September 2004 1:59 AM
To: [log in to unmask]
Subject: Re: Ankle manipulation, was GRF on Forefoot, What Moves?
Joel,
You wrote: "As for the different methods of manipulation, I cannot comment
on this area as I know relatively little about manipulation techniques.
However, all I
am commenting on is the methodology of the trials and the results of the
techniques."
Although I am only a clinician, from a methodology standpoint, it seems to
me that that reproduction of technique would be essential to prove or
disprove effectiveness.
You also wrote "In your trial, as Hylton rightly points out, the reliability
of the ankle
measurements should have been assessed and reported as such measurements are
know to sometimes be unreliable. Also, a control group should have been
included and appropriate blinding of the ankle ROM assessor as to which
group the participant belonged to. The Fryer paper addresses this nicely.
On the whole, there was some room for bias in your trial."
Having those adequately trained in research protocol is critical to
broadening the reach of podiatric medicine worldwide. However, being
unnecessarily critical of those of us who practice and publish from the
perspective of a clinical practice, needs to be carefully thought through.
Hylton's original letter to the editor in JAPMA actually questioned the
integrity of our work in this paper (it was rewritten after we discussed the
nature of these accusations). I found that initial letter most distasteful,
as I would assume any of the mailbasers would when they knew their work was
honestly and sincerely reported in their publication.
We tried to be as objective as we could by separating those manipulating
from the person measuring. I was not the only clinician performing
manipulations, and Jenna Shearstone, the person doing the measuring was not
present when manipulations were performed. (It should be noted that Jenna
was quite skeptical about the effects of manipulation prior to the
completion of this study.) Each subject was measured TWICE prior to
manipulation and TWICE afterwards. As for the control, I have never seen
ankle joint range of motion spontaneously change other than for ankle
fracture. Therefore, we believed that the double measurements before and
after were adequate in assessing the changes in ROM. All the authors
practiced and perfected the measurement techniques with Ms. Shearstone prior
to starting this study. Considering that a single, trained examiner was
used for all measurements, and single examiner reliability has been
estabished in prior papers, we sincerely believed that this was a reasonably
objective method. Leaving the details of this out of the paper was indeed
an error. It does not, however, change the findings. The change in motion
we measured was so substantial (5 degrees + average, greatest was 17
degrees), that even if examiner error occurred, it would not have biased the
results away from the obvious conclusion that manipulation can be an
effective method of care. Moreover, since the alternative to this is
Achilles tendon lengthening surgery, and there were no negative or harmful
effects from ankle manipulation in either the study or clinical practice,
providing this information to podiatrists worldwide seemed quite appropriate
to all of us involved in this study.
In addressing Craig Payne's comments about stiffness rather than ROM
changing from manipulation, I would hope that this is the case. Considering
that joint manipulations are designed to take an immobile structure and
mobilize it...it would stand to reason that stiffness could be positively
altered. And if it is stiffness that is the fundamental change, with ROM
secondary to it....that, as far as clinical outcome goes, is fine with me.
We only measured ROM and I am glad that Craig is looking into this is
greater detail.
With your request for "Please, someone out there set this trial up!", and
Craig's response that it is in the works, I am glad that 4 years after my
original publication, this is now taking place.
I have no problem with having my work, thoughts and ideas questioned. I do
have difficulties with those who would "throw the baby out with the
bathwater" because in their eyes, methodology was imperfect. Building from
works such as these is important. Knocking them down without providing
anything else to build upon, should be frowned upon by the entire
profession.
Howard
Howard Dananberg, DPM
21 Eastman Avenue
Bedford, New Hampshire 03110
603-625-5772
fax 603-625-9889
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