Rheumatology 2006;45:751–756
Advance Access publication 17 January 2006
doi:10.1093/rheumatology/kei254
Patient perceptions of physical therapy within
a trial for back pain treatments (UK BEAM)
[ISRCTN32683578]
M. R. Underwood1, G. Harding2 and J. Klaber Moffett3 in collaboration
with the UK BEAM trial team
Objectives. To explore the views of participants in a randomized controlled trial of physical treatments for low back pain about
the treatment packages they received in the trial.
Methods. Within a randomized controlled trial that found small to moderate benefits from adding a manipulation package or an
exercise programme to general practice care, we elicited participants’ views on the treatment using an open question in
participant questionnaires. These data were analysed using an adapted framework approach.
Results. We received a total of 1259 comments from 1334 participants. Participants randomized to usual general practice care
reported dissatisfaction with receiving only ‘usual care’, which consisted of providing analgesic medication without providing an
explanation for their pain. Those randomized to a manipulation package felt the intervention was appropriate to their needs and
commonly reported striking benefits. Participants assigned to the exercise programme developed a sense of self-reliance in
managing back pain, although some failed to be sufficiently motivated to continue their exercise regimen outside the classes.
Conclusions. This qualitative analysis has found much clearer differences between the groups than the main quantitative
analysis. This suggests that some of the added value from being allocated to additional physical treatment for low back pain is
not being captured by existing methods of measurement. Improved methods of assessment that consider a wider range of
domains may be needed when interpreting the added value of such treatments to individual patients.
Health services researchers are increasingly gaining an understanding of how the process of implementing clinical interventions
in randomized controlled trials informs their interpretation [1, 2].
These processes may be particularly important when interpreting
the results of randomized controlled trials of physical treatments
for musculoskeletal disorders, such as low back pain, which may
at best produce small effect sizes [3–5]. These small effect sizes
contrast with the popularity of such treatments with patients
and the high rates of satisfaction with osteopathy [6] and the
dissatisfaction with general practitioners found in some empirical
studies [7]. A review of existing community studies of patients’ and
practitioners’ beliefs and expectations suggests that there may be
some tensions between the expectations of patients and their treating practitioners around diagnostic and treatment models used
by the two groups [S. Parsons, A. Breen, N. Foster, G. Harding,
T. Pincus, S. Vogel, M. Underwood, submitted for publication].
An example of such a trial of physical treatments is the UK Back
Pain Exercise And Manipulation Trial (UK BEAM). In this trial
we found that, when compared with ‘best care’ in general practice
[8, 9], a package of spinal manipulation [10] produced a small to
moderate benefit at 3 months and a small benefit at 1 year; that a
programme of exercise [11] produced a small benefit at 3 months
but not 12 months; and that manipulation followed by exercise
produced a moderate benefit at 3 months and a small benefit at
1 year [12]. These effects are less than those we sought when
designing this trial; however, the economic analysis suggests
that these treatments are cost-effective additions to general
practice treatment [13]. To explore these effects further we analysed
participants’ views on the treatments they received within the UK
BEAM trial, which were expressed as free text at the end of the
questionnaire, with a view to gaining some insight into why the
treatments were less effective than we had hoped.
Methods
We have reported our methods and results of the main trial in
detail elsewhere [12–14].
Participant recruitment and follow-up
We recruited 1334 participants aged 18–64 from 181 general
practices from the Medical Research Council General Practice
Research Framework (http://mrc-gprf.ac.uk/) in 14 clusters across
the UK. All participants had consulted these practices with simple
low back pain. To exclude those people whose pain would resolve
rapidly without treatment, all participants had had pain for at least
4 weeks when randomized. The Northern and Yorkshire MultiCentre Ethics Committee provided the ethical review.
Interventions
We used a factorial design to compare ‘best care in general
practice’—the control treatment, in which we trained practice
teams in the active management of back pain [9, 12], and they
provided participants with copies of The Back Book [15]—with
1
Centre for Health Sciences, Barts and The London, 2Department of General Practice and Primary Care, Peninsular Medical School, 3Institute of
Rehabilitation, University of Hull.
Received 15 August 2005; revised version accepted 11 November 2005.
Correspondence to: M. R. Underwood, Centre for Health Sciences, Barts and The London. E-mail: [email protected]
751
ß The Author 2006. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: [email protected]
752
M. R. Underwood et al.
TABLE 1. Best care in general practice
Ineffectual GP care
‘GPs do not seem to understand back pain, and their only solution is painkillers, which only hide the problem!’ (A33-19-2024)
‘(I) feel study has not helped me with dealing with any back pain as only put into ‘‘to see GP’’ category.’ (A22-13-2163)
‘I was extremely disappointed when your initial assessment ‘‘randomly’’ excluded me from any form of positive treatment, relegating me to GP
management . . .’ (043-16-2040)
‘I had hoped to receive expert help when I needed it, but got nothing in return.’ (A04-14-2086)
Use of medication
‘Back pain is relatively under control whilst taking medication.’ (680-13-2006)
‘I have kept the prescribed by my doctor and find when I have exerted myself too much and my back is then painful, I take these for a few days and
this relieves the pain.’ (900-17-2007)
‘I have now been on painkillers for one year and I worry that I may become . . .’ (584-12-2058)
‘I have stopped taking ibuprofen because of indigestion and the various forms of painkillers prescribed have such horrendous (side effects)’
(A06-17-2000)
‘I am continually taking ibuprofen 400 mg (3–4 a day) and sometimes wonder if, by dulling the back pain and thereby enabling myself to do more
physical activity, I may be doing more harm than good.’ (233-16-2009)
‘(I) am determined to try to manage back pain a little better without resorting to painkillers all the time.’ (337-13-2061)
‘I would have liked someone to find out the cause of the problem, not just take tablets to ‘‘dull’’ the pain.’ (796-13-2241)
‘Painkillers only mask the problem, not solve it.’ (023-16-2002) ‘pills are not the real answer to the problem.’ (A71-13-2017)
Self-help advice from the GP
‘I have taken the advice of the doctor and the information booklet on back pain. I go to the gym 2–3 times a week where I weight train, swim and
relax in the steam room/jacuzzi. When my back hurts I scale down my gym work and concentrate on stretching . . . Regular exercise has helped me
manage my health.’ (480-13-2028)
‘My back pain in both mine and my doctor’s opinion is caused by stress, so a lot of the time it’s a question of ‘‘getting on with it’’, working through
the pain and trying to relax when possible – in mind if not body.’ (337-11-2017)
(i) an exercise programme consisting of an initial individual
assessment followed by up to nine group classes over 12 weeks
delivered in community facilities [11], and (ii) a spinal
manipulation package delivered in roughly equal proportions
by chiropractic, osteopathic and physiotherapy professionals [10].
We invited participants to attend up to eight sessions over up to
12 weeks. Some participants received manipulation followed
by exercise; for clarity we have not included data from these
participants in this analysis. All practitioners providing treatment
across all arms of the study were asked to provide positive
and non-threatening messages to patients, encouraging a return
to normal activities consistent with the Royal College of General
Practioners guidelines and The Back Book.
themes from individuals’ limited free text. Unlike that arising
from conventional qualitative semi-structured interviews, our data
were not information-rich, i.e. allowing us to locate individuals’
responses in a broader context. Instead we had only fragmented
accounts of respondents’ experiences. Nevertheless, we were able
to develop an index of pertinent issues generated from these data,
in accordance with patients’ treatment allocation. These issues
were then collated to form loosely constructed categories, which
we examined to identify emergent themes. These themes emerged
from a systematic process involving initial data reduction. This
comprised selecting those excerpts of transcripts which provided
our initial focus, assembling these data into matrices to identify
the main direction of our analysis, and finally developing a content
analytical interpretation of these matrices.
Qualitative data
Participants were followed up using postal questionnaires at 1, 3
and 12 months following randomization. In our baseline questionnaire and at each follow-up we invited participants to provide
general comments about their back pain. The whole final page of
the questionnaire (A4 size) was available for their response. It is
these data that we have analysed here. We have analysed comments
regarding best care in general practice, the manipulation package
and the exercise programme separately. All free text comments,
ranging in length from single sentences to lengthy paragraphs, were
transcribed verbatim into an Access database and then formatted
for an Excel spreadsheet for the analysis. The free text comprised
participants’ descriptions of their experiences and was not
recorded as predominately either negative or positive. Instead
the comments were considered as illuminating participants’
perceived rather than their actual experience. We found no
obvious dissonant cases, i.e. individuals whose responses could
not be accommodated within our analytical framework. This
may reflect the constraints of expressing oneself fully by means of
a free text box.
Data analysis
We initially mapped the free text data using a modified framework
approach [16] to disaggregate, systematically, the qualitative
data. The modification involved our attempt to explore emergent
Results
We recruited 1334 participants. Follow-up questionnaires were
received from 1118 (84%), 1029 (77%) and 995 (75%) participants
at 1, 3 and 12 months, respectively. We received written comments
from 157/1334 (12%), 365/1118 (33%), 389/1029 (38%) and 348/
995 (35%) of the baseline, 1-, 3- and 12-month questionnaires,
respectively. It is these comments that are the basis of this analysis.
Best care in general practice (Table 1)
One strong theme to emerge from participants allocated to best
care in general practice was a perception of the ineffectual nature
of back pain management by their general practitioners (GPs).
Some participants reported positive experiences following advice
from their GP, but there was a sense amongst many participants
that GPs were non-specialists who had only medicines to offer by
way of treatment. This perception of the GP as non-expert and
back pain problem needing ‘expert’ treatment might reflect the fact
that people assigned to this form of treatment felt they were being
denied more specific help.
There was also a sense that drugs, which were considered to be
the principal solution available from GPs, were inappropriate
for back pain. Those allocated to a ‘GP only’ treatment regimen
were therefore disappointed not to receive any special or
individually tailored ‘expert’ treatment.
Patient perceptions of physical therapy in a back pain treatment trial
753
TABLE 2. Manipulation package
Treatment success
‘The treatment I have received for lower back pain has made a tremendous difference to me. I would recommend to anyone to seek the help of a
chiropractor. I can’t believe the difference it has made to me.’ (486-11-2060)’
‘The osteopath has at present cured my back problems. It took about 5/6 visits for the pain to disappear completely.’ (A24-11-2010)
‘My back problem has had a vast improvement since seeing the physiotherapist.’ (654-11-2017)
‘The treatment I received on the BEAM project totally rectified my back pain.’ (725-11-2022)
‘I have found my back pain much improved in the four weeks since I joined the study. The five treatments so far by the study chiropractor have been
most helpful. I feel that this treatment is far more suitable than continually having to take analgesics.’ (004-11-2002)
Explanation of pain
‘The osteopath . . . explained the problem I have with my back, and also has improved a great deal now I understand . . . why the pain
occurs.’ (276-17-2197)
‘My physiotherapist has given me some exercises to strengthen my back muscles and I am finding them most helpful. My own view is that a little
professional education to each back patient would enable them to understand what is happening to them . . . Being educated about my back means
I now can help myself, thus saving myself a lot of pain.’ (710-10-2062)
‘I feel I gained a great deal of information and was taught self-help.’ (023-18-2079)
‘I do, however, feel that I have the knowledge exactly what the problem is.’ (A26-16-2040)
Holism
‘The holistic attitude to back pain, along with the chiropractor’s treatment, seems to be most successful for me, i.e. weight loss, exercises specifically
for my back problem etc.’ (328-11-2000)
‘The treatments by the osteopath made my whole body feel more relaxed and supple. Joint pain in my knee has cleared up completely. My back is
much more supple.’ (337-10-2076)
Treatment failure and short-term benefits
‘The spinal manipulation which I was allocated, although not unpleasant at the time, did not make any difference to my back pain in the long run.’
(A82-19-2009)
‘My back pain worsened after treatment by chiropractor.’ (330-18-2000)
‘When I was getting treatment, I felt 50% better, plus I was getting lots of relief and able to do things for longer periods. Now I’ve reverted back to
normal it was a great disappointment to me that the treatment couldn’t carry on.’ (796-19-2202)
‘My back pain eased slightly when I was seeing the chiropractor but has returned after my sessions were finished.’ (796-12-2142)
‘This treatment is fine for a fortnight after the treatment, but that’s all it lasts, but for that fortnight I felt great.’ (796-18-2018)
‘The osteopathic treatment that I had under the UK BEAM trial made my back feel much better, but it soon started to return to its old painful self
when the treatment stopped.’ (233-14-2170)
Several respondents referred to the GP as being unable
adequately to address their back pain—as they had presumably
had previous access to their GP. Consequently, the GP was
considered unable to offer anything other than medicines.
Some expressed their disappointment in terms of being relegated
to a service which had not succeeded in managing their
back pain effectively, describing a GP consultation variously as
‘a waste of time because all you get is tablets’ (685-11-2052), or
unnecessary because ‘he just gives me a prescription for painkillers’
(616-10-2006) or prescribes ‘a little time off work and to take some
ibuprofen’ (487-13-2050). Receipt of a prescription from a GP
has been analysed by some researchers as a ‘gift’, affirming the
therapeutic nature of the relationship [17]. However, for some
participants in this study, this was considered far from the
case. Some construed it as an affirmation that the GP had
exhausted the range of services he/she could offer and ‘could do
no more’ (728-13-2094), while others took a less charitable view,
claiming that GPs only ‘palm me off with anti-inflammatory pills’
(328-15-2021).
Despite the misgivings of some about GPs’ tendency to prescribe
medication for back pain, it was clearly one effective means of
exercising some control over their pain. One recurrently cited
concern was over the sustainability of a long-term pharmacological
approach to back pain management. This concern over the
possible long-term and short-term effects of the medicines led
some to reconsider their regular use. While medicines have a
place in controlling pain, they did not provide what the
patients required, namely addressing the cause rather than their
symptomatic pain.
Being offered guidance on self-help was considered by some to
be considerably more efficacious. Receiving a plausible explanation about the cause of the back pain which accorded with the
patients’ own views had a significant empowering effect in enabling
them to self-manage their pain effectively. However, receiving
such an explanation was reportedly the exception rather than the
rule, despite the fact that practices were offered training in an
active management strategy.
Manipulation package (Table 2)
A notable feature for participants who were randomized to the
manipulation package was a perception of the appropriateness of
their treatment, that is, physical rather than pharmacological.
Some subjects were effusive about the efficacy of manipulatory
treatment, with reports that their therapies were spectacularly
effective. However, in many cases the success was put down to the
guidance and individual exercise programme accompanying their
manipulation therapy. Some perceived improvement was due to
receiving an explanation for their pain. Moreover, the benefit for
these patients extended beyond their back pain to other aspects
of their life, such as regulating weight gain/loss. However, several
respondents commented that their pain was getting worse or had
not improved as a consequence of joining the treatment regimen.
The experience of the manipulation package, although initially
perceived to be useful, was reported to have left some patients
feeling that they were back at square one. After an initial positive
effect following their therapy, when it finished some reported
their pain returning. For some patients it appears the positive
effect depended on having the therapist continue to provide the
treatment. An alternative explanation for these findings is that
some subjects were becoming dependent on their therapist.
Exercise programme (Table 3)
Several issues emerged from participants assigned to this therapy,
the majority of whom evaluated it positively. Even those who
found the exercises caused them some discomfort appreciated
the positive effects exercise provided. Some, however, felt that,
despite the virtue of exercises, they were beyond help. The benefits
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M. R. Underwood et al.
TABLE 3. Exercise programme
Effects of programme
‘Although the exercise classes do seem to be strengthening my back, they have also aggravated an old neck injury.’ (258-15-2044)
‘The exercise classes did help improve my mobility, but some of the exercises, particularly the twisting, did give some discomfort.’ (276-12-2057)
‘The exercise class is a very good idea in terms of gradually strengthening your body without causing too much stress on any particular area of the
body. I am doubtful, though, if it has any impact on the problems with my back.’ (863-13-2014)
‘Even with the treatment, I feel my back problem will not go away, although the exercise classes helped a little.’ (870-12-2013)
‘The exercise classes have got me in a very much improved mental state.’ (233-11-2019)
‘I have found this (exercise routine) to be very beneficial, both physically and mentally.’ (A71-18-2020)
‘I attended all the exercise classes allocated and found them to be of some help – both physically and also by talking to the physio who held the
classes.’ (972-16-2043)
Benefits of continuing exercise
‘The exercise classes that I attended were an excellent discipline in that they ensured at least an hour a week was set aside to improve flexibility and
general fitness.’ (A03-11-2028)
‘Since attending the exercise class I am feeling so much better. The discipline of attending regularly has made my system far better.’ (725-13-2018)
‘My back pain certainly improved when I did the exercise classes, and I was most disappointed that I could not carry on with them. I have tried to
do some of the exercises at home since but it is hard to keep up because of the lack of space and the motivation.’ (A22-11-2070)
‘Found exercise classes v. useful, but need further motivation to keep the momentum going.’ (152-12-2045)
‘I am continuing the exercises at home and hope to have a more long term benefit.’ (150-12-2039)
‘I find back pain improves with regular exercise at local gym. If attending three times a week, back pain eases.’ (130-13-2001)
‘During the exercise classes the physiotherapist recommended joining a gym under the GP scheme. I am now using the gym regularly (approx. 3–4
times a week). This exercise has greatly improved my level of fitness, as well as strengthening my stomach.’ (023-17-2081)
‘The treatment I have been lucky to receive on this scheme has taught me how to deal with any increase in pain. That is, it has taught me that
exercise has actually helped my back to recover quickly.’ (A43-15-2017)
Negative views
‘I found the exercise class made by back pain worse.’ (915-19-2004)
‘The exercise classes were pointless; they just caused me more pain and aggravated pelvic injury from two years ago, causing a lot of pain which
doctors just don’t seem to want to know.’ (A04-10-2007)
‘I feel that the exercise class is geared to people who do no exercise at all. As I exercise every day I find it a waste of time getting to and from the
class.’ (693-17-2000)
‘I am surprised that no one has asked what forms of exercise I take, particularly as most of the exercises I do at the class, I have already been doing
myself. My back pain is now worse than when I started the trial . . .’ (A55-18-2004)
‘I didn’t find the exercise class very beneficial as I walk and ride a cycle every day to help with my back pain.’ (796-14-2146)
‘I am already a physically active person and the study did not take this into account.’ (A26-13-2038)
of exercise were reported by participants to be both physical and
mental. Exercise classes, in addition to having a positive effect on
mental health, also fostered a sense of self-reliance in managing
back pain. This was frequently expressed in terms of a sense of
discipline or structure in the lives of participants, which the exercise
programme provided. Despite their positive experience of supervised exercises, some admitted to being insufficiently motivated to
continue their exercise regimen outside of the classes. For those
sufficiently motivated to continue with their exercises, the result
was, for many, a new sense of being enabled or ‘taught’ to selfmanage their back pain. For some this simply followed from their
continuing their exercises outside the class at home. For others it
involved attending a gym on a regular basis, sometimes under a GP
referral scheme. The perception of exercises as providing a sense
of control of their back pain was not, however, shared by all.
For some participants who were already physically active, exercise
held no promise of improving their back pain—indeed, these
participants had already decided that exercise was an ineffective
treatment.
Discussion
This study has provided some interesting insights into the
experience of the UK BEAM treatments and patients’ perceptions
of the treatment they received. There are some limitations to our
analysis. In modifying a framework approach, we necessarily
compromised the scope of our analysis, limiting the robustness of
our interpretation because our analysis was founded on brief
written comments received from a minority of participants rather
than a detailed narrative collected from a carefully selected
sample. It is likely that those with particularly good or particularly
bad experiences within the trial were more likely to complete this
optional part of the questionnaire, producing polarized views
on participants’ experience. Our analysis was therefore potentially
biased against those whose perceived experiences were more
neutral and therefore not recorded. Nonetheless, this approach
did allow us to make use of comments from a considerable number
of individuals, although data perforce are incomplete. The data
are also relatively superficial and cannot be seen as a substitute
for careful analysis of more detailed interviews in which the
interviewer has explored the participants’ beliefs and experiences
in detail [18]. These data were collected in the rather artificial
environment of a randomized controlled trial, which means that
our findings may not be directly transferable to the normal clinical
situation. Nevertheless, these data do give us some insight into
patients’ perceptions of their experiences when allocated to three
different treatment approaches for back pain. This could inform
our future management strategies.
We are unaware of any previous studies that have been able
to compare patient experiences of different primary care
approaches to treating back pain. An important strength of this
study is that within a randomized controlled trial we can be sure
that participants’ prior beliefs and experiences did not affect their
choice of treatment.
The most striking observation from these data is the contrast
between the benefits reported by participants across the three
treatment groups. In the main quantitative analysis, differences
between the outcomes on the main measures were less clear. In
this qualitative analysis, GPs were often seen as nothing more
than purveyors of drugs—issuing pain killers without any real
understanding of what was causing the patient’s pain—whilst
participants randomized to the manipulation arm of the study
saw the practitioners as experts delivering, in many cases exactly,
what was needed in terms of hands-on therapy accompanied by
credible explanations for their pain. This distinction between the
Patient perceptions of physical therapy in a back pain treatment trial
or polarizing patients’ views during the qualitative interview,
which in turn could influence their response within the quantitative
study.
In summary, this analysis supports the view that the process of
care for those with low back pain is a complex subject that can
affect the interpretation of clinical trial results. Those designing
future randomized controlled trials of physical treatments for
low back pain need to give more consideration to understanding
what goes on within the consultation, how to measure the outcome
or outcomes of interest, and whether randomized controlled trials
are always the best tool to address the research question.
Key messages
Rheumatology
GP as non-expert and back pain problems needing ‘expert’
treatment might reflect the fact that people assigned to best care
in general practice felt they were being denied more specific help.
Participants randomized to the exercise programme had the
least opportunity to assume a passive stance in relation to their
therapy. Unlike those assigned to the manipulation package,
participants assigned to the exercise programme were required to
participate directly in the management of their back pain. In this
respect, responsibility for managing their back pain was placed on
the participants themselves—with the exercise sessions providing
guidance in undertaking therapeutic exercise. These participants
perceived both physical and mental benefits from the exercise
programme. These observations are consistent with the main
quantitative analysis in that it produced changes in some
attitudinal scales as well as short-term benefits related to function
and pain reduction. Randomization to the manipulation package
was associated with a sustained benefit in measures of spinal pain
and disability.
However, it is clear that there is a substantial difference in the
reported experience of participants in the three groups that was
not reflected in the effect size observed in the main quantitative
analysis. There is a great range of comments amongst the
participants in each group; some reported good experience of
GP care and some reported that they were made worse by the
manipulation package or the exercise programme. Additionally,
there is a suggestion that these contrasting reports relate to
‘resentful demoralization’ [19], in which those randomized to
GP care felt that they had been deprived of access to improved
treatment and that GP care was simply providing more of a
treatment that had already failed. To a lesser extent this was also
evident in the exercise group, with some participants, who already
exercised regularly, feeling that there could be no additional benefit
from the exercise programme. This may be an important observation when considering the selection criteria for any future study of
similar exercise programmes. Clearly, a moderately light exercise
programme such as that used in UK BEAM is less likely to benefit
those who are already exercising regularly. Only a small proportion
of people with chronic pain choose active strategies such as exercise
to cope with their problem: those who tend to report lower levels
of pain [20]. When patients’ preferences were elicited within
another trial of exercise, 63% preferred to be allocated to this,
while the rest did not express a preference [21].
It is well recognized that patient satisfaction with treatment
might not relate to outcome as measured though validated
questionnaires. However, this analysis reveals a broader range of
issues that may not be adequately identified using our standard
outcome measures. In other studies, patients have reported greater
satisfaction with an intervention that includes a hands-on
approach compared with one that does not, even though healthrelated quality of life measures may fail to show any difference in
change over time [22, 23]. Patients’ expectations of benefit from
particular treatment approaches may be an important factor in
the outcome of, and satisfaction with, low back pain treatments
that is compounded by the gap between what is offered by
health-care providers and what patients expect [24, 25].
One explanation for our findings is that those randomized to
exercise or manipulation had greater time and attention paid
to them. However, some other studies of physiotherapy show
little additional benefit to clinical outcomes from greater exposure
to conventional physiotherapy [26, 27].
Our work suggests that current outcome measures may not
fully measure the effects noted by patients. There is a suggestion
from these data that randomized controlled trials on their own may
not always be the most appropriate means of assessing physical
treatments for low back pain. Another, possibly better, approach
is to carry out an in-depth qualitative study nested within a
randomized controlled trial. A suitable subsample of patients
can then be selected across different arms of the study. However,
careful consideration must be given to the potential risk of biasing
755
Participants in randomized controlled
trials of back pain may experience
benefits other than the main trial
outcome.
Improved methods may be needed to
assess outcome in back pain trials.
Acknowledgements
UK BEAM was funded by the Medical Research Council and
NHS Research and Development. We are grateful to Suzanne
Parsons for comments on an earlier version of this paper.
M.R.U. has accepted speaker fees from the General Osteopathic
Council.
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