I wholeheartedly concur with what Douglas White has said below because:

1. It walks a balanced path that might best avoid a clash of intuitions
between more than one practitioner.

2. It reminds us that as professionals, we cannot use intuition solely as
reason to use a specific treatment, or moreso promulgate one treatment over
another to others, as seems to be a common inclination.

And yet, I am not criticising intuition; in fact I consider it to play a
vital role in finding truth. Ideal intuition to me might be interpreted as
"the cognitive faculty's short cut access via parallel processing to stored
memory". And I am even prepared to allow for a bit of metaphysical/Spiritual
catalyst in this process.

Hence, intuition then at least is dependent on what we have in our memories.
To illustrate, few physios would intuit using a physio technique they have
not been taught or read about. For instance, some physios might intuitively
consider applying ultrasound to a condition that has no supporting evidence
or even when the condition's pathophysiology is not understood; however
these same physios might not intuit crystal therapy (putting different
coloured crystals on various parts of the anatomy) as a treatment, even
though it has as much evidence as ultrasound in this example.

Further, as professionals, we must recognise that psych research shows that
what people take as intuition is very much subject to mood congruence or
state dependence. And let's not forget that the gambling industry is
perpetuated by people's confidence in intuition.

So what is the role of intuition? I believe if one has an intuition about a
treatment choice, one should trial it and if successful, then trial under
more rigorous circumstances until validity and reliability are assured,
before getting too zealous about its universality.

However, I am not trying to be anally retentive and stop the free flow of
ideas here. I am only trying to stimulate us all to contemplate a little
more clearly and deeply about how we derive our beliefs.

Cheers
Bruce






Colleagues:


A few comments on EBP. We do not have all the answers to our research
questions
by a long shot, but we do have a wealth of evidence that is available to us
now.
Do we not agree that it is our responsibility to synthesize the evidence
that
exists and incorporate that evidence into our current practice? I believe we
should practice according to the best evidence that is available to us at
the
time. While there is an important place for "intuitive" approaches in
practice,
that "intuitiveness" should be based on the best available evidence. This is
what truly makes us experts and skilled clinicians. PT educational programs
and
continuing education providers should present in the context of the research
that is currently available.


In response to the two messages below.


Lynda: You mentioned that the medication is "ointment" based. What is the
chemical make up of the ointment? Most such ointments (in the USA) are
petroleum
based. We know from the literature that US does not penetrate petroleum. In
fact
there are very few bases that allow for adequate dose delivery. Unless the
medication is compounded with a base that has been specifically shown to
allow
for adequate dose delivery the treatment will not be at all effective. This
is a
beautiful example of where we should (and I don't mean to imply Lynda has
not in
this case) be applying the literature to practice.


Henry: Lateral epicondylitis has been shown to be a misnomer. The literature
shows there is no inflammatory process with this condition. Hence many
authors
now use tendinosis. [Tendinosis of the elbow (tennis elbow). Clinical
features
and findings of histological, immunohistochemical, and electron microscopy
studies. Kraushaar BS, Nirschl RP, J Bone Joint Surg Am.1999
Feb;81(2):259-78.
Review.] However, there is clearly no consensus as to treatment approaches
as
the citation below articulates. From the studies I have read, and I haven't
read
them all, exercise seems to be the only PT intervention that has been shown
to
be effective.


I am curious as to why you choose to use US. Was the increase in strength
temporary?


TITLE:
                            Lateral tennis elbow: "Is there any science out
there?"
AUTHORS:
                            Boyer MI; Hastings H 2nd
AUTHOR AFFILIATION:
                            Department of Orthopaedic Surgery, Washington
University School of
                            Medicine, St Louis, MO, USA.
SOURCE:
                            J Shoulder Elbow Surg 1999 Sep-Oct;8(5):481-91
CITATION IDS:
                            PMID: 10543604 UI: 20008949
ABSTRACT:
                            As orthopaedic surgeons, we are besieged by
myths
that guide our treatment
                            of lateral epicondylitis, or "tennis elbow."
This
extends from the term used to
                            describe the condition to the nonoperative and
operative treatments as well.
                            The term epicondylitis suggests an inflammatory
cause; however, in all but 1
                            publication examining pathologic specimens of
patients operated on for this
                            condition, no evidence of acute or chronic
inflammation is found. Numerous
                            nonoperative modalities have been described for
the
treatment of lateral
                            tennis elbow. Most are lacking in sound
scientific
rationale. This has led to a
                            therapeutic nihilism with respect to the
nonoperative management of this
                            condition. An examination of the literature can
only
lead us to believe that
                            most, if not all, common nonoperative
therapeutic
modalities used for the
                            treatment of tennis elbow are unproven at best
or
costly and time-consuming
                            at worst. Most of the published literature on
the
nonoperative treatment of
                            patients with lateral tennis elbow consists of
poorly designed trials. The
                            selection criteria are nebulous, the control
group
is questionably designed, and
                            the number of patients is often too low to avoid
a
serious loss of study power.
                            These studies therefore have a high beta error,
implying an inability to detect
                            a difference between groups, even if one truly
existed. If clinical signs and
                            symptoms persist beyond the limit of
acceptability
of both patient and surgeon,
                            then an array of surgical options are available.
These range from a 10-minute
                            office procedure (the percutaneous release of
the
extensor origin with the
                            patient under local anesthetic) to an extensive
joint denervation, in which all
                            radial nerve branches ramifying to the lateral
epicondyle are directly or
                            indirectly divided. How is the surgeon to
choose,
given the fact that most of
                            the published surgical studies are case series
of
one type of operation or
                            another, consisting of patients operated on and
evaluated by the same
                            surgeon, who has a vested interest in his or her
own
patients' successful
                            outcome? The orthopaedic surgeon therefore has
very
little on which to "hang
                            his hat" when it comes to objective data to
guide
treatment of patients with
                            lateral tennis elbow syndrome. In the final
analysis
we are guided simply by
                            our own subjective viewpoint and clinical
experience. In 1999, to have such a
                            common clinical condition have such a paucity of
peer-reviewed published data
                            of acceptable scientific quality is
disappointing.
In this review article we will
                            examine the "myths" of tennis elbow: the name,
the
salient features on
                            history and physical examination, the diagnostic
modalities, the pathology of
                            the "lesion," the anatomy of the lateral elbow
and
extensor origin and why it
                            has led to such confusion in differential
diagnosis,
the nonoperative and
                            operative treatment of tennis elbow, and finally
the
various studies that have
                            been carried out on elbow biomechanics as it
relates
to the pathoetiology of
                            true "tennis elbow." It is our hope that the
reader
will emerge with a clearer
                            picture of the pathoetiology of the condition
and
the scientific rationale (or
                            lack thereof) of the various operative and
nonoperative treatment modalities.



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