This discussion illustrates the difficulty of analyzing case studies. Case
studies give suggestions for treatment--they can not offer any directions
for what works on a large population of people. There is a "natural
history" to all disease processes, disc herniations are no exception. I
give my patients the analogy of the flu--if they came to me with the flu,
and I told them they needed to come to my clinic everyday for milk and
cookies for the next week, they would report to all the newspapers they had
found someone who can cure the flu with milk and cookies! How else could
they have gone from feeling so bad to so good in only one week. Similarly,
the whole discussion of TA appears it may be a chicken or egg kind of
issue. Just as reducing ones fever during the flu does not cure the flu,
how do we know that inhibition of the TA is not just a symptom of the
problem. By treating the TA, or manipulating the spin, or doing
stabilization exercises, McKensie exercises, mobilizing the spine, all may
assist in improvement or just coincide with the natural history of the
disease. Is there any research showing that focusing on the TA gets better
results than the "general" exercise program you initially suggested?
In the past, I have asked for some orthopedists to randomly send 10
patients to me for my eclectic intervention and 10 patients to a McKensie
(or any other therapist or chiropractic). Well, no other practitioners
were willing to participate. Recently a large orthopedic clinic has
started there own PT clinic and they hired a therapist who is very well
trained in treating the spine. This week I have seen two of their
failures. I am excited about the way this will work out. We will finally
get to start to see where they are successful and where they
fail. Unfortunately, this "direction" of referral will not show where I
fail or where we might have gotten similar results--it will only serve to
make me look better as I am sure I will have success where they have failed
(in some instances). Since I don't get first shot at the patients, there
is no where for them to go after I fail and they will end up with endless
injections. What would make the most sense is that we get random referrals
or referrals based on geography--unfortunately, economics dictates that all
referrals go in house first--the stupidity of our health care system never
ceases to amaze (after all, is it an economic incentive to only refer to
your own PT practice or is it because it is the best PT practice around?).
At 11:18 AM 1/6/01 +0000, you wrote:
>Dear Scott
>
>The main reason for shaking off the shackles of single school guru led
>physiotherapy (which you clearly have), is that it opens your mind to other
>treatment possibliities.
>
>In severe and complex cases, I rarely find one treatment approach solves the
>problem. This chap may need a cocktail of reasoning, from exercise, manual
>and pain therapy, tailored made for his syndrome. Or more commonly one
>approach takes us so far, eg a percentage better and then they plateau. It
>is at this point we must either adopt a different approach in rationale or
>technique or concede defeat.
>
>The exercise regime you have given him has clearly served him well, however
>perhaps it is time to rty something new. The patient also clearly has a
>responsibility of their own and if he is not complient with your advice,
>this may be the reason for his slight worsening.
>
>Another possibility exists, and this is true of us all so don't take it
>personally. His improvement may not have been due to the initial treatment,
>but the passage of time placebo etc.
>
>My final point is that the efficacy of a treatment does not validate or
>underpin the rationale behind it completely. It is just a good indicator.
>Perhaps Sood may give us an update on his recent patient request and this
>may well give us some insight into either medical problems mimicing
>musculoskeletal, or the lack of MRI result releability; a similar case in
>hand.
>
>Good luck and remember not to beat yourself with a stick. Don't look at the
>10% lost, rather the 90 % gained.
>
>Warm Regards Kevin Reese PT UK
>----- Original Message -----
>From: Scott Epsley <[log in to unmask]>
>To: <[log in to unmask]>
>Sent: Friday, January 05, 2001 11:42 PM
>Subject: Re: Correct Muscle Action?
>
>
> > Along the lines of previous discussions on this list of Transversus etc. I
>have an observation to put to Mel and the list for comment.
> >
> > As I have said, I was trained at the University of Queensland where much
>of the TA research has been based, thus it was hammered into me how
>important it is. As I also have said I do not believe it to be the "guru"
>concept it has been suggested it is.
> >
> > Last year I had a patient who presented with severe back pain, radiating
>into both legs, almost nil lumbar flexion, two centralised disc bulges etc.
> >
> > I spent about six months all up supervising a rehab program consisting of
>gluts, abdominals, erector spinae, and supposed transversus exercises
>without being paranoid about the isolation component of these exercises -
>thus they were more generalised abdominal exercises.
> >
> > He attained a significant level of relief, could walk for 40 minutes, had
>very little leg pain, but was still in discomfort with certain activites
>such as sitting, standing and high levels of physical activity. I suggested
>he continue his exercise program and join a gym to continue an overall
>fitness and strengthening program.
> >
> > I saw him at the movies last night, and he is still at the same level as
>when I last consulted him, though he did not take my advice about the gym
>program. He has been to a back clinic set up here in Brisbane which
>ultrasounds transversus and shows its activation/isolation during isolated
>contraction. Apparently he is in the worst 10%.
> >
> > I would have thought that generalised exercise would have improved the
>recruitment of TA - therefore why is he supposedly in the worst 10%?
>Secondly, does actively isolating a muscle necessarily mean that you use it
>during movement etc and vice versa, does inability to isolate and contract
>it mean that you don't recruit it during movement? Does Mel or the likes
>have references supporting this?
> >
> > Any comments would be welcome.
> > ---
> > Scott Epsley
> > PHYSIOTHERAPIST
> > Northside Sports Injury Centre
> > Brisbane, Australia.
> >
> > e-mail: [log in to unmask]
> >
> >
> >
> >
> > Get FREE Email/Voicemail with 15MB at Lycos Communications at
>http://comm.lycos.com
> >
|