Dear Julie
This sentence was the shortest way I have seen to describe the fact that
many MT techniques may work, but not for the reasons we feel. This is
essentially a labelling problem. IE when we do a Maitland unilateral on the
lumbar spine are we; moving a facet joint, accessing a bladder acu point,
giving phasic muscle stimulation, doing soft tissue work in terms of trigger
point or specific soft tissue mobilisation etc?.The list is endless.
Therefore we must be careful that the explanations we give for the efficacy
we see in our techniques do not stay blinker us to one possible explanation.
About the case in question. Flexion adduction are two of the potential 3
movements that stretch piriformis. They are, with medial rotation, the same
movements that will mobilise the sciatic nerve, particularly at the
pelvis/hip. Even some aspects of the specific neural tension techniques are
under debate. A paper, not at hand, dealt with this recently in
'physiotherapy' admittedly for the median nerve.
Given the multitude of muscles that attach from lumbar and sacral spines,
ilium to hip, how can we ever be sure that a gross movement as the one we
are looking at, isolates piriformis. This problem haunted me as a student,
we a resisted shoulder movement and this was meant to mean a single rotator
cuff problem, when several groups of muscles were responsible for that
movement (Cyriax).
On the piriformis stretch is it the muscles under tension or what they are
doing to the joint complexes, ie lumbar/sacrum/ilium/hip ?. Also ligamentous
attachments eg sacrotuberous, are we putting this under more tension in this
technique, perhaps indicating a peri/intra articular SIJ problem. Another
endless list. Other connective tissue links above and below the hip may also
explain tightness and pain, if you want it I'll elaborate.
Finally what a particular muscle does, throughout its three axis of combined
movement is very difficult to quantify. Have a look in the Kendalls testing
book at what the hip adductors do in different positions of flex/ext and
rotation. If you do not need to sit in a dark room with a damp towel around
your head you are a better physio than me.
#
So in short these are the reasons why I feel differentiation is a nightmare.
This is not to say that I don't try, it is important to be aware of the
uncertainty. I do not diagnose I hypothesise, I am right when the patients
movement, function and pain are restored to normal or close to it. This I
believe allows me to go other places when the patient is not improving,
rather than the arrognant belief that I am a diagnosing God and if the
patient does not get better, it is because they are bonkers in the head
(pyschogenic pain a la Cyriax)
Hope this helps Regards Kevin Reese PT UK.
-----Original Message-----
From: [log in to unmask] <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Date: 30 October 1999 18:28
Subject: Re: Piriformis stretch
>Hi Kevin
>
>I am interested in your last comment. " The efficacy of a technique
>does not validate the rationale behind its use". Could you explain that a
>bit further. Also...I do try to differentiate between their use. I do not
>think of it as a nightmare but rather quite important in determination of
>treatment and functional use and exercise.
>
>
>Julie
>
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