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Dear Herb You have made several very interesting points and I would like to discuss them in order. 1 Your opening comments relate to the inability of case studies to give generiseable results with regard to the larger population. If people think there is safety in large population groups, which may or may not be homogenous, attempting to analyse a single variable, this would be true. However some very large RCT's have made some blisteringly bad conclusions, eg philidimide (sorry for the appaling spelling.) Some mignt say smaller numbers analysed more closely and in detail might tell us more. There are semi'statisticial analysis of SSED eg auto lag coefficient, two band standard deviation, etc; see Ottenbacher. Another possiblity is to do lots of SSED's for generiseable data. I heard some years ago the private practionner group in the UK were planning a 3000 strong SSED experiment. Therefore I do not agree with your judgments with regard to the weaknesses of SSED's. 2 Your second point regarding the flu is true of every piece of research one can conduct. IE (not a shout just the start of a sentence) did we change what is wrong or was it a peripheral sigh, placebo, passage of time etc. This dilema is true of all research and not peculiar for single case studies. People take comfort from the statistical analysis from RCT's which has flaws, but as stated above SSED's can generate statistical information. 3 I am not sure what your 10 cases of your 'eclectic intervention' as opposed to another therapist would tell us. The information gained would only tell us that in those circumstance one had 'triumphed' over the other. The problems with our profession is we tend only to see our successes, not our failures who go to other people. On what basis are you 'sure' you would have cured the fwo failures. Remember will all need self belief to practice but as Sir Lawrence Oliveer once said ' you learn more about your performance from the critics than the plaudits'. Also using your own arguments regarding single case studies why would these 10 cases give meaningful data when other SSED's don't?. I hope this has not come across as confrontational. I always enjoy your input and you are clearly anexperienced and talented therapist. So absolutely no disrespect is intended, only discussion. Warm Regards Kevin PS Sood are we going to get an update yet ? ----- Original Message ----- From: Herb Silver, PT, <[log in to unmask]> To: <[log in to unmask]> Sent: Saturday, January 06, 2001 1:35 PM Subject: Re: Correct Muscle Action? > 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 > > >