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Call for research papers visit www.research-sites.nstemp.com Publish your research papers to the web ----- Original Message ----- From: Scott Epsley <[log in to unmask]> To: <[log in to unmask]> Sent: Monday, January 08, 2001 10:07 AM Subject: Re: Correct Muscle Action? > This has turned into an interesting discussion of statistical analysis, much of which is over my head. However my point was not to present a single case study for generalised analysis, with limited diagnostics etc. etc. It was merely to discuss the role of TA, whether it can be adequately rehabed by more global stabilisation exercises as suggested by some on the list, or if indeed Jull etc. are correct and it needs to be isolated to be effective. > --- > Scott Epsley > PHYSIOTHERAPIST > Northside Sports Injury Centre > Brisbane, Australia. > > e-mail: [log in to unmask] > > On Sun, 7 Jan 2001 10:09:42 > Herb Silver, PT, wrote: > >At 10:48 AM 1/7/01 +0000, you wrote: > >>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. > > > >*** A single case study does not translate into multiple single case > >studies and analyzed. > > > > > >>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. > > > >*** I agree with your intended criticism. I think that multiple single > >case studies are the way for PT to go. Double blind studies can be very > >misleading and can deprive participants from state of the art care (even > >though state of the art may not be the best--until we do the studies, we > >just have to do the best we can) > > > > > >>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 agree with you--I will be successful, only because of the order of > >the intervention. I will be deprived of learning where the other therapist > >will be more successful than me, only because of the order--they will not > >see my failures, so it will only serve to make me look better, when in > >fact, my approach may not be better. But, this is mutiple case studies--10 > >cases. I was commenting on trying to discuss one case, when there is no > >clear evaluation--"the patient presented with severe back pain,radiating > >into both legs, almost nil lumbar flexion, two centralised disc bulges > >etc." This is not enough information--was there weakness, reflex changes, > >positive nerve root tension signs,, etc?? Pain radiating into both legs > >and two bulging discs makes me wonder about the size of the discs--two > >bulging discs, unless they resulted in significant stenosis, would not > >typically produce bilateral leg pain. So, my question would be, what is > >being treated, TA inhibition, sciatica, HNP--without an intervention aimed > >at a cause, I believe the results will be random. In my situation, I found > >both patients to have very easily treated joint dysfunctions that respond > >well to manual therapy (at least the techniques I was trained in--manual > >therapy is not generic, as I hope we all realize). So, what I might learn > >is that I am better at treating patients that present with limitations that > >I can identify with the type of evaluation I perform. If I never see any > >patients with sciatica from this referral source, it might be that they do > >an excellent job with sciatica (I will never really know because of the > >manner in which these referrals are coming--hence my request for random > >referrals of enough size to start being able to discuss differences in > >results and treatments). > > > > > >>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. > > > > > >*** Actually, your comments reinforce my intended, but obviously poorly > >stated, point--ONE case study is difficult to even comment on, especially > >in this type of forum. Mutliple case studies, where we get good > >demographic data, and have consistent interventions, based on the data (we > >don't want to treat all "back pain" the same, but, using a thorough > >evaluation, try and determine the causitive factors and treat those > >factors, not the patients history or their symptoms, but try and determine > >the underlying cause), then we would be able to compile interventions. For > >examplle, We would see that everyone who came into your clinic with back > >and leg pain that was reproduced with SLR, responded within 3 visits, but > >those that had leg pain, not reproduced with SLR did not do well in your > >clinic, but did well in my clinic--then we could look and see what we were > >doing differently and modifiy our approach--this would certainly be > >beneficial to our science/art. > > > > > >>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 > >> > > > > > > > > Get FREE Email/Voicemail with 15MB at Lycos Communications at http://comm.lycos.com