February, 2016

Evidence based treatment, friend or folly?


Jonathan Maister

The objective of this article is to provoke discussion. Based on a case study (one among many in my years of practice) I wish to explore the concept of “Evidence Based Medicine”.  In recent months I have found it to be burdensome and I ask my colleagues across our country to share their views.

Evidence based medicine, based on the accumulation of data, statistics, possibly with double blind studies and a myriad of control groups, is the proposed foundation of a respected medical profession. There is merit in this. But my sense is this something which we, as Athletic Therapists, must not be strictly beholden to in our practices.

We have the luxury, unlike medical doctors, to push the boundaries in our treatment protocols. No surgeon will experiment with a procedure until it has been studied, documented and scrutinized in an academic scholarly environment, and there is wisdom in this. I would not like an orthopaedic surgeon repairing my ACL using a technique that he or she had just thought of in the hours preceding.

In this particular instance I was treating an otherwise healthy 53 year old female with a long standing history of Spondylosis or Spondylolysthesis. She was unsure of the spinal level or the exact diagnosis. She was, however, troubled by the associated pain which she felt along the posterior pelvis. Her other major complaint was pain in the left hamstring, more specifically near the proximal hamstring attachment which radiated distally.

The minutia of her signs and symptoms are not relevant. These were not extraordinary. However, my treatment rationale does merit further scrutiny.

Clinical analysis clearly indicated that the pre-existing Spondylosis (Spondylolisthesis) was the overriding condition. The increase in facilitation of the NS caused by the spine's structural changes could conceivably cause a cascade of musculoskeletal consequences. The pelvic-sacral orientation is easily governed by the pull of the anterior and posterior musculature both of which have components that act thereon superiorly and inferiorly. This is true for the innominate bone as well as the sacrum as independent entities. These muscles are innervated by lumber nerves. Lumbar nerve facilitation could also have a direct effect on major nerves such as the sciatic nerve, hence the symptoms mimicking hamstring pathology. SI pathology could also in turn affect associated musculature such as the piriformis which in turn could cause sciatic discomfort due to their close anatomical association. Certainly, in this instance it is conceivable that a SI condition and muscle hypertonicity due to nerve facilitation can have a reciprocal relationship, both precipitating mutual symptomatology regardless of the initial lesion. In either scenario, the lumbar spinal pathology was in my opinion, the overriding consideration. Pain in the left SI would be explained by its compensatory hypermobility due to the R side's immobility as revealed in the seated and standing flexion tests.

My aims were:

1] Decrease NS facilitation

2] Decrease pain and associated immobility

3] Decrease associated Muscle holding patterns

Treatment method:

The treatment objective was to decrease NS facilitation which would have a global effect on the musculoskeletal component. The rationale is that the body has an innate ability to self correct. With the passage of time and as the person gets older, this ability is compromised. However, by accessing the NS through an appropriate modality, this self-correcting response is reactivated. While some in the “old school” non-complimentary medical field may view this phenomenon with some cynicism, it is widely hailed among Chiropractors, Massage Therapists, Athletic Therapists, Osteopaths and many Physiotherapists. My technique of choice was Craniosacral Therapy. In fact the premise of my treatment was gleaned from discussions over the years with numerous colleagues who are Osteopaths and Chiropractors.

In this instance I used three techniques. With the patient prone at all times, I applied  traction to the sacrum inferiorly from L5 in concert with the Craniosacral rhythm. A combination of unwinding with the traction, and holding the sacrum distally until still-point was reached were all used. The primary objective was to allow the sacrum to position itself optimally. (This obviated the use of Muscle Energy for example, which is another option though this may not have addressed the NS facilitation).  For the second technique I simply engaged the sacrum and, without traction, simply used standard Craniosacral manipulations as the sacrum flexed and extended in concert with the flow of Cerebrospinal Fluid. Treatment was implemented over approximately 35 minutes. The sacrum and innominate bone did correct and the soft tissue did respond by softening,  but I also did direct fascial work along the posterior crest to release the residual soft tissue restriction.

Response: One treatment was all it took to alleviate all the patient's symptoms. Objective testing was negative post treatment. In subsequent discussion the patient reported ongoing relief for almost a week.

The original source of my treatment modalities may indeed have supportive evidence based studies – but it would be best if I asked my Osteopath colleagues. As a non Osteopath I learned from my peers, I implement and most importantly, I improvised! The techniques I used was one that was one I was never specifically told about but were indicated in this instance. Nor had I ever been shown Craniosacral Therapy of the sacrum prone. Yes, years later I did learn as part of my professional development course (courtesy of Anne Hartley) the prone technique of traction to the sacrum, but by then I had for years been treating the sacrum successfully in the prone position. 

The point is this. I recall no conscious discussion with my peers advocating how to treat this condition with these techniques. In fact one of the techniques I employed was, as stated, an adaptation of a technique usually done supine. Adaptation and improvisation is something I do frequently in my clinical practice. This is reflected in presentations I have had the privilege of doing for CATA and other parallel organizations.

Perhaps I am a maverick. Perhaps my instinctive type work parallels that of many of my esteemed colleagues. I would like to know! However ingenuity, initiative, instinct, and experience combine to form an entity that catapults us to a new level as health care professionals, and we deserve the respect for this! The challenge I have had in recent months is translating ongoing raw observational experience with successful treatments, to the world of academic literature and treatment workshops. Elements of the material have been recognized as academically sound (Direct Fascial work, Myofascial unwinding, Craniosacral Therapy etc, have supporting literature somewhere). Yet that apparent quantum leap to academic recognition simply because a technique or condition's treatment protocol has been adapted or re-purposed, has become a challenge. My fear is an obsession with “Evidence Based Medicine” will stifle the “Art” in our “Medical Science!”  The accumulation of our experience is a treasure trove to be cherished for the future. It must not be left to languish in a dusty chart or sent to the shredder without a record of some kind being made, perhaps in a personal and then communal archive of case studies.

I urge my Athletic Therapy colleagues to have a discussion in this regard, especially those in the academic milieu. If we can take this leap of faith and overcome the challenge of “Yes, that seems plausible, but can you provide Supporting Evidence”, the possibilities are endless.

The views expressed in this article are that of the author and do not reflect the views of CATA.


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