I would appreciate thoughts on this article by other clinicians preferably with links to related journal articles.
Based on your understanding of the SIJ, what are your thoughts on content of the article and the author’s reasoning?
Well, the author is certainly a talker, I’ll give him that. This is honestly the same line of reasoning and heuristic that is used to defend almost all “experience based” positions. It follows the format:
- Overly complicated historical reference to why no one has this figured out even though it is staring them in the face
- Nod to current pseudobullshit (see bullet point related to slings)
- Rebuttal of current evidence using No True Scotsman fallacy “However, those studies utilized varying definitions of what was considered a “positive” test, and the examiners had varying levels of experience or expertise in orthopedic physical examination and treatment skills, with one “classic” study utilizing students to examine their subjects!”
- Overly complicated evaluation without any references to the validity reliability of the tests used (Most people here would cite Laslett’s cluster paper Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint - PMC However, the research by and large states we have no gold standard for determining if the SI is the primary pain generator. In regards to the special tests I typically defer to Chad Cook’s paper Orthopaedic special tests and diagnostic accuracy studies: house wine served in very cheap containers - PubMed
- Overly reductionist approach utilizing more pseudoprofound bullshit (how is hypomobility assessed and how reliable is it? What is the evidential role of leg length discrepancy is SIJ pain (there is none), How reliable are we in assessing “soft tissue restrictions” (we are not), and holy shit are we still talking about the transverse abdominus?
It turns out that the individuals often thought of as “the best PT they have ever met” are mostly just really dynamic speakers without any real substance to what they are saying. Some would argue this just further emphasizes the role that beliefs have in treating individuals. I wrote a piece that has a few more citations than that.
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Haha yeah he seems like a talker.
Thanks for your thoughts and they are mostly in line with mine, just more refined and confident. I expected to hear most of that but just wanted some reassurance and literature support since I’m surrounded by PTs with this thought process all day, every day, so I sometimes start to lose confidence in my thinking.
I have tended to use Laslett’s thoughts in regards to evaluation of the SIJ as a pain generator. The cook paper you posted was interesting and obviously makes an important point with regards to the quality of diagnostic accuracy studies (ex: good gold standard?). Looks like there might be some good papers in the reference list to look through as well.
I deal with the transverse abdominis talk all the time.
So do you have any favorite papers that refute the TA theory? Would love to see them to more strongly support my clinical reasoning.
I have read and shared your post from the logic of rehab many times.
I likely would have prodded a little more on how you check his TA contraction and would pay a large sum of money to see the clinician effectively measure “isolating” it. For references, Ben Cormack does a good job in the blog linked below of summing the research.
https://cor-kinetic.com/core-stability-does-it-work-for-lbp-a-look-at-the-evidence/
I would also recommend the editorial exchange between Allison and Hodges that can be found in the following articles
[Transversus abdominis and core stability: has the pendulum swung? | British Journal of Sports Medicine
](Transversus abdominis and core stability: has the pendulum swung? | British Journal of Sports Medicine)https://www.researchgate.net/publication/23676978_Transversus_abdominis_A_different_view_of_the_elephant
Part of the issue is larger in that most of the studies were done with emg which comes with an entirely different set of problems when considering crosstalk and some signals being greater than 100% MVIC which should have thrown up some red flags. Motor control exercises in general are an interesting (my use of interesting is typically in line with a Southern woman’s use of “Bless your heart”) way of looking at things as it implies there is a “right” way to do things. To the quote from Cormack’s piece, the brain remembers movements, not muscles. We even see this is some of Gabrielle Wulf’s work on internal and external cueing where providing an external cue made people more accurate at a task and decreased emg signal (same flaws with EMG here).
I think the trope is more just to pick an arbitrary muscle we cannot see. The multifidi, quadratus lumborum, and transverse abdominis have been the scourge of low back pain for years without any real supportive evidence. Motor Control Exercise for Nonspecific Low Back Pain: A Cochrane Review - PubMed To say it there is “no clinically important difference between MCE and other forms of exercises or manual therapy for acute and chronic LBP” should be a pretty damning nail in the coffin for all of the love that TvA has received. But this gets at a bigger picture problem of the conflation of clinical research and clinical applicability. There were studies showing different activation patterns of TvA over time (in both directions) and this different was automatically assumed to be the cause. We make fun of the over utilization of MRI for diagnosing MSK problems then turn around and use EMG and ultrasound to immediately blame a muscle for every problem. That is just stupid.
Thank you for the great information. Look forward looking at the links you provided.
Thanks for the link to Saragiotto 2016 paper. Will be sharing with all colleagues that will listen.