C o n g r e s s P r e s e n t a t i o n D im e n s io n s o f e x c e l l e n c e “ S e c o n d c u r v e t h i n k i n g ” AND PROGRESS IN PHYSIOTHERAPY W e are liv in g in tim es of e n o r m o u s c h a n g e , n o t ju st h ere in S o u th A frica w h e re g re a t a n d ra p id changes are o cc u rrin g a t ev e ry level of society a n d sp e c ific a lly in h e a lth care d e liv ery a n d in e d u c atio n , b u t rig h t across th e w o rld . N e v e r before has th ere b ee n su ch m u ltisy ste m change - socioeconom ic, sociopolitical, tech ­ nological - all im p actin g u p o n th e h e a lth sy s te m a n d th e f u tu re d e liv e ry of h ea lth care. Im p ac tin g too u p o n th e h ig h e r e d u c a tio n sy stem a n d u p o n th e p re p a ra tio n of u n d e r g r a d u a te s fo r p ro fe s s io n a l practice. T h ere w o u ld b e n o -o n e w h o w o u ld d isa g re e w ith m e th a t change is a co n sta n t fe a tu re of o u r lives, no on e w h o w o u ld d isag re e th a t the pace of ch a n g e is increasing. Does it h a v e so m e th in g to d o w ith th e im m e d ia cy of co m m u n icatio n , th e a m o u n t of in fo rm atio n tra n s ­ m itte d ? S u p e rfa s t in fo rm a tio n d e liv e ry sy stem s in electronic o r h a rd copy create a n im m e d ia cy of in fo rm atio n w h ic h can th re a te n to o v e rw h e lm u s - e-m ail, fax, voice­ m ail, to sa y n o th in g of h ard c o p y m e m o ra n d a d e sc e n d in g o n to o u r desk s like ticker ta p e a t a p arad e. N e w tech n o lo g y m ean s th a t w e can be reach ed in sta n tly fro m all over th e country, if n o t th e w o rld , a n d as th e sp e e d of m ach in es increases so is th e ex p ectatio n th a t a n sw e rs w ill be fo rthcom ing. Faxes stre a m in, CORRESPONDENCE: R u th G ra n t BPT M A ppSc is P rofessor of P h y sio th e ra p y a n d D ean, F aculty of H e a lth a n d B iom edical Sciences, U n iv ersity of S o u th A u stra lia, A d elaid e, A u stralia. h e lp fu l secretaries, a d m in is tra tiv e assistan ts o r th e like, p h o n e to check th a t th e fax h as a rriv e d safely, a n d to asc ertain w h e n a re p ly m ig h t be forth co m in g , (a n d I h a v e n 't even m e n tio n e d th e m obile phone!). This in fo rm atio n tech n o lo g y era h a s c o in e d th e te rm " c o m m u n i- cophilia" - th e irresistible d esire to s e n d m essages. C an w e n o t im m e d i­ a te ly call to m in d , a c o m m u n i- c o p h ilia o r tw o in o u r o w n d e p a rtm e n t, h o sp ital, p ro fessio n al association o r u n iv ersity ? W hilst w e co n te m p la te th e p ace of ch a n g e a n d th e im m e d ia cy of in fo r­ m a tio n , I a m re m in d e d co m p ellin g ly of th a t g re a t English p o e t a n d w rite r of this c e n tu ry T S E liot, a n d th is e x tra c t fro m C h o ru ses from "The Rock". "Where is the Life we have lost in living? Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?" S o m e tim e s w e w o u ld h a v e to ag ree th a t w e h av e m a d e too little m o v e m e n t in th e d irec tio n of th e h iera rch y of " in fo rm a tio n - k n o w ­ led g e - w isd o m " im p licit in Eliot's poem . In fact o n e of th e effects of recent technological p ro g ress is to focus ev e n m o re tig h tly o n th e in fo r­ m a tio n e n d of th a t sp ec tru m . Has the medium become the message? C learly a d im e n sio n of excellence for each o n e of u s, for o u r p ro fes­ sional association, for th e o rg a n isa­ tio n for w h ic h w e w o rk b e it a h o sp ital, u n iv e rsity o r h e a lth facility e ith e r p r iv a te o r p u b lic , is th e successful m a n a g e m e n t of change. THE P A R A D O X O F SUCCESS C h a rle s H a n d y h a s b e e n d e sc rib e d as B ritain's fo rem o st b usi- RUTH G R A N T n ess g u ru . H e h a s w ritte n m u ch a b o u t m a n a g e m e n t of change, a n d fo r th e n ex t few m in u te s I w ill d ra w q u ite h ea v ily from his b o o k e n title d "T he E m p ty Raincoat: M ak in g sense of th e fu tu re ". (W hy d id H a n d y give th e b o o k th is title? "T he e m p ty ra in c o a t is to m e, th e sy m b o l of o u r m o st p re ssin g p arad o x . If econom ic p ro g re s s m e a n s th a t w e b ec o m e a n o n y m o u s cogs in so m e g re a t m achine, th e n p ro g ress is a n e m p ty p rom ise. T he ch allen g e m u s t b e to s h o w h o w p a r a d o x ca n be m an ag e d ."). M ay I p re se n t a n excerpt from The E m p ty R a in c o a t, th e s e g m e n t is titled "T he R oad to D a v y 's Bar": The W icklow M o u n ta in s lie just o u tsid e D u b lin in Irelan d . It is an a re a of w ild b e a u ty , a p la c e to w h ich , as a n Irish m a n b o rn n e a r there, I re tu r n as often as I may. It is still a b a re a n d lovely place, w ith u n m a rk e d ro a d s, a n d I still g et lost. O nce, I s to p p e d a n d ask e d th e way. 'Sure, it's easy,' th e local replied. 'Ju st keep g o ing th e w a y y o u are, stra ig h t a h e a d , a n d afte r a w h ile y o u 'll cross a sm all b rid g e, w ith D a v y 's Bar o n th e far side, y o u c a n 't m iss it!' 'Yes, I'v e got th a t,' I said, 's tra ig h t o n to D a v y 's Bar.' 'T h a t's right. Well, h alf a m ile b efore y o u g et there, tu r n to y o u r rig h t u p th e hill.' It see m e d so logical th a t I th a n k e d h im a n d d ro v e off. By th e tim e I re a lise d th a t th e logic m a d e no se n se h e h a d d is a p p e a r e d . A s I m a d e m y w a y d o w n to D a v y 's Bar w o n d e rin g w h ic h of th e ro a d s to the rig h t to take, I reflected th a t h e h a d ju st g iv en m e a v iv id e x a m p le of p a ra d o x , p e rh a p s ev e n th e p a ra d o x of o u r tim es: b y th e tim e y o u k n o w 4 SA J o u r n a l o f Ph y sio t h er a py 1998 V o l 54 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) w h e re y o u o u g h t to go, it's too late to go there; or, m ore dram atically, if y o u k ee p o n g o ing th e w a y y o u are, y o u w ill m iss th e ro a d to th e future. Because, like m y Irish m an , it is easy to explain th in g s looking b ac k ­ w a rd , w e th in k w e can th e n p re d ic t th em fo rw ard s. It d o e s n 't w o rk , as m a n y e c o n o m ists k n o w to th e ir cost. The w o rld keeps changing. It is one of th e p a ra d o x e s of success th at th e th in g s a n d th e w a y s w h ich got y o u w h e re y o u are, are seld o m the th in g s to k ee p y o u there. If y o u th in k th a t they are, a n d th at y o u k n o w th e w a y to th e fu tu re because it is a co n tin u atio n o r w h e re y o u 'v e com e from , y o u m ay w ell e n d u p in D a v y 's Bar, w ith n o th in g left b u t a chance to d ro w n y o u r so rro w s a n d rem inisce a b o u t tim es past. THE S IG M O ID CURVE R eflection u p o n th is took H a n d y to th e concept of th e S igm oid C u rv e FIGURE 1 w h ich g ra p h ic ally re p resen ts cycles of life - a w a x in g a n d w a n in g - w h e th e r it be g re at em p ires, a b u si­ ness o r c o rp o ra tio n 's rise a n d fall, th e ch a n g in g face of a profession, e v e n a n i n d iv id u a l's p ro g re s s th ro u g h life in th e ir p ro fessio n al e n d e a v o u rs, in th e ir p e rso n a l rela­ tionships. If h o w e v e r all th ere w as to life w a s w a x in g a n d w a n in g it w o u ld be p re tty d ep ressin g . The secret of co n stan t g ro w th is to sta rt a n e w sig m o id c u rv e before th e first o n e p e te rs out. The correct place to sta rt this second c u rv e is at p o in t A (Figure 1). This seem s logical, th ere is still tim e, th ere is en e rg y to get the n e w c u rv e th ro u g h its initial explo­ ra tio n a n d flo u n d e rin g s before the first c u rv e b e g in s to d ip d o w n ­ w a rd s. This is ob v io u s really. H ow ever, all th e m essages at p o in t A w h ich are c o m in g th ro u g h to th e in d i­ v id u a l, to th e o rg a n isa tio n , to a p ro fe ssio n are th a t e v e ry th in g is g o ing fine a n d it w o u ld be folly to c h a n g e w h e n th e c u r re n t a p p r o a c h e s / recipes are w o rk in g so well. W h a t w e k n o w of change, be it p e rso n a l ch a n g e o r ch a n g e in o rg a n ­ isations, tells u s th a t th e real energy fo r c h a n g e co m es w h e n w e are looking a t o v e rw h e lm in g evidence th a t c h a n g e m u s t ta k e p lace , o r w h e n w e are lo o k in g d isa ste r in the face viz a t p o in t B o n th e curve (Figure 2). But at this p o in t it is g o ing to re q u ire a m ig h ty effort to get th e o rg a n isa tio n u p to w h e re it s h o u ld b e o n th e seco n d curve. It is o ften at p o in t B th a t in d iv id u a ls are m a d e re d u n d a n t an d n e w p e o p le are b ro u g h t in a t th e to p , b ec au se it is b eliev e d th a t p e o p le n e w to th e situ a tio n w ill h a v e th e credibility a n d different vision to lift th e place back on to th e second curve. H o w m u c h w iser it is to sta rt th e second cu rv e at p o in t A - as H a n d y s u g g e s ts th is is th e p a th w a y th r o u g h c o n tra d ic tio n th r o u g h p a ra d o x , th e w a y to b u ild in g a n ew f u tu r e w h ile m a in ta in in g th e p resent. The second curve, b e it a n ew p ro d u c t, a n e w w a y of o p e ra tin g , a n e w strategy, a n e w cu ltu re, is going to b e noticeab ly different from the old. T hose w h o le a d th e second c u rv e are n o t g o ing to b e th e p e o p le w h o lead th e first curve. • th e co n tin u in g re sp o n sib ility of th o se o riginal lead e rs w h e th e r th e y be in o u r p rofession o r h e a d in g a c o rp o ra te o rg a n isa tio n is to k e e p th e first cu rv e g o in g lo n g e n o u g h to s u p p o r t th e e a rly sta g e s of th e second curve • th ese orig in al lead e rs w ill fin d it te m p e r a m e n ta lly d iffic u lt to a b a n d o n th eir first c u rv e w h ilst it is d o in g so w ell, even if th ey recognise th a t a n e w c u rv e is n ee d ed . For a tim e th erefo re n e w id eas a n d n ew p e o p le h a v e to coexist w ith the old u n til th e seco n d c u rv e is estab lish ed a n d th e first b eg in s to w ane. The h a tc h e d area b elo w th e peak is th erefo re p o ten tially a tim e of confusion. Two sets of p eo p le, tw o FIGURE 2 SA J o u r n a l o f Ph y sio th era py 1998 V o l 54 No 4 5 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) se ts of id e a s c o m p e tin g for th e future. T he co n cep t of th e S igm oid C u rv e h as h e lp e d m a n y p e o p le a n d m a n y in s titu tio n s to u n d e r s ta n d th e ir c u r r e n t d ile m m a s. T h e q u e s tio n alw a y s ask e d is " H o w d o w e k n o w w h e re w e are on th e first curve?" H a n d y s u g g e s ts th a t th a t each p e rso n m ak es h i s / h e r o w n p riv a te a n d p e rso n a l a sse ssm e n t of th eir p o sitio n or th a t of th eir o rg a n isa­ tion, o r in d e e d of th eir profession, o r th e ir p rofessional association; to d ra w th e first cu rv e as th e y see it, a n d to m a rk it to sh o w w h e re th ey are now. A lm o st in v a ria b ly H a n d y h as fo u n d , w h e n th e y reveal th eir p ercep tio n s of th e curve, th e re is a c o n s e n s u s th a t th e y a re f u r th e r alo n g th e c u rv e th a n a n y of th em w o u ld p re v io u sly h a v e a d m itte d . T hey are n e a re r to p o in t B th a n p o in t A. S ECOND CURVE T H IN K IN G A N D PROGRESS IN PH Y S IO T H ER A P Y T he d iscip lin e of th e seco n d curve re q u ires th a t o n e alw a y s a ssu m es th a t o n e is n e a re r th e p e a k of th e first cu rv e a n d s h o u ld b e sta rtin g to p r e p a r e fo r th e s e c o n d cu rv e. O rg a n isatio n s s h o u ld a ssu m e th at th eir p re sen t strateg ie s w ill n e e d to b e re p la c e d w ith in tw o to th re e years. In d iv id u a ls s h o u ld also w o rk on th e a ssu m p tio n th a t life w ill not co n tin u e as it h a s forever, a n d th a t a n ew d irectio n w ill b e n e e d e d in tw o o r th ree years. In d e e d as H a n d y h as a r g u e d , th e a c c e le ra tin g p a c e of c h a n g e s h rin k s e v e ry S ig m o id C urve. It m a y w ell be th a t th e a ssu m p tio n tu r n s o u t to b e w ro n g , th a t th e p re se n t tre n d s for ex a m p le in o u r o w n p ro fe ssio n , a n d its ro le in h e a lth ca re d e liv e ry ca n b e p ro lo n g e d m u c h longer, a n d th a t th e first c u rv e w a s really o nly in its infancy. If th is p ro v e s to b e so, n o th in g h a s b e e n lo st o n ly th e e x p lo ra to ry p h a s e of th e sec o n d c u rv e h a s b e e n d o n e . N o m ajo r co m m itm e n ts w ill h a v e b e e n u n d e r ­ tak en u n til th e seco n d c u rv e o v er­ tak es th e first, w h ic h w ill n e v e r h a p p e n as long as th e first c u rv e is still on th e rise. K eeping th e tw o cu rv es g o ing w ill becom e a habit. T he d is c ip lin e of d e v is in g th e seco n d c u rv e w ill h o w e v e r h av e h a d its effect. It w ill force o n e to challenge th e a ssu m p tio n s u n d e r ­ ly in g th e first c u rv e a n d to d evise so m e p o ssib le altern ativ es. T his k e e p s u s q u e s tio n in g a n d striv in g for relevance in a tim e of ch a n g e a n d is a n essen tial d im e n ­ sion of excellence. T he p a ra d o x of success th at, w h a t g o t u s w h e re w e are, w o n 't k ee p us w h e re w e are, is a h a rd lesson to learn. Second c u rv e th in k in g w ill com e m o s t n a tu r a lly fro m th e se c o n d g en eratio n , th o se w h o w ill in h erit th e fu tu re of th e in s titu tio n , th e o rg an isatio n , th e p ro fessio n or th e society. T h ey w ill h o w e v e r need b o th p e r m is s io n a n d e n c o u ra g e ­ m ent. T hey m u s t realise th a t w h a t th e y m ig h t p riv a te ly th in k of as re v o lu tio n or ev e n s e d itio n in a pro fessio n al sense, is p o ssib ly th e w a y a h e a d in d u e c o u rse . N e w id eas can a n d m u s t exist w ith old. It is also im p o rta n t th a t th e second g e n e ra tio n accepts th eir re sp o n si­ b ility for seco n d c u rv e thinking. P e rh a p s y o u h a v e fo u n d th is v ery theoretical to d ate, p e rh a p s it has h e lp e d y o u to p u t a fra m e w o rk a r o u n d c h a n g e b e it p e rs o n a l, professional, org an isatio n al. Let m e seek to illu stra te w h a t it is a b o u t u s as p h y sio th e ra p ists w hich g iv e s u s g re a t h o p e in th e se ch a n g in g tim es as w ell as co n sid er­ able challenge. T he ab ility to n otice th in g s th a t e a sily e sc a p e a tte n tio n , d e sc rib e th e s e w ith " c la rity a n d rig o u r" (Rose 1986) a n d p ro p o s e /d e s c rib e re la tio n sh ip s b e tw e e n th em , are th e h a llm ark s of m a n y of th o se p h y sio ­ th e ra p ists w h o h a v e m a d e a m ajor c o n trib u tio n to o u r k n o w le d g e b ase in p h y s io th e ra p y . T h ese w e re p e o p le w h o w e re n e v e r c o n ten t, w h o w e re c o n s ta n tly see k in g . C linicians w h o p u t as m u c h sto re on le arn in g d e riv e d w h e n trea tm e n ts d i d n 't w o rk , as w h e n th e y d id . C lin ic ia n s c o n s ta n tly e n g a g e d in sec o n d c u rv e th in k in g . C linicians w h o p ro v id e d th e sp rin g b o a rd for m u c h re se a rc h in p h y s io th e r a p y a n d ce rtain tre a tm e n t a p p ro a c h e s n o w co m m o n ly in use. We n ee d th ese p e o p le n o w as n ev e r before, a n d th e y are ce rtain ly a m o n g st u s today. P h y sio th e ra p ists are in th e tru e st sen se - ag e n ts of ch a n g e - w e seek to effect ch a n g e in o u r p a tie n ts ' lives, w o rk in g w ith th e m to achieve th is a n d in d e e d s ig n ific a n t life sty le c h a n g e is o ften re q u ired . In a very tru e sense for th e m th e secret of g ro w th or q u a lity of life is to sta rt a n e w c u rv e b efore th e first p eters o u t. We often w o rk w ith p a tie n ts n e a re r to p o in t A w h e re e v e ry th in g is g o ing w e ll except th a t th e y h av e h a d for exam ple, a first ep iso d e of a c u te lo w back p a in (LBP). It clears u p quickly. T hey are p e rh a p s u n c o n ­ v in ced of th e n e e d to a d o p t an y p r e v e n ta tiv e s tra te g ie s - th e m essag es com in g in to th e m th a t th e y w ish to tak e n otice of, are th a t it w a s a m in o r p e rtu rb a tio n a n d th e y re co v ered quickly. W h e n after p e rh a p s a n u m b e r of recurrences a n d a clearly w o rse n in g con d itio n , th e e n e rg y w ill be th e re to ag ree th a t lifestyle m u s t change. S ta rtin g th e s e c o n d c u rv e a n d p a rtic u la rly g e ttin g back to w h e re th e y w e re b efo re w ill n o t b e as q u ic k ly a c h ie v e d h o w e v e r, or p e rh a p s n o t ac h iev ed a t all. H o w effective are w e at tu rn in g s u c h a d v ic e in o n o u rs e lv e s , of effecting ch a n g e in o u r o w n lives, of c o n trib u tin g to th e c h a n g e process in o u r association, school, h o sp ital, d e p a rtm e n t or p riv a te practice? T he D ecem ber 1996 issu e o f S pine is d e v o te d to a series of p a p e rs from th e first ev e r In te rn a tio n a l F o ru m for P rim a ry C are R esearch o n Low Back P ain". D r G o rd o n W ad d ell in his k ey n o te a d d re ss s ta te d "Back 6 SA J o u r n a l o f Ph y sio th era py 1998 V o l 54 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) p a in is a 20th c e n tu ry h e a lth care disaster. There is w id e sp re a d ag ree­ m e n t th a t m o st cu rren t h e a lth care for n o n specific LBP is in a p p ro ­ p ria te a n d ineffective. We n ee d a fu n d a m e n ta l c h a n g e in clinical m an ag e m en t... We also n e e d fu n d a ­ m en tal re o rg an isatio n of th e h ea lth care sy s te m to d e liv e r th a t im p ro v e d m a n ag e m en t". C o n c o m ita n t w ith W a d d e ll's p a p e r are ones b y Koes et al (1996) a n d F aas (1996). B oth c o m p rise u p d a te d re v ie w s o f ra n d o m is e d con tro lled trials of sp in al m a n ip u la ­ tion a n d exercise th e ra p y respec­ tively, in th e m a n a g e m e n t of LBP. K oes e t al (1996) concluded th a t • th e efficacy of sp in al m a n ip u la ­ tion for p a tie n ts w ith ac u te LBP an d also w ith CLBP h as n o t b ee n estab ­ lished • th ere certain ly are in d icatio n s th a t m a n ip u la tio n m ig h t be effective in som e su b g ro u p s of p a tie n ts w ith LBP Faas (1996) concluded t h a t • in ac u te LBP exercise th e ra p y is ineffective • in su b ac u te back p ain , exercises w ith a g r a d e d a c tiv ity p ro g r a m "d e se rv e atten tio n " • in chronic back p a in in ten siv e ex ercise o r fitn e ss exercises " d eserv e atten tio n ". In term s of th e Sigm oid C u rv e th ese fin d in g s m ig h t w ell b e in te r­ p re te d a t p u ttin g u s a t p o in t B. W hilst w e m ig h t tak e com fort th at e v e ry b o d y else is th ere w ith u s - it w o u ld be u n w ise for u s to d o so. SECOND CURVE TH IN K IN G A N D ITS COM PATIBILITY W ITH THE P H Y S IO T H ER A P Y CLINICAL PRACTICE M O D EL O F DIAGNOSTIC PR O B LEM SO LV ING W h at is em erg in g h o w e v er is th e s tre n g th of th e se c o n d c u rv e th in k in g a n d h o w com patible th is is w ith th e p h y s io th e r a p y clinical p ra c tic e m o d e l of d ia g n o s tic p ro b lem solving. H e re th e th e ra p ist seeks to elicit th e precise d y sfu n c ­ tio n lin k ed to th e p a tie n t's sp in al p a in a n d disab ility a n d u ses this in fo rm atio n to p rescrib e tre a tm e n t b a se d u p o n th e p re se n tin g d y sfu n c ­ tion a n d th en assess th e outcom e. L e t m e illu s tr a te E xam ple 1 A. Recent stu d ie s b y H id es et al (1994) a n d (1996) h a v e s h o w n localised seg m en tal d y sfu n c tio n of th e m u ltifid u s to occur after a first e p iso d e of ac u te or su b ac u te u n ila t­ eral LBP. T he m o st im p o rta n t fin d in g of the seco n d s tu d y w a s th a t m u ltifid u s m uscle recovery d id n o t occur sp o n ­ tan e o u sly o n th e re m issio n of sy m p ­ tom s. T he clinical significance is th a t a lth o u g h these p a tie n ts w ith LBP a p p e a re d fully reco v ered after th eir in itial a c u te p a in s u b sid e d , th eir m uscle sy stem h a d n o t recov­ e re d . H id e s fo llo w e d u p th e se p a tie n ts w h o h a d in itia lly b e e n assig n e d in a ra n d o m ise d control trial to tw o g ro u p s - m edical tre a t­ m e n t only a n d m ed ical tre a tm e n t p lu s specific lo calised m u ltifid u s h o ld in g exercises. The o n ly d iffer­ ence in all th e o u tco m e m easu res, at b o th 4 w e ek s a n d 10 w eeks w a s in th e m u sc le re c o v e ry (u ltra s o u n d im a g in g w a s u s e d to d e te r m in e m u sc le size th ro u g h o u t). M u scle size h a d n o t re tu rn e d to n o rm a l in th e n o n exercise g ro u p b y 10 w eeks. The m u ltifid u s m uscle h as been sh o w n to be a n im p o rta n t p ro v id e r o f s e g m e n ta l s p in a l stability. F u rth e r-m o re , d y s fu n c tio n in th e m u ltifid u s is co rrelated w ith p o o r fu n c tio n a l o u tco m e in p a tie n ts w h o u n d e r g o d isc su rg ery . H id e s h y p o th e s is e d th a t th o se p a tie n ts w h o se p a in h a d reso lv ed a n d w h o re tu rn e d to n o rm a l activity, b u t in w h o m th e m u ltifid u s h a d n o t recov­ ered, m a y d o so w ith a p re d isp o si­ tio n to fu rth e r in ju ry a n d recurrence of LBP. In d e e d th e final p a r t of th is s tu d y just su b m itte d for p u b licatio n h as sh o w n th a t th o se w h o d id n o t g e t this ph y sical im p a irm e n t better, h a d a h ig h ra te of recu rren ce of th e LBP, 80 p ercen t of p a tie n ts in g ro u p 1, c o m p a re d w ith 30 p e rc e n t in g ro u p 2. E xam ple 2 B. W ork b y H o d g e s a n d R ich ard so n (1996) h a s clarified the c o n trib u tio n of tra n s v e rs u s a b d o m in u s to sp in a l stab ilizatio n in su b je c ts w ith a n d w ith o u t LBP. T h ese p h y s io th e ra p is ts s o u g h t to ev a lu a te th e te m p o ra l sequence of tr u n k m u sc le a c tiv ity a s so c ia te d w ith ra p id a rm m o v em en ts. In th e c o n tro l su b jects th e y f o u n d th a t tra n sv e rsu s a b d o m in u s w a s in v a ri­ ably th e first m u scle active a n d this occu rred before or sh o rtly after the d e lto id m uscle, a n d w a s n o t in flu ­ enced b y a rm m o v e m e n t direction. T his s u p p o r te d th e h y p o th e s is e d role of th e tra n sv e rsu s a b d o m in u s m uscle in sp in a l stiffness g e n e ra ­ tion. By co n tra st th e co n tra ctio n of th e tra n s v e rs u s a b d o m in is w a s s ig n ific a n tly d e la y e d in p a tie n ts w ith lo w back p a in w h e n all arm m o v em en ts w e re p erfo rm ed . The re su lts p ro v id e ev id en ce th a t th e CNS in itiates co n tra ctio n of th e m uscles of th e tru n k in a d v a n ce of lim b m o v em en t. T he co n tractio n of TA is h y p o th e sise d to c o n trib u te to th e control of forces asso ciated w ith lim b m o v e m e n t b y increasing the stiffn ess of th e lu m b a r s p in e in a n tic ip a tio n of lim b m o v e m e n t . T his w o u ld lim it in te rs e g m e n ta l tra n sla tio n a n d ro tatio n al forces a n d m a y p ro v id e a m o re stable lever over w h ic h o th e r tru n k m u scles can act. Finally, this o b serv ed deficit m a y p ro v id e a basis for th e d e v e lo p m e n t a n d e v a lu a tio n of re h ab ilitativ e a n d p re v e n ta tiv e strateg ie s for p a tie n ts w ith LBP, focusing o n re so lu tio n of th e a n o m a ly a n d re s to r a tio n of n o rm a l function. H a v in g g iv e n y o u th o s e tw o exam ples let m e re tu rn to th e re p o rt of th e fo ru m of le a d in g researchers in th e field of p rim a ry care research o n LBP. T h e 50-60 in v ite d researchers set as a m ajor goal the d ra ftin g of a n a g e n d a for fu tu re p r im a r y c a re re se a rc h on LBP co n sid ered to be of h ig h est priority. T w e n ty (20) re se a rc h p rio ritie s w e re d elin ea te d . F ar a n d aw a y th e h ig h est ra n k e d (w ith 30 votes) w as SA J o u r n a l o f P h ysio t h er a py 1998 Vol 54 No 4 7 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) th e follow ing research p rio rity "C an d iffe ren t varieties or s u b g ro u p s of LBP be identified a n d if th ey can, w h a t criteria can b e u s e d to differ­ en tiate a m o n g them ?" The goal w as th a t clin ically u s e fu l s u b g ro u p s m ig h t be d e fin e d in term s of d ia g ­ n o stic ch a rac te ristic s, b e h a v io u rs , im a g in g s tu d ie s , ty p e o f care so u g h t, re sp o n se to th e ra p y o r o th er factors. If su ch s u b g ro u p s c o u ld be re lia b ly d e te r m in e d , th e se fo ru m p a rtic ip a n ts ex p ressed g re a t in tere st th e n in fu rth e r d eterm in in g : (1) h o w s u b g ro u p s d iffe re d in te rm s of th e n a tu ra l course of the LBP (2) w h e th e r tre a tm e n t a n d m a n a g e m e n t s tra te g ie s c o u ld b e tailo red to each su b g ro u p . W h a t w o n d e r f u l o p p o r tu n itie s th is p re se n ts fo r p h y s io th e ra p ists b ec au se th is p rio rity is so co m p a t­ ible w ith th e p h y sio th e ra p y clinical p ractice m o d e l of: • diag n o stic p ro b le m solving • recognising clinical p a tte rn s or reco g n isin g p a tie n ts w h o d o n o t fit a p a tte rn • rig o ro u s asse ssm e n t • careful, re g u la r re co rd in g of the fe a tu re s of th e p a tie n t's d is o rd e r a n d re sp o n se to tre a tm e n t T he w o rk of H id e s et al (1996) a n d H o d g e s a n d R ic h a rd s o n (1996) p re v io u sly referred to, is illu stra tiv e of th e precision of th e d elin ea tio n of th e d y sfu n c tio n in LBP. C learly as p h y sio th e ra p ists w e are som e w a y d o w n th e track in p ro v id in g som e clarification of th a t first research priority. A n o th e r d im e n sio n of excellence for u s as p h y sio th e ra p ists m u st be th e extent to w h ic h w e can p ro v e th e efficacy of o u r tre a tm e n t m eth o d s. We h av e th e ability b u t d o w e h a v e th e co m m itm en t? We m u st fin d it b ecau se w e are close to p o in t B in th e S igm oid C urve. I h a v e w a lk e d d o w n th e ro a d to D a v y 's Bar in m y p re se n ta tio n to y o u today, p e rh a p s I h a v e m o v ed a w a y fro m m y title D im en sio n s of Excellence? EN S U R IN G P R O FE S S IO N A L EXCELLENCE In conclusion I w ish to a d d re ss q u ite p ra c tic a lly w h a t th e i n d i­ v id u a l p h y sio th e ra p ist - y o u a n d I - can d o to striv e for, a n d en su re p ro fessio n al excellence a n d second c u rv e activity. M ay I su g g est fo u r a p p ro a c h e s (these are b y n o m ean s a com plete list). W h e n y o u see th ese item ise d I h a v e n o d o u b t y o u w ill recognise m a n y activities y o u are en g a g e d in already. H o w e v e r all of u s can d o som e of th ese th in g s m u c h b e tte r th a n w e d o th e m now. RECOGNISE Y O U R G REATEST ASSETS T h ese a sse ts in c lu d e th e follow ing: • Your skills in o b serv atio n , clin­ ical re aso n in g , d iag n o sis a n d y o u r " h a n d s on" p ro fessio n al expertise. We are u n iq u e ly q u alified m o v e­ m e n t specialists, n o o th e r p rofession h a s th e special a rra y a n d d e p th of skills w h ich p h y sio th e ra p ists have. • Your role in th e p ro m o tio n of h e a lth a n d a h ea lth y lifestyle, n o t ju s t in re s to r in g fu n c tio n o r in re h a b ilita tio n of d y s fu n c tio n . Because th e d e m a n d s on p h y sio ­ th e ra p ists to re sto re fu n c tio n a n d to re h a b ilita te p a tie n ts h a v e b e e n great, w e h a v e n o t b ee n able to give th e a tte n tio n to h e a lth p ro m o tio n a n d p re v e n tio n th a t w e sh o u ld . A s a p ro fessio n w e c a n n o t ig n o re this v ital role. If w e d o, w e d o so at o u r peril. • Your p a tie n ts are in d e e d a great a sse t. We le a r n m u c h fro m o u r p a tie n ts a n d th e y in tu rn are great a m b a ssa d o rs for p h y sio th erap y . E X TE N D Y O U SPHERE O F INFLU ENCE This m a y b e ac h ie v ed th ro u g h : • Your p atien ts. Each p a tie n t h a s a sp h ere of influence, u se this in an e th ic a l a n d p ro fe s s io n a l w a y to en h a n ce y o u r profession. • E n su rin g y o u are a n excellent p ro fessio n al role m odel. • Taking a n d m a k in g o p p o rtu n i­ ties in y o u r h o sp ital, p riv a te p ra c ­ tice, school, university, g o v e rn m e n t com m ittee, p ro fessio n al association. • P ro m o tin g a h ea lth y lifestyle in th e com m unity. F or exam ple, this m ig h t be d o n e th ro u g h y o u r role as a p a re n t in th e local school, y o u r m e m b e r s h ip of p h ila n th ro p ic o rg a n is a tio n s lik e R otary, y o u r in v o lv e m e n t in sp o rt as a p a re n t or a d m in istrato r, y o u r m e m b e rsh ip of a ch u rch o r relig io u s g ro u p , • E stab lish in g strateg ic w o rk in g links. For exam ple, w ith y o u local c o u n c il, local in d u s try , local m e m b e r of p a rlia m e n t; o r if y o u are in e d u c a tio n , p la c in g s tu d e n ts u n d e r su p e rv isio n in areas w h e re p h y s io th e ra p y is n o t w ell k n o w n , no t ju st in areas w h e re th e role of p h y s io th e ra p y is clear. C O M M ITM E N T T O R ES EAR CH, DIRECTLY O R INDIRECTLY This can b e d o n e in a v arie ty of w a y s w h ic h include: • K eeping g o o d re co rd s of p a tie n t tre a tm e n t a n d o u tco m e. N a tio n a l d a ta on ty p es of p a tie n ts a tte n d in g fo r p h y sio th e ra p y tre a tm e n t, ty p es of tre a tm e n t given, n u m b e r of tre a t­ m e n ts a n d re su lts are lack in g in e v e ry co u n try . Y our re c o rd s can h e lp to a d d re s s th is deficit. • S tarting, o r jo in in g a jo u rn a l club in y o u r p h y s io th e ra p y d e p a rt­ m e n t, o r sch o o l o r g e o g ra p h ic a l area. R ead in g a n d d iscu ssio n w ith o thers, d iscu ssio n w ith o th ers an d c ritic a l e v a lu a tio n of p u b lis h e d p a p e rs is so im p o rta n t. • S h a rin g p a tie n t p r o b le m s / successes w ith o th e rs or su b m ittin g ca se s tu d ie s to y o u r n e w sle tte r. R e m e m b e r th a t o b s e r v a tio n a n d c o n te m p la tio n w e re th e h a llm a rk s of th o se clinicians w h o h a v e m a d e th e g re a te s t c o n trib u tio n s to th e d e v e lo p m e n t of o u r k n o w le d g e b ase for p h y s io th e ra p y practice. • Jo in in g o th e rs in a te a m to u n d e rta k e research. E stab lish close lin k s w ith y o u r S ch o o l of P h y sio th e ra p y or p ro fessio n al asso ­ ciation so th a t co llab o rativ e research m ig h t be th e outcom e. • U n d e rta k in g fo rm a l re se a rc h study. I c a n n o t stress too h ig h ly h o w v ital it is to o u r p ro fessio n th a t w e 8 SA J o u r n a l o f P h ysio t h er a py 1998 V o l 54 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) h a v e le a d e rsh ip in clinical research a n d in ev id en ce-b ased practice. • C o n trib u tin g to p h y sio th e ra p y re s e a rc h fin an cially , o r in o th e r w ays. E ven sm all financial co n trib u ­ tio n s can be in v alu ab le w h e n a d d e d w ith o thers. C o n sid e r m a k in g y o u r re co rd s, o r p a tie n ts av a ila b le for clinical research; co n sid er offering to be a co -su p erv iso r or assistan t su p e rv iso r of a s tu d e n t u n d e rta k in g a research project. CO NCLU S IO N T here is m u c h m o re th a t can be sa id on th e im p o rtan ce of p u rs u in g p ro fessio n al excellence in th e face of ra p id change. M ay I leave y o u w ith fo u r th o u g h ts b y w a y o f conclusion. First, a re m in d e r to those of us w h o lead team s of p h y sio th erap ists, th a t in tim es of ra p id change, staff d e v e lo p m e n t is of v ery g re at im p o r­ tance. Second, th a t th e p u rs u it of evidence th a t p h y sio th e ra p y in te r­ v en tio n is effective, is in d istin g u ish ­ able from th e p u rs u it of excellence in p h y sio th e ra p y . T h ird , th a t w e m u s t sh o w n o t only th a t w h a t w e d o as p h y sio th e ra p ists is effective, b u t also th a t w e are th e b est ones to d o it. Finally, th e changes a n d chal­ lenges th a t w e face as p h y sio th e ra ­ p ists as w e m o v e to w a rd s th e y ea r 2000, m a y be differen t from th o se of e a rlie r p h y s io th e ra p is ts , b u t th e y a re n o t g re ater challenges th a n th ey en co u n tered . Indeed change and challenge are simply opportunities in disguise. REFERENCES Em bracing the Future: A ddress by Dr Mamphela Ramphele on the occasion o f her installation as the 7th Vice Chancellor o f the University o f Cape Town (Unpublished) Faas A 1996 Exercises: W hich ones are worth trying for which patients and, when? Spine 21: 2874-2877 Handy C 1994 The Empty Raincoat: Making sense o f the future. Sydney: Arrow Books H ides JA, Stokes MJ, Saide M, Jull GA, Cooper D H 1994 E vidence o f lumbar multi­ fidus m uscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine 19: 165-177 H ides JA, Richardson CA, Jull Ga 1996 M ultifidu s recovery is not autom atic follow in g resolution o f acute first episode lo w back pain. Spine 21: 2 7 63-2769 H odges PW, Richardson C A 1996 Inefficient muscular stabilization o f the lumbar spine associated with low back pain. Spine 21: 26 4 0 -2 6 5 0 K oes BW, Assendelft WJJ, Van der Heijden GJMG, Bouter LM 1996 Spinal manipulation for low back pain: An updated systematic review o f randomised clinical trials. Spine 21: 2860-2871 R ose SJ 1986 Description and classification - The cornerstones o f p a th ok in esiological research. Physical Therapy 66: 379-381 Waddell G 1996 L ow back pain: A twentieth century health care enigm a. Spine 21: 2820- 2825 S U B S C R I P T I O N O R D E R F O R M F O R 1 99 9 (Non-SASP m em bers) PUBLICATIONS SA Journal of Physiotherapy 4 issues - Feb, May, Aug, Nov, PhysioForum 8 issues - Jan, Mar, Apr, June, July, Sep, Oct, Dec, SA Journal of Physiotherapy and PhysioForum (12 issues per year) LOCAL R1 2 0 .0 0 R1 20.00 R 2 4 0 .0 0 OVERSEAS R 2 9 0 .0 0 R 2 9 0 .0 0 R 5 8 0 .0 0 Prices include postage costs. SASP members receive the South African Journal of Physiotherapy and PhysioForum as part of their membership package. 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