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adherent nerve root, who knows how to treat it?
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adherent nerve root, who knows how to treat it? - September 22, 2006 8:18:00 PM
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rv36116
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Can folks who are not mckenzie versed let me know what methods you use to treat such a pathology in the patient?
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Re: adherent nerve root, who knows how to treat it? - September 25, 2006 1:42:00 PM
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rv36116
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Anyone?
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Re: adherent nerve root, who knows how to treat it? - September 25, 2006 2:13:00 PM
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proud
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RobPT,
I think the term adherent nerve root is rather "McKenzie". It will depend on your personal interpretation of the data...
I imagine dfjpt would figure the finding was CNS generated and find ways to "calm" things down...correct me if I am wrong djfpt.
For me, I would use most of Butler's work( flossing,etc). McKenzie would say it would require 6 weeks to work through the ANR. The problem is you need a client who consistently performs the "end range" movements...hard to find.
Sorry, this is from a McKenzie versed individual.
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Re: adherent nerve root, who knows how to treat it? - September 26, 2006 10:24:00 AM
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SJBird55
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Rob, to pose a question back to you... how do you know a nerve root IS adhered?
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Re: adherent nerve root, who knows how to treat it? - September 26, 2006 3:40:00 PM
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Jon Newman
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I agree with Proud--the definition of adherent nerve root would be helpful here. I found this definition which doesn't seem accurate to me. What do others think?
Adherent nerve root
A past derangement causing an episode of sciatica has resolved but the repair process has left some tethering or adherence that now inhibits full movement of the nerve root/dural complex
Flexion is limited and the patients feels end-range pain in the back or the leg (this is the only dysfunction that can cause peripheral pain ; all others cause spinal pain only).
Assuming we can get a consensus definition is there a gold standard for its detection? Does Cleland's book have anything to say about this?
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Re: adherent nerve root, who knows how to treat it? - September 26, 2006 5:20:00 PM
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rv36116
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there ya go, good def. and the signs/symptoms give a good description of the "why" sjbird
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 1:37:00 AM
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Sebastian Asselbergs
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Problem with this definition is that the limiting factors in flexion are "pain". Thus making this a strictly subjectively reported phenomenon - no "signs", just symptoms. So, would it not make more sense then to go with a pain reduction approach (a la dfjpt) than trying to reduce the "adhesion"?
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 1:51:00 AM
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SJBird55
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Jon, I don't believe that Cleland addresses "adherent nerve root"
I'm not trying to be contrary (of course, leading with THAT statement always leads some of you to misbelieve...), but the definitition provided still doesn't necessarily prove that an adherent nerve root actually exists. Combine the fact that there are nerve roots in the cervical region, the thoracic region and the whole lumbar region... that definition is kind of limiting, don't you think? Combine it with the fact that there is nothing in the definition that substantiated that the adherence really existed, except in theory, so I still am not sure there really is an adherent nerve root.
HeHe, Rob... I didn't ask "why"... I asked "how you know." BIG difference.
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 4:27:00 AM
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rv36116
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Sebastian.
"tethering or adherence that now inhibits full movement of the nerve root/dural complex
Flexion is limited"
Maybe that part wasn't clear enough for a sign? A limitation maybe?
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 4:29:00 AM
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rv36116
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SJbird, nevermind, you'll split hairs until the cows come home. I guess my question is answered then, if folks don't "believe" it exists, then they actually just don't treat it. Thanks, question answered.
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 4:40:00 AM
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dfjpt
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I personally don't like to treat things that I am expected to "believe" exist. I'd rather treat what I "know" is there, creating mesodermal misbehavior.
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 4:42:00 AM
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SJBird55
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LOL Well, how can you treat something that may not exist? It has nothing to do with splitting hairs.
Before you can discuss any type of treatment or approach, there does have to be agreement on what exactly you are speaking. I don't necessarily believe that we can technically diagnose an "adherent nerve root" with tests that are highly sensitive or specific nor do I really know that an "adherent nerve root" actually exists. Then, if an "adherent nerve root" does exist, well, do we really change the physical properties of whatever is causing the adhering? What are the physical properties of what is causing the adhering? Can we really "unadhere" it?
Since you believe it exists because you treat it... how do you know it exists?
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 6:31:00 AM
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ragempt
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do we really know what were treating with anything in the back or neck? sometimes I tell the patient I have no idea what is going on but if the symptoms respond with good prognostic indication then this is more important than any microscopic dx. In other words the tissue is not the issue.
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 6:54:00 AM
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proud
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Hold on now.
The "adherent nerve root" term tends to conjure up imagery that may mislead you about the actual presentation.
For the record, the classification is based on more than a subjective report. Here are examples of how clinical reasoning comes into play( in a McKenzie world):
1. The symptoms are produced as one would expect with the tissue on stretch and produces concordant pain or tightness at end range. Such that flexion of the lumbar spine in standing will produce the symtoms and may be restricted( or SLR if you will).
2. However flexion of the lumbar spine in lying does not.
3. Consistent with physiological principles, it takes time to develop( all mediators in place to produce "tethering"). So a 3 week onset of calf pain is exluded as possible ANR.
4. There will be no rapid changes in mechanical presentation with repeated movement testing. As such, time is required to resolve the ANR.
I utilze the McKenzie finding as part of a examination process ( cluster of tests) to arrive at the clinical impression. I also like rwillcott's contribution on how to manage these. AND..it has research which is always nice.
ragempt, well stated...the tissue is not the issue. Ultimately if I have exluded a variety of factors resulting in "calf" pain, then the "tethering" approach makes logical sense. whether or not it is actually tethered I do not know...but the clinical picture can be supported.
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 7:23:00 AM
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ragempt
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proud, i would have given the Mckenzie definition but Rob said he wanted another point of view. I wonder if he is not a fan of Robin or maybe he just wanted a different point of view
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 7:30:00 AM
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ragempt
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Proud, are you fond of Angillo Dimmagio stuff. he adds a little different twist to Mckenzie. Basically gets rid of all of the derangement catagories. Although I would not want to speak for him. He is very impressive to listen to.
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 7:32:00 AM
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dfjpt
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[QUOTE]The PT grasps the leg and applies a traction force while performing the SLR movement as far as it will go JUST SHORT OF THE EDGE OF PAIN or stretch sensation (Not further!).
Amazingly, the pain often disappears with slight lateral rotation, abduction or adduction of the hip, which allows you to go higher into SLR. It is crucial to maintain the traction force the ENTIRE time.[/QUOTE]Seems to me, that the only thing a practitioner would get any sort of solid grip on, using this technique, is skin. ;)
I would agree, pulling on skin, in all sorts of non-mesoderal ways, definitely can help reduce pain. Think of how the peripheral nerves disseminate upwards/outwards to become embedded in skin. How can anyone who pulls on it (regardless of what they "think" they're doing) not be affecting the nervous system, therefore?
I don't think these studies much support the gurus who developed the kinesthetically applications for mesodermal constructs, so much as I think they quietly say a lot about how sensitive skin/ectoderm is, and downregulatory pulling on it, creating an ectoderm/mesoderm differential, mechanically, can be.
I say the construct validity of "derangement categories", etc., doesn't hold water unless the skin and ectodermal sensitivity is ruled out as a confounding factor.
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 10:25:00 AM
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Jon Newman
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I have no reason to think adhered roots don't exist. In fact they have been shown to exist. I question whether pain down the back of the leg with forward flexion is diagnostic or that the aptei exercises are going to do anything particularly useful if there is indeed an adherence. And if someone let you tear away an adhered nerve from whatever it is adhered to without punching you in the face, what reason do we have to think that it wouldn't adhere again?
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 10:27:00 AM
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proud
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dfjpt,
>>>>I say the construct validity of "derangement categories", etc., doesn't hold water unless the skin and ectodermal sensitivity is ruled out as a confounding factor.<<<<<<
Yes, I think this is true. But again, the tissue is not the issue. I am sure one day we will figure out what is being influenced. But for now, it is beyond our abilities. So in my opinion, we need to standardize our assessments. This debate is a prime example. How can it be that a seemingly simple concept of nerve root adherence can have such wide opinions? Should not happen.
So we, as a profession, need to develop reliable assessment tools. BEFORE any RCT, we need to establish reliable assessment procedures to identify valid sub groups, THEN perform the RCT's...This is the very reason that RCT's tend to be flawed. Nothing wrong with the idea of a RCT, but as long as our profession ignores reliability in our assessments, all the "evidence" we are looking for will always produce questionable results. And we will have PT's who are skeptical of research, rightfully so, turn to "alternative" practices with dire consequences for our professional image.
Dfjpt...for most posters, I can get some grasp on treatment style. I really have no idea what you might do to... or for patients. In fact, if I go on SS, it is like entering a website with great ideas,insights and intellectual debate, but it feels like a vacum...lacking any substance. Care to fill me in on what I am missing?
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