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Re: adherent nerve root, who knows how to treat it?
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 10:40:00 AM
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proud
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Ragempt,
I have read some of Dimmagio's stuff, never taken a course. I imagine I would be a huge fan because, although the McKenzie assessment is very useful, I think it can be improved upon and things added and removed appropriatly.
Jon,
Have you taken any McKenzie courses? I think your concept of what an ANR within the McKenzie classification is askew. The nerve did not "adhere" for no apparent reason, it usually follows an inflammatory event. So why would it suddenly adhere again? And the treatment does not involve tearing away at it( really). The pain is on/off with no lasting pain. Hard to explain. I guess that is why I could never go on to teach...
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 11:05:00 AM
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Jon Newman
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From: Amherst, WI
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Adhered tissue is unadhered in what manner? Surgeons either have to cut them or put people under anesthesia in order to unadhere an adhesion. And why wouldn't there be an inflammatory event after such a thing.
If I have to see the world through McKenzie colored glasses to speak about anatomy and physiology with everyone then I think something is terribly wrong.
_____________________________
[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 11:58:00 AM
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ragempt
Posts: 111
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From: linden, michigan
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jon, you mean there is more things out there then Mckenzie? you mean like ultrasound, hot pack and tens right? im kidding. i got your point and i am a mckenzie guru. sometimes i get lost in mckenzie stuff
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 12:05:00 PM
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dfjpt
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proud,
[QUOTE]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?[/QUOTE]Proud proud proud... why are you making me spell this out for you?
On SS no one cares WHAT "treatment style" (whatever that is) people use. It's the last thing anyone cares about. What the site is there for is to provide a place for PT and others to understand at a deeper level what's going on, the verb of the treatment interaction, not the noun. We are drawing steadily closer to the conclusion that it doesn't matter a particle what "style" you use, what matters is what's going on meanwhile, to the nervous system of the person you are treating, at each level of it, how it is responding, how it is discovering ways of expressing itself better (motor outflow). If all you're looking for is a set of recipies for "do this then expect this to happen" (which is guru stuff and mesodermal madness), I'm sorry, you'll probably find SS lacking.
One more thing, we don't consider "treatment style" as anything in any way synonymous with "substance." Please don't conflate those two things.
Fondly,
Diane
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 1:25:00 PM
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proud
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Djfpt,
If I can clarify. By substance I mean...what are you doing to determine "HOW THE NERVOUS SYSTEM IS RESPONDING". If you go on the SS site, it's like entering a world of borderline genius...a whole lot of elegant talk...but no one says anything...
So back to my question...If the "mechanical" people are so wrong...what are you doing to help guide me? What are you doing with your patients?
You talk about who cares about treatment style, but good lord at the end of the day you have to treat someone...what are you and the SS gang doing? How hard is that to answer?
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 1:35:00 PM
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proud
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Jon,
I was not suggesting that you see things through McKenzie coloured glasses. I certainly do not.
But taking one of the courses to become familiar with one of the more researched PT tools cannot be a bad idea.
For everyone,
Whenever I mention research methods and the importance of standardized assessment tools and reliability...who agrees? I suppose what I mean is that if you go to a dentist and find that you have a cavity, it is likely that 10/10 dentists will give you the same DX.
I figure( as do most acedemic PT's) reliability in our assessments is paramount to advance our outcomes. It would improve our RCT's and perhaps lead to a better understanding of "calf pain" and what clinical patterns are best suited for what treatment.
If it turns out that putting your finger on the painful sight and asking the pain to "lead you"..."what do you want me to do"...than so be it. At least it can be supported in the literature.
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 2:00:00 PM
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ginger
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From: Melbourne Victoria
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Nerves get tight. Dura can be stretched. When adequate stretch effects are applied to dura, the performance of related structures can be seen to improve, along with reductions in pain associated with stretches to dura.
Ballistic stretches work well , the effects are long term and immediate. A quick stretch applied through end of range , repeated with force sufficient to elicit pain ( but not enough to get a slap Jon) 5 or 6 times will often be enough.
If the related spinal joint movements have been restored then jobs done.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 2:22:00 PM
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proud
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Ginger,
I thought of you when I posed my question to dfjpt. You will always provide some clinical insights on how you treat.
I will admit I have taken your continous mob idea and gave it a go on a stubborn PFS patient. Did not work, but the point was I reasoned out the anatomical connection and it made sense. So I gave it a go. The benefit of this type of communication. I just have no idea what Dfjpt is talking about most of the time.
All I want to know is can I apply all the "theorectical rhetoric" into my practice?
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 2:23:00 PM
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Jon Newman
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Hi GInger,
It seems that you've shifted from the tight muscles concept to the tight dura concept. How do nerves get tight and why does a single series of 5-6 painful stretches permanently elongate them?
It seems to be a universal phenomena that every time there is a discussion about a treatment approach, the person disagreeing is always advised to take the course. Why would that be necessary to discuss a veridical nerve root adhesion? It seems to me that McKenzie is using proprietary language that is ultimately unhelpful. If you want to reduce practice variation start with the language used to describe what it is we do and what it is we treat everyday.
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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 2:43:00 PM
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ginger
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From: Melbourne Victoria
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Hi Jon , no shifting needed, I've stuck with the "do what works best" concept. It doesn't require new concepts to consider dura as soft tissue that responds to long periods of low range movement with the local effects of inflammation , with shortening. Added to which the concept ( umproven) of adhesions along the nerve itself, further adhesions at or near the root , all of which one would assume to be effected to some degree by stretches . Particularly rapid end of range stretches like occurs with ballistic stretch.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 2:48:00 PM
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proud
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Actually Jon, I never disagreed with you. In many ways I agreed with your original thoughts on adhered nerves.
I commented on your interpretation of how foward flexion is diagnostic in the McKenzie system. It is not...So all I was suggesting is that before dismissing the concepts, it is sometimes better to take a course. Especially when the subject has a fair amount of research. I am not going to take any CST course to learn simply because nothing has been produced to tell me I should. With McKenzie, there is some merit within clinical trials so why not take one?
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 3:07:00 PM
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ginger
Posts: 647
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From: Melbourne Victoria
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proud, interested in your findings and issues with the PFS patient you tried L3 mobs with. I'm wondering a few things. How long did you mobilise L3 for . Did you get a resolution of tone there. Did you do any femoral nerve dural ( ballistic ) stretches . Assuming no trauma as part of the aetiology , was there swelling, VMO dysfunction?.
Cheers
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 3:21:00 PM
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Jon Newman
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Perhaps even more clarification is needed. I posted a definition for adherent nerve root found on the internet. I believe it was credited to Cyriax. In that definition it is stated:
[QUOTE]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).[/QUOTE]Then you stated:
[QUOTE]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).[/QUOTE]To which I replied:
[QUOTE]I question whether pain down the back of the leg with forward flexion is diagnostic[/QUOTE]Also note that I never even mentioned McKenzie at this point. I don't even know why he was brought up in the first place as I thought we were discussing adhered nerve roots with an appeal specifically to those not already wearing those glasses. Does McKenzie have something to do with adhered nerve roots that I don't know about? I know, take a course.
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 3:24:00 PM
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ginger
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From: Melbourne Victoria
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you two must love this forum , it gives you a chance to practice fighting with your wives, without the bother of having to wake up with them the next day , or seeking forgiveness for being a pedantic so and so.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 3:36:00 PM
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proud
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Jon,
I don't really know how to reply to that.
If you read my post on the McKenzie diagnosis you would see that flexion of the lumbar spine in standing is one part of the dx of ANR. By itself, that could be anything. In other words, it means nothing by itself.
And yes...take a course. All it is is another potential way to arrive at a clinical conclusion. No harm in that.
But you are correct, RobPT asked for other opinions on TREATMENT:
>>>>>Can folks who are not mckenzie versed let me know what methods you use to treat such a pathology in the patient?>>>>>
So far all I have seen is the APTEI link and my Butler suggestions. The rest has been hinging on the dx of ANR. Which is very concerning to me. So many intelligent professionals, and no one agrees. What does that tell you?
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 3:56:00 PM
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Jon Newman
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From: Amherst, WI
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That tells me that we're not actually good at diagnosing an adherent nerve root but that we are good at telling someone they have one if they present with your diagnostic criteria. Why someone would do that isn't clear to me. Is it your thought that when someone presents this way that they literally have a nerve root adhered to something?
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 4:07:00 PM
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KAK
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[QUOTE] 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 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.
[/QUOTE]Proud, I hear and agree with the above. However, I’m pretty sure that the “Soma Gang” is on to something big in regards to the nervous system being the tissue with issues.
[QUOTE] Adhered tissue is unadhered in what manner? Surgeons either have to cut them or put people under anesthesia in order to unadhere an adhesion. And why wouldn't there be an inflammatory event after such a thing [/QUOTE]Jon, A neurosurgeon once gave us an inservice on neural mobilization after surgery to prevent adhesions. He was big on prevention of this malady. He said that a true nerve root adhesion caused by scar tissue can’t be stretched or “torn”. His take was that the scar tissue was much tougher than the nerve structures and the nerve would be injured long before any scar tissue stretched or tore. He was quite convincing and spoke with first hand knowledge. I have no doubt that we can influence blood flow, but unadhering truly scarred nerves- I also have my doubts.
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 4:14:00 PM
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Jon Newman
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From: Amherst, WI
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Hi Kathy,
I agree that movement is important before the inflammation period is over and I don't think anyone would dispute that. In fact, it is a great reason not to avoid too many postures or positions in the first place unless some aspect of tissue requires protection from such forces. And of course I agree with the dubious treatment of an adhered root once it is in fact adhered, regardless of how we detect it.
_____________________________
[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 4:23:00 PM
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proud
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Jon.
Not my diagnostic criteria. Someone on here mentioned Cleland. I think something along those lines would have to come along to enhance our ability to dx with any degree of snOUT or spIN.
Something tells me that if that ever occurs, the McKenzie eval will be part of the cluster of tests. Much like it is in combination with 5 provocation tests for SIJ related pain( Huijbrets et al). For now, I use my own cluster of tests but never truly know...I call it using the best available evidence along with best practice.
When someone presents with calf pain...how do you go about dx and tx? Do you follow a set pattern of clinical tests to determine what you might do?
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Re: adherent nerve root, who knows how to treat it? - September 27, 2006 5:00:00 PM
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nari
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I think we have a problem with what the diagnostic term 'adhered nerve root' actually is.
As Kathy has already pointed out, it is a pathology that we are extremely unlikely to be able to do anything about. It is quite different from a sticky sort of neural tunnel where the nerve isn't gliding as it should. That we can do a lot about.
Disappointment with what SS offers is an admittance that clinical reasoning must follow set rules, made by various experts. Interest in the WHY and not just the HOW is a theme.
The problem with set rules is that they can change from year to year according to what has been demonstrated in the latest RCTs and other studies.
That's OK, so they should change, if shown to be based on incorrect premises. But working from basic biological principles tends to avoid the 'recipe' method of practice, and keeps the brain from rusting, as a bonus.
Amid the protests of "Heresy!"...
Nari
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