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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? - October 2, 2006 8:13:00 AM
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Bournephysio
Posts: 576
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From: Calgary
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Jon,
I was just trying to make the point (and it wasn't directed at you since I think that you'd agree) that whether you can detect tissue damage and can't do anything about it, or you can't detect tissue damage, that your treatment approach would be the same i.e. more of a pain management/cbt approach. I think that "no detectable tissue damage" is often emphasized too much. That leads to the thinking that there is no tissue damage or that if there is detectable tissue tissue damage you shouldn't be using a cbt/pain management approach. The Videman reference was just to provide an example of tissue damage that we would not likely to be able to detect.
Spine. 2004 Dec 1;29(23):2668-76.
The occurrence of anular tears and their relation to lifetime back pain history: a cadaveric study using barium sulfate discography.
Videman T, Nurminen M.
University of Alberta, Edmonton, Alberta, Canada. tapio.videman@ualberta.ca
STUDY DESIGN: The occurrence of anular tears and general disc degeneration of the lumbar spine was studied in relation to the lifetime frequency of back pain. SUMMARY OF BACKGROUND DATA: Although anular tears and ruptures are common targets for diagnostic and therapeutic approaches, the relationship between disc findings and back pain has been weak or nonexistent. METHODS: The data comprised barium sulfate discograms of lumbar spine levels from 157 male cadavers. The extent of "anular tears" and "general disc degeneration" based on posterior-anterior and side views were evaluated separately using a 4-point scale. Lifetime history of back pain occurrence and work were obtained from the families of 86 cadavers. To assess whether the risk of back pain changed with the severity of findings or the level of disc, we applied trend tests and proportional-odds logistic models for occurrence data. RESULTS: In early adulthood, the risk of anular tears was 0.6 to 0.7, whereas at retirement age, tears were practically unavoidable. The risk of full anular tears with barium sulfate leaking ("leaking" tear) was estimated to be 0.10 and 0.35 among the men in the age groups of 20 to 49 and 50 to 59 years, respectively. The risk of "leaking" tears was greatest at the L5-S1 levels. There were less severe degenerative findings associated with sedentary occupation but no differences between driving and physically light and heavy occupations. Overall, the risk of any anular tears and any general degeneration as defined was similar. The frequency of back pain had a highly significant relation to the occurrence of tears (model-based P = 0.0009). With a "leaking" tear, the model-based estimate of the risk of frequent lifetime back pain was 0.42, with an "outer" tear the risk was 0.20, and with no tears or "inner" tears the risk was 0.10 (the observed prevalence was 0). The effect of occupational loading was of borderline significance (P = 0.045). CONCLUSION: Anular degeneration of the lumbar discs appear earlier and are more clearly related to back pain than previously thought, most probably due to the better sensitivity of the BaSO4 discography method to detect tears.
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Re: adherent nerve root, who knows how to treat it? - October 2, 2006 10:16:00 AM
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dfjpt
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[QUOTE]Anular degeneration of the lumbar discs appear earlier and are more clearly related to back pain than previously thought, most probably due to the better sensitivity of the BaSO4 discography method to detect tears.[/QUOTE]So,.. I still fail to see any cause/effect relationship spelled out between pain and annular tears.
About thirty years ago, I heard of a study that showed that the "relationship" between the number of blocks of new sidewalk laid in New York city and the number of new babies born, within a specific time frame (a year I think it was) showed an astonishing and beautifully near-perfect 1:1 "relationship." This was used to point out that a correlation relationship means pretty much nothing.
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Re: adherent nerve root, who knows how to treat it? - October 2, 2006 1:17:00 PM
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ginger
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From: Melbourne Victoria
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Dianne, I certainly agree with your position on "professionalism" as argued with proud. That we are entitled , indeed responsible , for attending to our craft with a combination of specific and non specific intentions. With a careful ananlytical mind, not restricted by the what has gone before , but empowered to make rational as well as creative ( and possibly seen by others without vision as non rational ) adventures into what works best.
Your work deserves credit. I find however your dismissive attitude to others work gives you an edge that I find immature. To relegate 'pokers and prodders', along with your scathing attacks on 'mesodermalists' into some grab bag of fools bent on restoring nature by force, is , to say the least , odd.
Keep mindfull for heavens sake on your purpose, which , apparently , is to inform us of your craft. What I for one don't find fits into this is your regular attacks on streams of thought that you have abandoned , it seems in favour of the Shacklock/dorko kudos you get from entertainments amongst equals on SS.
We are all after the same thing Dianne, to share , to encourage , to learn. Why do you feel it necessary to find fault with ill tempered attacks on opinion and method that may well , with better understanding , be closer to your model than you think.
Breathe, rest your mind, take it easy, your insights are good, your outburts of fundamentalism just distance readers from your possible best outcome.
Cheers
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: adherent nerve root, who knows how to treat it? - October 2, 2006 1:36:00 PM
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proud
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Ginger,
It's like I said. If prone to single dimension thought, that is where the trouble begins. Just as manipulation will not work for some, tickling with a feather( or simple contact) will not work for some. It's evidence based/best practice that sets us apart.
I have never discounted the work of Shacklock/Butler, however only request that info is used in conjunction with evidence based practice. I utilize the work of these individuals. It sounds to me that dfjpt does not perform anything but her "skin" approach( no manipulation, no stabilization etc). At least the dismissive tone in her posts leads in that direction...that would worry me.
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Re: adherent nerve root, who knows how to treat it? - October 2, 2006 1:36:00 PM
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Sebastian Asselbergs
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Just a thought: Proud, how would you design a biofeedback RCT? "Controlled" being the operative word in this context - usually aimed at "controlling" for placebo. Problem with biofeedback is that in order for it to be effective, IT REQUIRES the active involvement of the person/brain .....
I don't even begin to think of "blinding"....
In your world of PT, biofeedback would not be one of our techniques then, right?
And Doug, the article by Videman shows a correlation without showing a causal correlation. That doesn't mean it isn't useful as a point of interest, but we should be careful drawing conclusions and inferences regarding pain experiences.
_____________________________
Mundi vult decipi
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Re: adherent nerve root, who knows how to treat it? - October 2, 2006 1:43:00 PM
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rwillcott
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dfjpt said:
"I am concerned that if this trend continues, if "professionalism" continues to be defined as you state, PT will be forced to "prove" it shouldn't do anything, never has, and never will. It will have its head so far up it's *** it will disappear completely."
What do you mean when you say PT will be forced to "prove" it shouldn't do anything, never has, and never will?
Within the last 5 years there has been a tremendous amount of excellent research in PT. As a profession we have done an excellent job taking our heads ot of our #$%%#.
We should welcome anyone who forces us to prove what we do. With all the great research being performed it will only take us to the forefront of MSK rehab where we belong. If there is any question about the birght future we have then I suggest going to the evidence in motion website.
Cheers,
Rob
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Re: adherent nerve root, who knows how to treat it? - October 2, 2006 1:43:00 PM
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dfjpt
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Gee, I feel that I'm coming of age when someone suggests I'm immature. I'll take all you said as a compliment Ginger. I don't lay all the blame on mesodermalists, I'm just trying to figure out why PT is taught backwards, inside out and upside down.
Proud, it is not like "what you said".. and there is no tickling with feathers. There is occasionally an outpouring of sweat by a patient, as they lie there apparently doing nothing, but never by me.
Rob, I read EIM regularly. But I look forward to seeing it become more than a mesodermalist sandbox in the playground of manual treatment, albeit a popular one, someday.
Sebastian, cool thought.
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Re: adherent nerve root, who knows how to treat it? - October 2, 2006 1:46:00 PM
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proud
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Sebastian,
Not sure I follow. Plenty of RCT's have been performed for pelvic floor training using biofeedback. The control group will perform the pelvic floor exercises without biofeedback. Biofeedback works for this group.
I would have to read those studies to see methodology. Not my particular area of interest.
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Re: adherent nerve root, who knows how to treat it? - October 2, 2006 1:50:00 PM
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proud
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And dfjpt,
>>>>There is occasionally an outpouring of sweat by a patient, as they lie there apparently doing nothing, but never by me.>>>>>>
I don't get it.
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Re: adherent nerve root, who knows how to treat it? - October 2, 2006 1:58:00 PM
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SJBird55
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From: Michigan
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Diane, if you'd like your views to be read, shared, thought about, you need to post comments. Soma is a start, but you aren't even approaching the sandbox with those so called mesodermalists. You don't even want to play with them.
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Re: adherent nerve root, who knows how to treat it? - October 2, 2006 2:14:00 PM
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dfjpt
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SJ, I think it's the other way round.
Proud, when a brain changes its output or its integration of input, sweating often occurs.
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Re: adherent nerve root, who knows how to treat it? - October 2, 2006 2:42:00 PM
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PainFree
Posts: 83
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dfjpt,
It would seem to me that you would likely find more allies among many chiropractic camps than among your own colleagues. While you may disagree with their protocols and the research substantiating them, there are many chiropractic techniques that have been where you are heading with your concepts and have been there for decades. I will admit that there are many more camps in my profession that try forceful mechanisms but I think that there is a logical place for them as well.
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Re: adherent nerve root, who knows how to treat it? - October 2, 2006 3:03:00 PM
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srcase
Posts: 551
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From: Michigan
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proud,
[QUOTE]So RCT's into specific interventions is where I am coming from. [/QUOTE]I believe you posted this reference titled "A Review of the Literature on Evidence-Based Practice in Physical Therapy" by Joe Schreiber, in which he stated the following:
"One challenge for clinicians attempting to utilize this hierarchy has been the application of results from RCTs to physical therapy practice. Some authors have suggested that physical therapists only read and utilize RCTs when seeking out evidence for practice and to disregard lower levels of evidence.39 However, there are inherent difficulties in applying evidence generated by RCTs to a clinical population.9 For example, the array of unique clinical circumstances a therapist treating a child with cerebral palsy must take into consideration is daunting. These include, but are not limited to, the child’s age, type of cerebral palsy, motor ability, cognitive ability, behavior and motivation, family involvement and support, home environment, and educational placement. The results from highly controlled RCTs often are not directly applicable to an individual patient. Thus the practitioner is required to make an interpretative “leap” in determining whether the results from any research, including RCTs, yields the best evidence to support a clinical decision.8,40 As noted by Bithell, “…There is no intrinsic reason why a clinical experiment developed to prove pharmacological efficacy should be the best way to demonstrate effectiveness of therapies which depend so much on human interaction.”9 The concept of a hierarchy of evidence, as derived from medicine and pharmacologic investigations may not always be applicable to the array of factors that influence physical therapy outcomes because of the variability inherent in these types of patients, in patient-therapist interactions, and even in statistically significant results.9,40
Several other limitations related to the perceived “gold standard” of RCTs have been identified.9,10,25,40-42 In physical therapy, RCTs are typically efficacy studies involving distinctly selected patient subgroups in university medical facilities. This information is not always relevant to real-world clinical practice.10,25 In addition, the research procedures of randomly assigning patients to an experimental or control group, using standardized outcome measures that may not have real-world relevance, and the difficulty of blinding investigators and clients to the research procedures all make RCTs difficult for physical therapists to implement, interpret, and utilize.10,41
Along with the methodological limitations, there is often a difference between an optimal and objective research outcome, and an optimal individual clinical outcome. Physical therapy intervention is typically complex, long term, and specifically related to the patient. Translating research results, even those results from high quality RCTs, into specific clinical decisions for an individual patient or client is challenging.1,40,41 Teasing out one aspect of a clinical intervention for study in isolation may lead to what has been termed a Type III error, whereby the interactive effects of an intervention are not considered.43The scientific method focuses on one variable at a time across a given number of identical research subjects to determine a single generalizeable outcome. Clinical practice deals with countless variables at a time with one person in order to generate a range of outcomes intended to satisfy that person’s goals, needs and desires.11 Oftentimes, efficacious research regimens that work under ideal research conditions are not implemented if they do not address relevant clinical issues and cannot be applied to individual patients.1,44,45 A recent review of research and review articles in four national physical therapy journals during a 12-month time period produced a relatively small yield of articles containing scientific evidence that was both clinically useful and of high quality.46 An important and ongoing challenge for researchers is to generate clinically relevant findings that subsequently influence practice."
I think I know where you're coming from in this thread, but I also want to remind you that the answers are not so simple. Thanks for the link to this article, btw. Sorry for the long post, but I thought it was good info for viewers of this thread.
Sarah
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Re: adherent nerve root, who knows how to treat it? - October 2, 2006 3:10:00 PM
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dfjpt
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Thanks for the long post Sarah.. I was wondering where I'd read that before. Painfree, [QUOTE]there are many chiropractic techniques that have been where you are heading with your concepts and have been there for decades.[/QUOTE]I beg to differ. Seriously and on every count. Chiro has never concerned itself much with neuroscience to my knowledge. Plus much of this neuroscience has only been around for a decade or less. I'm not saying there haven't been any results gotten clinically by chiros, just that there's never been a very good underlying concept, and still isn't.
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Re: adherent nerve root, who knows how to treat it? - October 2, 2006 3:22:00 PM
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PainFree
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I understand that neuroscience has taken a big leap forward in the last couple of years and I attempted to relay my agreement with you by stating that you would disagree with the protocols and the basis by which these chiropractors attempted to substantiate their techniques in the past.
I think you are mistaken in implying that all chiropractic techniques today do not have a very good underlying concept. Some, perhaps many? Yes. As does PT.
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Re: adherent nerve root, who knows how to treat it? - October 2, 2006 3:38:00 PM
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Jon Newman
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Hi Doug,
Yes I agree. In fact I'd add that even if there was something I could do about the tissue damage that I would use the approach I'm using at least. I can't imagine why I wouldn't.
Proud,
Simple Contact = tickling with a feather? Come on. What motivates that comment?
_____________________________
[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? - October 2, 2006 11:45:00 PM
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Randy Dixon
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just happen to believe that we must expose ourselves to the rigours of research into concepts that we propose. Otherwise we are using patients as lab rats. That is unprofessional and lowers the standard to the many many many self proclaimed magical cures. This is a "profession" first. In my opinion.-Proud
I don't particularly disagree with the sentiment here, but isn't the argument that we should be doing things like RCT's? Who are we going to do them on?
This is more than just an inconsistency that I decided to pick on, the problem with many treatment techniques and the rigorous methodology needed to prove their efficacy is that they are done by clinicians. A person who is dedicated to helping every patient to the best of their ability has a hard time NOT providing a treatment so that patient can be a control.
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Re: adherent nerve root, who knows how to treat it? - October 3, 2006 12:16:00 AM
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nari
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Sarah
Excellent post. Hopefully it will be read and interpreted usefully.
I don't understand the lab rat analogy...it suggests that clinicians shouldn't do RCTs. ??
If we are planning to do the best by our patients, and all of us here are doing so, to the best of our ability and current knowledge, then that is a good start. However, Lorimer Moseley has stated in one of his papers on neurophysiology education for patients and PTs (Journal of Pain. 2003. Vol 4 Issue 4 pp 184-189)that unless we provide "current and accurate" pain information for our patients, then we are not following EBP standards. By the posts here, it seems that some PTs are slipping with respect to EBP.
Or are the valued RCTs more important?
Nari
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Re: adherent nerve root, who knows how to treat it? - October 3, 2006 1:38:00 AM
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Sebastian Asselbergs
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Proud, my understanding of a well-designed 'controlled" study is that it is controlled for placebo. That has been impossible for any biofeedback study.
I was making a point that RCTs are very good to have, but that (see Sarah's long and great post) we will not have many for a lot of what we do.
I think I will exit this discussion - was interesting, but I expect no major changes in anyone anytime soon. Hopefully we will percolate the info and make use of what others have said to us....
_____________________________
Mundi vult decipi
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Re: adherent nerve root, who knows how to treat it? - October 3, 2006 4:25:00 AM
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dfjpt
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Lorimer Moseley has backed up his work with two RCTs. That's good enough for me, Nari.
I don't know how we'd design anything that could control for placebo effect in manual therapy.. (I think that's what we're really all about actually...we should really stop denying that we function/our main role is as placebo inducers.)
Even if you are faking your grips, your mobs, your pops, not tuning the ultra sound on, whatever.. you are still contacting the patients'/subjects' bodies' skin layer. You are still stimulating skin/brain somehow (even if "poorly" according to our own sets of conceptual hallucinations and perceptual fantasies).
Their brains will automatically do whatever they can with the information. Some/many of those brains will take the input and run with it, produce a response.
By turning the whole idea of placebo over and knowing more about the brain, instead, we can learn to easily stimulate the brains of the patients we treat to fix themselves. Less becomes more. We therefore become catalysts helping reactions to occur, rather than interventionists imposing change (or at least imagining we can). And we could get even the slow brains (the ones that do not easily produce placebo, or have placebo easily elicited) to produce correction (Weber-Fechner).
This isn't decline in the profession, it could be a revolution instead.
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