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When Evidence Doesn’t Match the Theory

January 27, 2008 by

Change is hard.  Gary Taubes has an excellent editorial in todays NY Times that does the unthinkable of challenging the medical establishments idea that cholesterol plays a key role in heart disease.   It is a fascinating piece that looks at the recent evidence that the combo drug Vytorin had fared no better in clinical trials than the statin therapy it was meant to replace. 

Right after I finished reading the piece I got an email from one of my students that goes something like this…  I continue to get resistance from my CI to using spinal manipulation in LBP management.  I think the best I can do is just teach by example, observe, and only offer information when asked.  I feel that my CI though apparently knowledgeable is not receptive to my sharing of EBP in the clinic.  He has read the more recent manipulation papers but that has not convinced him to change.  I don’t know if he is just afraid deep down, because maybe the current literature supporting the manipulation techniques that we have learned in school is enough to “get the patient better” and that the techniques from the various certification courses are not necessarily needed or the BEST to obtain clinical success. 

Hmm…change is hard.  It’s a drag when the evidence doesn’t match our well intentioned theories.  Why are some folks resistant to change and others embrace it?

Tim

28 Responses

  1. John Ware says:

    Tim,
    I could’ve been this student’s CI a few years back before I started reading this blog, taking a fresh look at the research in PT and searching my own soul about what kind of PT I wanted to be.
    I am certainly no different from the rest of us who are resistant to change. There’s such comfort in the “tried” even if it isn’t true. However, I personally grew so tired of trying to feel those miniscule amounts of movement that the “experts” swore were feel-able, and meanwhile noticed that it didn’t seem to make a hill of beans of difference if the patient had and ERS or an FRS before I applied a thrust through their lumbar spine.
    Of course the evidence has continued to mount supporting the notion that all that time and effort I spent searching the spine for the “holy grail” of restricted segmental motion may have been in vain. For the vainglorious, perhaps this was, and is, too big an ego blow to accept. For me, still possessing perhaps a shred of humility, I’ve had to let it go (I still like to do side-glide tilts in the c-spine, though).
    A man I respect once told me that ego is fear, they are indistinguishable. I think it’s easy to figure out why those with a stake in the certification programs that teach these outmoded concepts are resistant to change- they’re afraid of losing a lucrative part of their living. The rest, and vast majority of the rest of us? I don’t know what we’re afraid of.
    John

  2. John Ware says:

    Tim,
    I could’ve been this student’s CI a few years back before I started reading this blog, taking a fresh look at the research in PT and searching my own soul about what kind of PT I wanted to be.
    I am certainly no different from the rest of us who are resistant to change. There’s such comfort in the “tried” even if it isn’t true. However, I personally grew so tired of trying to feel those miniscule amounts of movement that the “experts” swore were feel-able, and meanwhile noticed that it didn’t seem to make a hill of beans of difference if the patient had and ERS or an FRS before I applied a thrust through their lumbar spine.
    Of course the evidence has continued to mount supporting the notion that all that time and effort I spent searching the spine for the “holy grail” of restricted segmental motion may have been in vain. For the vainglorious, perhaps this was, and is, too big an ego blow to accept. For me, still possessing perhaps a shred of humility, I’ve had to let it go (I still like to do side-glide tilts in the c-spine, though).
    A man I respect once told me that ego is fear, they are indistinguishable. I think it’s easy to figure out why those with a stake in the certification programs that teach these outmoded concepts are resistant to change- they’re afraid of losing a lucrative part of their living. The rest, and vast majority of the rest of us? I don’t know what we’re afraid of.
    John

  3. Sean Sadler says:

    Don’t forget also that change involves work and effort. Most of humanity is content to be comfortable, dare I say complacent, in their knowledgebase. When evidence comes out that turns what you’ve been doing on it’s head and requires you to make an effort to learn HOW to do the new treatment methodologies, most folks, I’m convinced, just don’t want to have to take the time to deal with it. After all, if states didn’t require us to complete so many hours of CE a year, how many of us would actually make the effort to go out and continue striving to expand our knowledgebase.
    -Sean

  4. John Ware says:

    Human nature requires an incentive for change. Certain individuals possess an innate self-motivator quality that is driven by idealism. These are the folks that are helping to drive our profession ever so slowly forward. But we need more numbers, we need more incentives. We need a free market to drive innovation and excellence in care.
    The current system is becoming increasingly driven by cost-containment, and various lobbies trying to avoid being the one who gets cut. As usual, PTs get the short end of the stick because not enough of us are even motivated enough to belong to the APTA, much less give any money to a lobbyist(forgive me if I sound negative; we just lost another battle with the chiros for direct access).

  5. Jason Silvernail says:

    Completely agree with what John and Sean have said above, however there’s another issue to bring up.
    Perhaps at least part of this problem is not the treatments being applied but the absolute lack of any intelligent theory behind them. I feel that in our programs and in our postgraduate education we are doing a very poor job of doing some key things – like knowing the relevant basic science in our profession. We have programs and postgrad courses STILL teaching the gate theory as the primary means for reducing pain and that manual forces through mobilization and manipulation can change the form and substance of mature connective tissue. Just two examples.
    This plays out in the clinic like this:
    -Student says they are going to use manual therapy on a patient.
    -OK, I say. Why?
    -Well her left C4/5 is stuck closed.
    -Why would that hurt? I ask.
    -Blank stare in response. Well, it’s blocked you see, and…uh…
    While certification companies teaching the ERS/FRS crap are certainly to blame, if our students came out of school understanding the science behind their practice better, these organizations would wither and dry up.
    If we’re going to say we’re different from the Chiros in that we actually teach science-based practice in our schools (as opposed to teaching some science clustered around a few interventions like a technical school- as Allen Botnick DC says), then we’ve got to do a better job at this.
    Of course, policing the academic world would be a great start, as has been identified on this blog before.
    Trivia question – did you know that there is at least one PT school I know of where one of the professors teaches a Barnes Myofascial Release course in their actual curriculum? Would you believe this professor is also a Fellow of the APTA? Anyone know where?
    We have a long way to go.

  6. Jason Silvernail says:

    Found another blog post where we discussed similar concepts.
    That blog post is here.

  7. Jason Silvernail says:

    Sorry- the link didn’t come through. Darn HTML tags!
    Let me just post the full link:
    http://blog.evidenceinmotion.com/evidence/2006/08/what_does_my_sa.html#comment-20860792

  8. Paul Mintken says:

    Speaking of the evidence not matching the theory, has anyone listened to the podcast on the PT Journal website titled: Classification and Manipulation for Low Back Pain—Should They Be Linked?
    Debators: Timothy W Flynn, PT, PhD, OCS, FAAOMPT, and Christopher Maher, PT, PhD; Moderator: Daniel L Riddle, PT, PhD, FAPTA
    http://www.ptjournal.org/misc/podcasts.dtl
    http://www.ptjournal.org/cgi/content/full/88/1/DC1
    Dr. Maher talks about his recent article (Hancock MJ, Maher CG, Latimer J, et al. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial. Lancet. 2007;370(9599):1638-1643.) in which they standardize the “medical” care, but let the PT “pragmatically” choose what manipulation intervention to use. Is Dr. Maher a PT or a physician? Why would they standardize the medical treatment and not the PT treatment? Further, when the results of the study do not “match” the results of the derivation and validation of the lumbopelvic manipulation CPR published by Flynn et al (2002) and Childs et al (2004), he concludes that the rule does not predict who will benefit from manipulation. Huh? Is that not like comparing apples to oranges? If I had a clinical prediction rule that demonstrated that aspirin lowered the risk of heart attack, should I expect it to hold true for all NSAIDS, applied “pragmatically” by their health care provider? I don’t think so. Aren’t we talking about “science” here?
    He further goes on to say that we are going down the wrong path with classification based treatment, and states that we should move back to a pathoanatomic approach to the examination and treatment of LBP. Huh? What evidence matches that theory? Haven’t we poured enough research dollars in to the pathoanatomic LBP model?
    Dr. Maher is free to pursue this line of research, but I have patients coming to see me tomorrow with low back pain. If they have no red or yellow flags, have a duration of pain less than 16 days and no pain below the knee, I will be performing a lumbopelvic manipulation on them.
    Paul

  9. Paul Mintken says:

    Sorry if this post is redundant and repeats many of the points John Childs made in his earlier post. Still trying to catch up after the holidays…
    Paul

  10. Paul Mintken says:

    This book was on my holiday wish list, but Santa didn’t get it for me. He left me a note saying that he had heard bad things about artificial disc replacement…Too bad, because I really wanted to see what “evidence” was cited.
    POST-SURGICAL REHABILITATION AFTER ARTIFICIAL DISC REPLACEMENT:
    An Evidenced-Based Guide to Comprehensive Patient Care
    By John N. Flood, DO, FACOS, FAOAO,
    Roy Bechtel, PT, PhD, and
    Scott Benjamin, PT, DScPT.
    By the way, if you need a disc replacement, Dr. Flood will put one in for you.
    http://www.lansingorthopedic.com/pages/flood.html
    Paul

  11. Carina Lowry says:

    Hi Paul.
    You stated “He further goes on to say that we are going down the wrong path with classification based treatment, and states that we should move back to a pathoanatomic approach to the examination and treatment of LBP. ”
    I think I have to argue a different point here Paul. I don’t think he is saying that the source is the end all be all that you and many others state he is saying. I think he is stating that we should not forget the source or what could be possibly causing the pain.
    For example, let’s take the spine. A person with low back pain may present with pain to the knee. This pain could be referral from PIV joints, nerve root, or disc. I would hope that anyone can follow the clinical reasoning that the treatment may be different for these three “sources” of pain. For the PIV joint, possibly manipulation or mobilization would be THE best treatment, especially if they fall in the CPR criteria. The nerve root may be adhered or just compressed…so you may treat it with neural gliding for a strictly adhered or you may refer to a surgeon. If it is merely compressed or irritated from extruded disc material, direction specific exercise may be beneficial or traction even could be indicated, especially if the pt centralizes with these treatments, or the pt may respond to an opening type of manip to further open the foramen so to speak. And so on and so forth.
    I think the prognosis would be different for these different “sources” as well–it’s fairly easy to manipulate the spine for a PIV source problem and this is likely to clear up very quickly with good prognosis especially if they meet the CPR. This is the home run. For a nerve root, it’s likely to take longer and doesn’t have as good of a prognosis…and a disc issue likely has even worse prognosis, especially if it is sequestered and changing the chemical environment of the surrounding tissues (ie the nerve root).
    So I think that to throw out the source all together is missing the point. It is there in your clinical decision making whether you intentionally think about it or not. I think this may be more what he is saying…but then again maybe this is just my interpretation of what he is saying.
    Carina

  12. John Ware says:

    Carina,
    I don’t know that having that much pathoanatomical information that you referred to is going to provide as accurate clinical decision making as you suggest. I’m with you on the directional preference/treatment-based classification approach, but I think too much focus on the pathoanatomy can lead you down a rabbit’s hole, and I think the research thus far supports that notion.
    The fact is that there are likely multiple pain generators in the majority of LBP conditions, which may actually wax and wane depending on what that patient did before he came into your clinic. So, I think that focusing on pathoanatomy may lead the clinician to make false assumptions. And false assumptions can lead to ineffective and/or inefficient treatment interventions. And, of course, since we get paid more for the more we do, such pain generator hunting becomes the rationale for doing more to the patient.
    I think Paul’s nutshell comment about red and yellow flags, which may included dangerous pathoanatomy, is a reasonable approach given what we currently know.

  13. Carina Lowry says:

    Hi John.
    I respectfully disagree with you that pathology is not important. I do not advocate that we increase costs by unnecessary procedures and imaging and in fact most of the time I am trying to talk my patients out of requesting such imaging unless they are surgical candidates and truly ready to actively pursue surgery (ie failed conservative care).
    I am concerned overall with the profession relying too heavily on CPR’s. I do not believe that the authors of these CPR’s meant for them to replace all clinical decision making and only be based upon evidence. Might I also politely remind you that the CPR’s are in the infancy stage. One one that I have seen has passed stage 2 (Validation) and not a single one has passed stage 3 (Conducting an Impact Analysis for proof of efficacy and cost effectiveness). If you are confused about this, you may want to read Child’s and Cleland’s article on development and staging of CPR’s in 2006 PTJ.
    I guess I am thinking that by blindly following the CPR can lead to false assumptions as well and that it could possibly lead to reasoning errors which could delay the patient from receiving the care needed.
    My question I pose for you is this: If you do have a patient that meets 3 of 5 criteria (the most common category) with a 68% chance of responding to manipulation and you do manipulate them and they do not respond, what do you do? Would you tell me what you would explain to the patient who just happens to fall into the other 32%?
    I think that evidence is great and kudos to all those out there really putting it on the line…but evidence should be a complement to your clinical reasoning–not the only basis.
    Carina

  14. John Ware says:

    Carina,
    Did I say that pathology is not important? Doesn’t the determination of “red flags” require a thorough knowledge of pathoanatomy and other potentially pathologically processess, including the influence of metabolic and connective tissue disorders?
    I am very away of the staging of CPRs. In fact, I recently gave a presentation on the very topic cautioning the audience of nurses, physicains and case managers on leaping too soon onto the CPR bandwagon. By the way, at the point a CPR passes stage 3, it is termed a CDR, or clinical decision rule, and should become a standard of care. I would not suggest or advocate for the current CPRs relative to PT practice be adopted as standards of care at this point.
    In answer to your question regarding how I would treat a patient who didn’t respond to lumbar manipulation who met 3/5 criteria on the CPR: I would revert to traditional best practice utilizing either a treatment-based classification system for a truly acute case or movement system impairment-based categorization in a patient with a more chronic/recurring condition.
    What I take issue with in your comment is the attempt to delineate and separate patients into categories based on pathoanatomy. In your example of the patient with spinal pain with reference to the knee you imply that the pain referral pattern is due to one of these possibilities. I’m saying that the referral pattern could be all three to varying degrees and/or even some other tissue that makes its way across the lumbar spine to the thigh.
    Evidence of some kind- whether based on biological plausibility, placebo or outcomes studies-should be the ONLY basis from whence clinical decisions are made. And an effort to prioritize the evidence should be paramount. Otherwise, clinical decisions become a game of intellectual relativism where all evidence is considered equal, and we end up in the current practice variability mess we’re in now.

  15. Paul Mintken says:

    Hi Carinna,
    I just don’t know if we are ever going to be able to isolate the pain generator in the majority of patients with low back pain. Even if we had xray vision, that vision would give us many false positives, as asymptomatic people have heaps of pathology and never have pain. Boden et al and Jenson et al found that up to 64% of people with no symptoms have disc pathology (meaning only 36% were “normal”), and 21% had spinal stenosis despite having no pain.. Borenstein et al followed these same subjects for 7 years, and the imaging findings did not predict the future onset of pain, even in the presence of severe herniations. Fraser et al. conducted a 10 year follow-up MRI study on a group patients with “symptomatic” disc herniations. The subjects were randomized to receive a laminectomy, a chymopapain injection, or a placebo injection. 37% still had the “symptomatic” disc herniation at 10 year follow-up, and the presence of the herniation had no bearing on patient satisfaction. Masui et al. followed 27 patients who were treated conservatively for symptomatic lumbar disc herniation, with follow-up MRIs done at 2 and 7 years. At 7 years, all patients had progressive disc degeneration, and the MRI findings did not predict persisting pain. The authors concluded, “Clinical outcome did not depend on the size of herniation or the grade of degeneration of the intervertebral disc in the minimum 7-year follow-up.” Boos et al studied 46 asymptomatic subjects in “high risk jobs” and looked at their spine with MRI. 85% had DDD, 76% had at least 1 disc herniation and 17% had nerve root compromise.
    How do you know that the ‘pain generator” for the patient sitting in front of you is the disc herniation the MRI says they have? You don’t, without further invasive study. I saw a lot of the patients in the mid-1990′s who wer post-laminectomy and they still had the “same pain” that they originally sought care for. So seeing is not believing when it comes to LBP, it requires confirmation via some invasive procedure to inject the joint or the disc or whatever and see if the pain goes away. I would argue, in the absence of red or yellow flags, this is not only unnecessary, but potentially harmful. If someone continues to have pain past 6 weeks, that is a different ball game, but central sensitization may be kicking in and the clinical picture gets really muddy. The other thing that is interesting is that I am sure that subgroups exist within patients with a defined pathology (let’s say a disc herniation). Some patients with disc pathology respond to specific exercise, some respond to traction, some respond to stabilization and others to manipulation. I would much rather know the clinical characteristics that tell me which patients respond to which treatment than what the actual pain generator is.
    Further, even if the patient has a symptomatic tissue, let’s take the disc again as an example, it will likely get better with time. Herniated discs in the lumbar and cervical spine have been shown to not only reduce in size after a period of conservative care, but in many cases disappear upon reimaging. Mochida et al showed that 40% of the time cervical discs reduced in size with time, and 60% of lumbar discs decreased in size. They also found that the larger the herniation, the faster the rate of regression. They concluded that disc resorption depended upon the acuity of the injury and the size and location of the herniation. Discs tended to change most dramatically early on and more so in the lateral or sequestered type of herniation. Interestingly, most of the patients did well with conservative management regardless of the severity of the MRI findings. Mochida later found large concentrations of macrophages in excised disc material, so the reduction is size most likely comes from phagocytic action as the body attacks the herniated material. Bozzao et al. demonstrated that 63% of the patients treated nonsurgically with epidurals, medication, etc., demonstrated disc resorption upon repeat imaging. Ellenberg et al. documented that patients with CT evidence of herniated discs and EMG evidence of radiculopathy had a 78% rate of disc reduction. Matsubara found in a similar study that medical care involving medication, traction, PT and epidural steroid injections resulted in reductions in the size of the disc 60% of the cases. In another prospective study, Bush et al. showed disc regression in 12 of the 13 cases studied.
    So if we hunt for the “pain generator” in every patient, it will financially devastate our broken health care system. My question is, as Tim and John and Josh are fond of saying “Is the juice worth the squeeze?” Not in my book. If Gordon Waddell says the pathoanatomic model of low back pain is a failure, I would tend to agree with him.
    References:
    • Boden SD et al. “Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects: A prospective investigation.” JBJS (Am) 1990; 72A:403-408
    • Boos N, et al. “1995 Volvo Award in clinical science: The diagnostic accuracy of MRI, work perception, and psychosocial factors in identifying symptomatic disc herniations.” Spine – 1995; 20:2613-2625
    • Boos N, et al. “Natural history of individuals with asymptomatic disc abnormalities in MRI: Predictors of low back pain-related medical consultation and work incapacity.” Spine 2000; 25:1484
    • Borenstein G, Boden SD, Wiesel SW, et al. “The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic individuals: A 7-year follow-up study. JBJS (Am) 2001; 83:320-34
    • Bozzao A. Lumbar disc herniation: MR imaging assessment of natural history in patients treated without surgery. Radiology 1992;185:135-141.
    • Bush K. Pathomorphologic changes that accompany the resolution of cervical radiculopathy. Spine 1997;22(2):183-187.
    • Ellenberg MR. Prospective evaluation of the course of disc herniations in patients with radiculopathy. Arch Phys Med Rehab 74; Jan 1993, p. 3.
    • Fraser RD, Sandhu A, Gogan WJ. ‘Magnetic resonance imaging findings 10 years after treatment for lumbar disc herniation.’ Spine 1995 20(6):710-4.
    • Giuliano V, et al. ‘The use of flexion and extension MR in the evaluation of cervical spine trauma: initial experience in 100 trauma patients compared with 100 normal subjects.’ Emerg Radiol. 2002 Nov;9(5):249-53.
    • Ito T, Yamada M, Ikuta F, et al. Histologic evidence of absorption of sequestration-type herniated disc. Spine 1996;21:230-4.
    • Jarvik JJ, et al. “The longitudinal assessment of imaging and disability of the back (LAIDBack) Study.” Spine 2001;26: 1158-66.
    • Jensen MC, et al. “MRI imaging of the lumbar spine in people without back pain.” NEJM 1994; 331:369-373
    • Jenson MC, Brant ZM, Obuchowski N, Modic MT, Malaksian D, Ross JS: “Magnetic resonance imaging of the lumbar spine in people without back pain.” New England Journal of Medicine, 1994; 331: 69-73
    • Komori H. Natural history of herniated nucleus pulposus with radiculopathy. Spine 1996;21(2):225-229.
    • Maigne JY. CT followup study of 21 cases of nonoperatively treated cervical soft disc herniation. Spine 1994;19(2):189-191.
    • Masui T, et al. ‘Natural History of Patients with Lumbar Disc Herniation Observed by Magnetic Resonance Imaging for Minimum 7 Years.’ J Spinal Disord Tech. 2005 18(2):121-126.
    • Matsubara Y. Serial changes on MRI in lumbar disc herniations. Neuroradiology 1995;37:378-383.
    • Mochida K. Regression of cervical disc herniation observed on MRI. Spine 1998;23(9):990-997.
    • Powell MC, et al. “Prevalence of lumbar disc degeneration observed by magnetic resonance in symptomless women.” Lancet 1986; 2:1366-7
    • Saal J. Nonoperative management of cervical herniated disc with radiculopathy. Spine 1996;21(16):1877-83.
    • Saal JA, Saal JS, Herzog RJ. The natural history of lumbar intervertebral disc extrusions treated nonoperatively. Spine 1990;15:683-686.
    • Saal JA. Natural history and nonoperative treatment of lumbar disc herniation. Spine 1996;21(Suppl):S2-9.
    • Saal JS, Saal JA, Yurth EF. Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine 1996;21:1877-83.
    • Weishaupt D et al. “MRI of the lumbar spine: Prevalence of intervertebral disc extrusion and sequestration, nerve root compression and plate abnormalities, and osteoarthritis of the fact joints in Asymptomatic Volunteers.” Radiology – 1998; 209:661-666.
    • Wiesel SW, et al. “A study of computer-associated tomography: I. The incidence of positive CAT scans in asymptomatic group of patients.” Spine 1984;9:549-51
    • Wood KB, et al. ‘Magnetic resonance imaging of the thoracic spine. Evaluation of asymptomatic individual s.’ JBJS (Am) 1995 Nov;77(11):1631-8.

  16. John Ware says:

    Everyone copy, print and frame Paul’s last post. While your at it,
    be sure to send copies to all of your less inquisitive colleagues who are busy “opening” facets and foramina. As Spicoli said, “Learn it, love it, live it.”
    Thanks, Paul, that’s a gem of a post.

  17. Jason Silvernail says:

    Tremendous, Paul.
    I’ve copied that and will use it in the future.
    John’s right, if people could internalize this, we’d be about 100 years ahead of where we are now in terms of treating back pain.
    Carina-
    While I understand where you’re coming from, there are some issues here. You mentioned that we should know if the pain is coming from the PIV joint, nerve root, or disc. I would say that since none of those three items depolarize and send action potentials to the brain, that none of those can be the origin of the pain. The origin of pain is nervous tissue. Now, we can say that what we really mean is that the pain is coming from the nerve tissue in the PIV joint, in/around the nerve root, or in/around the disc – but then it begs the question for why other local nerve tissue not in those exact spots is not considered – there’s a lot more sensory nerves in and around the spinal column than just those around those 3 structures. Unfortunately we have no valid and reliable way to differentiate exactly what part of the nervous tissue is the primary nociceptive driver, and as John said it’s entirely possible that it’s more than one location contributing variously to the total nociception and therefore the pain state. I think we have to come to the conclusion that the best we can do is make an assessment of whether the pain is primarily mechanical or chemical in nature, and treat it appropriately. This issue of “magic hands” diagnosis (not that you are suggesting this, but others have) of a specific location 3-4 inches deep in the spine is just silly. And counterproductive.

  18. Carina Lowry says:

    Wow Paul.
    Very nice work, and frankly what I would expect. I am not saying that we pour our efforts into finding the exact source…I don’t think I ever said that. I said that we should not discount the source–meaning that we should keep our hypotheses broad enough to avoid making clinical reasoning errors. I do not think the evidence is there right now to determine if each tissue will respond to a specific treatment, however I don’t think the evidence is there either to say that a specific tissue will not respond to a specific treatment.
    By saying that the source is irrelevant is taking a big piece of the whole clinical picture and painting over it. It does make a difference with prognosis and is the underlying theme of the beloved treatment based classification system. Yes, the classification approach took all of the prior treatments based on source and combined them whether it be the manipulation category, the direction specific category or the traction category. While some may argue that the McKenzie system of repeated movements is not based upon moving the disc (Jason you know I am referring to you), the bottom line is that somewhere somehow we are relieving input to painful nociceptive pain generating structures. And no Jason, I never said that the pain is from the PIV, etc however these tissues are innervated and can provide nociceptive input to the system.
    I don’t think we should discount the source but I also don’t think that we cannot begin treatment until we know the exact problem. I think that there should be more lateral thinking in PT as this is where the true innovation and new research ideas come from…
    Carina

  19. Jason Silvernail says:

    Carina-
    We know the exact problem. Speaking peripherally it’s either mechanically or chemically-based nociception from nerve tissue.
    I read your post to be saying we should be finding out the exact location of the nerve tissue in order to treat it, and I think John and I are saying such a search is fruitless. Unless I have misinterpreted your post?

  20. PaulS says:

    Paul. Great post, and I thought I was ‘smart’ in copying and pasting it for the next time I present on the spine. I became even more jealous when you merited a ‘Fast Times’ reference.

  21. John Ware says:

    I have to ditto Jason on this one, Carina. I would never say that pathoanatomy is irrelevant, but only that it is relevant with respect to PT in terms of it providing red flags. I think that more often than not it becomes a “losing the forest for the trees” venture, and gets a lot of otherwise intelligent clinicians measuring “the angle of the dangle” too often.
    Another study was recently published at Medscape, which found that young, active military personnel with radicular symptoms only had good outcomes from microdiscectomy if their MRI showed either an extruded or sequestered disc. Those with “contained” HNP did not show nearly as much benefit from the procedure, despite the fact that they had similar leg and LBP scores prior to the procedure.
    Think about all the patient’s that come into PT clinics with this presentation who have a “contained” HNP. How many of them in the study became the victims of nocebo when they learned that they had a “herniated disc?” The study indicated that these patients had “failed” PT. It didn’t say if PT included categorization using treatment-based, MDT or MSI classification systems. In fact, it didn’t say what PT was at all. Do you think the PT treatment was standardized with an attempt to categorize? I doubt it.
    PTs are wasting precious time and effort searching in vain for the pain generator. I say let’s leave that to the surgeons and pain management docs. We should be focused on SCREENING for pathoanatomy and DIAGNOSING pathological movement.

  22. Carina Lowry says:

    Hi John.
    Even though there is nothing I like more than a fiesty disagreement, really you keep making my points for me. I would like to have the full reference for the study you mentioned in your post regarding the recruits if you could so kindly pass it on.
    My point of view is this: of course the pts with the sequestered disc did not respond to PT but responded well to surgery. The pathology was severe enough that surgical intervention was needed. I am not sure why the others did not respond because I don’t know what PT entailed. Maybe there were other contributing factors and yellow flags, who knows? However I can tell you that if I did have someone with severe pathology such as the extruded/sequestered disc, I would not be wasting my time seeing them for 6-12 months in PT, that’s for sure. It would be interesting to see if these pts also had the normal presentation of true neuro complications–reflex changes, sensation changes, and motor changes…or if they progressed to them. I have had several pts that did not have these “neuro” signs initially but progressed to them during PT treatment and ended up as surgical candidates and did quite well.
    On the flip side though…if I had these pts and we could not change their symptoms, I would not keep trying to repeatedly do a treatment that was not working…
    I was quite interested in this statement–”Evidence of some kind- whether based on biological plausibility, placebo or outcomes studies-should be the ONLY basis from whence clinical decisions are made.” I agree with you to a point but also believe the best evidence based medicine is a combination of the best available research, the patient preferences, and the clinician judgement–which entails clinical reasoning, critical thinking, and experience. That’s how I interpret Sackett anyway…I think this is one of the major flaws in the PT education model in the U.S. We are teaching our students WHAT to think but not HOW to critically question and critically think.

  23. John Ware says:

    Carina,
    The article is from “Spine,” but I got it from the Medscape listserv, so I’ll provide that link: http://www.medscape.com/viewarticle/568734?src=mppine
    The inclusion criteria were young, active duty military (average age 27) with radicular symptoms below the knee, positive PSLR or positive neuro deficits.
    There is no description of the PT intervention. Only that conservative treatment, including PT and epidural steriod injections, was tried for at least 4 months prior to surgery.
    Those inclusion criteria, I think, are pretty broad. The determination of “radicular” symptoms is frought with subjectivity. Many of the clincal tests for neurological screening also have questionable validity. However, if you couple clinical signs with +MRI findings of severe disc pathology, then I think you’ve got a pretty clear clinical scenario. Turns out that nearly 80% of these subjects had obvious (sequestration/extrusion) disc pathology on MRI that corresponded with their clinical presentation. For the remaining 20% or so it was much less obvious on MRI, AND they didn’t do nearly as well with surgery.
    So, for a PT treating the 20% with these inclusion criteria, what good is it going to know that they have a “contained” HNP? What benefit is it to know that the disc is a source of pain at all? Or that the nerve root is effaced by the disc? You’re hopefully going to determine the presence of abnormal neurodynamics during your examination anyway. What if the “radicular” symptoms turn out to be IT band fasciitis with peroneal nerve irritation? What good is it to know that the patient has a “contained” HNP then? Knowing that fact may lead many PTs to continue in vain to “treat” their disc despite Paul’s long list of evidence above, which strongly suggests that to be a waste of time.
    Both TBC and MSI systems are based on movement pathology, which allows PTs to provide diagnostic information that is distinct from what the surgeons and pain docs are concerned with. If we keep our eye on the pathological movement “ball,” then our profession will continue to grow distinctly from the medical specialties, and we won’t be in unfruitful and unnecessary competition with them. On the other hand, if we want to be like the chiropractors, we can bamboozle the public into believing that we can treat their “slipped disc” with a little advice on nutrition, spinal manipulation and $5000 worth of traction.

  24. John Ware says:

    Carina,
    The article is from “Spine,” but I got it from the Medscape listserv, so I’ll provide that link: http://www.medscape.com/viewarticle/568734?src=mppine
    The inclusion criteria were young, active duty military (average age 27) with radicular symptoms below the knee, positive PSLR or positive neuro deficits.
    There is no description of the PT intervention. Only that conservative treatment, including PT and epidural steriod injections, was tried for at least 4 months prior to surgery.
    Those inclusion criteria, I think, are pretty broad. The determination of “radicular” symptoms is frought with subjectivity. Many of the clincal tests for neurological screening also have questionable validity. However, if you couple clinical signs with +MRI findings of severe disc pathology, then I think you’ve got a pretty clear clinical scenario. Turns out that nearly 80% of these subjects had obvious (sequestration/extrusion) disc pathology on MRI that corresponded with their clinical presentation. For the remaining 20% or so it was much less obvious on MRI, AND they didn’t do nearly as well with surgery.
    So, for a PT treating the 20% with these inclusion criteria, what good is it going to know that they have a “contained” HNP? What benefit is it to know that the disc is a source of pain at all? Or that the nerve root is effaced by the disc? You’re hopefully going to determine the presence of abnormal neurodynamics during your examination anyway. What if the “radicular” symptoms turn out to be IT band fasciitis with peroneal nerve irritation? What good is it to know that the patient has a “contained” HNP then? Knowing that fact may lead many PTs to continue in vain to “treat” their disc despite Paul’s long list of evidence above, which strongly suggests that to be a waste of time.
    Both TBC and MSI systems are based on movement pathology, which allows PTs to provide diagnostic information that is distinct from what the surgeons and pain docs are concerned with. If we keep our eye on the pathological movement “ball,” then our profession will continue to grow distinctly from the medical specialties, and we won’t be in unfruitful and unnecessary competition with them. On the other hand, if we want to be like the chiropractors, we can bamboozle the public into believing that we can treat their “slipped disc” with a little advice on nutrition, spinal manipulation and $5000 worth of traction.

  25. Paul L aka MrXtramean says:

    I’m not a PT or medical prof., I’m a patient. I had a work related HNP (extruded) resulting from a sudden onset phyical ativity. after the intial pain in the lower back, I went to my chiropractor. I actually saw him about 4 times over a month and then he took x-rays. He wasn’t 100%, but his thought was a herniated disk at L5-S1.
    So off to my PCP who turns around a gives me diagnos of “slight prostate infection”. My symptoms were low back pain with groin area pain. I was sent away with a perscription for a prostate infection. 3 weeks later I was in twice as much pain as I was before. This is now 3 months after intial start of low back pain. I returned to my PCP, but saw a younger doctor (the other Dr. was very old, my main PCP), who sent me to have an MRI done. Result postive herniated disc. I was sent to Neurosurgeon.
    Neurosurgeon decided no surgery due to my very large extruded disc was not directly compromising a nerve and I only had intermitted sciatica.
    1 year after the injury I’m still haveing LBP, unable to return to full normal activies. I’m diagnosed with depression. That follow year was the worst of my life. Major depression and still dealing LBP.
    3 years laters, pain back is getting worse. At 4 years, pain more worse. In the 5th year, I have, what I call a “breakdown”. I am unable to control the pain and the problems no more.
    I start to have numb/pins & needles feeling in the lower left leg and foot. Then I start to have intense arching, burning pain in both ankles. This moves after 2 weeks to the soles of my feet. This pain is severe and causes me to limp and takes about 2 hours off my feet for the pain and ache to subside. But as soon as my feet touch the ground, the pain comes back. I have sharp pains above the knee caps. I see my PCP.
    My PCP moves my leg around and does nothing more. I left his office so confused and worried. My another appointment with a different doctor. He does large nerve conductive test and the results, negative. he thinks it’s muscles, but does nothing to treat me. I have some bright blood in my stool and call for full physical. Results, negative. Blood from hemrroids. At this point, I’m still in much pain and guess what, he does nothing.
    A month later I’m in incapitating pain and have to take a work LOA. I see a neurologist, neurosurgeon, my chiropractor and I doing PT 3 times a week. Finally a doctor ask me if “I” want an MRI. Dumb question, given my symptoms. I see, “It’s about time.”
    MRI comes back showing my 2002 herniated disc has been resorped. A couple of doctor’s say my pain is partially from the injury but now mostly from DDD.
    I was on a LOA for 2 months and I am back to work half-time. I have an appt. with a Orthopedic surgeon soon.
    I’ve started to have “pain spots” or something like the trigger spots of myofacial or fibromyalgia.
    What I’ve learned. I will never trust another doctor to know what I think they should know. If doctors follow the normal “guidelines”, then patients will suffer, but the process, “supposedly” is the correct process in evaluating patient symptomology. The process makes me think the doctors aren’t really concerned about the “origin” of the pain as much as they are waiting a more clear problem to arise so they can have a “reason” to call for more expensive test or procedures.
    This, in my opinion, is where a doctor needs to set aside the academics and really listen to the patient. Don’t wait for problems, go looking for answers.
    I’ve spend all my free time now to reading to educate myself in anatomy. I’ve brought test ideas to my doctor and he just ignores and says he won’t do them without more physical findings. I wanted to punch him in the face. I’m the one in pain, on LOA, why would he wait?
    Anyways, I read over aticles now just like this one all the time. You folks are donig “Something” to better the situation. That’s a good thing. As long as you and I are not idle and keep “wanting” to know more then the patients, like me, will be treated faster and better. Don’t be a fence sitting practitioner for your patients. Listen to them and research for them treatments that show results. And even if results aren’t 100%, then at least you have eliminated possible probable causes.

  26. Thanks for the inspirational thoughts you have here. Keep up the good work!

  27. nice blog.. I’m sure everyone can relate this topic. i think its very nice to read for.thank you more power.

  28. Abel Masse says:

    Abel Masse

    Thanks again for the blog post.Really looking forward to read more. Want more.

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