In this episode, physiotherapist Adam Dobson discusses lumbar radiculopathy and its management. He highlights the challenges in assessing and diagnosing lumbar radiculopathy, emphasizing the importance of precise terminology and understanding mixed presentations. Adam also explains the role of the neurological examination and the stepped-care approach in managing lumbar radiculopathy. He emphasizes the need for an economical approach to treatment, focusing on patient preferences and activities that are meaningful to them. Adam also discusses the role of physiotherapy in supporting patients' recovery and the importance of balancing tissue-based and biopsychosocial approaches.
Schmid AB, Tampin B, Baron R, et al. Recommendations for terminology and the identification of neuropathic pain in people with spine-related leg pain. Outcomes from the NeuPSIG working group. *Pain*. 2023;164(8):1693-1704. doi:[10.1097/j.pain.0000000000002919](https://doi.org/10.1097/j.pain.0000000000002919)
Konstantinou K, Lewis M, Dunn KM, et al. Stratified care versus usual care for management of patients presenting with sciatica in primary care (SCOPiC): a randomised controlled trial. *Lancet Rheumatol*. 2020;2(7):e401-e411. doi:[10.1016/S2665-9913(20)30099-0](https://doi.org/10.1016/S2665-9913(20)30099-0)
Stynes S, Konstantinou K, Ogollah R, Hay EM, Dunn KM. Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain. *PLoS One*. 2018;13(4):e0191852. doi:[10.1371/journal.pone.0191852](https://doi.org/10.1371/journal.pone.0191852)
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Adam Dobson: I think first of all, just the terminology, the
00:00:03
term radiculopathy is still overly used, when we're actually
00:00:09
meaning radicular pain.
00:00:11
Mark Kargela: Where do you see?
00:00:12
Maybe some of the challenges, whether it be a new physio, a
00:00:14
student physio in uni or even some experienced physios, where
00:00:18
there's some struggles in maybe concepts or examination skills
00:00:22
or assessments, because I'm just curious where you feel folks
00:00:24
fall maybe a little bit short on that.
00:00:27
Adam Dobson: We want to enter the pathway advice and education
00:00:30
supported exercise, nerve root block, surgical consultation.
00:00:36
We want to enter that pathway at the least intrusive position.
00:00:42
So now that doesn't necessarily mean.
00:00:45
RODECaster Pro II Chat &: Lumbar radiculopathy.
00:00:47
If you practice in a musculoskeletal practice, you
00:00:49
see these regularly.
00:00:50
But are you classifying them correctly?
00:00:52
Are you assessing it and examining them using best
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practice.
00:00:56
Are you using correct terminology when diagnosing
00:00:58
them?
00:00:59
In this week's episode of the modern pain podcast, we'll sit
00:01:01
down with Adam Dobson and discuss this and more.
00:01:04
Adam shares his expertise and I'm confident that you're gonna
00:01:06
come out of this episode with a better understanding of lumbar
00:01:09
radiculopathy.
00:01:11
If you want to go deeper on topics like this, make sure you
00:01:13
check out our community@modernpaincare.com
00:01:15
forward slash community.
00:01:17
Now onto the episode.
00:01:19
announcer: This is the Modern Pain Podcast with Mark Kargela.
00:01:23
Mark Kargela: Adam, welcome to the podcast.
00:01:26
Adam Dobson: Thanks for having me, Mark.
00:01:26
Good to be here.
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Mark Kargela: We've been able to get to know you a bit digitally
00:01:30
through Twitter and hearing a lot of your discussions around
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lumbar radiculopathy and definitely a thing we see in
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clinic regularly and hopefully this week's episode will get
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into that a bit and give you guys some actionable things that
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you can use in clinic to better examine, better treat and better
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move these folks into more evidence based and person
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centered approaches with lumbar radiculopathy.
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But before we get into that this week, Adam, do you mind
00:01:52
introducing yourself?
00:01:53
And I'd love if you could let folks know how you ended up
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specializing in this specific topic.
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Adam Dobson: I'm Adam.
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Hello, everyone.
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I'm a physiotherapist from the UK in the northeast of England.
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I I specialize and work almost exclusively with patients with
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lower back pain.
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related problems.
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So I don't actually see the whole of the spine, which I know
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is a little bit novel.
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Although you kind of do inadvertently.
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I help people with low back related problems so that low
00:02:26
back pain, ridiculous kind of syndromes, stenosis, ridiculous
00:02:31
pain.
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And I also run a rehabilitation program.
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for people with persistent back pain.
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So it's everything lower back, everything people related.
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I've done that for about five or six years now.
00:02:45
Prior to that, I worked privately in orthopedics and I
00:02:49
always had an interest in spines, had a brilliant mentor.
00:02:53
At the time who brought the service on kind of mentored me
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kind of enriched a lot of critical thinking.
00:03:01
And we went on a couple of cognitive functional therapy
00:03:04
courses together.
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So it's kind of like the back and the spine become a big part
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of my life, maybe about 10 years now.
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Mark Kargela: It's interesting how we all find our little
00:03:15
niches of in our practices and things like that.
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And the low back, obviously, there's plenty of low back pain
00:03:21
around to support many clinicians.
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So I will have to touch upon a little bit of your experiences
00:03:27
with cognitive functional therapy, how that kind of
00:03:29
integrates within your management of lumbar
00:03:32
radiculopathy.
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Let's touch upon a little bit of where you see some of the
00:03:36
challenges with lumbar radiculopathy when it comes from
00:03:40
an assessment kind of components.
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That's where we'll start.
00:03:43
Maybe where do you see?
00:03:45
Maybe some of the challenges, whether it be a new physio, a
00:03:47
student physio in uni or even some experienced physios, maybe
00:03:51
maybe where there's some struggles in maybe concepts or
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examination skills or assessments, because I'm just
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curious where you feel folks fall maybe a little bit short on
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that.
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Adam Dobson: I think first of all, just the terminology the
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term radiculopathy is still overly used when we're actually
00:04:10
meaning radicular pain.
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Even the word sciatica, of course but.
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terminology in documentation between clinicians is often
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quite imprecise.
00:04:21
And so if you're going to use those words then we should have
00:04:24
a kind of a operational definition.
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It's a nice paper by Annina Schmid just last year, which
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kind of looked to operationally define some of these terms.
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That's a brilliant paper to start on.
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I would also say as well is, The patients often have quite mixed
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presentations.
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So we have this kind of idea that people have pain types,
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where we have neuropathic pain at one side in a box, and then
00:04:52
we have nociceptive pain at the other side in a box.
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And so the neuropathic kind of presentation is almost the
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radicular pain and then the nociceptive kind of presentation
00:05:05
is the somatic referred pain, but in reality, that these
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presentations can be quite blurred.
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so we know the epineurium of the nerves are innervated.
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So you can, we can have a nociceptive radicular.
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We also know that the axons of neurons can be sensitized by
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inflammation, so you can have what we call a neuritis.
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You can have radicular symptoms without any compression on a
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scan.
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We can't kind of write radicular pain as not going on just
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because they don't have those classical symptoms.
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neuropathic symptoms and equally a normal scan doesn't
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necessarily mean that they don't have radicular pain.
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So it's not that simple.
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Mark Kargela: Typical clinical phenomenon, you know, we want to
00:05:57
learn this kind of black and white algorithmic linear view of
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a condition and wish it would be that way in clinic.
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But I guess that's what makes it fun being in the clinic, trying
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to kind of hash through some of these mechanisms and differing
00:06:07
presentations.
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I'm wondering with, and I want you to correct me if I'm wrong
00:06:11
on this, but I think with this, you bring up radiculopathy being
00:06:15
thrown out there imprecisely.
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My understanding, and maybe you'll correct me here on air,
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which is completely cool, because definitely I've been
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wrong before.
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I'll be wrong again.
00:06:23
Is that like true radiculopathy is when we have hard neurologic
00:06:26
signs accompanying the diagnosis.
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Am I right in saying that?
00:06:30
Or is that kind of terminology or definition not correct?
00:06:33
Adam Dobson: So it's it's a loss of function to oppose to a gain
00:06:37
of function.
00:06:38
So it's not even describing a pain state at all.
00:06:42
The neuro, a physiotherapist often use the term Signs,
00:06:47
they've got hard neurology.
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I don't know if you use that over there in the States, Mark,
00:06:51
but I've never really seen a surgeon use the term hard
00:06:55
neurology but it essentially means that they have a loss of
00:07:00
sensations or hypoesthesia a loss of muscle power or reflex
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loss.
00:07:06
So it's a loss of function.
00:07:07
to oppose to an increase of function, which is interesting
00:07:11
because nerves can become hyper excitable also when they're
00:07:15
injured.
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so it's, Gain and loss.
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Gain means a kind of an addition of a symptom.
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so pins and needles technically is a gain of function, even
00:07:26
though it's a kind of nervy sensation.
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But the radiculopathy is exclusively in relation to
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sensory loss, power loss, or reflex loss.
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Mark Kargela: I'm wondering if you can speak to a little bit
00:07:38
more of that mix presentation.
00:07:40
I know you mentioned the nociceptive versus neuropathic
00:07:44
and how folks kind of, again, we don't have to get into the nitty
00:07:47
gritty weeds of all of, the every different mixed
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presentation, but I'm wondering if you can go a little bit into
00:07:52
that mixed presentation thought process and where maybe there's
00:07:56
some Misunderstandings and misapplications of kind of
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diagnostics and treatments.
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Adam Dobson: I tend to think first of all, is there evidence
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to suggest that the pain may be in some.
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on some level related to the nerve root at all.
00:08:11
Okay.
00:08:11
There's a paper by Stein's which is, there's a nice little
00:08:15
algorithm that you can use.
00:08:17
And if they have pain below the knee, if the leg pain is worse
00:08:21
than the back pain if they're, if the kind of context fits and
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there are other signs and symptoms, then the totality of
00:08:29
the information is pointing towards it being a nerve root
00:08:33
type problem.
00:08:34
Now, if they have those classical neuropathic symptoms
00:08:38
the burning, the electric shock type symptoms, they imagine a
00:08:42
spectrum to the far right.
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You've got those classical neuropathic, ridiculous
00:08:49
symptoms.
00:08:49
And I like to use the word ridiculous neuropathic.
00:08:52
So at the far right, and then moving a little bit kind of to
00:08:57
the middle.
00:08:58
Right.
00:08:59
You've got those it's more of a nociceptive or an inflammatory
00:09:03
type description, but they still have the dominant leg pain
00:09:08
that's worse than their back pain, et cetera.
00:09:10
You've been able to bring on their leg pain doing some kind
00:09:13
of mechanosensitivity tests.
00:09:16
So we, we need to not kind of, you know, die on that hill.
00:09:23
With the descriptions there is a paper also there's a kind of
00:09:27
rehash of the IASP kind of algorithm.
00:09:31
So the neuropathic, which I, to be fair I've kind of had a love
00:09:35
and hate relationship for many years because weakness isn't in
00:09:39
there and and neither is numbness.
00:09:42
So it's well, clearly they have a nerve that's damaged because
00:09:45
they have a foot drop, but so that pain is probably
00:09:48
neuropathic, but but that wouldn't be included, you see,
00:09:52
so this paper looks to recalibrate that a little bit
00:09:55
and you can follow the steps but really it's the totality of
00:09:59
information.
00:10:00
Having pain in your calf with some semblance of relationship
00:10:05
with their lower back.
00:10:06
I would say that's almost like a shorthand for a ridiculous pain.
00:10:10
I'm looking certainly from an interventional perspective and
00:10:13
an educational perspective.
00:10:14
I'm looking, I'm kind of trying to increase my, I would call it
00:10:18
diagnostic confidence.
00:10:20
So there's a couple of ways to do that.
00:10:22
That could be.
00:10:22
The clusters, the steins paper you know, confidence in the
00:10:26
patient's report of that information, the context you
00:10:30
probably want to be somewhere near 70 percent and above.
00:10:35
to be kind of saying, you know, I think this is radicular in
00:10:38
nature.
00:10:38
Mark Kargela: I'm wondering too, with young physios and
00:10:42
definitely some probably some seasoned physios, we can always
00:10:44
improve our clinical practice with, as far as your neurologic
00:10:48
examination goes with these, obviously there's a standard.
00:10:50
myotomal, dermatomal, reflexes, central, you know, upper motor
00:10:55
neuron things.
00:10:55
I'm wondering if there's anything else you add to that or
00:10:58
if there's anything you've commonly seen as you've maybe
00:11:00
mentored younger clinicians or other clinicians that isn't
00:11:03
maybe where ideally it should be if we're going to really
00:11:06
confidently be able to kind of get our hands or our head around
00:11:10
some of these diagnoses.
00:11:12
Adam Dobson: My examinations probably become more economical
00:11:15
over the years, Mark to be honest I probably do less now
00:11:18
than I did a few years ago.
00:11:21
I think we need to think about safety and we need to think
00:11:24
about evidence that is going to move the needle in terms of.
00:11:29
Managing that patient.
00:11:32
So I have a very standard economical power and reflexes
00:11:38
screen.
00:11:39
That that touches on all the main nerve roots, but it's quite
00:11:43
economical.
00:11:44
I don't do all the little toes for instance So I would do that
00:11:49
in all patients that I would see even lower back patients from an
00:11:53
educational perspective Because we Patients cannot declare,
00:11:59
sometimes they will not declare that they have weakness in their
00:12:02
leg.
00:12:03
I once had a patient who had a a foot drop and they didn't
00:12:06
declare it.
00:12:07
And I didn't notice it when they were coming in.
00:12:10
And when I said, have you got any weakness in your legs?
00:12:12
They said no.
00:12:13
And then, you know, as soon as we sat them on the edge of the
00:12:16
bench, she had a really floppy foot.
00:12:19
So missing that as a junior physio is a kind of a is, will
00:12:24
be a tragedy.
00:12:26
So, definitely reflexes and power with all of your patients.
00:12:31
If you can't get them tested well in sitting, do it in lying,
00:12:34
do it in some different positions.
00:12:36
And that's really one thing to, to learn is have a standard
00:12:40
approach that, but then know how to test the muscle function in
00:12:45
different positions, if you've been standing or lying.
00:12:47
Mass sensory testing is even more economical.
00:12:51
So, I would only screen way for light touch sharp appreciation.
00:12:59
If the patient reports that they have a sensory deficit in the
00:13:04
leg.
00:13:05
So if they if they.
00:13:07
tell me fairly early on that the outside of the left calf is
00:13:12
numb.
00:13:13
I would weigh that high.
00:13:15
And then I would obviously investigate that and compare to
00:13:18
the other side.
00:13:19
But I think for cultural reasons, for time reasons for
00:13:25
value reasons, doing an indiscriminate test of all of
00:13:30
their dermatomes from their upper thigh all the way down to
00:13:33
the foot in a busy clinic that they've not reported anyway.
00:13:37
So how useful is that information?
00:13:39
I don't do that anymore.
00:13:41
And I think that there's this tendency, particularly from
00:13:45
experienced physios, to say, Oh yeah I check sensory more.
00:13:49
They just reel it off.
00:13:50
They say, I check sensory.
00:13:51
But how do you do that?
00:13:53
And how are you deciding to do that?
00:13:55
And I think we're giving the impression that they're doing
00:13:59
that properly over skin with every single patient.
00:14:03
That's not realistic.
00:14:05
And I would wager that they don't.
00:14:08
Rubbing your hand over their leg with a trouser on that you may
00:14:12
as well not have done that at all.
00:14:14
Mark Kargela: You bring up also good points with different
00:14:16
positions.
00:14:17
Having students regularly, it's always like you learn it in this
00:14:20
one way of doing it, right?
00:14:21
We all learn our neurologic examination sitting with our,
00:14:24
you know, lab partners, you know, sitting across from a
00:14:27
student this way.
00:14:27
And it's just, it's always been interesting to see how difficult
00:14:30
that is, but a big aha moment for a lot of younger clinicians
00:14:33
of like, yeah, I guess I could do this laying down or, you
00:14:35
know, in different positions to make it, you know, still be.
00:14:38
Good information just accommodating the patient,
00:14:40
right?
00:14:40
Especially patients with low back pain sometimes don't like
00:14:42
to sit or if they sit more than a few minutes, things get pretty
00:14:46
painful.
00:14:46
So it's good to have some different approaches to, to
00:14:48
accommodate the person in front of you.
00:14:51
I think one other thing people can benefit from this is kind of
00:14:53
understanding that whole stepped care approach that I know you
00:14:56
talk about a bit.
00:14:58
And maybe that goes into some of the Natural history of this
00:15:01
thing because there's the U.
00:15:03
S.
00:15:03
is probably the worst.
00:15:04
I remember working at the Mayo Clinic.
00:15:06
Love the place.
00:15:07
There's some great people there.
00:15:08
Don't get me wrong.
00:15:08
But I remember seeing acute radiculopathy is and the
00:15:12
physicians would get them and it was like every non guideline
00:15:15
based thing you could possibly throw at it.
00:15:17
Let's image it.
00:15:17
Let's inject it.
00:15:18
Let's do everything.
00:15:19
That's just again way outside of getting some of it.
00:15:23
Of course, if there's progressive neurologic loss and
00:15:24
things, but I'm wondering if you could speak to a bit of yeah.
00:15:27
The step care approach as far as how you when you have somebody
00:15:31
these I know it can be dependent on timeframes and where they are
00:15:34
in the situation in their exact presentation, but I'm just
00:15:36
wondering your thoughts on how you would manage one and maybe
00:15:41
making these decisions on.
00:15:42
Hey, this is a conservative care is doing what it needs to do, or
00:15:44
hey, we need to step up into more higher level levels of care
00:15:48
where maybe imaging and neurologist or spine search and
00:15:52
consults might be in order.
00:15:53
Adam Dobson: There was a nice study, a randomized control
00:15:56
trial, the SCOPIC trial here in the UK.
00:15:59
And what it found was that fast tracking patients for more
00:16:04
interventional treatments was no better.
00:16:08
Yeah.
00:16:08
than a stepped care approach.
00:16:10
So there is evidence for a stepped care approach.
00:16:12
There's also a study called the nerves trial that shows that the
00:16:17
nerve injections with when patients who don't have profound
00:16:21
neurological deficits is just as helpful as microdiscectomy.
00:16:27
So already we can see that stepping our patients from less
00:16:34
interventional to more interventional patients makes
00:16:38
sense.
00:16:39
We know that big groups of people get better anyway by 12
00:16:43
weeks in one study, 50 percent of patients had 75 percent at
00:16:48
one year.
00:16:49
And we know the patients who are very acute symptoms like under a
00:16:52
couple of weeks.
00:16:53
Many of those patients do well and never access care.
00:16:57
So we We want to kind of take a stepped approach.
00:17:00
We don't have very good prognostic data, so we don't
00:17:04
have a crystal ball, unfortunately, Mark, to kind of
00:17:06
say they should definitely kind of be injected immediately or
00:17:11
operate on immediately.
00:17:13
I suppose the scopic trial was The hope was that was going to
00:17:17
give us more data in that direction, but we don't have, we
00:17:21
don't, we can't do that right now.
00:17:22
So, we want to enter the pathway advice and education supported
00:17:28
exercise, nerve root block, surgical consultation.
00:17:33
We want to enter that pathway at the least invasive, least
00:17:38
intrusive position.
00:17:40
So now that doesn't necessarily mean.
00:17:43
The they're all at the beginning.
00:17:45
It doesn't mean they all start with advice and education, but
00:17:49
we want to try and enter At the lowest reasonable chevron now
00:17:53
There are a number of factors that we can go into that
00:17:57
contribute to that But that's the general gist of a stepped
00:18:01
program that's what we use in the nhs That's what I would use
00:18:05
to patients where we're a little shy of You sticking needles in
00:18:10
patients and operating on patients.
00:18:13
And we can maybe go through those variables if you like,
00:18:15
Mark.
00:18:16
Mark Kargela: No, that'd be great.
00:18:17
I'd love to, for you to go into those.
00:18:19
That would be very helpful.
00:18:20
Adam Dobson: So the red lines obviously is the patient
00:18:23
presents with red flag pathology.
00:18:26
So, the three Ps is a nice way to think about that.
00:18:30
So they are progressive, weakness.
00:18:34
So you see them over a couple of visits and they've gone from a
00:18:37
four out of five to a three out of five.
00:18:40
So it's kind of, it's getting worse over the visits.
00:18:44
Profound weakness or anything under three or two, anything
00:18:48
under three out of five would indicate they've got a profound
00:18:51
weakness in the leg.
00:18:53
And the other one is poly root.
00:18:56
So if they seem to be weak at a couple of different root levels,
00:19:01
so maybe the ankle and the knee, then those patients you just
00:19:04
need to move them up.
00:19:05
You just need to move them to your specialist service, to your
00:19:09
specialist clinic, whoever that may be.
00:19:13
Other things like pain severity may come into it.
00:19:17
So, I don't necessarily think that just because they've had
00:19:21
pain for two weeks, three weeks that we shouldn't inject if you
00:19:25
have access, if they've got severe leg pain and they have a
00:19:31
preference towards interventional management
00:19:33
they're safe and you have access, we do have data that
00:19:37
injecting early.
00:19:39
Is helpful so that could be a consideration I tend to find
00:19:43
that many patients really don't want to be injected immediately
00:19:47
So so their kind of preferences are taking that out of your
00:19:51
hand, I guess there are a couple of Kind of outcome measures that
00:19:55
you can use to look at disability and leg pain severity
00:19:58
But just getting an understanding of how much this
00:20:01
is interfering with the patient's life is obviously
00:20:04
going to be a good way to look at it diagnostic confidence
00:20:07
again How confident are we that this is a ridiculous problem?
00:20:12
Are we going to be looking at interventional management when
00:20:17
it's pretty equivocal, a presentation, or perhaps their
00:20:21
main problem is their back.
00:20:23
So if they have some leg pain but their back pain is their
00:20:27
main problem.
00:20:29
We're not going to be considering injections for those
00:20:31
people because it's not their main problem.
00:20:34
It's their back, you know, 60 percent of all people with back
00:20:39
pain have leg pain.
00:20:41
So, so it's not like everyone who has leg pain.
00:20:45
has radicular pain or indeed that even if we do feel they may
00:20:50
have some radicular involvement that a nerve root injection is
00:20:53
going to be helpful.
00:20:55
The last thing I would say is if they're getting better, if
00:20:58
they're getting better, even if they're not fully recovered, we
00:21:02
probably don't want to be injecting those patients.
00:21:04
So if they have a trend of general improvement, maybe over
00:21:08
six, eight weeks and they're managing and they're on board,
00:21:11
With advice or maybe supported exercise, then we probably want
00:21:16
to hold on to those people.
00:21:18
Mark Kargela: That's helpful for sure.
00:21:19
I know a lot of folks are probably going to benefit from
00:21:21
hearing some of that.
00:21:22
Good review for some of us and definitely good tips and
00:21:25
pointers.
00:21:25
Definitely there's some things that I hadn't thought about
00:21:27
quite as in detail.
00:21:28
So thank you for that.
00:21:29
The economical approaches, neurological approaches, you
00:21:33
kind of talked about kind of your economical exam because
00:21:37
there's like a difference between, you know, a busy clinic
00:21:41
where you got patients coming in on, I'm not sure how frequently,
00:21:44
but often on the half hour, sometimes more quickly,
00:21:46
especially if you have any, you know, urgent cases that need to
00:21:49
get squeezed in and that type of thing.
00:21:51
I'm wondering kind of economical, not only from a time
00:21:55
aspect, but maybe economical from a cost aspect.
00:21:59
I know NHS is much more cost aware, I guess.
00:22:03
I mean, the U.
00:22:03
S.
00:22:04
system sometimes is more revenue based as far as what, what gets
00:22:08
done is often what you know, and that's not always the case.
00:22:11
There's some great healthcare systems that are very
00:22:12
conservative in nature, but I sometimes want to pull out even
00:22:17
the remaining hair I have left when I hear like people just
00:22:19
automatically jump into surgery and you hear their symptoms
00:22:22
going into that were like mild, you know, none of the red flag
00:22:25
things that you spent, you know, spoke about that were, you know,
00:22:28
You know, it's dictating a, you know, stepping up with the care
00:22:30
into some more interventional ways of getting at it.
00:22:34
I'm wondering how you look at the economical kind of concepts
00:22:39
again, both from a time and financial aspect as you manage
00:22:42
these cases.
00:22:44
Adam Dobson: So, yes, I think that in terms of the care that
00:22:48
we offer, I suppose I am quite economical in terms of I don't
00:22:53
think all patients need courses of physiotherapy.
00:22:57
You know, they've had this awful thing land on them out of the
00:23:01
blue.
00:23:02
You know, they were going about their business fine.
00:23:05
And these things can be quite, you know, they've never had a
00:23:07
problem before, and all of a sudden they've got this raging
00:23:10
leg pain, strange sensations into the leg and then we're
00:23:15
coming along and going, you know what, we need to develop a all
00:23:18
singing and dancing rehabilitation program.
00:23:21
They may not have time for that.
00:23:23
They may already have.
00:23:25
Interests and activities that they like to do.
00:23:29
So, kind of meet the patient where they are.
00:23:31
It may be that we encourage them, you know, look you, you
00:23:34
would usually cycle.
00:23:36
You know, maybe see how you feel doing some short cycles, a walk
00:23:41
in program.
00:23:42
Maybe they're still going to the gym.
00:23:44
And we say, look, we can incorporate some aspects into
00:23:48
that.
00:23:49
But I don't try to see it as like, you know, you have to come
00:23:52
to physio for six sessions.
00:23:55
I think it's depends on what the patient wants.
00:23:57
Thanks.
00:23:58
And it depends how much time they've got.
00:24:00
It may also be that we tell them to back off some things.
00:24:03
It might be that, you know, perhaps you need to back off the
00:24:07
gym a little bit if it's too intense.
00:24:09
So advice and education, having clear route for review, using
00:24:16
the neurological exam to tell a story about the nature of their
00:24:20
problem.
00:24:22
And then using, we have in the UK something called PIFU.
00:24:26
Patient initiated follow up.
00:24:29
So essentially it's kind of, this looks like it's improving.
00:24:33
You're doing some, you're doing some good activity.
00:24:37
We know this is largely a time thing.
00:24:39
You know, you're managing your problem from what you're telling
00:24:43
me.
00:24:43
Let me leave the door open.
00:24:45
And you can enter within a, an amount of time if you need to.
00:24:50
So I'm kind of anti Come to the clinic every week.
00:24:56
All, you know, the bells and the whistles.
00:24:58
I don't think that we need to do that necessarily.
00:25:01
Mark Kargela: Was that a transition for you at all?
00:25:02
Do you think as far as I know earlier in my career, I felt
00:25:05
like this need to have to feel needed in a patient's case, I
00:25:08
think to where I almost like probably looking back
00:25:10
recommended I'm much more fine with saying, Hey, similarly,
00:25:15
like this trajectory looks good.
00:25:16
A lot of education, reassurance and hey, leave the door open,
00:25:19
like you said.
00:25:20
And you know, occasionally people still come back and might
00:25:22
need maybe, okay, there are, it does look like it's progressing.
00:25:24
It took a turn for the worse.
00:25:26
But I'm wondering if that was a difficult transition for you at
00:25:28
all.
00:25:29
Adam Dobson: I worked privately before I came to the NHS and as
00:25:34
a band five physiotherapist, so I was very wet behind the ears
00:25:38
and I was certainly kind of, It was instilled into me that, that
00:25:43
we need to see these patients regularly.
00:25:45
We need to treat them regularly.
00:25:49
And I have to say for a period of time, I felt quite awkward
00:25:53
doing that.
00:25:54
Like I felt a bit uncomfortable.
00:25:56
It was almost like there were things that weren't being said.
00:26:00
So the patient was begrudgingly coming for a tennis elbow or
00:26:04
something like that.
00:26:05
And I was, you know, doing the same things I did last time.
00:26:08
And the, I got the impression a patient doesn't really want to
00:26:11
come, but they're coming because I'm asking them to come.
00:26:15
And I'm well, we're do, I'm doing and saying the same things
00:26:18
we did last time.
00:26:19
So, but it was a kind of like a culture isn't it of you comfy
00:26:24
your six sessions, you get your calls.
00:26:26
Successions cause that's the best way to do it.
00:26:29
And when I moved into working in the public sector, because, you
00:26:34
know, time and resources are a variable, I guess.
00:26:38
I become more well, what would you like to do?
00:26:41
And these are our options and kind of leaving it in their
00:26:45
court to decide.
00:26:46
So we could do this, we could do that.
00:26:48
And.
00:26:49
Having worked a little bit more privately in, in recent times,
00:26:53
I've carried that over really at the end of the consultation I'm
00:26:57
less a physiotherapist, more a musculoskeletal professional and
00:27:02
I'm so, nothing serious going on.
00:27:04
These are your options.
00:27:05
We can work together over X amount of time you know, if it
00:27:10
was a tending related problem or I can design some.
00:27:14
strategies you can take on and leave the door open, or you can,
00:27:19
you, we can say bye today and and you're doing some great
00:27:24
things already.
00:27:25
So I've certainly changed my, my, my way of thinking and way
00:27:30
of practicing.
00:27:31
Mark Kargela: That sounds familiar as far as your
00:27:33
transition.
00:27:34
I think.
00:27:35
You know, we're talking to physios, you know, both here in
00:27:37
the States and abroad, you know, in the private setting, there
00:27:39
could be some pressures economically of maybe having to
00:27:43
see people more frequently, again, different reasons.
00:27:46
So I'm fortunate.
00:27:47
I work in a university clinic setting where it's very much,
00:27:49
you know.
00:27:50
What's best for the patient.
00:27:51
Not that again, we can't do some things, of course, if we're
00:27:53
seeing people in person, but I do tend to echo the thoughts of
00:27:56
oftentimes people don't need formal bouts of physio.
00:27:59
I mean, if they want it, that's not, you know, you give them an
00:28:01
option, like you said, and You can work together, support
00:28:03
somebody in the natural healing, let their natural healing
00:28:05
process take center stage instead of some amazing
00:28:08
technical prowess that we're trying to bestow upon them.
00:28:10
And that I think over complicates matters and
00:28:12
oftentimes gets them, you know, in the thinking that's a
00:28:15
necessary or must have part of the recovery where oftentimes
00:28:20
the body, if given the right context and the right support
00:28:22
can kind of write the ship on its own.
00:28:24
Adam Dobson: I And appreciate Mark, just to say, I suppose
00:28:27
it's very easy for me to say that because I can do it.
00:28:32
But, you know, I don't have those additional pressures.
00:28:36
So I appreciate that might be, it's easy when you don't have
00:28:40
that pressure to say that.
00:28:42
But I also think we've got to be a little bit modest with what we
00:28:45
can provide and what we can do, certainly in this area.
00:28:49
But in all areas, I think it's become pretty apparent.
00:28:52
that most of the improvement that we see in problems that do
00:28:56
have natural histories is probably not because of what
00:29:00
we're doing physically.
00:29:02
Mark Kargela: that's sometimes such a hard pill for physios as
00:29:04
well.
00:29:04
I know for me, probably earlier in my career, I struggled for
00:29:06
that.
00:29:07
But I, I think recovery coach is a good way to look at it
00:29:11
sometimes as far as supporting what bodies are designed to do.
00:29:14
And a lot of times it's insulating them from a lot of
00:29:18
interventional narratives or things on the internet and Dr.
00:29:21
Google and things.
00:29:22
I'm wondering how much you deal with that in your practice as
00:29:25
far as.
00:29:26
You know, patients where they've, you know, watched the
00:29:29
latest YouTube video or they've you know, googled whatever.
00:29:33
And then they come in with all sorts of catastrophic thoughts
00:29:37
or needs to have these, you know, major tests.
00:29:39
Maybe, is that one, something you deal with?
00:29:41
And then two, you know, what's your approach to kind of maybe
00:29:44
talk people off the cliff of jumping into interventions that
00:29:47
may not be, You know necessary at that point in their
00:29:52
Adam Dobson: so in this particular group, if you're
00:29:54
getting to those kind of typical ridiculous neuropathic cases
00:30:01
that they're fairly easy actually.
00:30:03
Because they, and I suppose that's why clinicians, some
00:30:07
clinicians will lean towards tissue based narratives because
00:30:13
I suppose that there's less conflict.
00:30:15
There's less challenge when you're there, but with those
00:30:18
barn door cases, you know, the nature of the problem.
00:30:22
the prognosis of the problem.
00:30:24
You know, they're, they think it's a nerve problem and it is a
00:30:28
nerve problem, you know, and some cases if they've got, you
00:30:31
know, these nerves may be injured.
00:30:33
So, you know, there is a medical language that applies and we,
00:30:39
when it's appropriate, sensibly, we should be talking about that.
00:30:45
So we, we shouldn't be just because we're developing.
00:30:49
More into a biopsychosocial approach doesn't mean that we
00:30:53
when there is a clearly a structural Element going on.
00:30:57
I don't think we need to be shying away from that still the
00:31:00
B, isn't it?
00:31:02
What I would say is more challenging is those kind of
00:31:09
recurrent cases where they kind of come and they don't have
00:31:12
symptoms anymore, but they've had it several times in the
00:31:16
past.
00:31:17
Chronic cases are very can be quite difficult because, even
00:31:22
when you use the labels and say, well, yeah, you have ridiculous
00:31:26
pain or we're reconceptualized sciatica.
00:31:29
Many of those patients are just not going to respond to
00:31:33
interventional management.
00:31:35
That, that would also include patients who've had previous
00:31:38
surgery.
00:31:38
It seems to be that operating on patients who have already been
00:31:42
operated on when they've got rigid, residual or chronic,
00:31:45
radicular symptoms just don't do well.
00:31:49
So the conversations around that when there is a tissue narrative
00:31:52
and it's appropriate to use can be difficult because the, We're
00:31:57
not really managing them with interventions as such.
00:32:00
They become chronic pain patients.
00:32:03
So, even though they have a legitimate label.
00:32:06
It's similar with stenosis, I guess.
00:32:09
Although I do find it a little bit easier with stenosis if you
00:32:12
meet them earlier and they've not had surgery.
00:32:15
So, so I suppose the other group is just that quiver call group
00:32:19
where they've got some other pain states going on.
00:32:22
They've got some leg pain, but it's just not really adding up
00:32:26
to anything ridiculous in nature.
00:32:29
And many of those will push for.
00:32:31
for imaging, you know, understandably, I guess in some
00:32:35
cases.
00:32:35
And I think as a junior physiotherapist, those kind of
00:32:40
gray areas are more challenging for sure.
00:32:44
Mark Kargela: Definitely plenty of gray out there in the clinic.
00:32:45
That's undoubted you speak to a bit about the place for tissue
00:32:50
based mechanical type diagnoses And I think there's been
00:32:54
rightful criticism, especially around, you know, the craze of
00:32:56
pain science and Pain neuroscience education to, and
00:33:00
you'll hear just, you know, bad examples of physios just
00:33:03
completely shelving, like a good physical neurologic examination
00:33:06
and immediately defaulting to, you know, this pain, chronic
00:33:10
pain, persistent pain, and get way into the pain neuroscience
00:33:13
education weeds with people.
00:33:14
Is that something you've seen too, in your, Practice or in
00:33:17
your experience where and maybe I know for me, I did have a
00:33:20
period where I probably swung.
00:33:21
I know I talked to Jack March and other folks who I think we
00:33:23
all have this, like, you know, new information.
00:33:26
We grab it and like, Oh my God, I want to just, you know, change
00:33:29
the world with this new information.
00:33:30
And it comes back to reality of like, okay, right person, right
00:33:33
place, right time, not just bombard everybody with it.
00:33:35
Is that been your experience that you've seen with the pain
00:33:38
science craze?
00:33:39
Adam Dobson: I think that it might be a bit of a
00:33:42
misrepresentation to be honest.
00:33:44
I think on people would probably look upon me and think he is,
00:33:48
cause I am, you know, very invested in rehabilitation and
00:33:51
biopsychosocial.
00:33:53
working.
00:33:54
And just because you hold those views, it doesn't mean that you
00:34:00
don't examine your patients, that you don't triage patients,
00:34:04
that you don't consider sinister pathology.
00:34:07
I actually think that to arrive at this place, and still
00:34:12
champion it after a period of time.
00:34:16
To find yourself in this place, you have to have gone through
00:34:20
that and respect the tissues and the structures to find yourself
00:34:25
at this place.
00:34:27
I personally feel and certainly you will get misrepresented on
00:34:32
Twitter quite a lot if you champion things like, you know,
00:34:36
we need manage stress and we need to we need to reduce this
00:34:40
overprotective movement strategies.
00:34:43
You know, those things can still be true and have a place and
00:34:47
still be vigilant for.
00:34:50
Serious pathologies and tissue based kind of diagnosis.
00:34:55
Like, so I'm kind of like straddling the bench because the
00:34:58
reality is they're both relevant, but so I, yeah I think
00:35:02
it's probably, I think.
00:35:05
I would see less individuals who are just totally chomping at
00:35:09
paying neuroscience hard, you know, and just kind of
00:35:14
forgetting about that.
00:35:15
I would say it's probably the other way around if I'm honest.
00:35:18
Mark Kargela: I think it's these false dichotomies that get
00:35:19
created on social media where, you know, one side saying all
00:35:22
you're doing is thinking about the tissues.
00:35:23
You're not doing any.
00:35:25
any talking with people and getting to know their unique
00:35:27
stories.
00:35:27
And then the other side saying the opposite, where a more
00:35:29
nuanced view of that you nicely demonstrate is, you know, it's
00:35:34
all of it, you know, you can't, you got to do all of it and make
00:35:36
sure each patient gets a thorough examination to look at
00:35:40
maybe whatever sides of those coins that they may fall in.
00:35:43
And that's obviously a lot of gray and challenging you know,
00:35:48
things we have to, you know, weed through with patients.
00:35:50
I'm wondering as we talk about the physiotherapy input into
00:35:54
these management of cases, I know it's different and
00:35:56
different NHS might be a little bit different in the U.
00:35:59
S.
00:35:59
I know there's definitely like in the military here in the U.
00:36:01
S.
00:36:02
I mean, we got kind of similar, I think, to extended scope
00:36:05
practitioners there in the U.
00:36:06
K.
00:36:06
where there's, you know, prescribing rights and can order
00:36:09
imaging and do different things.
00:36:10
I'm just wondering.
00:36:11
In the general scheme, maybe in your practice, and then maybe
00:36:13
what you see physiotherapy's ideal role in the management of
00:36:18
these cases should be, like, what kind of input do you feel
00:36:20
like we need to be having in the management of these cases?
00:36:24
Adam Dobson: So it probably will depend on the position within
00:36:28
the pathway that you work in.
00:36:29
So I work in triage, so I will, While Sam, I'll be considering
00:36:35
all management approaches and I'll have access to all of those
00:36:40
management approaches, including the interventional ones.
00:36:44
So I don't have to move anyone further up the line before I
00:36:48
would investigate.
00:36:49
But I am a physiotherapist and I, like I said, I do subscribe
00:36:54
to doing as little as is required.
00:36:57
And I would say our roles as coaches.
00:37:00
As educators, as safety netters, as as just, you know, decent
00:37:07
human beings you know, remaining vigilant well educated in these
00:37:13
particular areas.
00:37:15
I'm certainly one for, I love my reflex hammer.
00:37:18
And and becoming very efficient with your reflex hammer, with
00:37:22
your handling skills, with your education.
00:37:26
So, but we're not fixing people, are we?
00:37:28
You know, we're offering the prognostic information that
00:37:33
what's the likelihood of their recovery.
00:37:36
We're being realistic within coaching and facilitating
00:37:40
approaches that reduce suffering, that help them make
00:37:44
sense to keep them doing things that they value and not to scare
00:37:51
them, you know, so, so we're not pushing things back in.
00:37:55
We're not fixers.
00:37:57
We're not mechanics we're coaches.
00:37:59
And actually the evidence for physiotherapist interventions,
00:38:03
you know, whatever they are ultrasound and taping and you
00:38:07
know, Mackenzies and whatever, the evidence is actually very
00:38:11
poor.
00:38:11
So, you know, we can't really you know, physiotherapists or
00:38:16
physical therapists or.
00:38:19
analogous professionals or anyone in terms of conservative
00:38:23
management, none of us can say that we do, we offer amazing
00:38:28
treatments because the evidence doesn't exist.
00:38:31
It's very poor.
00:38:33
It's not to say that we don't we can't help in that direction.
00:38:37
You know, we need to be modest, I think right now.
00:38:39
Mark Kargela: As I mentioned earlier, sometimes I think we
00:38:41
want to feel like this.
00:38:43
Maybe it's a self worth thing in the grand scheme of our
00:38:46
profession feeling like we're really making a difference that
00:38:48
we have to have this like agency over a person's recovery, where
00:38:52
the reality of the situation is, you know, a lot of these
00:38:55
conditions are going to navigate the way these conditions
00:38:57
navigate naturally.
00:38:58
And we can definitely support it in a more efficient manner and
00:39:02
give more adaptive advice to have people hopefully recovering
00:39:05
at a better rate.
00:39:06
More rapid rate than need be.
00:39:08
But as you've mentioned, also nicely recognizing folks where,
00:39:11
man, this is more than just your recovering.
00:39:13
Ridic.
00:39:13
There's some serious, you know, red flag signs.
00:39:15
It's progressive.
00:39:16
It's poly route.
00:39:17
It's things that need more of a stepped approach to where we can
00:39:21
be the facilitator of getting those folks up the chain a bit.
00:39:25
So, I'm wondering last topic, and then I want to respect your
00:39:29
time as far as where you were.
00:39:31
The role of activity plays.
00:39:33
In your I know you've already spoke to a bit of that as far as
00:39:36
like, Hey, maybe I need to pull somebody back from the gym.
00:39:38
Maybe I need to, you know, get some people moving a little bit
00:39:41
who are more on the self immobilizing self, you know,
00:39:45
limiting where maybe it's not necessary.
00:39:47
I'm just curious how you kind of look at the role of activity as
00:39:50
you're managing some of these cases.
00:39:52
Adam Dobson: we want to know what they already don't we?
00:39:54
So what's the level of activity that be leisurely, if it'd be
00:39:59
occupationally, if it'd be kind of a commuting kind of thing
00:40:04
what's your level of activity in different domains in your life?
00:40:07
And are they.
00:40:09
Doing what they usually do, or are they doing less?
00:40:12
What's the level of that?
00:40:13
Are those things too painful?
00:40:16
If those things are too painful to do and it's unacceptable to
00:40:20
the patient then we might be advising backing off.
00:40:25
So if they do four spinning classes a week, and they're, and
00:40:29
they are in intense pain in their spinning class and they're
00:40:33
falling off the spinning bike.
00:40:34
Then we may perhaps go, you know, it might be helpful for
00:40:37
healing to back away from that.
00:40:39
Maybe they do an office job.
00:40:42
Factory job and standing all day long and that is particularly
00:40:46
uncomfortable.
00:40:47
Can we get them, can they take time off?
00:40:50
I don't think that's always a bad idea.
00:40:53
If what they're doing is comfortable then can we just
00:40:57
continue as they are?
00:40:58
Or maybe we can dial it up a little bit.
00:41:01
We do know that there is some evidence for cardiovascular
00:41:04
exercise.
00:41:06
being helpful to the recovery of axons when they're injured.
00:41:09
So the, some basic studies in rats but, you know, trying to
00:41:14
get a person who's in.
00:41:15
Quite a lot of pain to push themselves on a cycle might be a
00:41:19
hard sell.
00:41:20
Following on from that if they want some kind of program they
00:41:26
want to do something else then.
00:41:30
You've got lots of options, haven't you?
00:41:32
You can do your McKenzie's if you so wish.
00:41:35
I generally look at like basic stretching.
00:41:38
We have something on our website called backtracks.
00:41:40
So basic stretching, walking programs swimming but really, I
00:41:46
don't want to try and reinvent the wheel.
00:41:49
And you know, I just want to get a feel for what, Patients want
00:41:53
to do and kind of go, you know, entertain them and go down that
00:41:57
route while we're given this time, but I think we need to be
00:42:01
very heavy on the expectations, you know, we can't expect that
00:42:05
this problem will get better in a week, just does not work like
00:42:09
that, you know, if you get the expectations, right.
00:42:12
And you you get to know your patient and all the usual things
00:42:16
you've listened to them, you've examined them, you've, I like to
00:42:19
use a model I've got like an anatomical model I know that's
00:42:23
some people talking about nerves and discs So, so yeah, I've got
00:42:29
a bit of a flow chart that I've developed that I talk about and
00:42:33
some can maybe share that with you, Mark, but a very basic
00:42:37
algorithm to determine if we need to push someone or pull
00:42:41
them back or what type of activity we want to do, if it's
00:42:45
therapeutic and kind of structured or if it's, you know,
00:42:49
push, get some more spinning sessions in.
00:42:53
Mark Kargela: Anything you can share, we'll, we would greatly
00:42:55
appreciate.
00:42:56
And we'll link the articles that Adam mentioned earlier on in the
00:43:00
show notes, so y'all can take a look at those as you try to help
00:43:03
better help your practice as far as managing some of these cases,
00:43:05
I wanted to thank you for your time today, Adam, I really
00:43:07
appreciate it and really appreciate your expertise and
00:43:10
sharing it with us today.
00:43:11
Adam Dobson: Thank you very much, Mark.
00:43:13
Mark Kargela: For those of you listening, if you can subscribe,
00:43:14
wherever you're listening to this podcast, for those of you
00:43:16
watching on YouTube, we'd love if you could subscribe and maybe
00:43:18
even share this episode with somebody else who could help
00:43:20
benefit from learning a little bit more about lumbar
00:43:23
radiculopathy, but we'll wrap it up there and we'll talk to you
00:43:25
all next week.
00:43:27
announcer: This has been another episode of the Modern Pain
00:43:30
Podcast with Dr.
00:43:31
Mark Kargela.
00:43:32
Join us next time as we continue our journey to help change the
00:43:35
story around pain.
00:43:36
For more information on the show, visit modernpaincare.
00:43:39
com.
00:43:40
This podcast is for educational and informational purposes only.
00:43:43
It is not a substitute for medical advice or treatment.
00:43:45
Please consult a licensed professional for your specific
00:43:48
medical needs.
00:43:48
Changing the story around pain.
00:43:51
This is the Modern Pain Podcast.
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