Talking certainty, uncertainty and EBP with Raymond Ostelo

We’re still working on the cover design for our upcoming book Understanding Sciatica - a frustratingly long back-and-forth process with the designer that I wish I’d started much earlier…In the meantime, I thought I’d re-send this podcast that Annina and I recorded in September 2020. It’s still the most popular episode of the pod. Might nerve pain be the most interesting thing in the world?Below are the timestamps for the Q&A, with some relevant pictures and links. (Please by aware if you are reading this through your podcast app, the pictures and links may not show). If you have not heard from Annina before, I recommend her episode of The Physio Matters Podcast as a good introduction on this topic. Today’s podcast takes more of a deep dive!Timestamps0.00 - 2:55: intro2:55: is radicular pain neuropathic?I reference Annina and Brigitte Tampin's classification for low back related leg pain which you can see more about hereAnnina mentions the NeuPSIG grading system for neuropathic pain:6:48: ectopic activity from abnormal impulse generating sites Ectopic means "in the wrong place". Ectopic activity means action potentials arising from the wrong place in the nerve. For example, instead of arising in the peripheral terminals as they should, action potentials can be generated in the nerve trunk or the dorsal root ganglion. In entrapment neuropathies, this will typically happen when a patch of the nerve becomes demyelinated and ion channels lodge in that part of the cell membrane. This picture shows the process in a nerve that has been completely cut, but the concept is the same for nerves that are merely crowded out.9:07: mechanisms of stress-induced radicular painI mention a paper by Elspeth McLachlan which found that after sciatic nerve ligation, noradrenergic axons in rats sprout into the dorsal root ganglion and form basket-like structures which can activate sensory neurons.12:19: allodynia, wind up and other neuropathic pain features in radicular pain14:55: reaction of dorsal root ganglion to nerve root injury Dorsal root ganglion19:08: distal changes in radicular pain, loss of nerve fiber density I mentioned a study by Andrasinova et al. that showed loss of intra-epidermal nerve fiber density in people with radiculopathy. This beautiful artwork by Kathleen Sluka shows intra-epidermal nerve fibers.26:08: antidromic impulsesAntidromic impulses are action potentials that go "the wrong way". They are part of some normal physiological processes, I think, but when associated with pain and ectopic action potentials they are pathological.One possible cause of antidromic impulses from dorsal root ganglion ectopia - pic from Sorkin et al.28:48: why would nerve trunk blocks reduce nerve root pain?I mentioned a paper from 1990 by Xavier et al. where they note that nerve blocks to the sciatic nerve trunk eases radicular pain, and suggest this might mean antidromic impulses are important for radicular pain. I also mentioned a study by North et al. that found nerve blocks distal to the nerve root ease pain.Another interesting read is this paper from 1984 by Norden et al., who measured antidromic activity in the sural nerves of two people with radicular pain - activity that correlated with increases in symptoms.34:05: avoiding pain or pushing through the pain37:33: can we determine the underlying mechanism of radicular pain clinically?Annina mentions case studies from McKenzie practitioners who can reverse loss of function, like a foot drop, through repeated movements. She suggests this might be a sign of ischaemia. I have not been able to find a video of this. But on Mark Laslett's course he showed a video of one of his patients who developed myotomal weakness - unable to heel walk - when sitting slumped but recovered strength with repeated extension.40:47: oedema as a cause of compression 43:17: surgery for longstanding radicular pain46:06: Annina asks me why I'm so interested in sciatica!49:30 - end: discussing the role of observation and creativity versus rigour and quantitative data in scienceUnderstanding Sciatica, with contributions by Annina Schmid, will be published…. soon? This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit tomjesson.substack.com

Thanks for reading the 38th edition of my newsletter. This newsletter tracks my research as I write a book about lumbar radicular pain!EDIT - The sound quality of this podcast is quite poor - you have been warned. I will try to transcribe it one day.This edition, it’s my pleasure to bring you my conversation with Ash, a project manager from Chennai, India, who has a long history of back pain and sciatica but has nevertheless pursued his powerlifting goals and, to a great extent, recovered from pain. Ash is deeply insightful about his journey and about his pain. During our conversation, he told me not only about how he approaches training with pain, both practically and psychologically, but also how he has found that things like sleep, stress, work and friendship all have a bearing on how his back pain and sciatica feel.One thing that struck me during our conversation was how much work Ash has put in to teaching himself about pain and exercise. He showed me piles of notebooks and, on his laptop, reams of pdfs. He’s a skilled and tenacious autodidact. This is greatly to his credit, but it did also serve as a reminder to me of how hard it is for all of us - laypeople and clinicians - to get our heads round this pain thing. I think this episode will be useful for clinicians who want a reminder of the power of education and of the right approach to training. I also think that, like my conversations with triathlete Kate Charlton (here and here), this episode will be useful for athletes with sciatica who want to get back to training.Finally, here are some links to the resources Ash mentions during our conversation (asterisk = particularly strong endorsement from Ash):* The Gift of Injury book by McGill and Carroll* *Austin Baraki lecture* *Explain Pain book* *Barbell Medicine* *Recovery Strategies by Greg Lehman* Muscle Strength Pyramid approach* Stronger by Science website* Strength System, biopsychosocially enlightened gym in Chennai* Back Pain talk by Mark Rippetoe* *Aches and Pains article by Austin Baraki This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit tomjesson.substack.com

Thanks for reading the 31st edition of my sciatica newsletter. This newsletter tracks my research as I write a book about lumbar radicular pain!Hi from San Jose, California, where I’m visiting the in-laws!Here’s part two of my chat with Adam Dobson, where we discuss neuropathic pain, nerve assessment, exercise and rehab for sciatica, and more! Find part 1 here.And here’s a few links to stuff Adam mentioned during our conversation:* The IASP grading system for neuropathic pain* The work of Dilley and Bove* This trial by Mathieson and colleagues* My newsletter on dermatomes* Kerezoudis on the effect of epidural steroid injections on bone mineral density* Adam’s bengal catI hope you enjoy our conversation - let me know what you think! You can contact me by replying to this email.Lastly, a quick reminder of the free sciatica email mini-course, which is for anyone who wants to get up to scratch on the basics!Til next time,Tom This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit tomjesson.substack.com

Thanks for reading the 30th edition of my sciatica newsletter. This newsletter tracks my research as I write a book about lumbar radicular pain!I must say things have been pretty quiet on the book front this week! In the time I’ve had to work on it, I’ve mostly just been wading through the literature. It seems like on any topic there’s really only a few key papers that give you most of what you need. But you have to read all of them to find out which are the key ones! It’s slow going at times…Anyway, this week I want to share with you a podcast I recorded with Adam Dobson, a physiotherapist from the North of England with a keen interest in spinal pain (and author of this patient info leaflet).I would describe Adam’s approach to assessment and treatment as pragmatic and sensible! I think our conversation will be particularly interesting for people who are used to assessing and treating people with low back related leg pain, and know a bit about the basics of radicular pain, but still feel like they’re trying to put the pieces together to come up with an approach that works for them and their patients. This first podcast, part one of two, focuses on assessment including referred pain, vascular masqueraders and other peripheral neuropathies!At the end of this email, I have put some links to some of the papers and resources that Adam mentions.Lastly I just want to say a huge thank you to Adam, not only for taking the time to talk but also for putting himself out there to talk about his practice!Til next time!TomPapers and resources mentioned in this podcast:* Adam refers to Schmid and Tampin’s schema for understanding low-back related leg pain* Here’s Adams extension of that schema, where he’s cast the net a bit wider (if this is too small, click here to see a bigger version)* Here’s Adam’s summary of the ABPI test* On referred pain, Adam mentions Kellgren, McCall on facet pain, and Lesher on hip pain.* On entrapment neuropathies, Bowley and Doughty* The BMJ paper and infographic on peripheral artery disease* Mathieson on pregabalin This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit tomjesson.substack.com

Thanks for reading the 25th edition of my sciatica newsletter. This newsletter tracks my research as I write a book about lumbar radicular pain!This week I spoke to Kate Charlton again! When we spoke last year, she was recovering from her second bout of radicular pain, getting back into her training and everything was going well. Since then, Kate’s pain returned. She chose to have surgery and so far, her recovery is going really well. In the podcast, we talk about:* Her decision to have surgery* Returning to training after surgery* Attitude and mindset* And much more!And, after last week’s newsletter, it was interesting to hear that Kate’s cold foot recovered immediately after her operation!This conversation, and our previous one, will be useful for any of your patients who have radicular pain and want to return to sport, especially if they train and compete at a high level.That’s it for this week! With a deadline looming, I’ve got to get back to work!Til next time,TomP.S. Here are some photos of some mourning doves that have started visiting our balcony. I’ve given them some seeds. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit tomjesson.substack.com

Thanks for reading the 19th edition of my sciatica newsletter. This newsletter tracks my research into all things lumbar radicular pain!This week I spoke to Professor Raymond Ostelo! Raymond recently published a fantastic review of the evidence behind the treatment options for sciatica (link should be open access). In our conversation, we talk about the evidence behind the conclusions of his review. I ask Raymond about:* How much confidence we should have in the evidence around sciatica* Whether our research methods are sensitive enough to pick up on differences between treatments* How clinical expertise fits in with evidence based practice* What study he would conduct if money and recruitment were no object!* How he thinks two trials he has been involved in - those lead by van Helvoirt and Luijsterburg - should inform our practice* And more!I hope you enjoy the podcast.Other bits and bobs* I recommend the latest episode of The Back Pain Podcast, a conversation with David Poulter about discs. He describes disc material as being like crab meat with added water…* I learned a lot from the conversation under this tweet by Luke Murray, asking for advice for his friend with severe acute radicular pain. Here’s some highlights:It strikes me that a lot of the options for Luke’s friend are based on no research evidence or poor research evidence. In fact, there is high level evidence that says that oral steroids, anti-neuropathics and steroid injection have little meaningful benefit for people with sciatica. But anyone with an ounce of common sense would know that this doesn’t mean these things “don’t work”, and anyone with half a heart would know this doesn’t mean we shouldn’t think about using them. So much of the decisionmaking in this space comes down to clinical experience, knowledge of the mechanisms, and your own philosophical stance on what research evidence *is*. (Which Raymond and I talk about in the podcast!)* Book update! Here’s a photo the kanban for the book - this is just the first part, “What is Sciatica?” Sticky notes go from the “pending” column to “researching”, then “writing”, then “editing”, then (empty so far!), “done”. (If the photo looks confusing to your eye - the sticky notes are on a mirror!).So far, I have written 30,000 words of this section. I expect it will get shorter (and better) as I edit and cut. To help me along I have made a contract with my mate Nils where he gets £1,000 from my account if it’s not finished by February 1st… Nils is exactly the kind of person who would happily take my money, so this is a good extra bit of motivation. But today is Sunday so I’m off to play tennis! As a reward for Houston being near-uninhabitable in the summer, we are enjoying warm, sunny days in November. Til next time,Tom This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit tomjesson.substack.com

Thanks for reading the 17th edition of my sciatica newsletter. This newsletter tracks my research into all things lumbar radicular pain!For this week’s podcast I spoke to Mark Laslett! Here’s the timestamps for our conversation, with some links to one or two papers Mark mentions:1:38: On somatic referred pain.2:40: “Do you have a theory of what's going on when someone has radicular pain but their MRI does not show anything to explain it?”7:11: “Does largely compressive radicular pain have a different clinical picture to largely chemical?”12:10: The role of injections in the wider treatment plan. Mark refers to this study.16:20: Using screening questionnaires.19:25: Mark's approach to practice and different treatment modalities.24:50: How treatment of radicular pain has changed over time, the natural time course of radicular pain and speed of onset as a predictor of recovery.30:44: “Is there a role for exercise in treating someone whose radicular pain does not centralise?”33:33: “Are there any long term restrictions on movement after radicular pain has settled? And for squatting and deadlifting specifically?” Mark refers to this paper.39:39: The role of anti-neuropathic pain medications.43:40: Coming changes to Mark's online course and treating low back pain when research and guidelines feel vagueThanks to Mark for taking the time to talk. I sent him a list of questions ahead of time but it got lost in an email thread so he didn’t see it. When we realised this before recording, he said “Well if I needed to prepare to answer your questions, I shouldn’t be answering your questions!”. What a pro!Other bits and bobs* I was mortified to notice I’d commited a typo in the *title* of last week’s newsletter. But, no one noticed… right?* Tina has updated her already-brilliant website Living Well With Pain so now it’s even better. Great, practical information for patients and clinicians on sciatica, in particular persistent sciatica. * Here’s another really impressive spinal cord prosection* A new RCT by Julie Fritz and colleagues randomized 220 people with sciatica to receive usual care or usual care with four additional sessions of physical therapy. After six months, the early physical therapy group had an average 5.4 points better score on the Oswestry and an average 1 point less back pain - differences of debateable clinical importance. There was no average difference in leg pain. Unfortunately, I cannot access the full paper yet so I don’t know what the PT consisted of, or what they classed as sciatica etc. But the results seem disappointing although not that surprising. I think it’s really valuable to get an idea of how much PT treatment affects radicular pain so that we can decide how best to spend our time with patients and advise them on what to expect.Incidentally, the paper seems to be a very similar design to an older paper by Luijsterburg et al., and both found that patients getting extra PT reported greater treatment success but that their symptoms weren’t that different. * Here’s my chat with Jack Chew, talking about research (maybe not much new to readers of this newsletter) and from 18 minutes on I pretend I have it all figured out when it comes to social media and news consumption. Til next time!Tom This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit tomjesson.substack.com

Thanks for reading the 15th edition of my sciatica newsletter. This newsletter tracks my research into all things lumbar radicular pain!Today I was up bright and early to attend Annina Schmid's online course on assessment of entrapment neuropathies. Annina was kind enough to talk with me afterwards for a podcast! Our conversation mostly focused on the mechanisms underlying radicular pain.Below are the timestamps for the Q&A, with some relevant pictures and links. (Please by aware if you are reading this through your podcast app, the pictures and links may not show). If you have not heard from Annina before, I recommend her episode of The Physio Matters Podcast as a good introduction on this topic. Today’s podcast takes more of a deep dive!Timestamps0.00 - 2:55: intro2:55: is radicular pain neuropathic?I reference Annina and Brigitte Tampin's classification for low back related leg pain which you can see more about hereAnnina mentions the NeuPSIG grading system for neuropathic pain:6:48: ectopic activity from abnormal impulse generating sites Ectopic means "in the wrong place". Ectopic activity means action potentials arising from the wrong place in the nerve. For example, instead of arising in the peripheral terminals as they should, action potentials can be generated in the nerve trunk or the dorsal root ganglion. In entrapment neuropathies, this will typically happen when a patch of the nerve becomes demyelinated and ion channels lodge in that part of the cell membrane. This picture shows the process in a nerve that has been completely cut, but the concept is the same for nerves that are merely crowded out.9:07: mechanisms of stress-induced radicular painI mention a paper by Elspeth McLachlan which found that after sciatic nerve ligation, noradrenergic axons in rats sprout into the dorsal root ganglion and form basket-like structures which can activate sensory neurons.12:19: allodynia, wind up and other neuropathic pain features in radicular pain14:55: reaction of dorsal root ganglion to nerve root injury Dorsal root ganglion19:08: distal changes in radicular pain, loss of nerve fiber density I mentioned a study by Andrasinova et al. that showed loss of intra-epidermal nerve fiber density in people with radiculopathy. This beautiful artwork by Kathleen Sluka shows intra-epidermal nerve fibers.26:08: antidromic impulsesAntidromic impulses are action potentials that go "the wrong way". They are part of some normal physiological processes, I think, but when associated with pain and ectopic action potentials they are pathological.One possible cause of antidromic impulses from dorsal root ganglion ectopia - pic from Sorkin et al.28:48: why would nerve trunk blocks reduce nerve root pain?I mentioned a paper from 1990 by Xavier et al. where they note that nerve blocks to the sciatic nerve trunk eases radicular pain, and suggest this might mean antidromic impulses are important for radicular pain. I also mentioned a study by North et al. that found nerve blocks distal to the nerve root ease pain.Another interesting read is this paper from 1984 by Norden et al., who measured antidromic activity in the sural nerves of two people with radicular pain - activity that correlated with increases in symptoms.34:05: avoiding pain or pushing through the pain37:33: can we determine the underlying mechanism of radicular pain clinically?Annina mentions case studies from McKenzie practitioners who can reverse loss of function, like a foot drop, through repeated movements. She suggests this might be a sign of ischaemia. I have not been able to find a video of this. But on Mark Laslett's course he showed a video of one of his patients who developed myotomal weakness - unable to heel walk - when sitting slumped but recovered strength with repeated extension.40:47: oedema as a cause of compression 43:17: surgery for longstanding radicular pain46:06: Annina asks me why I'm so interested in sciatica!49:30 - end: discussing the role of observation and creativity versus rigour and quantitative data in scienceOther bits and bobs* I recommend this Words Matter podcast with Rani Lill Anjum.* These diffusion tensor imaging pictures of lumbar nerve roots are beautiful! From Shi et al. and Eguchi et al. That's it for this week! I'm off to bed now to wake up early again (on US time) for Colette Ridehalgh's half of the course tomorrow, on treatment of entrapment neuropathies. Til next time,Tom This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit tomjesson.substack.com

Thanks for reading the 13th edition of my sciatica newsletter. This newsletter tracks my research into all things lumbar radicular pain!This week I’m talking to Giacomo Carta.Giacomo is a basic science researcher in neuromechanics, neurorepair and neuroplasticity. He’s also a physical therapist! We discussed his research and his hopes for the future of neurodynamics, nerve pain treatment and physiotherapy in general.I hope you enjoy our conversation. Tom This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit tomjesson.substack.com

Thanks for reading the 11th edition of my sciatica newsletter. This newsletter tracks my research into all things lumbar radicular pain!This week's podcast is a Sciatica Story with Drew JordanDrew got sciatica about one year ago. He was on holiday and tried surfing for the first time which seems to have triggered it, and he spent a lot of time sitting which seemed to make it worse.After one or two false starts and misdiagnoses, he found out what was causing the pain, found a physical therapist who helped him a lot, and started making progress with his pain. He recently made a video on youtube explaining his approach and what worked for him called Sciatica Survival Guide. Drew has an incredible systematic, reflective, “big picture” approach to getting on top of his pain. His video, and I hope this podcast, will be helpful to clinicians and people with pain alike. I think it will be particularly useful for anyone who is trying to work out their personal “pain triggers” and how to manage them.I hope you enjoy our conversation!TomLinks:⚡ Drew’s Sciatica Survival Guide⚡ Drew’s Sciatica Playlist This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit tomjesson.substack.com