Adam Dobson
@adamdobson123
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Father. Physiotherapist in back pain. Prepping Painful Lumbar Radiculopathy course. Mini leopard cohabitation 🐆
Stockton-on-Tees, England
Joined February 2016
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Send us removal request.
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My course title has had a little upgrade 😍
MASTERING LUMBAR RADICULOPATHY
Are you North or are you South (of Nottingham).
This November, I'll be running one of my first-ever 2-day courses. The early bird for the November course ends on the 1st of October. In December, I'll be
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ACL injury watch with caution 😲
Just watch this tibial anterior translation. Wow.
¿Rotuliano? 🦵 Efectivamente gran demanda de cuádriceps, pero: ese apoyo en cara posterior de la tibia =
#LCA
. No hay ejercicios malos, pero si olvidamos que hay más estructuras que los músculos y cual es su velocidad y capacidad de adaptación 📝📌 los podemos convertir en eso 🏥
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Here is a thread on FMS. If you’re a generalist or a specialist you see pts with FMS (dx or not) and it matters. Here is some needs to knows. 1/8
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BIG NHS UPDATE!!!
Our pt facing Lumbar Spinal Stenosis (LSS) booklet is now live and ready to download and use!!!
Thanks so much to
@EmmersonUK
@SouthTees
Special contributions from
@AnninaBSchmid
and
@PainCurious
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Here is a tweetorial on bending and low back pain.
Bit of a longer one but a number of juicy papers included.
1/9
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Radicular pain and/or radiculopathy. A thread on decision making.
1️⃣ setting the scene
3Ps or serious suspicion aside. What does the evidence tell us
❇️ Wait and see
❇️ Physiotherapy
❇️ Nerve root blocks
❇️ Microdiscectomy
👇👇👇
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Do you know the differences between your disc bulges & your herniations? How they classified?
I've been playing about with some illustrations for my 'Navigating Painful Radiculopathy course in 2024. So here we go.
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BIG update folks!!! NHS 10 back facts & posture handouts are now available to share and download
south tees hospitals>services>back pain triage and treat> patient information
@rwalshphysio
@SouthTees
@NBP_CN
#QualityNHS
#QualitySouthTees
#AboutTime
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Physios do not FIX anything. You're not a mechanic, your pt is not a machine.
Hands are not scalpels or magic wands. Unless there is actual evidence of dislocation, you ain't pushing stuff in, realigning or adjusting anything.
Most sensible professionals do no think this 👍
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@erik_gry
@ItsKieranDrew
@GregLehman
Yep. Here you are.
2000 retweets. What the heck. Irresponsible.
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CHECK THIS OUT!!
Proposed statement to have embedded on all lx MRIs in England
Currently away with patient groups and radiology stakeholders.
#BestMSKHealth
@DerekGriffin86
@laurarathbone
@georgetgoodwin
@TPMPodcast
#therapylive2021
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BIG NHS update!! '10 Sciatica Facts'
Download, Share & Discuss
Shortly be available on our website
Special contributors
@rwalshphysio
@thomas_jesson
@AnninaBSchmid
@PainCurious
@k8purcellphysio
@LivingWellPain
@SouthTees
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A word to the wise.
All lumbar root pain is leg pain (almost) but not all leg pain is root pain. 🦵 ⚡️
Clinicians role is to test the priors. Not just accept them
Use your stynes critera. IMO most of its not.
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@erik_gry
@ItsKieranDrew
@GregLehman
Heavy heads, avoiding a slouch. I wonder if intelligent people consider actually reviewing scientific literature before doing these?
Here a lay, surprisingly well researched article in the guardian
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A contentious and poorly understood/applied aspect of assessing and managing patients with radicular pain.
'Nerve Mechanosensitivity' ⚡️
(otherwise known as neurodynamics)
Part 1
Part 2
Hats off
@simensletten
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I’ve recently finished a rehab programme. It was emotional!
I am back in the clinic. It had me thinking about comms and so-called motivational interviewing
A basic to engagement is simple - do folk like you and what you have to say?
Here are 7 helpful pointers
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4 must own LBP papers
Dx triage - when to be concerned with structure
sinister and serious-specific disorders
safety netting with uncertainty
while not operating defensively
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Sneak preview of a little project I have been working on as part of back pain service
@SouthTees
&
@NBP_CN
@rwalshphysio
@coastphysio24
@PhysioPainAssoc
Adapted with permission by
@PeteOSullivanPT
&
@DerekGriffin86
Original artwork, great messaging and quality NHS👌👌👌
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Lumbar spine modic changes. A🧶
1⃣ What are modic changes
2⃣ LBP associations
3⃣ Management with antibiotics
4⃣ Closing thoughts
Disclaimer: While I am not an interventionalist, it does not preclude me from being critical of the care my patients may otherwise receive🫡
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For anyone who needs to hear this you do not need to slap a label on LBP to help them:
*Listen
*Rule out serious n radic syndromes
* Identify contributors
* Propose small but meaningful changes
* Communicate
* Be humble in uncertainty
* Onward refer if needed
👇👇👇👇
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3 MUST reads for contemporary LBP management 🔑
From fear to safety with
@jpcaneiro
CFT framework with
@PeteOSullivanPT
Labels with
@MaryOKeeffe007
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'NHS BACK Tracks' is onto its final phase 😍😍😍
50 exercise 'Tracks' for pts and therapists to use freely.
Create a flowing playlist, learn by doing. Gone are the stuffy explanations, sets n reps. Coming v soon.
Below is a little video snippet
@SouthTees
@EmmersonUK
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Below is a tweetorial on Diagnostics Labels in Low Back Pain.
1⃣ Labels. An easy fit, A societal expectation!
2⃣ The opposition
3⃣ Non-specific LBP
4⃣ Evidence to support Non-specific LBP
Its a bit of long one but i hope its helpful.
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I recently did a talk on sciatica.
Here is a small but important part of pt care - prognosis and treatment planning. As promised
@Martin_Nekkolai
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Second BIG NHS update folks!!!
'10 Do’s and Don’ts:
Managing long-lasting low back problems’ booklet is now available to download and share.
@rwalshphysio
@SouthTees
@NBP_CN
#QualityNHS
#QualitySouthTees
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NHS England launch 🔥 🔥 🔥
*Priming Information to patient prior to MRI
* Link to info on report
* Info to share with clinicians
NHS sign up below
Further elaboration to follow
#BestMSKHealth
#GIRFT
#PatientReps
@coastphysio24
@NHSEngland
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Sitting right or 'correct' from a health perspective is just not something humans should be worrying themselves with.
Sit how ever you like ✅️
Move if its more comfortable ✅️
Exercise ✅️
Reframe your understanding of this phenomenon & let the baggage, including naff,
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Dry needling compared to sham needling. Yet more evidence of no effect.
Made-up treatment. Made up mechanism of action. 'Needless' to say we should move on.
"Based on the results of this study, we cannot conclude that DN has better effects on pain sensitivity and central pain modulation immediately post-intervention, compared to SN"
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Do not manipulate the spines of those with painful radiculopathy
Do not manipulate the spines of those with axSpA
Do not manipulate the spines of those with osteoporosis
Do not manipulate the spines of those with suspected unstable health conditions
……maybe don’t do it at
Today’s teachable moment
If you are MANIPULATING patients with Ank Spond, there is an entire profession that will stand opposite you in court to explain why what you did was “a bit murdery”
#orthotwitter
#medtwitter
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1️⃣ Radicular pain and/or Radiculopathy and MRIs.
Caveat edition.
Base your dx probability primarily on presenting features/Hx and NOT scan.
1) Pain below knee
2) Leg pain worse than LBP
3) Sensory or motor report
4) Some kind of definable radiculopathy
5) A Hx that fits
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Unlike lumbar radicular pain, cervical radicular pain can be felt in places other than the limb.
If your pt presents with scapular pain 1) screen standard neuro exam
2) Look for any muscle wastage
3) Test the neck as an attempt to reproduce pain.
4) Consider pain descriptors
📷 Typical patterns of pain in
(a) C5;
(b) C6,
(c) C7;
(d) C8 and
(e) T1 radiculopathies...without arm pain
👇👇👇
according to
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A key feature in suspected lumbar radiculopathy is your reflexes.
An asymmetrical loss of S1 reflex with concurrent leg pain with a history that fit is a good way to improve dx confidence.
Remember. Bilateral loss of S1 reflexes in middle & older age is pretty common.
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Here is a thread on the contentious topic of Spinal Osteoarthritis. Helping to challenge the biases a little from time to time.
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Building on my radicular pain and/or radiculopathy. A decision-making thread.
Let's talk sensory testing 😵💫.
Some of this will be opinion based as much of the nuts n bolts 🔩 have yet to be scrutinised.
But I've had many reflections, conversations & sleepless nights.
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Lumbar radicular symptom referral patterns are variable and often do not conform to textbook dermatomal maps.
Here
Furman & Johnson 2019
Induced lumbosacral radicular symptom referral patterns: a descriptive study - ScienceDirect
And here.
Hasvik et al
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BMJ article: diagnosis and treatment of sciatica 2019 👇👇👇
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I often get this in the clinic, anyone else ?
I need an MRI to see what is wrong 😕
OR
I was referred for an MRI to see what is wrong.
This is a massive misunderstanding of how imaging fits into clincial picture and we need to educate!!!
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Belated Christmas presents have arrived - looking for high impact visuals in the waiting area. Next step GP land?
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NHS BACKTracks is now live for public testing!!! 🤩
‘A platform designed to help people with back pain explore movement’.
👇👇👇
We've aimed for simplicity, a contemporary feel, safety messaging, and less prescription. Pick your 'TRACKS' (exercises),
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If this is you as a physio, it's time to re-evaluate 🤣
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On a regular basis I encounter pts with completely normal MRI scans 👇👇
Not equivocal or uncertain, just normal.
But they belong to people with LBP with varying ages and disability.
There is more to LBP than damage & structure.
Image courtesy of Frank Gaillard
@Radiopaedia
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Let’s talk about escalating and deescalating care in painful lumbar radiculopathy. I am often asks when I should refer my patient on – usually in reference to time to onset. ⚡️⚡️⚡️
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Things I DONT do in a spinal clinic in 2023.
✳️Assess apparent & true LL 🦵
✳️Assess & blame flat feet 🥴
✳️🏷 things with the suffix 'ogenic'
✳️Assess hamstring length 😮💨
✳️Blame posture
✳️Blame the core
✳️Blame how much a person can bend (be more interested in how)
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Osteoarthritis in over 16s: diagnosis and management
Really are step in the right direction 😍
No acupuncture, no electrotherapy, no inappropriate imaging. Nice linear decision making
Even like the layout, much more accessible.
@physiojack
This is dreamy
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I am back on the digital art train. Labelling my cauda equina. Visualising root levels in relation to disc levels at more than one location can be tricky. So I've mapped the whole lx spine out below.
Vertebral bones (bodies) are identified and designated by numbers
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Does anyone else feel that SMART GOAL SETTING is super contrived and unhelpful.
In reality I feel like change is fluid, organic one one step following another. Setting 'long term' goals way ahead of an uncertain future feels ill witted and setting ourselves up for failure.
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🚨 Course update 🚨
I'm chuffed to announce the official launch of my website, 'The Radicular Clinician'
The website will primarily serve as a platform for my Painful Radic Course. It's early days, and I'll be learning a lot by doing, especially in
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A strange & fascinating muscle.
The relationship of scapula to latissimus dorsi (cadaveric video). via
@scientissimum
#MedEd
#MedTwitter
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Revised interactive clinic poster for low back problems 😊😊. Some refining but pretty happy with it.
@SouthTees
#PatientEngagement
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An infographic on lumbar radicular pain based on a talk I did with the
@Physiotutors
from a while back below.
I really quite like this. Exists in higher res.
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Here is some actual, sensible evidence based information on sciatica by the
@E3Rehab
boys.
Scientific, sensible and comprehensive 👏
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You may be aware of this chart of 'primary root involvement
L2: hip ext
L3: knee ext
L4: ankle DF/inver
L5: Big toe ext
S1: Ankle DF/ever
S2: Knee ext
And yet this study shows 23% of disc herniation compressing the L5 nerve root had foot drop (DF weak)
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If you read anything this week read these two papers on LBP and comms.
Words and labels truly DO colour how we view our bodies, our recovery potential and what we think we need.
Authors in the next tweet go follow them ☺️
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GP referral
- explain back pain multifactorial
- pain meds harmful long term
- graded activity helpful
- referral for further input.
Well, this is fab 👏
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I propose most MSK dx are non specific with 'dress up'. High certainty is an Illusion.
We basically manage aggs, eases, function and goals. Mediation of change remains a black box.
'Some' exceptions:
Serious pathology
Dislocation
Tendon rup
Boney injury
FS
Radiculopathy
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Dear patient/fellow human
Your GP/Physio/Health care provider may ask questions about your thoughts on your pain problem, your expectations and treatment outcomes.
This is not because they are 'clueless' or that they don't care. Quite the opposite.
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Crazy cool info if you manage patients with persistent atraumatic heel pain. 🕺
ICYMI
We published a revision to our 'Heel Pain - Plantar Fasciitis'
#ClinicalPracticeGuideline
#OpenAccess
➡️
#yourJOSPT
#PlantarFasciitis
#HeelPain
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Time for my annual recommendation of this brilliant paper.
If you want to develop a little more around spinal anatomy, terminology and MRI standards I recommend this paper related to lumbar disc stuff 😎
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Flat feet: deformities or healthy anatomical variants?
Normal varient. Research support!!
Some tried to give me a drubbing for this a while back ☹️.
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Recently watched
@PeteOSullivanPT
and Peter Kent's CFT webinar hosted by
@MaryOKeeffe007
👇👇👇
Paper here
The paper and its criticisms are plenty. Here instead are some paraphrased soundbites. Mainly on misconceptions.
1⃣/🔟
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Here is an infographic I worked on a little while ago with the
@Physiotutors
boys. I have added the references in. If you want a copy with a hyperlinks consider contacting Physio tutors.
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One of the most well-read MSK clinicians in the biz. This gentleman is an orthopaedic surgeon!!
We need more surgeons contributing to the challenges, nuances & messaging that goes into everyday practice decisions.
Take a listen.
Orthopedic surgery office based decision making isn’t easy …
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? Lumbar lordosis as a cause of back pain like is like ? Big nose for face pain.
Therapists, observe all you like but please...
😟
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Few words to myself around telehealth/consults generally 🤔🤔
1) don't go into a consultation with any perceived expectations or barriers - let the conversation flow were it wants to go
2) Give the patient time to talk, air any concerns - even if you think its irrelevant
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What I consider to be 'AdvAnCEd' MSK practice (spoiler: do the basics well).
✳️ Listen more, talk less (at the beginning).
✳️ Use a basic exam to educate.
✳️ Offer a solution that requires as little change as possible.
✳️ Think of the end at the beginning.
✳️ Know when a
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Right you lovely lot.
Great webinar event for you
Join us and explore the care & rehab of older people with persistent non-traumatic MSK conditions – LSS, hip OA and sh OA
5th October
7 to 8:30pm
#OlderPeoplesDay
#MyLocalCSP
@CSPNorthEast
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Does Your Bedside Neurological Examination for Suspected Peripheral Neuropathies Measure Up?
I may do a tweetorial on this as a part of my radiculopathy decision-making series.
Practicality and clincial value at the heart!!
Final form PDF 👇👇👇
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Contrary to the belief. Radicular pain isn't always textbook neuropathic.
Perhaps things sit on a spectrum with only descriptors at the far ends being easy to label.
If your pts calf pain is aching, don't rule out radicular pain. But one aspect of dx confidence ⚡️
👇👇👇
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Two important key questions to ask in clinic when managing expectations
1) what do YOU think is 'causing' your pain/function problem
2) what do you think needs to change to improve your situation
A heap of gained information to help shape your education and direction
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Physiotherapy
Be a decent human, do the basics well and.........no, that's it!!!
Carry on ☺
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I've no context.
But this is NOT how you treat early stage ACL reconstructed knees or otherwise. Wow.
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Have you ever had a situation where a pts pain location and patterns didn't add up and/or varied.
Examination/imaging didn't offer anything.
Labels 🏷 were useless?
Yes?
Welcome to the reality of real people and real situations. More common than folk like to admit.
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Not able to display large posters in your employers clinic room?
Print and bind them and use them as educational tools. Currently have 10 patient facing ones
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This is the single best educational piece on gluteal tendinopathy ever created, specifically for studious patients seeking in-depth knowledge.
@E3Rehab
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CFT produced large and sustained improvements for people with cNon-Specfic disabling LBP at considerably lower societal cost than that of usual care.
Download paper here
Pt facing videos on all aspects of the trial here
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MRI scanners are not a diagnosis scanners. They do not show pain.
*MRIs offer a detailed look at a bunch of tissues appearances
*Consider what could be normal
*Consider a patients presentation and suspicion.
* If correlated, consider the irritated over the irritator
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LBP & Scans
a) Early imaging: poorer outcome, opioids, negative beliefs
b) Clinical reporting ⬆️ outcomes
c) normal scans ↔️ reassurance
d) Scans with no serious pathology or correlated findings without change of management: pt 😡
Takeway: Scans have drawbacks. Consider them
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The third batch of individual videos has now been edited. I'm very happy with them. Session 4 is this weekend.
Here, we have the pSLR. There is no operationally defined way to perform this, but I've approached it in a way that makes sense, based on evidence, and leaves less room
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✅️ Further dated, antiquated information here.
✅️ Giving people problems that they can never overcome
✅️ No good scientific references offered
✅️ Further challenging the good work of already burnout clinicians.
I am sure Conor is a nice guy but really. 😵💫😤
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Osteoarthritis is largely a clinical disorder. That is, your problem is required to fit a cluster of findings
Imaging is for suspicion of serious pathology and surgical planning only.
Changes without correlation are just that. Normal age changes.
Here is the ACR/NICE hip
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No differences between GLAD and open label placebo for knee OA at one year.
Might be helpful to consider that only 29.4% continued to exercise after GLAD.
A problem of adherence or ineffectiveness? 🤔
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Get ‘unstuck’ on neurodynamics for lumbar radicular pain.
A brief thread. 🧵
We’ve recently had some content on nerve mechanosensitivity and lumbar radicular pain. I thought it’d be a good opportunity to share some work, and my thoughts on neurodynamics as a treatment.
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This is quite cringe, actually. Sorry.
A 'master' clinician with those hands. Competition with colleagues, sales type metrics.
Like a car salesman with superficial swagger.
How about. Are you honest. Do you communicate well. Do you provide options & exhibit good reasoning 🧏♂️
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Some vitally important messages from the BACK to Health Programme.
* Rest is rust
* Sore but safe
* Hurt not Harm
* Believe your own data
* No challenge, no change
* Best posture your next posture
* Slouch on
* Bendie, bendie, no extendie 😉
Appreciate some more....
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1️⃣
A tweetorial on navigating the role of imaging in spinal care.
* Comms
* Triage
* Consequences
* CPD for upskilling/interpretation
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I am too old to benefit from exercise!
Introducing Bob....
Indeed. Awesome.
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Here is an MRI 'like' image of the lumbar spine on an axial view.
⚡️Here, We have a right-sided disc protrusion with right transiting S1 nerve root compression (Remember, imaging reverses the view).
⚡️Note the descending nerve roots. They are free to move around, but when
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How to sit correctly. How to move correctly. How to breathe correctly. 🫤
At best, superficial content baiting. At worst, unhelpful, unsupported paternalistic claptrap.
Sit, bend, move, and breathe as you like. Freedom and variety is good 👍
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FND. Previously known to be a diagnosis of exclusion. No more.
Diagnosis and management of functional neurological disorder
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I spelt Amitriptyline correct today - first attempt. Small wins 🏆 👌
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It's amazing how many people with persistent non-specific LBP suffer with v poor sleep, stressful lives, strained relationships, weight gain & loss of identity.
And yet, many still see no relationship with their pain experience. Not even tangentially.
#MoreWorkToDo
#NotTaboo
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In order to satisfy their disdain for the term, Persistent Non Specific Low Back Pain (pNSLBP), some resort to misrepresentation.
Here are SIX important things to consider when critiquing the term yourself.
1⃣ pNSLBP is a research term. But it IS also a term used by clinicians
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No new content but wanted to share that our pt facing booklets are now standardised to A5 landscape format
Short lasting/general
*Posture
*10 Back Facts
Persistent pain
*10 dos and donts
Sciatica
*10 sciatica Facts
Working with designers on LSS 🙏
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Pt told by radiographer their back was a 'mess' on scan.
Cheers AHP person. Really helpful stuff 👏
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Need this for level 4 in managing LBP, apparently.
Few buzz words, few antiquated ideas, few daft tests & load of unhelpful information about the body.
🥴
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