Mark Laslett
@marklaslett_NZ
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NZ Registered physiotherapy musculoskeletal specialist. Special interest in science of diagnostics. Online Instructor. Retired from clinical practice 2024
Christchurch
Joined September 2016
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Here are links to a recent Podcast with Marian Tondo of PT Pro Talk
Spotify:
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This is awesome. The lat dorsi wraps the inf angle & keeps it against the chest wall. Ain't nature grand?
Good morning
#medtwitter
! Today we would like to share with us this amazing
#anatomy
case of upper extremity. In this cadaveric video you can witness the relationship of scapula to latissimus dorsi.
#orthotwitter
#scientissimum
💪🏼
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Patient from last week: Biggest Sequestered disk I have ever seen. Wow
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For those struggling with the differences between nociceptive back pain, somatic referred pain, radicular pain & radiculopathy, I recommend this paper It does not include discussion on the influences of psychosocial factors, just the patho-anatomy
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This is good. a specific exercise protocol for subacromial pain is better than general exercises and reduces patients chosen use of surgery. 5 Year follow up - from the team & my almer mater at Linkoping University
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@DrNeenaJha
Perhaps it is time to start a conversation about the responsibility of patients towards their own well being? We offer advice all day, but how often does a patient really act on education that requires more than passive care or pill taking?
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No! Stop politicizing the profession. Stop filling the curriculum with political agenda, & start refilling it with real science, real evidence. Spend more time & money on real time clinical experienc - in clinics.
Climate change must feature in physiotherapy curriculums - Prof Gillian Webb
#IGNITE23
#IGNITE2023
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5 myths about LBP.
1.Back pain is a disease or medical condition
2.Diagnosis of back pain is not possible or very difficult
3.NSLBP is a valid categorization
4.Risk factor ed for LBP is a good treatment
5.Any exercises is good for backs
See....
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I am looking at he cervical spine moving. Look at C5/6 and C6/7. Even though there are significant disc protrusions indenting the thecal sac, the spinal cord still remains well protected.
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Saw case of disc resorption in a few months. Here are MRIs March 2023, Sept 2023 & March 2024. Symetrical LBP started as leg pain stopped. Now no rad symptoms at all. The resorption happened since Sept 2023. Amazing.
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New and final SIJ paper by me just formally published Laslett M. Clinical Diagnosis of Sacroiliac Joint Pain. Techniques in Orthopaedics. 2019;34(2):11.
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I have a chiropractic joke but it needs some adjustment
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here is my lecture on deconstructing Non-Specific Low Back Pain. It's free access. I will be interested in comments. Enjoy
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I really dislike being misquoted. A recent paper says this: "Accordingly, Laslett [4] found that manual therapy with lumbopelvic stabilization is a promising technique that helps improve overall quality of life." I NEVER SAID ANY SUCH THING!!!
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Yesterday, saw the first McKenzie posture syndrome in years. (4 years duration LBP) in an active 21 yo. Full ROM all directions. Repeated movements, no effect. SIJ tests negative. ONLY prolonged sitting or standing produced pain. Correcting posture abolished it rapidly
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Agree. Energetic differences of opinion is what projects science forward. Adam & I don't see eye to eye on many things, but he has the right to voice his opinion as we all do. It is time for some to learn some resilience & self confidence without feeling wounded all the time
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How is this test "Positive"? If the criteria for positive are met, what is it positive in relation to? What disease or condition does it diagnose or how does the test contribute to a diagnosis? Frankly this looks normal for a young man who is not especially flexible
One of our first year undergrads Jack (with consent ) with a positive modified Thomas test... what is your diagnosis ?
@UoS_Physio
@thecsp
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Just read abstract of Masters Thesis on Mulligan techniques for "SIK Dysfunction" Under Methods "..60 subjects having clinical diagnosis of sacroiliac joint dysfunction (anterior innominate) were randomly allocated to two study groups". I couldn't continue
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This a new slide I have added to an upcoming presentation on best evidence for LBP
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Is this Chronic NSLBP? 20 yo male. RMDQ 4/24. Pain 9/10 worst, 7/10 Avg, 5/10 best. CSI 6/100 (nil), DASS21 all normal. Pain 2 years persistent/daily worsening. No DP or CP: rep Movt tests NE. SIJ provoc tests all negative. Inflamm screens negative. Waddya reckon?
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SIJ "dysfunction" is not a pain concept. It is a presumed mechanical disturbance beloved of manual therapists, having no evidential basis in science & tests for it are unreliable/invalid. SIJ pain is real & diagnosed by controlled SIJ blocks. see my papers on the subject
@marklaslett_NZ
Hi Mark, new grad here. When is SI truly the source of nociception and what causes this? Asking to clarify best updated literature and avoid falling into pitfall of assuming SI "malignment" or "movement disorder". Thanks!
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The paradox is real. How can the spine be so strong & stable if LBP is the greatest cause of disability? How can prognosis be so good if 1/3 stiil have significant LBP at 12 months? Directing care only to the average (guidelines) is so limiting
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This "Less than 5-10% of all low back pain is due to a specific underlying spinal pathology." is BS. Less that 10% of patient ever get a diagnosis-that's true. Perhaps because the war on diagnosis itself has been so succcessful? Guess what. Incidence & disability continue to rise
"Less than 5-10% of all low back pain is due to a specific underlying spinal pathology. The remaining 90-95% should be managed with conservative treatments." This article looks at diagnostic triage for low back pain and how practice should change
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No. And even if you could, it is irrelevant anyway. SIJ pain is rarely, if ever an issue of 'dysfunction' / mechanical displacement/position
The SI-joint have minimal degrees of movement. Kibsgård et al. 2017 found that movement of the SI-joint during active straight leg test only produced 0,3-0,8 degrees of movement.
Can you really palpate movement that small?
thx
@paincloud1
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@AdamMeakins
We often don't see eye to eye Adam, but good luck. Dealing with bureacrats who have the power to destroy is a daunting affair. Stay strong.💪
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I am delighted to announce that my short e-book "Back Pain: Diagnosis & Management Beyond Guidelines" is now on Kindle for US$11.49
A lot of work but hopefully worthwhile intro for many readers
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@CoachJakeAAllen
1. How can you know if the pelvis is anteriorly rotated with tests that are unreliable & have never been tested against a referrence standard (validity)? There isn't one.
2. Even if you can detect this mythical entity, where is evidence that what you recommend, effects change?
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@SeanGTGibbons
We need a clinical diagnosis before we know what to look for in imaging. If the patient is asymptomatic, there is nothing to look for. MRI is a structure scan, no a pain scan
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If no "Chronic" pain was structural, total hip joint replacements would not work. They do
@Clark650James
@marklaslett_NZ
My pain is structural. The research by Butler, Moseley and Louw has been intepretted to mean that no chronic pain is structural. That chronic pain is all purely an output of the brain, with no structural cause, ever. So to cure the pain, you change the brain.
This is not true.
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Eh? Graded activity VERSUS physiotherapy? That's physiotherapy vs physiotherapy isn't it?
The short-term effects of graded activity versus physiotherapy in patients with chronic low back pain
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Tomorrow I move into new clinic. Lots of preparation over the last week or so.
@ACadogan_NZ
& I have started the first specialist physiotherapy facility in NZ. Excellent!
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@Retlouping
@jaysonsipress
Thank you David. I will go further. So-called SI dysfunction as an entity & as a cause of pain is a creation of manual therapists perpetuated by teachers. Regretably I was one in the 1970s. There is no evidence and plenty of evidence against the concept.
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Today I have just completed the content for my online course BP302 Diagnosis & Treatment of the Radicular Syndromes. 8 hours of actula video instruction. Overall about 15 hours. Should be released early November. Really proud of it! have to do BP300 & BP301 first tho'
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This is my world - from this morning. L2 burst fracture 8 years ago. Right buttock pain never change after 4 surgeries, CT guided piriformis injection etc etc.He has had it all. Physio, chiro, osteo, 6 diifferent pain service specialists. Nocibo from PNE is real too
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Non-specific LBP is a diagnosis
Mention one scientific opinion that you’d defend like this ✍️
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disagree. manipulation is a valuable option on occasions. Many lumbar lateral shifts require manual correction, because the patient simply cannot do it to start with. Unlocking a knee needs MT too. You are being too unidimensional
To all my fellow physios... the only ‘manipulations’ you need to learn are those you make to your patients rehab variables!
#LoveExercise
#HateManualTherapy
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Finally! Excellent start. Let's bury non-specific. NSLBP is not a condition - it is a symptom, like headache bellyache, foot pain, chest pain, brachalgia. It conveys no more information than the patient's description of pain location. There is no 'best' rx for a symptom
Only 7.4% of RCTs on ex & MT for NS-LBP' included sub-classification criteria.
"This may hamper finding a treatment effect if an intervention is effective only for a subset of the population."
Worth considering when reading/interpreting LBP intervention studies.
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@BJSM_BMJ
No problem. Same as if the paper had all female or transgender authors. Quality, originality, accuracy are the key factors, not gender
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I have just had a paper accepted for publication. Hopefully the last I will write on the SIJ. Interestingly it was a paper requested by a surgical groups wanting a review of evidence based clinical diagnosis. I usually refuse requested papers, but they were genuinely interested
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@AdamMeakins
@TaylorAlanJ
@RogerKerry1
@MattLowPT
@chadcookpt
so how is manual therapy the problem here? The patient has not been helped by MDs & PTs, but can't see that they have even tried MT. The DC surely will & will probably fail too, but MT is not the problem here, lack of Dx & approp Rx is. Your dislike of MT beyond rationality
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2 days ago ED referred pt: 2 wks of severe R sided buttock and calf pain. He had left shift & extension obstruction. Manually corrected shift & taught self correction followed by asymmetrical extension recovery. Follow up yesterday: No shift 80% better. Gotta love it
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People believe in many undetectable things. We are just emerging from the Dark Ages of Musculoskeletal science. In spite of science tho' some will always have faith! They feel something, & SIJ movement is what they believe they feel. Sad, but it will never vanish
"Movement in the sacroiliac joint during the single-leg stance is small and almost undetectable by the precise radiostereometric analysis". How many clinicians believe they can assess the SIJ mobility is beyond me!
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Just sent to me by
@VicenteHenneman
. This is a good read. A SR of diagnostic tests in Lumbar Spine & LBP
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@JoseMiguelPobl5
@Retlouping
Herniation is not a source of pain, it is a pathology. Can discs cause pain? Yes with or without herniation. Do some herniations hurt? Yes sometimes because of the distorted outer annulus, sometimes because it irritates something else (dura or root). Do all herniations hurt? No.
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Nice work! This is a real phenomenon & one that is responsible for a small proporting of patients with NSLBP. Can be the start of endplate / vertebrogenic pain with endplate oedema changes appearing on MRI soon after. It can happen without obvious trauma, & in teenagers
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This is not a photoshop image. This photo of Aoraki Mt Cook with a cloud formation resembling a New Zealand bird call the tui was taken by Susan Blick last Friday. Tuis really look like this!
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David Poulter presentation of 2 cases of Lumbar Anterior Derangement via
@YouTube
Video circa late 1980s. Historic!
Provided on
@Retlouping
request & obviously with his permission
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The individual patient is different from the population mean/median. Strategies to help the many are of little help when dealing with the individual. Giving an average Rx to the average patient will get you....average results. You happy with that?
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Sometimes we need to make the options clear to our patients!
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How can you say that "Back pain is rarely caused by damaged spinal structures" ? What is the basis of that sweeping statement? If you accept the view that 90% of LBP is of unknown or unknowable source/cause (I don't) then you cannot also say there is no 'damage' with 90%
@PeteOSullivanPT
“Back pain is complex, individual & BPS....Back pain is rarely caused by damaged spinal structures
Identifying & addressing the factors unique to the individual is the key”
Reassurance
Reactivation,
Consistent PA
Finding a safe, tolerable starting point
Being supported are 🔑
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@honest_physio
@ShoulderGeek1
@GatesPhysio
@tomgoom
@AdamMeakins
@JOSPT
@KMiddletonCSP
@thecsp
@Retlouping
@PeteOSullivanPT
@gsingh1902
2..Were your undergrad teachers actually practising i.e. seeing patients? This is what must change. No teacher of a practical profession should be a teacher full time. At least 30% of their time should be spent seeing real patients & being responsible for outcome.
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@TheRedbaiter
The fact that he would state he would censor, is confirmation that objective journalism has been shoved aside to make room for the propaganists. The PIJF shelters these grifters from the real market place. The coalition government has a mandate - don't he & his mates get it?
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it creates the notion that we don't know the causes of LBP. Wrong, we do. It also creates an environment among clinician of hopelessness - that diagnosis is impossible & we are left only with general principles like risk management & CBT. We can do better than that
@marklaslett_NZ
@Steven_AK
Great summary. We should not be afraid to make a clinical diagnosis to help guide a treatment / management strategy. NSLBP as a diagnosis can...create a scenario for the patient of confusion
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This is great summary of current evidence about NSLBP. I have Some issues with conclusions and interpretation, especially with regards to diagnostics, and I believe
@CGMMaher
and colleagues make conflicting statements. Nonetheless, important read for all
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Can someone get a pdf of this paper for me please
This looks intersting..
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Herer's an interesting patient: mid 20s female with ipsilateral shift. Correction of shift caused pain to change sides but not the shift i.e became contralateral. It has taken 6 weeks but now asymptomatic. Minor residual shift remains.
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Oh Dear. Will the nonsense ever stop?
Self-Treatment of Chronic Low Back Pain Based on a Rapid and Objective Sacroiliac Asymmetry Test: A Pilot Study
😩🥺🙄
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@AdamMeakins
Happy to podcast with you on your back injury. You choose an independent host & I will be there. Wasn't 'sniping'. Just commenting on SoMe content you put up. That's what you are seeking isn't it? You don't follow me, so you would not have seen the positive comments
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@adamistrong
@business
As I read the yet-to-be peer reviewed article, the best protection you can get, is to get the disease. Seems that surviving COVID19 stimulates the immune response 13X more than the vaccine. Is this a surprise or useful? Trouble is, you have to survive it. I'll take the vaccine
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Saw a back pain patient yesterday with directional preference to flexion. Unilateral para sacral pain. Two SIJ PP tests positive. 4 weeks duration after soccer collision fall accident. Xrays normal. Normally consider this discogenic but unconvinced. We will see if Flex prog works
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That's where you get into trouble Adam. It is that sort of blanket sweeping generalisation that is simply inappropriate. I cannot speak for any of the organisations teaching these methods, but they have all evolved to a greater or lesser extent as evidence accumulates
If you’re practicing physiotherapy today in 2023 like some antipodean bloke from the 1970s… you’re doing it wrong!
#Mullligan
#Maitland
#Mckenie
😎
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@DerekGriffin86
The problem with all SRs is that they simply pool mean values from RCTs. This is why ALL treatments (not just SMT) are no better than placebo or other Rxs. It is time to abandon RCTs of heterogeneous samples (like NSLBP) and stop wasting time averaging averages. GIGO
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Just completed a really good Webinar moderated by
@ACadogan_NZ
entitled Screening for Serious Pathology. The principle speakers were
@LaurafinucaneB
&
@Mercephysio
For those that didnt make it, a recording will soon be available from
@SMS_Courses
&
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@AdamMeakins
@DrBrookbush
It's a silly sign. Sure, patients want immediate pain reduction - who wouldn't? Sometimes it's possible too. The error here is that it's either/or. It isn't. Why can't patients have both when possible? If rapid pain relief not possible, assurance and clarity around Dx, safety etc
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My short E-Book on Diagnosis & Treatment of Low Back Pain is now available from Amazon Kindle. best viewed in colour on a tablet or laptop.
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Webinar: "The SIJ & pelvic Girdle Pain: What are we treating?" Wednesday week. You are welcome!
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I am now well into a complete revision of my sacroiliac and pelvic girdle pain course. It will take me a month, but the new structure and presentation will be a big improvement over past efforts. First two lessons done!
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@nz_media_watch
Henare's most unconvincing defense of a failed, expensive policy, even with Jack Tame only prodding lamely. Come on Jack! Can't you see that this whole thing was a rort. They soaked up $200m for no health outcome returns, & robbed the rest of the health sector of vital staff.
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Here is the YouTube link to my free lecture on Non-Specific Low Back Pain. French, Spanish and german versions are also available
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Download this paper & read it now. As usual
@chadcookpt
nails it with eloquence & an encyclopaedic knowledge of the relevant literature. Well done Chad! Modern manual therapy has evolved, mostly for the better. There are some persistent anachronisms, but they will become extinct
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Yes. It was Geoff Maitland who introduced the slump test. Bob Elvey started the upper limb nerve tension tests, and progressed the low limb ones to I think. Early thinking therapists (these both were Aussies).
When dinosaurs 🦖 walked the earth.
The origin of the slump test 1979
Classic paper by Geoff Maitland . Maybe time to revisit the “Guru”
Such a shame some young clinicians ignore our history.
Negative disc exploration: positive canal signs
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Dx Accuracy values for ACL tests from Massy et al 2017 Table 2. Lachmann remains best test, but Lever is nearly as good
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Now this a good paper on the prevalence of discogenic, facetogenic, SI joint pain as well as Baastrup's disease, insufficiency fractures - in presistent pain population Tertiary level diagnostics but demonstrates Dx is possible if chosen
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Yesterday examined a 47 yo fit, healthy woman with 18 months of persistent radicular pain L5 and mild deficit S1. MRI shows no disk herniation or other explanation for radicular syndrome. Minimal psychosocial aspects. Hmmmm. Working on it...
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@VincentRK
@joshlavalleeMK
And now we in NZ are over 75% fully vaccinated and still having to wear masks, and our current administration is coercively disciminating against those who consciously choose to accept the higher risk of serious illness. The country is being split into two classes Vax & Non-Vax
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@bahargnsayberk
@AdamMeakins
@Retlouping
@ashjamesphysio
Example of muscle activity in absence of brain function
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Just received notification of acceptance for publication in Pain Medicine of my paper ":"Commentary on Appropriate Use Criteria for SIJ pain". Should be out some time this year
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Traps & medial scap borders are the known most common sites of referral from cervical discs and ZJoints. This is old but relevant evidence
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I am working on another e-book which has a working title of "The Science of Diagnostics for Muculoskeletal Clinicians". This book is growing out of the instructional material of my online course:
Is this of interest to anyone?
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Here some images for this fellow.
41yrs manual worker. Fully lumbar flexion (hands on floor). Complete block to extension-relatively painless. Mild L5 sensory radioculopathy. No visible l;ateral shift, but scoliotic rotation visible mid flexion. X-Ray just done. Reports scoliosis and "lateralisthesis".
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>500 RCTs tell us that NSLBP is not responsive to conservative care. Inside the NS black box are known conditions. 60% of these cases have *never* been studied in a RCT where the diagnosis is confirmed. We simply do not know what Rx may be effective. The evidence gap is shameful
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Have see 2 acute severe LBP cases today from ED. Both using elbow crutches. No radicular/referred symptoms. One had acute lumbar kyphosis. rapidly reversible in 40 minutes (BP to extension). The other no DP but 50% better with flexion & extension. Neither needed crutches after.
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According to Annina Schmid, in peripheral entrapment syndromes, it is the peripheral NS drivers that cause the CNS changes, and the CNS effects are rapidly reversible one the peripheral drivers are successfully treated
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Am well advanced on construction of new course: Back Pain 201: Advanced Assessment. In last week, completed three lessons of the centralisation phenomenon. Yesterday started on directional presference material. SIJ, neuro screening, red flag & pain drawing lessons all done
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Mini case series of persistent LBP in 3 adolescent elite rowers. All three have same pathology, all three responded to strict extension protocol in less than a week.
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Just seen an acute "SOS" referral from an ED physiotherapist. Pt has dominant back & right groin pain, sluggish right patellar reflex on right & 30% weakness right quad. Injured yesterday lifting. Instant severe pain. No shift. Will treat with simple extension protocol..
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@gorskon
@EIPConsult
Classic example of having a conclusion then searching for evidence to support it - all the while ignoring the elephant in the room - all the evidence against your conclusion. Sad commentary on modern ed
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I will post a video of each of the remaining SIJ provocation tests every week until all are available. Then I will try to post case study videos from my video bank on a reguilar basis.
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@AdamMeakins
That remark is uncalled for. Is this just follower seeking Adam - titivating & stirring up the masses? McKenzie, Maitland & many others you blithely call gurus supported research that tested their ideas. Can you same the same or are you just a critic?
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A truly rare event! An actual diagnostic accuracy study following best practice and reported in line with STARD! Haleluja! That's what is needed in this nihilistic time.
NEW! Francis Grondin led ULNT diagnostic accuracy study here Modification in performance improves accuracy of tools
@DrTobyHall
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@GregLehman
A test for "stenosis, facets or back pain" is no test at all. This test is highly sensitive to many different pathologies, but specificity is poor. It is only of value when negative (rules out facet joint pain) See It is the extension/rotation test
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Posture is only a medical problem if it's habituated, repeatedly switches on pain, and posture modification consistently switches it off
Maybe 400,000,000 people are told each year 'It's your posture'. Our research challenges many postural assumptions
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Agree. I started with acupuncture in the late 70s. Many courses. Used it until mid 90s daily. Haven't used it last 20+ years except when requested. Placebo
And yes… before you all ask… I’ve tried dry needling… trained in it… and used it for a number of years!
It’s basically a big theatrical placebo!
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Today is first day in NZ after Level 4 lockdown - at level 3. The COVID 19 stats look good. We just have to manage return to normality properly. It will be slow and frustrating. However get to see my daughter S-I-L & two grandies tomorrow (agter 5 weeks). Yay!!
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Read these papers:
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Have made the decision to Telehealth my appointments from today. I have a comprehensive pre-appt questionnaire system in place last 12 months that propvides much valuable info. Can do 80% of my Axs/Rxsb using Skype /Zoom or just phone. Will worry about ACC later
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This is a daytime photo from Auckland, NZ Jan 2020 taken by my sister-in-law Christine. Normally this view is blue sky and water, green trees. This effect is not Photoshopped but a consequence of Australian bushfires 1400 miles / 2200km west of NZ. It's bad. Stay strong Aussies!
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