Natural history, Zotero, cowboys
Thanks for reading the first copy of my newsletter! As I continue to research radicular pain, I will use the newsletter to update anyone who is interested on the most interesting stuff I come across. If you want to comment on anything you read, or just chat about radicular pain, don’t hesitate to get in touch.
Where am I going with this??
I want to create a really, really high quality source of information on radicular pain, for patients and clinicians. Yes, that’s very vague. I don't know what format the finished product will take. Whether it is a website or an ebook or an online course… Not sure.
It does have a skeleton of an outline. The list of clinical questions I posted to twitter got some really helpful responses which have all been added, and I have come up with some more of my own. I have to make it a bit neater then I will share that.
Anyway, here’s the bulletin from the past couple of weeks!
Papers of the fortnight
Söderberg (1956)
Most of my recent reading has been around the natural history of radicular pain, or what I've taken to calling the "clinical course" since really, there isn't much data on what happens to sciatica when it's just left alone.
My favourite paper was this one from 1956 by the Swedish physician Lennart Söderberg. His breadth of knowledge and dedication to his research question is astounding, and the dilligene and care you can feel him take make the paper quite human and charming.
Like most of the older papers, Söderberg is quite clear that lots of people who get sciatica don’t get better, and those who do often relapse. Here’s a graph that summarises his patients’ symptoms over eight years (!). About 21% of his patients were still in moderate or severe trouble.
And here are some nice quotes:
"Sciatica is hardly completely explained by the knowledge of disc protrusions [...] Those acquainted with disc surgery know, for example, that apparently similar protrusions compressing the same nerve root do not always produce the same symptoms or signs"
"Physiotherapy has been, and still is, used to a large extent in the treatment of lumbago-ischias. In the light of our present knowledge of the commonest cause of sciatica, however, it may often seem less advisable to give this sort of treatment to a patient in the acute stage of the disease. On the other hand, after the acute symptoms have subsided, physiotherapy has proved valuable."
"The chronicity of this disease must be fully appreciated; most of these patients had suffered five years or more. There can be little justification for letting the disease run its course"
On the subject of charming older papers, a special hat-tip to the lovely hand-drawn graphs in this paper, from 1970, by Hakelius.
Langevin et al. (2015)
I have also done a lot of reading recently on trials of physiotherapy treatments for radicular pain. I will try to summarise all that soon. This paper by Langevin et al. was particularly interesting. For patients with cervical radicular pain, they tested whether manual therapy directed at increasing space in the intervertebral foramen to reduce pressure on a nerve root is more effective than manual therapy without this intention. Patients also got home exercises.
After treatment, there was no difference to be seen. After eight weeks, however, there was a difference: of 1.3 points on a NRS. But the confidence interval was wide and included a chance of no difference. So the authors rather do down their own results by taking this as evidence of absence, which is not the case...
Anyway it was an interesting study and considering how minor the intervention was, I don't think it's evidence there is no specific effect to manual therapy. In fact should probably be taken as very weak evidence that there is...
Nerdy research stuff of the fortnight
Reference managers! I am using Zotero as my reference manager. I switched from a haphazard Google Drive non-system to Zotero last summer. It was a right faff but worth it. I wish I had done it sooner. It makes it very easy to get papers in to your system. You just click a button on your browser. It's also really easy to share papers *from* your system. You just drag and drop out of Zotero into an email or a DM.
One very neat feature is that you can set up feeds from journals or search terms so new publications appear in Zotero - I made a video of how that looks. It’s very neat.
Other bits and bobs
Someone DM’d me on twitter asking for recommended reading on sciatica and I sent them this google drive folder. Some bangers in there.
Yes, I have said "sciatica" a number of times during this email! Call it laziness 🤷
I had a nice skype chat with a physio in Birmingham, UK called Jai Mistry. He is doing some research into the neuropathic aspect of radicular pain. Here is the protocol for his systematic review which he tells me has just finished. Jai wants to tease out whether there is an identifiable subgroup (there's that word!) of sciatica patients who have significant neuropathic pain, and if so can we identify them, and if so is there an intervention that would particularly benefit them. I have a nagging disquiet about the direction I am seeing of lumping over splitting in MSK care, and also of the emerging consensus that anti-neuropathics don't work *at all* for radicular pain. On the whole these are both good things I strongly support, but I am glad Jai is checking the bathwater for babies.
Personal news! After many months of waiting I finally have my interview date for a green card! We have an appointment in Detroit in April to prove our marriage is not a hollow sham.
More personal news! We also found out last week that in the summer we are moving to Houston, Texas! The "found out" part is because my wife applied for postdocs in a few different places and we weren't sure where she would "match". Very excited. 🤠🤠
Again, thanks for reading the first edition of this newsletter. I'm sure the format will evolve as it goes on. You can contact me easily if you want to chip in with any thoughts or pointers. That’s really what the idea of this newsletter is - I'd love to hear from you.
Happy hand washing,
Tom