Dear Barrett
Thanks for your answer but now I am more
confused!
You said there is no evidence for pain being
associated with intersegmental relationships - I responded by asking 'What about
spondylolisthesis?' and you say that this pathology is not really what Sahrman
is reffering to, what she is referring to are :"for the most part minor rotations and angulations of one vertebra on its
neighbor". But spondylolisthesis is EXACTLY what sahrman refers to in
the quote you attribute to her in your first e-mail:
As Dr. Sahrmann continues: "....one vertebra cannot change its sagittal
position with
another vertebra by more than a couple of millimeters before
contributing
to pain from spondylolisthesis."
She is talking about the pain associated with low
grade spondylolisthesis where control of movement outside what Punjabi would
call the 'neutral zone' of a lumbar segment is lost so instability occurs
together with inflammation and pain.
I think you are mistaken if you think that the only
spondlolisthesis that causes symptoms is one that includes "frank, compressive
compromise of the nerve". Many symptomatic
spondylolistheses are unassociated with such compression.
Your next quote I don't really understand at
all:
"Even at that,
her comment about a couple of millimeters of slippage being enough to produce
symptoms strikes me as an incomplete assessment of the condition. Pain is the
end result of an equation, not an event. Only when the mechanical deformation
within the system surpasses our tolerance for it do we begin to hurt. Simply
identifying the presence of a situation like spondylolisthesis doesn't tell us
that the patient hurts or even if the problem will necessarily worsen. To know
that we'd have to ask the patient, additionally assess their adaptive potential
and then see into the future."
I don't think Ms Sahrman was really pretending to
give a "complete assessment of the condition" in a single sentence. What she is
saying is that instability is sometimes associated with pain. Your
assertion that "Only when the mechanical
deformation within the system surpasses our tolerance for it do we begin to
hurt" seems a self-evident truth. Mechanical deformation takes place with every
step we take, I don't think you are contradicting Ms Sahrman when you say that
pain is a consequence (sometimes) of mechanical deformation that we fail to
tolerate.
To get back to the core of the discussion. If there
is no evidence that pain is associated with intersegmental relationships what
would your theory be concerning reduction of symptoms in say spinal fusions
where uncontrolled intersegmental relationships are passively 'controlled' and
pain reduces? Or the (research-proven) effectiveness of Core Stabilisation
education of low back pain recurrence rates where again the model of
uncontrolled intersegmental relationships and pain are central.
Do you have a more coherent theory regarding the
success of such interventions that does not include an association between
intersegmental relationships and symptoms?
John Spencer
----- Original Message -----
Sent: Wednesday, August 07, 2002 10:01
PM
Subject: Re: A Question of Posture
At 11:01 AM 8/7/02 +0100, you
wrote:
I am a little suprised to hear that you feel
there is no evidence for pain being associated with intersegmental
relationships. What would you attribute the pain to in spondylolisthesis
other than a disrupted intersegmnental
relationship?
John Spencer
John,
The intersegmental
relationships Sahrmann refers to are for the most part minor rotations and
angulations of one vertebra on its neighbor(s), not the pathology of
significant spondylolisthesis which in its truly symptomatic state would
typically include instability and frank, compressive compromise of the nerve.
In short, it's unfair to use this condition to demonstrate her point because
she's talking about something else. Even at that, her comment about a couple
of millimeters of slippage being enough to produce symptoms strikes me as an
incomplete assessment of the condition. Pain is the end result of an equation,
not an event. Only when the mechanical deformation within the system surpasses
our tolerance for it do we begin to hurt. Simply identifying the presence of a
situation like spondylolisthesis doesn't tell us that the patient hurts or
even if the problem will necessarily worsen. To know that we'd have to ask the
patient, additionally assess their adaptive potential and then see into the
future.
Some might say that postural assessment leads logically and
reliably to answers but I can't agree. It's a ritual that I don't expect to
see disappear soon, but that does make it an exercise in logic.
Thanks
for contributing to this discussion.
Barrett L. Dorko, P.T.
<
http://barrettdorko.com>
