Do nerves get stuck? Part 3: Integrating the evidence constructively
Many studies that were used as evidence were later found to be wrong. This means that they were never evidence.
Here is a statement:
"There is no evidence to support that nerves get stuck"
"There's nothing on Facebook or Twitter and my favourite bloggers say there isn't any evidence. They know a lot so I'll trust them on that".
"I wasn't shown much at PT school, no lectures, books or research so there can't be any decent evidence."
"There is no evidence for stuck nerves so we should not be telling patients that their nerve is stuck". Error: generalising from a lack of evidence either way.
More detailed reasoning:
"I don't know of any research that supports stuck nerves (supporting evidence).
Neither do I know of any research that shows that nerves don't get stuck (negating evidence).
Then again, I haven't looked properly:
- scientific search methods
- professionally recognised databases
- peer-reviewed literature
- communicated with leaders and experts in the field for information and advice on the research.
Hmm, so I really can't say if nerves get stuck or not."
So then, what do I do with my patient?
The next step clinically is to do an appropriate examination, searching for supporting and negating evidence in relation to stuck nerves IN THAT PERSON. The clinician accepts that, for the moment, they are not aware of any research evidence either way and that clinical decisions are now based on the PATIENT findings.
The examination should be done with an open mind, testing all relevant possibilities, balancing supporting and negating evidence.
Evidence for the slump test
From part 1, it is clear that there is value in performing the slump test because the diagnostic efficacy ratings for disc protrusion are not bad. Interpretation of the patient responses then becomes an important factor, particularly reproduction of the patient's clinical symptoms and structural differentiation.
However, the clinician remembers that an abnormal neurodynamic test is NOT a direct indication of a specific pathology. It is rather an indication that something in the neurodynamics is abnormal and the decision on cause is related to the entire evaluation. This may include radiology, clinical neurophysiology and other biomedical tests.
Explanation to the patient
"Here is what I've found, now let's discuss what you need and what you want". Do this in a way that balances your professional opinion with the patient's self-reported needs and goals.
Patient explanation - calling it a 'stuck nerve' is probably not a good idea. It's probably better to explain the problem in terms of movement, function and pain in a way that is meaningful to the patient. Offering them positive self-help solutions is also a key aspect of any explanation.
"There is evidence in support of a type of nerve problem which may involve some sensitivity and movement issues. The important thing at the moment is to give you some self-help things that you can do at home. These are designed to improve the function of the nerve which may also help your pain. Here is what you can do:"
Find a position or movement that eases the patient's pain. Often this is an 'opener' movement which we know from the clinical biomechanics studies reduces pressure on the nerve roots, for instance, and can produce instantaneous relief. Other techniques may include self neural mobilisation, postural education and advice on activity to ease pain and prevent irritation.
A key point here is that it is acceptable to be honest and informative to the patient. There is a lot of discussion these days about 'how we explain things to patients', which is clearly of great benefit. But one of the products is that clinicians are now often scared to explain their problem in biomedical terms. This can actually be a form of concealment which can finally upset the patient and cause further problems.
It is permissible and quite easy to explain biomedical problems in a healthy and constructive way that facilitates patients' self-efficacy, control and responsbility and the 'pinched' or 'stuck nerve' is one of these cases.
Research evidence is a critical part of understanding whether nerves get stuck or whether neurodynamic problems exist generally.
The key is marrying the documented evidence to what is happening in the patient.
The only way of knowing if the patient has a problem is to examine for it in terms of the patient's unique needs.
Practical courses in solving neurodynamic problems
NDS Neurodynamic Solutions runs courses globally on how to solve neurodynamic problems, integrating the newest and most reputable research with sound clinical reasoning and manual technique.