The Beyond Pain Podcast
Struggling with pain? Does it affect your workouts, golf game, plans for your next half marathon? Join The Joe's, two physical therapists, as they discuss navigating and overcoming pain so you can move beyond it and get back to the activities you love most. Whether you're recovering from an injury, dealing with chronic pain, or want to reduce the likelihood of injury tune into The Beyond Pain podcast for pain education, mobility, self-care tips, and stories of those who have been in your shoes before and their journey beyond pain.
The Beyond Pain Podcast
Episode 13: Living Well with Sciatica
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Summary
In this episode of the Beyond Pain podcast, Joe Gambino and Joe LaVacca discuss the topic of lower back pain and sciatica. They start off with some fun facts about the history of sciatica, including its Greek origins and early treatments such as cupping and blistering. They also discuss the overuse and misunderstanding of the term 'sciatica' and suggest using the broader classification of 'nerve root issues' instead.
The main takeaway is that true sciatica involves leg pain that is worse than back pain and extends down to the foot or toes. In this conversation, Joe LaVacca and Joe Gambino discuss the assessment and treatment of sciatica and nerve root issues. They explore the importance of understanding the difference between nerve root irritation and nerve root compression, as well as the role of movement in managing these conditions.
They emphasize the need for individualized treatment plans and shared decision-making with clients. The conversation also touches on the use of nerve glides and tensioners, the favorable prognosis of nerve root issues, and the importance of aerobic exercise for nerve health.
Takeaways
Sciatica is often overused and misunderstood as a term for any leg pain, but it should be reserved for cases where the leg pain is worse than the back pain and extends down to the foot or toes.
The history of sciatica includes early treatments such as cupping and blistering, and the term 'sciatica' originated from the Greek word for pain around the hip or thigh.
The term 'nerve root issues' may be a more appropriate and accurate classification for leg pain that is not true sciatica.
Proper education and communication with patients about their pain and diagnosis is important to ensure accurate understanding and appropriate treatment.
Differentiating between nerve root irritation and compression is important in guiding treatment decisions.
Nerve glides and tensioners can be effective in managing nerve root issues.
Individualized treatment plans and shared decision-making with clients are crucial.
Aerobic exercise is beneficial for nerve health and should be incorporated into treatment plans.
Joe Gambino (00:00)
Welcome back to the Beyond Pain podcast. I am one of your hosts, Joe Gambino, and I'm here with the lovely co -host, Joe LaVacca. You can find us on Instagram as always, at Joe Gambino DPT. That will be for me and for Mr. LaVacca or Dr. LaVacca over there, at strengthinmotion underscore PT.
Joe LaVacca (00:12)
Hello.
Joe Gambino (00:26)
This podcast is also found that has its own Instagram channel, Beyond Pain podcast on Instagram. And we also have a channel on the YouTube Cups of Joe underscore PT. Not sure why that's the only one that doesn't have the Beyond Pain branding, but because we've relaunched this bad boy since the Cups of Joe four episodes that we created back in like 2015.
Joe LaVacca (00:43)
That's a good point.
Joe Gambino (00:55)
I guess that's the reason there. And then as always, shoot us a DM, just DM us the word podcast. We'll be more than happy to just open a conversation with you and talk more. It could be about your pain. It could be not about your pain. We just love to connect. And there's an application form as well in the show notes. So if you ever feel like you need some help with your pain or anything that's going on, feel free to fill that out. And one of the Joes will get back to you. Joey Boy, how you doing?
Joe LaVacca (01:21)
I'm doing well. I got the ladies here this fine weekend. Well, they actually came in last weekend. We had a little family party get together celebration. They have since stayed. We went to a met game last night. That was a lot of fun. We are now gonna have a movie day after our famous growing or growing.
Joe Gambino (01:42)
Boom.
Joe LaVacca (01:51)
world renowned podcast here. We're going to go to lunch and then go see Inside Out 2. Have you seen Inside Out, Joe? I guess you're not into the movie. You have, okay.
Joe Gambino (02:00)
I have, I have seen, yes I have, I'm pretty sure I have.
Joe LaVacca (02:05)
It was good, it was good. It was a solid movie, solid movie. I appreciated the way they talked about emotions and growing personality traits and then made these things more complex as the girl got older. So now I'm really excited to see what they do with her, I guess, being in her formative teenage years. And having, well, I know, I know, I'm hoping that this movie will teach me a few things about how to deal with.
Joe Gambino (02:24)
Mm -hmm. Well, you're gonna find out real soon, Joe.
Joe LaVacca (02:33)
the growing emotions of a 13 year old and 10 year old girl. So, yeah, fingers crossed on that one, but I'm looking forward to that. Yeah, and then we got what? I mean, this is technically we're recording this leading up to Father's Day weekend. You got any plans for Father's Day?
Joe Gambino (02:48)
Yes.
I will be getting an early round of golf in. I got a 7 .36 tee time, so I wake up a little early, go enjoy some time playing golf. And then whatever Jen has whipped up for us and just chill and hang out with the fam the rest of the day.
Joe LaVacca (03:10)
Wow, wow, what a man statement. I'm going golfing and then whatever my wife has cooked up for me, that's what we're doing. Nice, nice man.
Joe Gambino (03:18)
huh. Yeah, yeah, yeah. We know we go, you know, for Mother's Day and all that stuff. You know, I plan the day and you know, we do. I just want something chill. I just want to spend time with the fam and you know, if we go to eat or whatever we end up doing, that's gonna be fun, you know, so.
Joe LaVacca (03:25)
That's it. That's it.
So you guys surprise each other. Is that what I'm hearing? Like you don't know what's gonna happen, she doesn't know what's gonna happen on Mother's Day?
Joe Gambino (03:36)
to yes yeah we'll usually ask like if there's something something you want to do you know like Mother's Day we went to the beach because that's like Jen's favorite thing in the world is about like a two -hour drive from here and then you know we were talking and I was like well you know her birthday is like the weekend after Father's Day so I was like all right what do you want to do it's actually in midweek I was like what do you want to do for your birthday and she looked at me she's like go to the beach so we're gonna go to the beach we have off on Wednesday like I've taken off on Wednesday you know
Joe LaVacca (03:46)
Very cool. Very cool.
Yeah.
Joe Gambino (04:05)
Juneteenth take off and then took off, you know, not work on her birthday. So we may go and stay the night down like the Wilmington area and just chill. So it'll be fun.
Joe LaVacca (04:07)
Yeah, that's right, that's right, Juneteenth, that's right.
So that's the same day, Jen's birthday and Juneteenth's same day.
Joe Gambino (04:20)
She's the day before. She's the 18th. Yes.
Joe LaVacca (04:22)
okay. All right. Got it. Got it. I was gonna say, I was like, then you have a reason to take off now. Well, I think it's, I think it's actually a national holiday. I think even like Bankstream stuff are closed now too, right? So that's great. That's awesome.
Joe Gambino (04:30)
Mm -hmm. Yes, yes. Most people, I don't think everyone gives a Juneteenth off. I'm not too sure.
Joe LaVacca (04:38)
So if they don't, they should.
Joe Gambino (04:40)
Exactly. Exactly. Well, enough about all that fun stuff today. We are talking about the lower back. We're talking about sciatica and other potential diagnoses. And you put a lot of a lot of effort in here with some notes. I'm taking a peek at it now. So why don't I'm going to let you just kick off this conversation. I have some ideas, you know.
Yeah, I kind of like this because I feel like you go out and you get the data and you take a lot of the research and put it in here and I just come in and like, you know, the anecdotal, you know, I just like to throw my clinical experience in there as we kind of go along. So I think it's a great, great tag team here. Yeah, yeah. Again, right. We got the philosopher and Joe LaVacca there and then you have me.
Joe LaVacca (05:17)
Here we go.
We have a one -two punch going here, Joe. It's really, really nice. And yeah.
Well, you asked me something last week and this is what's going to tie into, I think, leading into our sciatica pain episode. You asked me last week if I had learned anything and or what I had been reading and I shared some things about the book Super Communicators. And I got to say, I learned a lot of fun facts about sciatica. So I was hoping to start with fun facts, if that's okay with you.
Joe Gambino (06:00)
Mm hmm. That is fantastic. I love that.
Joe LaVacca (06:02)
All right. All right. Well, first fun fact, it actually comes from the Greek word "ischias" and that actually translates to pain around or coming from the hip or thigh. Here's also another fun fact. At the time when people were talking about "ischias" or "schias" and then I think it kind of progressed into sciatica and sciatica.
people were way more concerned when the pain just stayed kind of around the hip rather than traveling down to the leg or the foot. And really, because back then, it probably meant a much more serious diagnosis. Like you actually had a really true hip pathology or there was a chance you probably had tuberculosis. So I can see why having some nerve pain down the foot, you know, maybe back in the day was probably a little bit more comforting than maybe walking around with this idea that you had tuberculosis.
Joe Gambino (06:48)
Mm -hmm.
Hahaha.
Joe LaVacca (06:59)
So a few more people came on board. I didn't take everybody's name. I wanted to kind of keep it light and just fun. So excuse the fact that I did not put dates or names here, but if you want dates or names, I'm happy to put those in the show notes for everybody. But we're gonna break down sciatica into two different parts now, nervous and arthritic. And nervous sciatica was believed to be because of excess cold.
So all you needed to do was go apply some heat, go to the spa, put some soothing ointments or bombs on it. And then I was realizing like, that's a lot of the things people do today for this sciatica. This is...
Joe Gambino (07:39)
This is very Eastern medicine. You know, like especially, you know, I mean, Jen's mom, she's from China. I mean, like the whole thing about cold is like they like hate like anything like cold. Like you have to like do something warm. Like when Jen was when we had Olivia, I mean like.
She refused to allow Jen to have anything cold, like no ice cream, no cold water, everything had to be like hot because that's what's going to actually like allow her to heal and everything like that. It's interesting.
Joe LaVacca (08:07)
Wow.
Yeah, well, I think that's a good point because I didn't think about the wellness side of this too. I was just more thinking of like the treatments clients come in and tell me they've done. I went to the massage therapist, I got infrared therapy or sauna or like a hot / cold whatever. But maybe that's where like the whole idea of like having tea came from when you're feeling blue or feeling down, right? So you get that warm, I guess, energy, you mix the yin and yang of...
Joe Gambino (08:20)
Mm -hmm.
Mm -hmm.
Joe LaVacca (08:42)
keeping everything in harmony, I guess. So that's a fun thought. A little progression there from sciatica. How about this for other treatments, Joe? Cautery So we would just take a red hot iron, put it right there on the lateral aspect of your leg and your gastroc. Basically, if you could think of like where your fibular head is or like the lateral side of your shin, just put a little hot iron right there to cauterize that nerve from traveling down into your foot.
Joe Gambino (08:47)
Mm -hmm. Yeah.
Mm hmm. So really what if this if this was still today, I mean, we would be having the cups of Joe branding and going right into the aspect of the hip to stop, you know, stop Sadaka from progressing, you know.
Joe LaVacca (09:11)
We were doing lots of wild shit to each other.
Mmm, that's right.
That's right. That's right. Well, maybe, I mean, I know we're now we're bouncing back and forth a little bit, but like, maybe this is where the ideas of like, you know, injections came to be because they probably weren't injecting too much back in the 1700s, right? It's like, hey, well, let me just take something hot on your skin. And now you just have a new set of problems. I don't think your your nervous system will be focusing on your sciatica pain anymore because you've just been significantly mauled. But
Joe Gambino (09:35)
Mm -hmm.
Ha ha.
I will now treat this burn wound.
Joe LaVacca (09:53)
my God, yeah, I know, geez, then you're getting, probably back then too, your leg was gonna get infected and then they were just gonna amputate it anyway, right? I mean, that's probably the next logical progression. I didn't dig deeper than that.
Joe Gambino (10:03)
And then you have Phantom Lake pain and now we have a whole whole new set of issues, right? So that's funny.
Joe LaVacca (10:08)
Yeah, yeah. But I mean, it is interesting. And here's the last fun fact, right? So I'm going to butcher this this poor man's name. Dominic, Cotugno Cotugno I don't know if anybody has the actual pronunciations of names. I butcher names all the time. I'm not a not good at saying names. Are you good at saying names? Joe? You have a nice name. Joe Gambino. Like I like saying it. It's fun. Yeah. So anyway.
Joe Gambino (10:28)
Yeah, yeah, no.
Joe LaVacca (10:33)
In 1756, he actually wrote the first book on sciatica and he actually started shifting perceptions due to some new anatomy and physiology findings that were emerging in the field. And his idea, because he was also the first person to identify cerebral spinal fluid, was actually that there was this excess fluid kind of on the nerve itself. And then his treatments were cupping, blistering, and acupuncture because sciatica for a really long time.
actually became known as Cotugno's disease. So kind of interesting. So again, like all these initial thoughts of, it has to be fluid. it has to just be from cold. I mean, this was 300 years ago and we're still doing a lot of those things, which I find pretty fascinating.
Joe Gambino (11:22)
Yeah, and the Eastern medicine themes are popping up here again, cupping, blistering, acupuncture, right? It seems to be that they found the tricks first.
Joe LaVacca (11:32)
Exactly. Exactly. So I, so yeah, so those are just some fun facts. what did you think about those fun facts? I actually kind of liked a lot of the connections that you were making there, Joe, because I didn't, I wasn't thinking about, back and forth with today, all that stuff. So that was fun. You are, you are making lots of connections, for us here. So, I think the other thing that I always like to do when we talk about a specific topic and, and I started doing this a lot when I was teaching.
Joe Gambino (11:34)
Thank you.
I guess I'm the philosopher today, Joe.
Joe LaVacca (12:02)
is the lack of definitions. And I think this is when we really kind of, we kicked off the podcast, right? Defining pain and, you know, sharing definitions. I think, you know, we, we, I think we asked Tyler, you know, his definition or relationship of pain. I think we asked that of Mike, you know, we'll, we'll ask that of future guests as well. Cause I always think it's kind of really interesting to hear that. But do you think the term sciatica is.
Joe Gambino (12:07)
Mm -hmm.
Joe LaVacca (12:29)
overused, underused, misunderstood. I'd like to get your thoughts on that and then we'll try to maybe dive into a more appropriate definition together.
Joe Gambino (12:42)
Yes, I would probably say overused. And I'm again, right? I mean, it's it's probably like, you know, at any time, I think anyone has any sort of like, ridiculous pain doesn't matter where it travels, right? It's automatically sciatica. And I trying to think if even I hear that from like other medical professionals to write where like they had come in with their presentation of having some numbness tingling and they said their doctor.
told them that they had sciatica, right? But then when you look at the presentation, it doesn't match what you would expect from sciatica. So I would definitely say or think that it's definitely overused, but whether or not it's overly important, I think that it is, you know, we should be educating patients on what we think is actually going on, but it's not harmful for them to think it's sciatica versus like if the nerve impingement was somewhere else, unless it's actually going to change significantly the treatment that you would be.
prescribing, so to speak.
Joe LaVacca (13:42)
Yeah, I think we'll, we'll, we'll definitely close on treatment thoughts, but I agree with you. Anybody that has pain into the leg, I think instantly names it sciatica. Right. from the best information I can kind of put together, it's probably better to talk about sciatica into more of a broader classification, which is like nerve root issues. Right. So nerve root issues, we can.
maybe use interchangeably with sciatica, but the real key, and this came through a few different resources, is that your leg pain has to be worse than your back pain and typically extend down to the foot or maybe even toes. So I found that sort of like a nice way to maybe delineate what is a true nerve root issue. Because when, you know, I did some cross -referencing,
The other thing about leg pain is that when we stimulate almost any tissue in the back, it can refer pain down to the hip, down to the hamstring, maybe even just slightly below the knee. So this is where I think maybe, you know, the wording does matter a little bit just from like maybe a clinical sense, because maybe this is where prognosis comes in, because nerve root issues typically can take, you know, maybe a lot longer than...
you know, non -specific back pain to clear up. And if we're maybe not using that as a guiding light, maybe, you know, I start to overreact as a clinician, like, why isn't this getting better? we should probably send you for X, Y, or Z treatment and maybe, maybe certain things happen that don't necessarily need to happen. But I also was thinking about a couple of courses that I think we and you have taken. And one of the ones that first came to mind was FR or functional range release. And when we were doing.
spine work, I remember a few of the instructors specifically talking about the posterior longitudinal ligament of the backside of the sacrum and saying if we can palpate this, this will mimic pain going all the way down the leg. Then I thought how in school or in some other palpation course, we would talk about side atica. Do you remember side atica? Did they talk about that? Like where the glute medius or the muscle on the side of your hip?
can also sort of like refer that sort of like pain down the leg when it's deeply palpated or strummed. So that kind of jive that I don't think I ever really kind of like, again, like put those things together. So in your sort of opinion, I know you're doing a lot of virtual stuff right now. Are you trying to decipher if it's coming from like a lateral hip, a.
posterior this and if you do, how are you kind of setting that up in your virtual experience with people with nerve repair or sciatica?
Joe Gambino (16:44)
Yeah, I think, I mean, obviously a presentation is, you know, I mean, one of the clearer signs that I think there's like nerve root irritation would be, you know, how far it travels down. And then I also think about like, you know, from movement perspective, like what is it responding to? You know, I think you, you know, with what you said, as far as nerve root stuff, not responding as well, or as quickly as other things becomes a very determining factor for me, as far as like, you know, what.
might be going on. because if we can do some, you know, cause I think that you can have nerve irritation without necessarily having like a nerve root issue, right? Like you can still have some of these like underlying neurological things that happen. So it's how do you start to tease these things out? And then like, if you, once you start testing movement and going through movement and you see what kind of irritates things and what makes things feel better, right? You can start to, okay, well, maybe even if I didn't, I couldn't fully distinguish between a nerve root issue or.
Joe LaVacca (17:25)
Totally.
Joe Gambino (17:43)
just some other neural issues going on or maybe, you know, maybe it is coming from the back, right? But I can start to get an idea of like, okay, well, if we do nerve glides, they respond positively. If we move the spine or we, we load the hip this way, right? There's a positive response. And now I start to just get all this information that's from a movement perspective, right? And I tried to treat these movement issues versus saying like, you know, if I really am.
Struggling coming up with like a you know, something really does seem like a nerve root issue based on the symptoms the history I feel like the history gives me almost everything that I need and I feel like my testing at that point just becomes like a confirmation of The bias that I get from their story and if I'm having a hard time, you know Piecing together pictures or what I would expect from how they're presenting
doesn't quite match what they're showing me from movement or not responding the way then I, you know, I would just refer out to somebody in person or back to their doctor or wherever they need to go at that point, right? Because I can't say that I'm gonna have the answer to every single problem that somebody comes to me with, but at least I can give them an hour at that point, right? The education of what's going on, why things aren't mismatching, think about, you know, some other things that they might need to think about and then let's go see the appropriate person from here to rule out any sort of.
Joe LaVacca (18:42)
Mmm.
Joe Gambino (19:04)
things that can be potentially, that would really impact conservative care or the rehab process, so to speak.
Joe LaVacca (19:12)
Right. Right. I'm really glad you said that education piece. And I think for me, the education piece is probably the biggest thing that has helped me manage this, even from an assessment and a treatment standpoint. Right. So we mentioned that, all right, if we're trying to decipher, if it's a nerve root issue or sciatica, we said leg pain worse than back pain. So that was really helpful for me at the time. Right. And again, like understanding maybe the length of symptoms that happens. The other thing is with your straight leg raise testing,
It seems to be, it's not that the limitation of the straight leg raise is a positive finding. It's the actual recreation of the sharp and very localized symptoms that the people are feeling. So I think that's a big thing to understand for everyone is that, Hey, my hamstrings are tight and I have a little bit of pain into my hips. It doesn't mean that that's a nerve root issue or sciatic issue, right? If you have that leg pain and you go to like raise your leg and it sends the same specific signal.
maybe a little bit more of a sign of maybe something we want to dig deeper into. You know, as always, age is maybe a factor too. It seems that, you know, this is a more middle -aged process, maybe from the ages of like 40 to 60, it seems to affect the most people. So I'm always kind of keeping that in mind as well. So if they're really young, is this really truly a nerve root issue? If they're maybe a lot older, is there something else going on? So I always got my antennas going up with like the...
really young and probably the really older clients that we see. But then here's the, I think maybe the biggest one that has kind of, again, helped calm me down as a clinician is this idea of like, ridiculous pain and actually ridiculous opathy and how to maybe, like you said, send people out or refer people out. And from my understanding, ridiculous pain is sort of what we're talking about right now with sciatica or nerve issues.
So it's sharp, it's localized, it fits a pattern, but it's usually a sign of increased nerve activity. So the nerve is fine. It's actually a healthy nerve. It's just doing too much and overreacting to mechanical stimulus, right? As opposed to radiculopathy, which is nerve function, and that's typically a loss of maybe nerve health.
That's where you're going to see reflex and maybe even sensory loss. So I think when in doubt for anyone, if you're seeing weakness and if you're doing reflex findings, those are maybe things to highlight a little bit more because you cannot fake a reflex test. And I think that's really important whenever we're dealing with radiculopathy or a ridiculous pain anywhere. It could be in the arms too. If reflexes are diminished, that could maybe be a sign of something a little bit more serious.
And that's probably when I would definitely refer out to people or at least get more people on the team that would be able to offer quick decisions with maybe an injection or at that point, maybe potentially surgery. But I like what you said before, because I think less than about 2 % of these ridiculous pains really come from like a disc compressing on the nerve that requires surgery. Right. So I think that, you know,
when we think about how prevalent low back pain is, it affects 90 % of the world and probably dominates a lot of your caseload as it does with mine. But I only have maybe a few people in this year that I can count to have had a low back surgery at any point in their life. So I think that kind of jives a little bit.
Joe Gambino (23:11)
Yes, that's right. Because I muted myself so you didn't get any background noise, Joe. Yeah, so I mean, what I was saying is, you know, I think, you know, I was saying initially, right, like herniated discs, we know that there's some research that say that they will resolve, they can heal over time, right? So, you know, is that necessarily something I think really, when it comes down to surgery, it's really just like, how badly does it impact function? Does it improve over time? You know, can they?
Joe LaVacca (23:15)
Yeah.
Joe Gambino (23:38)
I mean, I've seen people with nerve root issues, right? Where it's like a significant impact on their days and they can't do anything without pain. In those cases, right? You're probably going, you know, surgery is something that should probably highly concern at that point. Because if you can't move at all and you can't even do anything to desensitize the symptoms, well, you know, we're going to need something a little bit more to get that process started. So here's things like that. And also one thing I look at and I think, you know, if you're somebody listening to this that has it is,
Is there normally what I see, you know, if there's like a, like an actual nerve root issue, we would expect that like, if you did anything, flexing the hip with the straight knee, if you bent forward at your spine, with the straighter leg, right? Like all these things are even just bending forward in general, right? They're going to reproduce a lot of these symptoms. So if there's mismatches in, well, one of these things kind of reproduces the symptoms a little bit, but another one doesn't. Well, then is it, you know, like, then I start to say, okay, well, maybe it's not really as much of a nerve.
issue as it is just some of these positions being more, you know, targeted to some sort of, I mean, it's right. It's still probably nerve tissue that's being irritated, but it's not going to be something that's as, you know, as deep as kind of like this really, you know, ridiculous, I think that's really starting to cause the nerves to have this issue. And I think motor loss is really that big one. Like, I mean, we, we know, right, those are red flag findings, right? If someone has motor loss, if you're like, all of a sudden something feels significantly weak in a short period of time.
Joe LaVacca (24:58)
Mm -hmm.
Joe Gambino (25:06)
a doctor's visit in that case is necessary. So I don't know what you have.
Joe LaVacca (25:13)
Yeah. Especially if that's prog, yeah. Especially if that's progressive too, right? Like, again, then if you've had nerve root issues, and you still have some weakness that's stable, I think that's a big, that's different than I think what me and you were talking about, like progressive motor loss, is the thing to sort of really kind of pay attention to for everyone. I know we're, we're throwing out a lot of these words and everything else, but I do want to remind anyone that's suffering from this is that.
Joe Gambino (25:29)
Mm -hmm.
Joe LaVacca (25:42)
most of the time this gets better. It does have a pretty favorable progression, albeit maybe slower than some of us would like. So a very small number of people, about 15%, seem to fully recover. Fully recover, no issues within about three to four months. An additional 30 % of those people take, eh, it's gonna maybe take a year, but for the most part.
Joe Gambino (25:46)
Hmm.
Joe LaVacca (26:07)
most people, about almost 80 % of people, are gonna gradually see this road get better and better over the course of the first 12 weeks. So the history is favorable. That's gonna probably bring me to the point of, well, what can we do? What can our clients do to maybe further their progressions along, ease some suffering? And in terms of treatments, do you have any...
Joe Gambino (26:11)
Mm -hmm.
Joe LaVacca (26:36)
Like again, initial go -to treatments, you go through your assessment, we're thinking that this is sciatica, a nerve root issue, you're doing some virtual stuff. I mean, I know I have probably like a rehearsal list in my head, right, of things I wanna take people through or at least show them initially. Do you have anything like that? And if so, what are your first initial go -tos?
Joe Gambino (26:58)
Yeah, I think in this, in cases where if it's like a true nerve root issue, true sciatic, it really depends on how they, if we do make it to go through an assessment process and all that stuff, it really depends on how they respond. Depends on whether I'm going to keep them on, you know, keep working with them or not. I'm doing it to refer out. You know, if they respond fairly, usually the first things I go to is doing some sort of nerve glide, right? Sciatic nerve glide, start them on their back.
start to find easy ways to get them into spine flexion and get the spine moving and you know, what can they do from even a hip mobility perspective to start to open things up and what can they even tolerate?
so that's, you know, I would probably say there, but I always say the first things I'm always going to just to see how they respond is doing some sort of gentle nerve gliding, just to see if it starts to either, you know, if it's going to always onto the foot, does it start to centralize things? Does it actually get that, that, numbness or whatever sharp pain that they're feeling? Does it start to get to move up the leg closer to the back?
Does it start to bring down symptoms as it have allowed them to move a little bit more freely and then really? Depending on how where their symptoms are that's really the first step about like bringing down pain calming down the system So this way they can actually start to move it unloaded and do things like that. I probably say that's where my starting point is But it's that's I think a harder, you know Because it really just depends on where those symptoms go and how how bad that person's feeling To really decide, you know what that those next steps are going to look like
Joe LaVacca (28:30)
Yeah, I would, I totally agree. I think sliders and tensioners are probably the number one thing a lot of people go to even clients when they come in with the pain, if they have seen a provider or they haven't because everyone's so educated now with YouTube and Google and everything else. They're like, yeah, a lot of people tell me I've done, I've done sliders, you know, I've done a lot of the active gliding stuff. And from the things I was reading this week, they do seem to be fairly.
Joe Gambino (28:52)
Mm -hmm.
Joe LaVacca (29:00)
beneficial, especially when paired with a physical therapist or maybe a movement practitioner that you're doing it with, right? Somebody that's going to, you know, coax you through the movement, be there with you, maybe touching you, maybe reassuring you a little bit. Right. And then. I think maybe even more so was this idea that for people who maybe can't develop or maybe afford the time of an exercise program, multiple manual therapy visits.
chiropractic care, physical therapy, you name it, this seems to be a really nice thing that people can do on their own that's cost effective that won't take them really a lot of sessions to really understand. I mean, whether it's virtual or in person, I've never really had anyone really struggle with the idea or concept of a slider or attentioner. So I think that that should definitely probably be in our bag of tricks for clients.
things from there seem to get a little bit more blurry where to go in terms of do we do stabilization exercises? Should we do functional motor control exercises? Should we just wait and see and just don't do anything? And I think from everything that I was able to gather this week, it's essentially meeting the patient where they at. What can they do? What do they enjoy?
Joe Gambino (30:05)
Mm -hmm.
Joe LaVacca (30:28)
What do they tolerate well? And ultimately, what can they be successful with when they leave? Right? So I think that when we compare motor control, stabilization, all these different things, it doesn't seem that one is better than the other. So this should give us a lot of options to say, Hey, look, we're going to throw some planks or some breath work out here or this or that. Well, I don't like doing breath work. I don't like doing this. Okay. Well, what do you like? I really like aerobic exercise. I really like biking. Okay, great. This is awesome.
Joe Gambino (30:32)
Exactly.
Joe LaVacca (30:59)
We can do that too. So that's where I think that shared decision -making with clients can really shine here when we're talking about nerve root issues, because it seems that doing anything plus exposure, right, our sliders, tensioners that we just mentioned, versus nothing or potentially like passive care, just with like your spas and your heat ointments and all these different things, is better, is safer, and...
Joe Gambino (31:04)
Hmm.
Joe LaVacca (31:29)
doesn't show that adverse reactions are a result. And I think one of the things that people always tell me is, hey, well, I don't wanna do anything that's gonna make this worse. I'm sure you've heard that. I'm sure people listening can relate to that. It does not seem in anything I've read that if you do a slider tensioner, if you do some planks, if you do a motor control exercise, if you do some breath work, or if you go on a long bike ride,
Joe Gambino (31:42)
Mm -hmm.
Joe LaVacca (31:57)
and your sensitivity increases, that does not mean your nerve or condition is getting worse. And I feel like I need to put that on a t -shirt, right? The biggest adverse responses from a lot of these studies was just a little bit of increased sensitivity that lasts about 24 hours. So how do you guide people if they are progressing some sliders or tensioners, they do get some sensitivity?
because I feel like this is where maybe our classic pain rules, maybe do we question those a little bit? Do we question these a little bit? What do you do with that?
Joe Gambino (32:33)
Read my mind, Joe.
Well, not really question them. I mean, I think the exact like there's a couple of things I want to bring up based on what you said. One of them is right. Like you pretty much said, right? Like, hey, if if something gets sensitive, it doesn't mean you're going to it. Things are getting worse and they usually last about 24 hours. Slight pain under four. They goes away within 24 to 48 hours. Seems to be a pretty good sweet spot for people to actually see.
progress, right? To desensitize the symptoms, right? So you pretty much just said it based on some research and things that you were reading, right? Like, again, right, these themes of pain guidelines coming back over and over again, right? To kind of like, it's okay, right? You're probably especially if you're dealing with something like this, you're going to experience some pain with movement. Well, we have at least an idea of like, okay, well, if it's not lingering around too long, and it just comes up a little bit, you know, maybe depending on that level of pain, right?
we can make the adjustments, right? Do we need to back off a little bit? Do we need to continue to do it? Just make sure there's rest and recovery in between sessions so that things could come back to baseline. How can we start to explore this without letting things get worse? So I think you kind of hit that, you know, like you already kind of alluded to it. So I don't know if we need to update our paying guidelines necessarily because it kind of seems we're kind of right in there. And I was actually going to mention this because you even said like, it's giving them what they tolerate. And that kind of always brings me back because clients always ask me like,
Well, what can I do? And I think we've talked about this on previous episodes, right? My answer is yes. You can go try a bike ride. You can go try whatever you want to do, right? And the thing that's going to tell us you can't is what happens afterwards. Is there a lot more pain? Can you not tolerate it? Because what we do know with almost anything from the lower back, more movement tends to be very, very favorable, right? So we can find activities you enjoy. We can get you on more walks.
If that feels okay, if we can get you to ride a bike and that feels okay. If we can get you to do some, you know, core work or whatever it is, right. And you start to feel better because you did it then yes, you're going to do more and more of that. Right. Cause the only things that we want to do in the beginning is whatever we can to sort of bring down that pain response. and the last thing I kind of want to, to, to you mentioned with that, with the nerve gliders and the tensioners and you say paired with the PT it does better. And I think that just.
You know, just from my own experience, I think why that is the case is because people don't realize that there is not a stretch, right? We're trying to like glide this nerve and you're not supposed to be pushing through symptoms because we already know you and I know, right? And other people in this industry know that nerves don't like to be stretched, right? That kind of force that gets applied to it when you really push through and try to stretch nerve tissue can be very, very irritating to it.
So when we're doing these nerve gliders, right, you're just kind of like tapping into the symptom and coming off and tapping like, right, we're just trying to free up a little bit more space for that nerve tissue to move. And I think that's where that education comes in. And that's where that coaching comes in. And then once they start to get that, now that they know, well, I'm not supposed to be like getting all this nerve tension and trying to hold the stretch for 30 seconds, right. And really trying to feel that tension all of a sudden now they become a lot more.
So I you know that just kind of came into my head where like if you're listening to this and you have back pain you want to go try a Nerve tensioner after listening to this make sure that you're not pushing through all these symptoms and that like nervy Stretchy tension in the back of the knee and the calf and all that stuff that can irritate those things start off easy and see if multiple reps and sets start to free up more space and if it does That's a great sign that those things are starting to work and then when you get up and walk around
Okay, hey, my pain was a four before and now it's a three and a half or three or two. Now you know it's really doing something for you. You should be sprinkling that in more throughout your day over and over again.
Joe LaVacca (36:30)
Yeah, I think that's such a great point. I've been telling people doing less more consistently is probably going to be a better recipe for most things than trying to go too hard too soon. Right. Not that everyone always listens, but it seems that, you know, this idea of just aerobic exercise, keeping that low to moderate seems to be more neuroprotective for nerves. And this is a big thing to really, I mean, maybe take away as a
closing point for us here, or maybe a last point is that, you know, nerves more than any other tissues love blood and oxygen. So when you're getting pain and you are moving, maybe we're moving too much, right? And that's causing some sensitization. If you're not moving and you're getting pain, maybe that's a sign that you need more movement, right?
So nerves heal, they hurt as they heal, as I usually will tell people. So don't be too worried about the ups and downs, right? That's gonna come with everything. But I think that if we keep that idea of that nerves love blood and oxygen, this is by aerobic work, really makes a lot of sense to me and clients. So I think that big picture kind of stuff is what we just really kind of said for the last 40 minutes or so is we wanna mitigate fear, we wanna...
help you prepare or help clients prepare for the future, right? Make sense of the pain, educate them, right? Especially on that idea of radicular radiculopathy or loss versus gain. And then whatever it is, just keep finding ways to move as you heal. And I think there's no probably better advice to kind of take away from our conversation than kind of summarizing those points, right?
Joe Gambino (38:26)
No, I love that. And I think that's a perfect summary of everything that kind of came up on this episode. And again, right, it always comes down to what they're feeling, what makes you feel better, what makes you feel worse and trying to, especially when you're in a lot of pain, right? Like double and triple down on the things that make you feel good and maybe, you know, if you have to, right, hold off on those irritating factors for a while. And then as things start to feel better, add in those irritating factors slowly and start to progress. And that's how we start to use.
movement right in this like in the injury space is like low level progressive overload that the tissues can tolerate versus like using your exertion level, which I feel like everyone tends to do. I'm starting to feel better. This nerve irritation feels like it's getting better. I know I can go out and deadlift 285 pounds. So I'm going to go deadlift 245 as my light entry point back in. And then you have a flare up because you're those tissues just aren't ready for that. Right. So now you start to take those movements.
And you're like, okay, well, let's see, can you tolerate 135 for a couple sets? great tolerated well, let's add 10, 15 % more tolerated. Well, let's add a little bit more right now. You're just letting those tissues start to actually get the benefit of movement and you're not exceeding what that threshold is. And as long as there's no pain, you just add a little bit more. And once you start to feel symptoms, well, now we can use those pain guidelines we talked about to start to make decisions. Should we push more? Should we back off? Do we need to rest and things like that? So I think it's a.
Very well said there Joy Boy.
Joe LaVacca (39:55)
All right, so stay sliding, stay moving.
Joe Gambino (39:59)
That's the new tagline for the podcast. Love it. Well, Joe, as always, love you listeners. We love you as well. And if you've made it this far on the podcast, extra love for you as well.
Joe LaVacca (40:01)
Hahaha.
Love you.