Ep. 187 - Does Directional Preference Really Identify Discogenic Pain? with Dr. Jean-Philippe Deneuville

Show Transcript

Is directional preference an accurate way to diagnose discogenic pain? Today, we are diving into a study that looked at directional preference's concurrent validity, compared to control lumbar discography, examined its diagnostic accuracy, compared it to the centralization phenomenon, and explored what this means for patients with persistent low back pain.

Our guest is Dr. Jean-Philippe Deneville, a physiotherapist and researcher with a PhD in mechanical bioengineering, and a McKinsey Institute faculty member since 2017.

He focuses on spinal pain and develops new diagnostic tools with the prismatic team. I am Mariana Parts, physical therapist, and this is PT Pro Talk, where leading clinicians share practical tips to improve your practice.

By the end of this episode, you will understand why directional preference achieved better outcomes than the centralization phenomenon for diagnosing mechanical discogenic pain and gain insights into subgroups of discogenic pain, including those with modic changes to inform your patient assessments and more.

If you're new here, don't forget to subscribe so you don't miss future episodes. Now let's dive into today's discussion. PT Pro Talk is only possible with the support of the forward-looking and innovative companies like Sarah Health, Remote therapeutic monitoring sounds great, but also difficult

Sara Health makes RTM simple and easy for your patients and providers. Check out sarahealth.com slash ptprotoc for a special offer. Neck care. Treating neck impairment? Get objective neck assessments with the neck care system.

Learn more at neckcare.com. Hi JP, welcome back to PT Pro Talk. How are you today? Hi, thank you for inviting me again and I'm very fine. Thank you. And you were just here, but now you had to come back because you just published a paper, right?

Fresh now in September. Yes, very fresh. I think it's two weeks ago. I think it has been published. So very fresh. Okay. So just to get started for the ones that don't know you, just give you a quick background about yourself

Okay. So I'm JP. I'm a French physiotherapist. I graduated in 2008, so it has been 17 years now that I'm practicing physiotherapy.

I'm also a senior faculty for the French branch of the McKinsey Institute. And I have also a PhD in biomechanics and I study Spinal disorder in a general way on the clinical side and on the basic science side with biomechanics study or more clinical study.

Just a quick pause to share something exciting. I've been working behind the scenes on a tool to make prescribing home exercises easier and faster for PTs.

It's built based on feedback from therapists who have told me they are tired of clunky search tools, limited customization, and complicated sharing

I will be sharing more soon, but if you're curious and want early updates, you can join the interest list using the link in the show notes

All right, let's get back to the conversation. Very good. And then for the people that haven't watched our previous episode together, it was a few episodes ago.

We discussed some other papers and your research, so that was very interesting if people want to go back and check that out.

But today we are discussing a different paper. So do you want to tell us what is the paper about? Yes, it's a paper that assesses the diagnostic accuracy of the directional preference compared to controlled discography to diagnose the discogenic pain.

It is based on the data that Marc Lacelette collects during his PhD 20 years ago. And one paper on this data have been already published 20 years ago.

And this is a secondary analysis in which we go deeper into the analysis to bring new information that have not been published until now.

Okay. And I just wanted to get started asking you, what is the difference between centralization phenomenon because you're going to discuss that on the paper and then directional preference for the listeners that are not familiar with the terms.

Yes, these two concepts are pretty close but a bit different. Centralization phenomenon is the rapid lasting and rapid lasting and I don't know in English.

Anyway, migration of pain from distal to proximal. So it's the phenomenon in which you see the pain of the patient going from the leg to the back of the patient after doing some mechanical loading.

So repeated movements, so it could be manual therapy, it could be posture, it could be whatever the mechanical load that you put on the back of the patient.

The patient describes the pain that is going from the leg or from the lateral side of the back to the central part of the back.

So this is a centralization phenomenon. And the directional preference, it's the direction of movement in which you see either the centralization phenomenon or a rapid decrease of pain without change with the pain topography.

So if you have a patient, you move it in extension, you see centralization. The patient has a directional preference in extension. But you can also have a patient that you move in extension.

You see a decreasing of the pain with no change in pain localization. For example, the patient have right buttock pain. You do some extension. The pain is still there after the repetition of movement, but it is significantly less.

And this is also a directional preference. And in the paper that we published, When he collected the data, Mark had few criteria to diagnose directional preference.

He had two criteria. So you must see an improvement of the pain that I say. It was what I described just before. You must see it quickly. So into the session, it should last until the end of the session.

And there is two other criteria. So you should be able to reverse it by doing some other kind of movement, for example, with the example that I took with extension procedures that centralize the patient, you should see that the flexion increases the pain of the patient.

So it's a reversible phenomenon into the session if you use the incorrect load. And the last criteria that Mark used at that time, it was you should see improvement in pain, worsening in pain, improvement in pain, worsening in pain at least twice into the session.

So you must see the repeatability of the process in the same session. So this criteria is quite, the criteria that have been used in this study are quite, are more strict than the ones that we currently use in the MDT world.

And it is, there is two reasons for this. The first one, it is because we are, when Mark collected the data, he was in the logic of research.

So you need to establish a very objective criteria to to be perfectly reproducible if other people want to replicate the study.

And the second reason, it was because he has only one session to determine if the patient is centralizing or has a directional preference.

And so he wanted to be sure. And so he took some very strict criteria. So that's it. Okay. And what were the main goals of the study? So when Mark collected the data 20 years ago, he wanted to determine if centralization or directional preference are predictable of the results of provocative discography.

Provocative discography is the gold standard to identify discogenic pain. So he wanted to see if centralization is linked to discogenic pain and directional preference is linked to discogenic pain.

20 years ago, he published a paper on centralization, but he did not include the data of the directional preference.

And now, 20 years after, I discuss a lot with Mark. I have a lot of exchange with him because of our common research project.

And he said to me that he has the data, but he never analyzed them. So I say, oh, we should do it. The goal of this paper is to analyze the data Mark collected 20 years ago to assess the diagnostic accuracy of directional preference.

Does the directional preference confirm that the patient has a discogenic pain or not? It was the main goal. Okay. And then how many patients were assessed? Do you remember? And how were they assessed?

So it was, I don't remember exactly, it was about 100, I think. Yes, it's around... 103. Yeah, around 100 patients were assessed. In reality, he assessed 207 patients, but only approximately 100 had a provocative discography.

So we compared these 100 patients with the result of discography versus direct preference for this 100 patients because for the other, we don't have the results.

And finally, I think it's 80 patients that was included because there is around 20 patients that he could not assess at all because they were too painful.

And so it's around 80 patients, I think. Okay. Okay. And so how they were assessed? They were assessed by a physio, right? First, and then discography. Yeah, there were two physios, Mark and Sharon Young, who assessed the patient.

The patient came to the clinics of the Dr. Charles April to get a diagnostic procedure with injections. So it was either discography, either zygapophysial joint block, either sacroiliac joint block, et cetera, et cetera.

And so the patient came. Mark sees the patient before the radiologist, before Charles April. He assess the patient, he collect all his data. And after the patient go to see Dr.

April that did the discography, all the assessment, the PT assessment was blind from the result of the radiologist and the radiologist procedure was blind to the PT assessment.

The PT was also blind from previous imagery and I think the questionnaire that the patient filled when he entered the clinic.

So there was a double blind procedure for this data collection. And what were the results? Yes, the funny part. So the results were pretty cool in reality.

We already know that centralization is a clinical phenomenon that is strongly associated with discogenic pain.

We know this from three studies, the one by Donelson in 1997, the one by Sharon Jung in 2003, and the one by Mark on this data.

I think it's 2005 or 2006. So we have already three studies that assess the diagnostic accuracy of centralization with pretty good results, but we never had any data on directional preference.

From the data that we had, directional preference did better than centralization. We had better results for for diagnostic property, for diagnostic accuracy, meaning that when the directional preference is positive, if we have a patient, if we could identify directional preference in a patient, we have a very good probability to have a discogenic pain.

So for the ones that love statistics, it's a likelihood ratio of 7.65. and specificity of 94, I think. So it's very good results. But the screening property of the directional preference is not very good.

By this, I mean when the directional preference is negative, we are not sure that the patient do not have a discogenic pain.

Meaning when it is positive, we have a good reason to think the patient have a discogenic pain. if the patient don't have a directional preference, we are not sure that the patient don't have a discogenic pain.

So this is pretty good results. It is better than centralization. I think it achieves with likelihood ratio, I think we have one point above.

And when we analyze more precisely the results, we could see that when the Why is the direction preference better than centralization?

Because we have less false negative and no more false positive. So it's good results. So it's better. And there were two of my questions. So what did you mean by screening properties?

So it's just like if it's negative, you cannot guarantee that they don't have a discogenic problem.

That's right. And then when you say that they have a better outcome than the centralization, so it's more comprehensive, I think that's what you put on the paper, comprehensive construct than centralization alone.

And why do you think that? I just want to talk more a little bit about that. It is because it is just what I've explained just before. We know... the way centralization and direction preference are defined makes them very closed.

But all MDT practitioners know this. We know that you have to have a direction preference to have a centralization. So it's a very closed construct. We know this in the way we define them.

But we never assess this definition or this way we've built this construct compared to more objective criteria with other objective measuring tools.

And now, by doing this, we know now that these two concepts are very close to discogenic pain. And we know that directional preference decreases the rate of false negative So it includes a bit more of patients, so it's more comprehensive, but without including more false positives.

When you're doing a diagnostic accuracy study, it's always a balance that you should find between the diagnostic property and the screening property.

Both tests, both properties are important, but when you are using them, it is not the same, you are not using in the same, you could not use them in the same way in practice.

When you use screening properties to exclude some disorder, it's especially effective for, you know, when you screen for serious pathology, it's very good to have some good screening tool.

But when you think in a way of diagnosis, of confirming disorder, you should have very good diagnostic properties.

So good specificity versus good sensitivity. It's the way you should reason. And by trying to include a bit more of patients, you could include also some false positive.

And this is a trick that you, this is the trap that you should not fall in when you are doing that kind of research.

And directional preference include more patients. without including false positives. So it's still very robust and it's more comprehensive because we have more positive patients that are true positive.

I don't know if I'm very, very, very clear. We should think of mathematics and the contingency table. Yeah, no, it makes more sense. Thank you for the explanation. and then the conclusions of the studies.

So what can we conclude from all of that? So it is, we could conclude what we've just discussed. It's directional preference is a good diagnostic tool.

It's not a good screening tool. So this is a main conclusion that we could have from this study. We tried to derive some clinical diagnosis rule to identify discogenic pain when we don't have directional preference, but we do not have enough patients to do this clinical diagnosis rule in a good way, so it's not good.

But this is the main conclusion. DP is good for diagnosing discogenic pain. It's not enough to exclude a discogenic pain because it could help But it's not enough.

Yes, it makes sense. And then I know you mentioned some modic changes in the study as well, right? So you're exploring some subgroups. And so what do you have to say about that?

At that time, when Marc collected the data, modic change was not very well known. He did not collect data on modic change. He said to me that now that I know how important it is, we should have collected data on this at the time, but they don't know this at the time, so no data on modic.

However, and this is a part of the discussion I think that you are mentioning, we know now that modic changes are very...

closely associated to discogenic pain. There is at least, I think, four or five studies comparing modic change to discography.

And there is very high diagnostic property. The same than directional preference. When you have a modic change, it includes a discogenic pain.

But if you don't have modic change, you could not exclude discogenic pain. And from Mark's experience, my experience, and the experience of most of the MDT practitioners that I know and that they know how to assess properly a DP and how to assess a modic change, we know that you don't have DP when you have a modic change.

Or it's very rare. It's not based on data for now. It's based on our experience. We are now collecting data on this. But for now, it's our experience. And when there is modic change, it's not very frequent that you have a DP.

It could happen. But it's very rare. You know, I've done a retrospective analysis of my case to my clinics. And I think I had 22 or 23 patients. I see 22 or 23 patients with modic change this last two years.

And I had only one DP in this group. So it's pretty rare. So in our discussion, we mentioned this. It's based on our experience, not on the data that we have collected.

that we have now, we are collecting data to confirm this clinical experience, but it's not based on objective data for now.

But this is very important for me because as directional preference is very good to include, not very good to exclude.

As modic change is very good to include, not very good to exclude. As both of them are not overlapping, That means that we have at least two categories that make us able to diagnose this coging pain.

And I think if we combine no directional preference with no modic change on the MRI, I think the screening property of the combination of these two results are much higher, I think, than just the one alone.

I don't know if I'm very clear. Yeah. they could be considered like two different subgroups of discogenic pain. Clearly. Right? That's it. Yes. Okay. And then I know that you also mentioned a few other subgroups of mechanical discogenic pain, right?

There is. The mechanical discogenic pain, it's the way we label the patients that have a directional preference.

It's the same name that... derangement in McKenzie, but it's more we use this term mechanical discogenic pain to be more, you know, understandable for people that are not into the McKenzie world to make, you know, a physician or surgeon able to understand that we are talking about something which comes from the disc and that could be influenced by mechanics.

So mechanical discogenic pain In the definition that we give into the paper, it's the patient with directional preference.

There is patient with modic change that is another group of patients with discogenic pain. In France, they are calling them active discopathy. I don't know how they call it outside of France, but it's another group.

And there is other patients that do not have directional preference. patients that do not have modic change, but have discogenic pain.

And this is the other group for now that need to be, you know, more, that need to be better characterized.

And it's a work that we are doing. And with Mark now, that we will do. It's not start for now, but it will start very soon. Mm-hmm. And were these groups that you're mentioning, the ones that the end-play driven mechanism and then the annulus driven mechanism?

This is how. This is not how. This is the way we should... For now, I only speak about pain, you know, discogel pain or pain due to modic change.

I did not talk about pathology. Okay. And, you know, pathology, it's the process that... make the structure of the disc degrading and maybe triggering some pain.

You could have some pathology without pain. Sometimes it happens. We all know this. We all see some patients with MRI showing discopathy and no pain.

But when you have a discopathy, you increase the probability to trigger some pain. we see more discopathy among low back pain patients than asymptomatic patients.

So the pathology, it's the process that is behind the modification of the structure that could lead, but only could, not always, that could lead to pain.

And in the paper, we discuss different kinds of pathology that have already been identified for DISC.

And there is two main patterns of discopathy for the disc. The one is annulus-driven. The one is end-plate-driven. So the annulus-driven is when your disc is under pressure structure.

By this, I mean that your nucleus is under pressure and encapsulated by your annulus. If you ruptured your annulus, you deflate the nucleus. There is a drop of pressure into the nucleus.

And this drop of pressure will lead to metabolic change into the disc. The cells which are into the nucleus and the cells which are in the nucleus and the annulus need some pressure to work properly.

And if your pressure drops, the cells don't have the information they need to work properly. And so they degrade, they destroy the disc. And by this first injury that you have into the annulus, you will have a process which is led by the cells of the nucleus and the annulus, which will bring the disc to a complete degradation.

This is the first mechanism and the second mechanism is nearly the same, but the injury is not by the annulus, it's by the end plate.

You have a rupture of the end plate, so you see a drop of pressure into the annulus. The cells don't have the information and they start to degradate the disk.

This is what we know from basic knowledge. It is from laboratory study or biomechanical study or biology study. This is one side of the research. What we've done with Mark, it's another side of the research.

It's more clinical aspects. But we see two different... Clearly, it's very well described. We see two clear different pathological pathways to...

for a disc to degenerate. And we see at least two very distinct clinical patterns. Maybe, and it is one hypothesis that we are making with the discussion of the paper, maybe the two different clinical expressions that we see are the expression of the two different patterns of pathology.

But for now, it's just speculation. It's just an hypothesis. We know both are true, but we don't know yet the link between the both.

And we are making the hypothesis for this. That's what I was going to ask you. I know it's just a speculation right now, but do you think that the end plate could be more related to the modic changes and then the annulus to centralization directional preference?

I think, so it's speculation for now. If I had to give my opinion, I think yes, but not perfectly. It won't be a perfect overlap, I think. But we should see, I think, more body change or pain related to body change within the end-plate driven degenerative process.

I think we should see this, but not a perfect match, I think. But it's pure speculation. We need to assess this. It's just a hypothesis. Do you have any plans in the future of going more into researching this topic that was discussed in this paper?

Oh, yes, of course. Now, you know, each time you do research, you... you partially respond to your question and you have 10 more questions that are coming just after.

So it never stops. Yes, we have several plans. The first one, we have several plans on the clinical side. The first one for me, it's to clearly demonstrate that patients with modic change or with active discopathy, like we call them in France, do not have directional preference, or at least do not have directional preference in the way we've defined it into the paper.

So this will be, for me, the first steps that we should do. We are planning to collect this data. It won't be very difficult to do. It's very simple. I think it's pretty simple.

We just need to plan this properly, but this will be the first. We have another plan to assess other discogenic pain category. We know, for example, that high-intensity zone that we could see on MRI, it's an hyper-signal of the nucleus on MRI, is very linked to discogenic pain too.

There is 12 studies on this. It's very good. But we don't know if directional preference overlaps with this subgroup or not.

So we will assess these two to see if we have a third group of patients. And in that way, we will have a very clear criteria to identify the big group of discogenic pain and all the subgroups that we have in it.

So this is the first plan on the clinical side to have good characterization, good definition, good validation of the group that we could define.

Then, and this is the work that we discussed on the last podcast, it's more on the basic knowledge side in which I'm working with MRI team and biology and biomechanical team in which we should...

better understand the way, better understand the disc pathology and try to make the link between the clinical expression.

Yes. And this will happen in the second time. Yes. After. I know that would be awesome to get those answers, right? It would be super cool. For me, yes. For you, I don't know. But for me, yes, it will be super cool.

And then I also saw that one of the secondary goals of the paper would be to develop the clinical diagnostic rules that you end up not being able to do it, right?

Because you didn't have enough people, right? Yes, that's what I was going to ask you to just mention. Yeah, and I think the data collection was not designed to establish this clinical diagnosis rule.

So we try to do them to see if we could have, you know, preliminary results that could help us with future research.

But now the results are not very good. So we could not use this. So we will need to collect more data to proceed on that goal. Mm-hmm. Okay. Is that on the plans as well?

Maybe. Yes and no. Yes, it should be on the plans, but we need to have some writers that know how to do discography.

And there is not so much now. There is not so much discography that are done now. So it will be difficult, I think. That's why I think these data are very, very unique.

It's because we have 100 patients with discography and examination. And now I'm not sure there is lots of centers in the world that are doing lots of discography like did Dr.

Chalapril. If there is some, it could be very great to meet this radiologist and for replicating what I've been doing but I'm not sure there is some.

Yes, so that will make it a little bit more difficult. Yeah, yeah. And it's very invasive as well, right? Yeah, yeah. And it's probably because it is invasive that there is much less discography now.

It's because we know that it's a very technical procedure. You know, you need to know how to do it. It's not very easy to do. you need to put a needle into the disc of a patient.

And not only one disc, it's at least two discs. But generally, it's three or four discs. So it's invasive. It's not very nice for the patient because when you provoke the pain by injecting some liquid into the disc, it's not very nice.

So for lots of reasons, discography is not too much used now. We need to find, it's what I explained in the last podcast, there is other device or other technologies that are developing now that could replace discography in the future, I think, I hope.

And when we will have that kind of technology, we could replicate this data from this study with other gold standard, it would be good too.

Yes. No, very good. And I was going to ask about the discography. So like the relation that you were making between the directional preference and the discography, you had to have like a painful disc.

Is that correct? And then other discs around, at least one would have to be negative, like no pain, right? So then you would that way be confirming that the person has a painful disc and then has directional preference.

And then you're assuming they are on the same, same level that the person yeah on the on the discography you know, to have a positive discography it's the way the procedure have been developed because you all, you with every test, even the better, the best test that you could imagine, there is some false positive always so discography we the first, the first description of discography, I think it's in the 40s i think and since the 40s There is a lot of research that has been done to understand in which way you could have some false positive discography and how we could decrease the rate of false positive.

And the best way to decrease the rate of false positive is to have at least one disc in which you provoke exactly the same pain that the patient described clinically.

by injecting the disc. And you must, you have to have one disc which is negative. By this, I mean when you put the needle in it, you push, and the patient says, no pain, I feel pressure, but no pain.

Why? It's because, you know, there is some patients which are, you know, sensitized, and each test you're doing is positive, always.

So if you have all discography positive, you could not confirm that the patient has all discs which are painful.

If you have one or two disc positive and one or two disc negative, that means that you have some positive and some negative and you don't have this clinical phenomenon of sensitization that could bring some false positive.

And by doing so, you decrease the rate of false positive. And this is the way the discogenic pain has been confirmed in our study.

Mm-hmm. Okay. No, very good. Anything else that you wanted to mention about the paper before we wrap up? Did I forget anything? No, no, no, no, no. You did very well. But it's just a personal view on this.

There is, you know, we could, as a physio, we could say by reading this paper, okay, that's fine. We have a a way to diagnose patient in which way it will help us as a physio to better treat our patient.

And this is a question that I am very frequently when I, because I'm doing some basic research, diagnostic research, et cetera, et cetera.

And I think there is a huge impact for the patient by knowing this. First, and for me, this is more important. You know, in the MDT world, we frequently say that we don't care about the structure or the diagnosis.

We only care about the clinics. Yes, but we are not living in a world that we are alone. We are with other people. We are working with surgeons. We are working with physicians.

We are working with other physios that are not MDT. And in the medical world, in the health science world, you could not say that you don't know what you are doing.

It's not like this, that this world is built. It's built on you know what you do, you try to understand what you do, and you progress from that field.

And by bringing some objective results, linking our clinical phenomenon to something other now, bring a lot of value you know, for the, and lots of value and lots of recognition by the other.

And I think this is a very important, a very important point. And secondly, it is not, it is not why the health science are built on, we try to understand what happened on the patient to build the clinical, the clinical procedure.

It's not something which is a, You know, totally stupid. There is a reason for this. It is because all the progress that we had in medicine or health science in general are based on that process.

We understand what happened, what is the pathology, how it will affect the patient, etc. This pathology will trigger some things, symptoms, etc.

that you could identify and then you develop a treatment. For us, with the MDT, there is, you know, we had, I think, McKenzie was a very good clinician and identified the centralization without all this knowledge.

This is not very frequent in the medical world. You know, most of the discoveries are based first on basic knowledge and you build up like this.

And even in physio, if you look at the way the research on tamiopathy is done, you better understand the way the tendon is living, the way the pathology is, the better are the treatment and you adjust the treatment.

So us, we've done the reverse. So it's good because we have some good clinical results. So it's fine. But we need to understand what we are doing because if we understand, maybe we will discover that by doing maybe a bit like this, we will be better and a bit like this will be better.

And this subtlety with the clinics will be bringing by the fundamental research, understand the pathology, understand why the patient have some pain like this and like this and like this.

And this is the way our medical world and the medical science is built. And it's not for no reason. There is a reason for this. And this... I think with this better understand will help in the future clinician to better understand what they are doing and maybe optimize their treatment.

And last element and last reason for me, and last reason for clinical importance of this result, it's based on the logic of diagnosis.

We know that patients with directional preference are performing well when we are treating them with directional preference.

We know this for Audrey Long and for the systematic review and the man. We know this. But there is also a group of patients that we don't know how to identify.

For example, and it will be very concrete. If you want to identify a patient with a facet joint pain, there is some. I see some patients like this. I am lucky enough to work with a radiologist that could do some block on my patient to confirm my clinical hypothesis.

So I see pretty regularly some facet joint pain patients, which are confirmed by the radiologist. And to identify that kind of patient, it is because I know that directional preference is linked to the disc.

And if I don't have directional preference, it decreases a bit the probability of discogenic pain. If the patient has an MRI nomadic, it decreases again the probability of discogenic pain.

So I should look on the other joint or the part of the spine. And by working like this, by It's what Mark Laslett calls the diagnosis by subtraction, by excluding progressively this category that you know how to identify.

And because you know direction preference is linked to discogic pain, you know modic chain is linked to discogic pain, when you have excluded this, the probability of discogic pain decrease, that facet joint pain increase, and maybe you have this.

And this is This has a direct impact on the clinics, direct. So this is the three main reasons to do this. It's a good rationale. It helps you on the diagnosis, right?

It helps on your rationale of excluding, and then it's going to change your treatment. And then also the other reason that you said, you kind of justify and give you some theoretical basis for the rationale that we have when you're seeing patients with MDT.

Because as we say, we know that we see the results, but it's good to be able to explain what's behind that and justify that.

Yeah. For example, I don't know if I mentioned this during the last podcast, but when I did my PhD, it was on the disk model.

So it was very biomechanics. And the first result I had, it was not very... If we think of it, it's not very impressive. It was, you know, results on a disk of a cadaveric ship that we put into an MRI.

We did a fissure. We see how the nucleus was moving. So it's very basic knowledge. It was to create the MRI sequence that allowed us to see this.

But before my PhD, my PhD mentor was, you know, your hypothesis of... of a nucleus moving into a fissure where, yes, I, yeah. And, you know, I was, you know, the nice physio, which is very motivated.

We wanted to do some research, which is very nice, et cetera. But my hypothesis was not very, very interesting for them. When I bring back the results, when we did this manipulation, this experimentation, and they see, the nucleus moving into the fissure, it was just a cadaveric ovin disc.

It's not very huge, huge evidence, but they radically changed. And they say, oh, and, you know, because, because, you know, surgeon, physician are working like this.

You need to understand the pathology to explain what you are doing in clinics. And now, They really changed the way they see physio now since I've done this.

And it's not very huge evidence. So we should be aware of this. And especially into the MDT world, we should focus more on this, I think.

If you want some credibility. Yes. And then it starts to make more sense for them. Like they see something. Oh, there is my... something there so we start paying attention and giving you more credibility yeah exactly it's exactly and and and we in my opinion, but it's only my opinion, we could not stay in your in in our position or oh, we don't know what we do, but it works, so it's fine.

I think it's we we could not we could not continue like this. Yeah, absolutely. No, I think it's it's a it's a great Yeah, it's a great work that we need to justify what we are doing.

So very important. Because as you said, we do live in a magical world and we need to show them why we are doing and why it works.

Yeah, and I think by doing this process, we'll better understand and we'll change our process to be more effective.

I'm pretty sure we will have some effect like this. Yes, understand better these different subgroups and help us diagnose and treat better.

Very good. Anything else, JP, before I'll let you go? No, that's fine. That's fine for me. Yes, no, it was a very good study and I'm glad that you came back to break it down with us and explain everything.

I think it's very, very cool. And then if people want to learn more about you or get in touch with you, how they can find you?

As I said in the last podcast, I'm not very present on the social media. I have a LinkedIn account, so maybe you could try like this. By ResearchGate, I look. Also, or by email. I don't know if I gave you my email for the last podcast.

I don't remember. You could use the one we... You could put it on... Yeah, if people want to join me, it could be like this. Okay. I'll add your email to the show notes and your LinkedIn.

Yeah. And as I say, I could travel. So if you want to invite me on the conference, I come. He's putting his invitation out there again, people. Yeah, exactly. He wants some invitation.

JP, thank you so much for taking the time and coming back here to share with us this new paper that's fresh.

So I appreciate you taking the time. Thank you so much. You're welcome. That's all for today's episode of PT Pro Talk. We hope you enjoyed this discussion. Be sure to follow us wherever you listen to podcasts so you'll be notified when we release future episodes.

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