Louis Gifford Head, heart and hands.

Since Louis’ death in February we have received many, many lovely words about him.  I would like to thank everybody again for taking the time to contact us-it really does help.

Louis had an impact on many peoples’ lives, and so, I was delighted to be asked by the Chartered Society of Physiotherapy(CSP) if they could dedicate a morning session to Louis at their annual conference in Birmingham, UK, on October 9th 2014.  Mick Thacker and Paul Watson will be speaking and we hope that you will come.  

We have called the session ‘Louis Gifford Head, heart and hands’.  There is a story behind this.  Louis’ younger brother, Colin Henwood, is a master boatbuilder in Henley upon Thames and has written a beautiful book of that name.  Louis’ neice, Megan Henwood, is about to release her second album, titled, Head, heart and hands.  Megan has written a song for Louis called, ‘Painkiller’. 
We think ‘Head, heart and hands’ describes  the physiotherapy profession in the broadest sense- we hope you do to?

Also, thanks to Adriaan and Collen Louw from the US – who have asked me if they can present, ‘The Louis Gifford lecture’, at their annual conference in June 2014, “… to bring recognition to one of the influential physios of our generation.”  

Check out the ISPI Clinical Pain Conference in 2014 - Minneapolis, MN – June 20-22, 2014  -  www.ispinstitute.com

Finally, Louis Gifford Aches and Pains, the book/s.  I am getting there, hopefully soon!

“My mate Louis” by Mick Thacker

Mick Thacker taken by Louis Gifford

Mick Thacker taken by Louis Gifford

Louis asked me to say a few words about him at his “do” last week. He gave me clear instructions to be honest, accurate and not to be too “nice”! Here is the gist of what I said, it was not intended to be exhaustive or for a physiotherapy audience but rather for his friends and family, I wanted to do him justice professionally straight from the heart and offer them an insight to the huge professional impact he made, who he was professionally and to demonstrate his brilliance and importance.

Louis started to train to be a physiotherapist in Sheffield in 1978. He had previously done a Zoology and Psychology degree and returned home from two years teaching in Sierra Leone. He secretly wanted to be like his dad, Vernon, a brilliant “hands on” physiotherapist. I loved how Louis talked about his dad, it always made his eyes sparkle just that little bit more, here is how he described him:

“His patients loved him. I came to realise that he was way ahead of his time – not only for his exceptional hands and ‘people’ skills but also for his diagnostic brilliance combined with his instinctive ability to instil physical confidence in his patients”.

My first thought on reading this was that it was about Louis, those of us who know him recognize him immediately in this description.

Louis wanted to be the best he could be – not to satisfy an ego, there wasn’t one! But so he could do the best for his patients whom he always saw as the focus whether teaching, writing or treating.

Inspired by Robbie Blake at college he wanted to be a manual therapist, he sought out and worked with the best the UK had to offer Paul Chadwick, Peter Wells and Agneta Lando amongst others. His quest to keep on improving led him to Adelaide to undertake the world renowned Graduate Diploma in Manual Therapy under the tutorage of Geoff Maitland. His year contained several notable classmates including David Butler and Mark Jones. Louis was the star pupil of his group, Geoff’s favourite and the only person he felt capable of following in his footsteps! Praise indeed.

Louis’ insightful thinking and skeptical nature meant that whilst he appreciated how much he was learning, something just wasn’t right, manual therapy applied to persistent pain patients didn’t make sense and wasn’t enough. He wasn’t seduced or limited by being a great manual therapist or by the best, it wasn’t working and he set about trying to find out why not.

He returned to the UK and set up practice at “home” with his partner and wife Philippa. He taught with David and their course became the thing of legend within the profession. Louis though was not happy with the direction that the courses were taking, they weren’t focused on the patient and their needs or answering the right sort of questions. On one of their trips Louis discovered Pat Wall’s work on neuropathic pain, here was something that made sense to him, that really helped him to understand some of the questions he had been asking himself and that patients demanded answering. He contacted Pat (the world’s foremost expert on pain) who offered to meet him for chat. Louis warmed to Pat immediately, a kindred spirit, both loved to smoke the occasional roll up and discuss science from the patient’s perspective. Louis was the first to suggest to him that pain was similar to memory, a topic he asked Steven Rose (the eminent memory scientist) to discuss with Louis. He was able to converse with the very best scientists because he understood and thought how they thought.

I got to know Pat well myself, which was not an easy task, as an iconoclast, he seldom referred to people with a depth of respect or passion, Louis was an exception, he asked me regularly how our friend in Cornwall was.

Here is Louis on Pat:

“Pat made you feel comfortable, he watched normal human life, he had the most likeable twinkle in his eyes that oozed rebellion”

I would suggest that we could swop Pat’s name for Louis’ and it would be a perfect description of him too!

Following his Master’s degree (Adelaide), Louis started to teach his Clinical Biology of Aches and Pains course. Finally he was teaching his own ideas, the ideas, which emanated from the best of current science and the questions patients asked in the clinic. The course was underpinned by an incredible wealth of support from the literature, Louis was a prolific and wide ranging reader, several authors owe him massive royalties for promoting their books! I loved exchanging books with him on every topic imaginable. He had an incredible ability to grasp the key messages and to assimilate them into his teaching and practice. I loved discussing things that came from his reading with him, our conversations were far reaching to say the least!

In the mid 90′s Louis was recruited by the Physiotherapy Pain Association (PPA), started by Heather Muncey, a star in her own right, the organization composed a handful of dedicated members. Louis and Philippa threw themselves into the support and promotion of PPA and were responsible for an exponential growth in its membership and they made sure all their professional contacts were fully exploited by the PPA also. It was an exciting time, refered to those of us involved as “The Physiotherapy Pain Revolution”. At the heart was Louis’ writing and his editing of the PPA newsletter and the publication of the Topical Issues in Pain books; presented as the PPA yearbooks the cost of publication and dissemination was underwritten by Louis and Philippa with no guarantee of success! The PPA continues to be a success today thanks to the energies of Louis et al from the early days.

Louis became and remains the most influential figure in the arena of pain and physiotherapy of his generation, his mature organism model revolutionised physiotherapy theory and practice and continues to influence the thinking of clinicians and scientists way beyond its’ intended audience.

His work was rightly recognised with a Fellowship of the Chartered Society of Physiotherapy, the highest professional award in the UK. This was followed by a Fellowship of the MACP – a double fellow no less.

I have great memories of our time teaching together, there are too many stories to relay here, including many of us questioning the sanity of what we were doing! My favourite was when he came and taught the undergraduates at St Georges, in the morning he was the supreme teacher, diligent and accurate and a lot more professional than I ever was! He realised this at lunchtime and told me he was going to relax in the afternoon, the session post lunch consisted of him recounting his LSD induced psychedelic experience at the Isle of Wight rock festival where he “saw” his hero Jimi Hendrix. Louis the professional and the rebellious – just as we all knew him! It was impossible for me to follow and whenever I bump into those students they always say what an amazing experience it was and how Louis was the best lecturer they ever had (thanks mate)!!

Louis pic - taken by Mick Thacker

Louis pic – taken by Mick Thacker

On a personal front, Louis and I became the best of mates, greatly at ease in each other’s company. Our names professionally linked through our teaching and writing together. I feel lucky, privileged and humbled to be mentioned together with him. He was the person from whom I would seek counsel in all aspects of life. He supported me from my early days, encouraging me to learn more and to follow my somewhat nerdy passion for the molecular aspects of pain; he challenged me and made me ask important and pertinent questions; lifted me when I found the occasional challenge daunting. I loved talking to him. Over the last few months I have had the amazing privilege to have proof read all 450 000 words of his new books. It is without exaggeration a masterpiece, it reignited my interest and passion for pain. We have had the most amazing discussions, allowing us the excuse to talk for hours at a time not just about the book but about life and his experiences, I will cherish these precious times forever. I loved him very much and will miss him more than words could ever describe.

The word great is over used today but Louis was a GREAT:

A great physiotherapist, writer and educator.

A great friend to many, many people.

A great brother to Adrian and Colin.

A great dad to Ralph and Jake who are the two loveliest young men I have ever met and whom we hope our sons grow up like!

A great husband –

To the other half of the team, Philippa, a force of nature!

Louis described her as “his rock” throughout their entire relationship; “no matter what Micky she always loves me”. Louis could not and would not have done it without you!

A great human – I think amongst all the great tributes and accolades that have been paid to Louis his greatest legacy is that patients all over the world are being treated more wisely and with more respect because of his ideas and teaching, both of which he gave freely and generously without a hint of self importance or ego. A truly great bloke!

Message from Philippa, Louis’s wife and partner

picture of LouisPhilippa here – the other half of the team.

Many of you may have already heard that Louis died on Sunday 9th February 2014 – our sons, Ralph and Jake, and I were with him.

Louis was diagnosed with prostate cancer 7 years ago – he was just 54.  His prognosis was pretty poor – so living this long has been a real bonus.  Louis just got on with life and lived with cancer – he definitely wasn’t a victim, sufferer or cancer fighter – he carried on working, but did stop teaching, and squeezed as much fun into everyday. He had a huge and wide number of interests – fishing, sailing, running, bike, golf, reading, writing, mushroom foraging, woodworking, breadmaking, snowboarding… and he was good at them all!

Last June he started to write full time – and around 450,000 words later we have 4 books (a boxed set!).  I promised  him that  I will get them published as soon as I can – there is still work to do but Louis  jumps out from every page.

Louis had no fear of death, although he would admit to wanting to live another 20 years- he had so much to do. He wanted no funeral, so we are having a party on Monday 17th Feb at our local beach café to celebrate him – we expect a crowd!  Louis made 2 requests – no black and he asked his very, very special friend Mick Thacker to speak.  Very few people and patients in Falmouth, where we live and work, know what Louis has done professionally.  To most he was just the local, but well respected, Chartered Physiotherapist at Swanpool – he didn’t want or need to be anything else.

A  remarkable, humble human.

We have received many amazing messages from all over the world and we would like to thank everybody for taking the time to write.  Louis touched (literally!) many people’s lives and he would be thrilled to see the words and thoughts of you all.  We will have another book of appreciation.

Thank you.

Philippa Tindle, Ralph and Jake Gifford

This blog will be kept open and I will add any material I have of Louis’s.  Louis was unable to write his ‘centralisation’ piece as promised because his new books took priority. Sorry.

Topical Issues in Pain – Relaunch!

[Go to the Topical Issues in Pain page to link to sellers]

After much deliberation and chatting with a good number of you, plus many of our old colleagues and friends who were involved in the UK pain revolution of the 1990′s and early 2000′s; Philippa and I decided to relaunch all the Topical Issues in Pain books with the intention of making them cheaper in all respects. Their quality though, remains excellent if not better than, the originals.

Topical Issue in Pain 1 and 2 have been out of print for about 4-5 years. Interestingly there has been a recent surge of interest in all five titles in the USA, Canada and even as far away as Australia and New Zealand.

We have had them republished by a firm called ‘Authorhouse’ as ‘print-on-demand’ books in hardback, softback and also in ebook form so they would be available easily worldwide and, super-cheap! ( If anyone buys a softback or hardback in Europe or Australia I’d love to know what they’re charging you for mailing!)

My big thing is that they are great books by world experts, the material is still hugely relevant, and to a great many ‘pain’ minds, need revisiting with the rather alarming lurch back to passive and modality based approaches to pain that seems to be going on.

Please don’t let Physiotherapy lose our speciality – skilled rehab, -and for pain, – skilled rehab used alongside skilled CBT techniques.

If you buy them as ebooks they are $3.99 – so you can get the full set for a tad less than $20.00!  You can download in pdf format – a strong recommendation!

I haven’t been posting any new material recently because I’m really in the last throws of my ‘giffords aches and pains’ book.  It looks like it’s going to be 4 hold in the hand sized books sold as one in a neat sleeve. Why 4 separate ? – because I’ve written nearly half a million words!  Controlled swearing, real patients, lots of pain material from the tissues to the brain and back out again…and lots of to clinically ponder I hope. If you like the style of the blog, the books similar!   I’ve thoroughly enjoyed writing it and I hope you all like reading it.  It’s been my life, and blended in is a story of my journey from frustration to fulfillment without being sentimental.  These final days take time but it should be well on the way by the early new year.   I feel it’s really going to happen now.

For those of you who attended my lectures and courses in the past -

‘The clinical biology of aches and pains’  ‘The nerve root’ and the ‘Graded exposure’ course – it’s these that form the backbone of the books plus a lot more.

So,

I’d love you all to tell your colleagues about the Topical Issues in Pain books and their new availability!

I’m still working on pain ‘centralisation’ piece – meaning centralisation in ‘McKenzie’ terms – and I’m also thinking about putting some thoughts out there about the graded motor imagery treatment.

Thanks for listening.  Don’t forget it’s ‘Movember’ – a good cause to back.

Louis.

How do you educate people about their pain and NOT make them think it’s in their head?

Apologies for being away for so long,.  The 2nd part of the ‘centralisation’ piece will happen when I get time and am in the mood.  In the meantime….

I have recently been in contact with a South African Physical Therapist called Adriaan Louw. He is based in the USA and has been heavily involved in researching aspects of neuroscience education as well as teaching courses on it, with experience in this area going back to the mid 1990’s.

Adriaan has recently released a book with co-author Emilio Puentedura called ‘Therapeutic Neuroscience Education: Teaching patients about pain.’  It is receiving excellent reviews is packed with information and is impressively referenced too.  It is available through this website:

http://optp.com/Therapeutic-Neuroscience-Education-Teaching-Patients-About-Pain-A-Guide-for-Clinicians#.Ul5c_1MyCgV  — and highly recommended!

Adriaan runs a teaching organisation in the USA called the International Spine and Pain Institute (http://www.ispinstitute.com)  which has a regular newsletter to which I’ve been contributing.  In the most recent newsletter (http://www.ispinstitute.com/newsletters/ISPI_Oct_2013_newsletter.pdf) Adriaan asked me the following question:-

Question: How do you educate people about their pain and NOT make them think it’s in their head?

The quick answer is don’t even mention the head!  I’ve covered this problem in my book and I find it very interesting.  I go into hallucination of smells, but that’s another interesting story.

In the old days, and still now occasionally, I will often explain to a patient that pain occurs as a result of two types of processing.  Here’s the chat:-

‘Think of a computer keyboard, a computer and a screen. The keyboard is your skin or your back, the computer is your nervous system and the screen shows what you feel.  Tap 3 times on the letter X on the keyboard and the processor produces three X’s that come up on the screen, Times New Roman font size 12 colour, black. That’s normal processing.’

Patient nods, but has an interested slight frown as if to say, what’s he on?

‘Right, I now tap 3 times on your skin, – and you feel three simple taps if you’re awake and concentrating, — and the taps are size 12 Times New Roman, — pretty mild!

Patient grins and nods, — Good, he’s listening and interested….

‘Right that’s the first kind of processing, it works fine.  If I bend your finger back, the harder I go the more it hurts.  If there’s an injury, the more inflammation the more pain. You do small movements it stops you. Your finger gets released, the pain goes down, the inflammation settles, same, the pain subsides, your movements get easier and bigger again.  Think of a healing cut finger and how the pain comes and goes as it mends.’

‘Got you…’

‘Here’s the second type of processing that we now know occurs in many ongoing pains. Same kit, keyboard, computer and screen….’

He’s still listening….

‘Tap 3 times on the X and then watch the screen and these XXXXXXXXXXXXXXXXXXXXX’s keep coming up one after another and they keep going and going, scrolling down the page and as they go they go from font 12 to 18 to 36, — then they change from standard black to purple to bright red, —  and they just keep on going.’

He’s nodding, he’s getting it… on I go…and ask him…

‘What’s the problem?’

‘Computer’s gone weird, processing gone nuts…’

‘That’s it! Tap 3 times on the skin, — and it’s agony when it should be simple taps, — not only agony, it goes on and on and gets worse and worse.  Normal sensation somehow gets channelled into the pain system when it shouldn’t.  Modern pain science tells us that this is what is happening in many pain states that have gone on long after the healing has finished.  So, you injure your back, it gets inflamed and it rightly hurts.  Normally the tissue heals and the processing goes back to normal, – you move and there’s no pain, – the inflammation goes, and the constant achy pain goes. Nice.  Sometimes though, the healing finishes and for some reason the pain processing gets stuck where it was in the beginning when it should have wound down and stopped….’

Now he’s looking concerned!

‘So my back’s healed but my processor’s gone wrong, that sounds serious.’

(Now you could go and get into deeper and deeper water here and end up talking about brains and in the head.  If you do, you need to know how to deal with it.  My advice for this short piece is: Try to keep it simple, and the best way to go is go towards how it’s dealt with not circuits in the mind stuff unless you’re really confident and think it worthwhile, which it usually isn’t.)

I address the patient again, — (What I say here varies depending on the patient and their presentation)…(and don’t be cocky here – that’s English for ‘smart-ass’)

‘Don’t panic, I deal with your sort of pain a great deal and there are plenty of positives and plenty of ways of helping and plenty of successes, especially once you’re comfortable understanding what I’m telling you.’

He raises his eyebrows and looks a bit more hopeful, – I continue.

‘Let me put it another way, there are two types of pain, the first one is called ‘helpful’ pain from the normal processing and the second one is ‘unhelpful’ pain from the weird processing.  I’m wondering if you can think of any ‘unhelpful’ pains that you may have come across, it doesn’t matter if you can’t, but have a think?’

There’s a pause, he looks puzzled.

‘The only thing I can think of is my mother-in-law had neuralgia’

I respond eagerly –

‘That’s a great example!  That’s pain from a nerve being irritated. The best nerve pain example that most people have heard of is shingles, it’s a form of neuralgia.

‘That’s exactly what she had!’

‘Good. If hers is like most, it starts when the person gets eruptions or spots on the skin where the nerve runs, they then become incredibly sore, and for some people after a few weeks the skin spots disappear but the incredible skin pain and sensitivity stays.  The skin looks normal, you touch it lightly – 3 taps… and you get the thousands of ‘X’s’ come up on the screen, it’s agony and it goes on and on.  Healed skin, huge amount of pain, -  ‘Unhelpful’ pain!’

‘She’s over it now; it took around 5 months to go’

‘Good, example, and if that can get better so can your back problem, all your scans and X-rays are fine and I’ve tested all your reflexes, sensation and muscle strength so there’s no nerve damage. What we’ve got to do now, is get you going again physically and shut the pain up by whatever means possible.’

‘Hey Louis, I’ve thought of another useless pain – the phantom pain that soldiers get when they’ve lost their legs or arms….’

I’m in with this guy now. Whenever he looks worried about the pain maybe coming a bit… I say, ‘processor’!  The talk can go into desensitising, — wherever’s productive and appropriate.  The key is to get on and start a graded normal movement recovery programme – and prove to him that the pain is not of importance via experience.

Louis.

26th September 2013.

Centralisation, Part 1: Mechanical pain, mechanical diagnosis and the Wrasse bite

(Part 2: Pain centralisation:- another stab at explaining a clinical observation – will be the next blog.)

The overall plea comes down to this… Could we please substitute the term ‘Mechanical pain’ with the term ‘mechanically patterned pain’?  This article explains what I think both are, what they mean, and why we should change.

This is rather long, sorry, suggest you go for a run first then grab a beer and a tranquilizer…

————————————————————————————————————–

Two days ago I cut my finger.  I was fishing and caught a sizeable Ballan Wrasse, about 3 lbs, the nearest thing to a pretty reef fish that the UK has, but no good for eating.  They’re good fun to catch but hard to get off the hook because they’ve very impressive sharp teeth and small hard skinned mouths. The end result is that after a tussle with the fish and a deeply embedded hook, it bit me and I jerked my finger out of its mouth which made the skin wound even worse.

My Wrasse wound helps this discussion, I’m sure, but not quite yet.

Mechanical pain – implies mechanical fault – implies it needs mechanics to fix… (to me)…

I have to say that the term ‘mechanical pain’ and accompanying phrases like ‘mechanical pain requires mechanical therapy…’ I’ve always felt uncomfortable with and feel need a bit of an airing.  One implication is that a mechanical fault needs mechanical forces to correct/help.  Clearly, if you break your leg there’s a mechanical fault and mechanical remedies like screws, plates and plaster are mighty helpful in the early management.  I fear that the term as applied in musculoskeletal pain presentations, particularly related to the disc in low back and neck pain, promotes the myth of ‘putting something back’ or ‘reducing a derangement’ in some way, and in so doing side steps the wonderful chemical-physiological-neurological-biological healing and pain process going on, which…. even for the skin, TAKES TIME, and moreover for the disc, is interminable and ultimately next to useless.

An aside on disc metabolism. 

For a biologist the disc is moribund – and therefore nearly/virtually dead in terms of response to injury… It’s metabolically incredibly slow:– biological turn-over rates of disc material are measured in years/life times.  If you’ve the time and interest, please read my chapter/discussion on this that’s on this blog at this link: http://giffordsachesandpains.files.wordpress.com/2013/06/06-chapter-ju.pdf

Particularly the section in the chapter that reads: But why does the disc bother to hurt?

A big point is that a damaged disc does attempt to repair itself but for the most part degenerates rather than aspiring back to a full and normal hydrostatic state of well-being.  It’s a bodge job and it doesn’t matter whether you rest or move, the outcome is much the same, your disc never gets back to how it was; dream on.  Putting a disc ‘back’ is also a myth, but there’s now plenty of evidence that any extruded disc material gets gradually ingested, nibbled away at and removed by the immune system. Clever, but you have to wait, it takes many months.   An important point for us all and our patients is that even though a disc may degenerate or be degenerate, it is still a good functioning structure and very strong.  Live on! (Changed joint mechanics is an interesting story…)

The big deal arises from the question… What’s going on when the pain goes rapidly, the range improves and the pain centralises…and very soon the patient’s pain has gone?  … and the answer is that the disc can’t have healed, recovered, reduced its internal derangement in a matter of a minute or two.. or even over the next few hours, days, weeks or months…

(Don’t get mad with me…hang in there.., yes the pain problem does improve rapidly but we need a better explanation than the anatomical and ‘reducing’- something ones.  That fluid moves in and out with movement, like all good collagenous tissues, is a given).

Some illustrations of my problems with the term ‘mechanical pain’ and the underlying notion of what ‘mechanical therapy’ does:

This illustration is typical of what I think needs challenging…

Note this quote is from (http://shp.missouri.edu/vhct/case1699/3LBPsyndromes.htm) that I found at the top of a 2 minute Google search using the term ‘mechanical therapy’ ….(this is the website from the University of Missouri-Columbia School of Health Professions… teaching new physical therapists what to think and believe..).  What this website is saying, is very familiar…and is what a great number of therapists the world over believe I feel…  (‘Oh no they don’t’… ‘Oh yes they do’… The scientific rigor here is exemplary.)… Here we go…

‘Symptoms tend to centralize and eventually diminish as the displaced disk material is relocated and the deformity of surrounding tissues is reduced……’

The rest of the material on the page is along a similar vein.

Thoughts….and discussion…The argument that ‘therapy works’ – that the pain goes with mechanical therapy (meaning with exercise, movement, manual therapy etc) doesn’t prove that what you are doing restores the mechanics back to normal at all. It just proves that movement helps the pain at that instant, or, if the patient gets better and better by repeating a movement over many days or a week or two, that the movement has helped to ‘desensitise’ or turn the dimmer switch down on the pain representation in the nervous system.  This includes the terminal zones of sensory nerve fibres in the tissues too.  It’s as if the nervous system ‘decides’ that the damaged tissue is not a real threat to homeostasis and there are better things to be getting on with… ‘Hey, disc, I know you’re all fissured and cruddy, man-up… I’ve got a life to get on with… you’ll cope…Bye…’  The sun goes down and the slightly embarrassed and rather meagre little sensitised nociceptor population turns over, pulls the covers up and goes blissfully back to sleep again. Amen.  Or, they stay awake but the nervous system decides to blank them and their central nervous system representation’s access to consciousness… ‘You know, I thought it was awful, but now that therapist has shown me how good it is to move again, I’ve changed my outlook…’

What I’ve just said amounts to this statement….  ‘That just because a pain rapidly improves with movement/mechanics/manual therapy – doesn’t mean that it’s reducing or fixing something in a very short space of time, that’s just not possible ….’  In fact some forces used may not even be doing the tissues any good even though the pain may get better.

Another example for consideration….

Let’s have one more example from what I’d call, (with no apologies until they can prove me wrong), …. a pseudo-scientific professional …..This is to get the balance,…..we love criticism of our competitors but we can’t take self criticism..I’m the same…but knowing you’re like this helps to quell the emotion a bit… (Please find time to read Stuart Sutherland’s brilliant book: ‘Irrationality’)

I’ll get to the ‘pseudo-scientific- profession’ example in a moment; it needs a little introduction ….ahem….

Mechanical and manual therapy in physiotherapy has forceful high-velocity ‘Grade V’ thrust techniques at one end of the spectrum and gentle Grade 1 mobilisations at the other……. Grade V’s were what we used to call ‘wopping the joint’ back in Adelaide in 1985 – hence our tee-shirts with ‘Wop 85’ on and a cartoon of the exact opposite, the Maitland grade 1 mobilisation, – ‘bending the fly’s knees’, printed under the ‘Wop’ statement.   For those who haven’t come across the bending the fly’s-knees analogy, it means that you place your thumb tips on the back of an obliging fly’s thorax which is obligingly standing on the spinous process you want to mobilise.  You then oscillate up and down just enough to bend its knees….a virtual technique pretty close to hands-right-off healing energy or is it energy healing?  It’s a small point, but our profession still does pseudo-science too….

Anyway, I am reminded of witnessing a McTimony Chiropractor doing a demonstration at an osteopath conference where I was giving a talk on neurodynamics, a long time ago…. Nothing’s changes here either…  Check out this website – http://www.mctimoneychiropractic.org/  and note this from the site…:

Chiropractic treatment is simply a method of adjusting the bones of your body to improve skeletal alignment. In doing so, it helps your nervous system work more efficiently, relieves pain and discomfort, and increases mobility.’

… and this….

‘Your McTimoney Chiropractor is trained to correct misalignments using quick, gentle and accurate adjustments which ensure you experience maximum comfort.’

The McTimoney chiropractic that I witnessed that day was with rather flamboyant and dramatic hands-on followed by a very quick ‘swipe’ of the hands across and away from the flesh… leaving the ‘flab’ oscillating for a moment or two…and probably a nano-film of skin removed…  and then there were lots of verbal positives about better movement, released and realigned segments… (the guy did feeble passive intervertebral movement (PIVM) testing and revealed how good it all was after the ‘flab wobbling’).  It was certainly on a par with a Maitland style: do a PIVM test, then do a ‘Grade 1’ mobilisation, then re-test the PIVM and praise the Lord.   As far as the result on the tissues and joint under the thumbs/hands are concerned… no direct effect whatsoever I’ll propose.

That processing could have altered I am definitely not denying, nor that good money is exchanged for a very brief encounter, or that it is classic pseudo-science because of the claims about what it does and how it works.

Now, if the patient gets up and moves a whole lot better… it must have influenced the joints’ mechanics??… No, see it as processing change and change in reflex/feeling/fear/muscle tone whatever and a new willingness to move… Is that subconsciously possible?  Very!  (See the continued discussion that’s at the end of the last blog about sex and leg length…There, I look at cranio v reflexology for back pain.. and hey, both reportedly fix the same pain as we found out by a good and surprisingly honest interview with the pain afterwards.)

The big issue here is the McTimoney notion of ‘realignment’, of change in mechanics from the hands on encounter….Come on!  At least Geoff Maitland never climbed over his Brick Wall and said that a Grade I was altering collagen… he just stood by the result and accepted something must have happened, or, binned the technique for that patient if it didn’t produce some change.

One problem the term ‘mechanical pain’ has to face is that without exception, all pains are the result of a neurobiological process, – they’re all about impulses, bio-electricity, electro-chemicals, consciousness and vast levels of complexity in representational areas and homeostatic monitoring modules of the brain, far from the injured tissues and the location of the pain.  Granted, mechanical forces start injury pains off… like the Wrasse’s teeth gouging and penetrating through my skin.  Mechanical pain exists at the moment of the physical injury.  Mechanics does the physical damage and leaves a physiological and anatomical mess for the body’s healing system to clear up and mend as fast as it can.  I think all would agree that no amount of movement at the time, or just afterwards can restore the anatomy quickly back to normal again…you just add to the injury surely?  Try sutures perhaps?  Is that the best modern medicine can do for a wound?  Virtually, yes!!

That movement and graded mechanical forces – usually produced by getting normal functional movements going again in a graded way, – helps healing tissues to form a healthy scar repair is not denied, but the healing biology requires TIME and patience and mechanical dips in and out.. And that is a bit of a problem in this age requiring the ‘instant fix’.  That is where ‘conning’ or ‘tricking’ the nervous system comes in and why we could all try and invent a new pain treatment.  See what you can come up with and… get away with too…  I’ve already written about ‘tricking pain’ here: -

http://giffordsachesandpains.files.wordpress.com/2013/06/editorial-issue-23-may-2007-tricking-pain.pdf

Instant changes in pain with treatment may be largely irrelevant to the overall healing process, other than making it feel transiently better (a psychologically positive step of course).  Or maybe it’s the same?  Or maybe you made it worse?  Did you wake up grumpy and couldn’t quite get the right atmosphere with the patient? … The patient didn’t trust you, thinks your weird…that creepy shudder effect perhaps…?  (Facetious Headline.. ‘Read all about it….Mechanical pain made worse by mechanical therapy because the therapist made the patient feel creepy…Therapist denies everything…’)

On the other hand, if you can do something to make the pain better, you can use the good result to reassure the patient that their system is capable of winding down and shutting up… all you have to do is help them to find a way of doing it…. That’s one good thing about a system that uses movement to change pain, so long as it doesn’t create fear of structure, as I see it, we’re good.

Something more positive now….Isn’t it great that sometimes sharp pain makes you actually want to move it and massage it a bit.   Writers and books about pain that tell you pain means stop, rest and avoid so as to let the injured tissues heal just haven’t listened to the reality of pain at all… don’t you just love to move your neck into that sharp pain occasionally to see if it’ll move a bit further…?  Don’t you just love to pick that scab off the wound…?  Clever pain!  ‘Sometimes sharp pain makes you want to try it and move it slowly… Aching pain and stiffness makes you want to get up and move… From time to time the tissues need a bit of movement and good adaptive pain gets you to do just that.

I’m pleading for those who think ‘mechanical’ in the clinic  to try and understand and embrace processing changes far more… and also think about the purpose behind movement making such dramatic and quick changes even though the movement could be making the tissue situation worse.  This question is an evolutionary ‘why’ question, ‘why’ would that sort of response have evolved?  I’ll answer that shortly.

Back to my Wrasse bite..Any piercing of the skin is an anatomical emergency, a sure threat to homeostasis and as a result we’ve evolved the most fantastically complicated response to shore it up, make it aseptic and physically safe.  The said process is chemical, immune, neuro-endocrine (C fibres and sympathetic efferents spew out neuropeptides), electrical and sedately physical too as the whole area re-grows to bridge the gap and draw the tissue together again.

The threat of the original ‘cut’ through the skin is almost instantly signalled by mechanical forces being transposed into electrical impulses at the ends of sensory fibres… all of them, that’s the Aβ, Aδ and C… some of which are also more than likely to have suffered damage themselves. (You can’t cut through the skin without cutting through sensory fibre axons and their nerve fibre terminal branches)

So, mechanical forces produce the cut and its pretty ‘ow’ straight away, (well the excitement of the fish held things at bay for a moment or two).  I knew I’d been cut though, I felt that, but it didn’t bother me… Then once I’d dealt with the fish and returned it, the cut was a little sore and there was blood all over the place for about 15 minutes.  Instinctive licking adds saliva – a natural antiseptic and clotting agent… and in the end I tie my handkerchief round it so I can get on with the fishing.  Didn’t bother me for the rest of the day.

Two versions of mechanical pain that I’m comfortable with:

1. Bend your finger back and keep going.  At some point it gets nasty and you usually want to stop because it’s smartly telling you that you’re approaching the tissues limits.  Or put your first finger in a woodworkers vice and start tightening it up.  If you’re awake and concentrating, the greater the force generally, the greater the pain.  Smart, evolution of a nasty sensation puts a stop to potentially damaging forces causing injury.  That clear relationship between force and pain is how we’d all love pain to behave in every problem and every patient… but it doesn’t.

2. Have a Wrasse bite through your skin… it’s the instant pain you get that relates to mechanical forces and then…anatomical damage…. etc….

Both 1 and 2 produce pain because of transduction of mechanical forces into impulses and those impulses reach the brain where pain production is an option for the brain to decide on.  So, well it was mechanical, but it instantly became….. a whole lot more complicated… very quickly… so is it mechanical pain then… ah? …..Up to you…., call it whatever’s easiest, so long as you don’t forget the processing in the brain part.

All pains involve the brain and ‘you’ the sufferer. It’s practically instant from mechanics to electrical to cognitive-emotional-behavioural… You imagine how you’d feel being bitten by a Wrasse…or having your finger in the vice? Right.., if your brain is switched on there’s psychology in every pain every time in every place…. The very word associated with pain is ‘aversive’ – and demands… ‘ alter your behaviour quick!’ … ‘avert’ means to back off, turn away…

A plea- don’t listen to these Cartesian dinosaurs who harp on about real pain equates to mechanical pain that needs mechanical treatment and that the other type of pain is psychosocial…  or ‘central mechanisms’ or even ‘not real pain’…. There was a pain revolution in physiotherapy from about 1995 to 2005 or so… remember?.. Or was it all a waste of time?  Some of us are starting to wonder!

Now, On-off pain with movement….in early acute stage and early healing…Back to my cut finger which is now, two days later, gaping, weepy, a bit crusty and…. I nearly said sore… But in actual fact, when I keep it dead still, with the finger in a position that doesn’t stretch the skin there is not one jot of pain, even though it’s clearly in the inflammatory stage of healing.  If I move it, bang, pain on… move it back, pain off, ….pain on…. pain off….pain on… repeated movement… on, off, on and off… and hey, the pain’s getting gradually less…. and I’m going further…. easy, less stiff too and wow…mechanics cures mechanical pain….!  Oh, damn, it’s bleeding again… never mind I’m moving it and its getting better… Same thing if you want to massage it… pain goes but it weeps and bleeds more… That drains the toxins away, clever see…there’s always a ‘smart-ass’ reason for everything… Oh! ah?.. mmmm, Yes, … and that’s why we like to move and massage a swollen joint or anything that’s swelling is it?  Could be….  Think like this: The swelling dilutes the inflammatory soup a bit, so swelling is an adaptive ploy, plus there are all the toxic breakdown products, they get diluted in the swelling too… Dilution by swelling reduces the ‘bad’ side effects of these products… But then the swelling makes it stiff and achy and so it makes us massage and move it to free it and in so doing…clear much of the fluid away ….  Ah, there’s a hand up in the audience… ‘So the RICE Rest/Ice/Compression/Elevation thing goes a bit against evolution then?’ … ‘I think so… swelling going up and down in the aftermath of early injury is a good thing… do it… don’t compress it for too long.. be guided by what it wants you to do, not what someone tells you, you should do’… ‘Ah! Right?’

Another question from the audience… ‘So getting the patient to stay in one posture for long periods, like for example maintaining the lordosis goes against the grain with evolution too…?’…..  ‘Good, you’re getting the idea.’

So early movement and pain on/off can be argued either way… may help, may make it worse… But the truth is that using mechanics (ie. Movement/forces of some kind) can make the pain better, even though it might be putting the healing and damaged area back a day or two….. so… ‘ Doc you advised I keep moving it, 10 every hour, or more often if it starts to bother me?…Yeah?  OK…. it keeps bleeding… I think your advice was nuts…

Frequently asked questions from the make-believe forum…

‘So does doing early movement matter if the injury’s in the disc?’  Answer… If it is just a disc, the answer has to be no, because what difference to the end result would it make anyway, it shouldn’t matter.  Wise action is to progress with graded build up of forces though.

Could movement be squeezing more material out of the disc and around nerves…?’  Well maybe it could, but Mike Adams the disc expert said that once an extrusion has occurred more material is unlikely to come out… Early end range movement and consideration for the nervous system is something important that needs considering.

‘Could the movement be making a bulging disc squash a nerve… and injure it without immediate or even later symptoms….?’ Well, yes it could and that’s something that needs considering….Graded increase in movement and range is the wise way forward.. On the other hand, it could just happen anyway, it’s hard to know!  Hunter gatherer’s never had a clue what was going on … and may have survived fine with a foot drop and a friend who helped them for a while..

The ‘Action more important than healing view’…this is the answer to the evolutionary ‘why’ question from earlier…

Why would the pain get less and less in the face of screwing-up the carefully crafted early healing process and putting it back a day or so?  All those fibrin strands and all those little platelets snugging in there, going, ‘What the bloody hell does he think he’s doing…that’s such a nuts thing to do?’

Think hunter-gatherer and you realise that using the injured finger is often essential and that hey, the process can start again anyway, what you don’t want is horrid pain when you really have to use your finger… And, imagine I’m out there fishing again just about to land this 8lb Pollock, no way am I going to let that beauty get away, grab it with both hands, the fish is bleeding, I’m bleeding again, but hey no problems, I’m not a haemophiliac, it’ll mend later.  Sorted.

Here’s another, my Philippa dropped a Calor Gas cylinder on the top of her foot recently.  It hurt enough at the time to curse and blame someone else.  For the rest of the day it eased right up, but it hurt like hell that night… what’s the point of that kind of pain?… That’s an evolutionary ‘why’ question that’s hard to think of an good answer for…but hang on a minute….  Injuring your foot is a bad thing to do because if you can’t walk you’re going to find it hard to run away, to hunt and gather…It seems that there are some parts of your body that are more painful when merely knocked or banged than others and one wonders why.. Now anytime you hurt your foot evolution has made it that it hurts like hell so that you learn to be more careful next time…You need your feet and they’re a little vulnerable down there….  Think about stubbing your toe…hurts like hell,  Yet, the same force on the side of your thigh, arm, trunk… not a problem, unlikely to damage either…  Same argument for banging your head… really bloody hurts compared to similar forces on other areas of your body….. evolution says… look after your noggin you nog..look after your feet too… and your eyes, they’re sensitive and important.  Nose?  Nah! (If you’re a bloke!)

Last time now….‘Mechanically patterned’ pain is no pain at rest, pain only with movement and no pain immediately after the movement.  So this pain from bending my cut finger was mechanically patterned, and shouldn’t be classed as mechanical pain with the connotation that it can only be fixed with mechanical forces.  Movement in the early stages of injury can be argued either way, but mostly we heal well even if it is mostly by scar formation which later may initiate degeneration, but, hey ho, the pain goes away and good function returns.  The evidence says rest longer than 3 days is detrimental for spinal pain.  Good rule.  Keep moving and if you don’t want to, maybe think about converting to becoming a tree, mind you, those windy days won’t be too pleasant.

On-off pain as time goes on….Now, I don’t want to make an argument for moving or not moving a musculoskeletal tissue just because a bit of neuro-chemistry and a brain is involved. I’ve spent my life trying to stop people resting and get moving and we know most tissues heal as we continue to function and that prolonged lack of movement is overall a bad thing.

The plea is to swap the term to ‘mechanically patterned pain’ and consideration of the state of the tissues based on other findings from the history.  For example, if my on-off pain in my finger was 2 weeks, 2 months or 2 years old and the pain subsided with movement it seems like a good ploy to do the movement to help desensitise it.  Note the thinking has shifted from mechanical fault fixing to ‘desensitising’ – using movement, or mechanics, to alter pain processing that’s stayed sensitive too long.  It’s maladaptive pain and sensitivity.   (I like to use the term Maladaptive pain processing in this context to mean pain out of proportion to the damage done).  ‘It’s time you shut up dear’.  In other words the tissue’s being a bit over-sensitive and there’s no point in having the amount of pain it’s having. Tell the brain too.

So give patients the de-sensitising message and a positive structural/anatomical/strong recovery one – or you’ll be stuck with the ‘it’s not fixed’ problem when they don’t improve… and the patient will end up with therapists like me who try to unravel their maladaptive pathological/anatomical/biomechanical beliefs…and then provide a much better and more hopeful perspective.

Too much early movement??  The battle of the neediest…Now, a bit of movement based pain modulation is always nice, especially at first….But it may be only up to a point.. I know, that if I keep on doing the movement to my cut finger right now, it’ll eventually get mighty sore, it’ll start to ache, I’ll end up being much more protective and it’s more than likely to stay sore for longer than it otherwise would have.  Short bursts of essential activity are fine, but eventually the tissue can win out in the continuous arms-race between the brain’s need for function and the tissue’s need for a bit of rest. (Remember, healing by scar formation of collagen takes months to a year or more…mechanically patterned pain that gets more and more sore needs consideration of this slow healing… and everyone being more patient with recovery time perhaps? Think of the time line for knee collateral ligament injuries for example)

Repeating movement of normal tissues….So repeated movement can be pain relieving and purposeful, but do too much and it often gets shitty.  This is even true of undamaged tissues.  Here’s a challenge…. do a repeated movement, say wrist extension to end range, make it fairly hard too… and I’d like you to set off to do maybe 200 reps., and see what happens… sort of thing a gymnast might do when practising their handstand routine say.  Count the number of handstands/reps to ‘sore’ and note if it leaves you sore for long afterwards.

Everyone varies, but there’s a good study in this for anyone wanting to do ‘normative studies’ – a passion of mine…  Don’t just do the wrist though, make sure you get normals to do all the spinal movements in all directions too… and find out the max, min and average ‘to-sore’ score.  It would be so useful to know in the clinic.. don’t you all agree??  Easy to do too and it’ll get you a masters.

Now, is it tissue tolerance or gating efficiency that you’re observing?  Get the observation done first and sort that out later… it’s probably a bit of both.  Don’t forget to measure pain tolerance of each individual before you start too… you know, put the forearm in ice cold water and see how long the subject can keep it in there for… remember us blokes can stay in longer if there’s a hot chick present while they’re doing it… Does that help us see that psychology is involved in pain with every pain, every time?

Research plea… Let’s stop trying to prove our techniques are better than placebo, they’re not… Let’s turn our attention to finding out more about normal responses and normal recovery history and timing… Recovery has been done quite well for frozen shoulder, poorly for sciatica and desperately needs doing for carpal tunnel syndrome, tennis elbow….. Achilles tendonitis, plantar fasciitis….  to name a few…

Now you’ve done those 200 handstands it’s time for the ‘Staying completely still’  test…. ….which is right at the other end of the spectrum.  I call it the ‘how-long-can-you-stay-still-for’ test.  Again it relates to mechanics in that it’s no movement and constant pressure, or constant stretch just about everywhere.   The ‘living/human-statue’ thing you see in street theatre… give them money and they usually move a little.. then, well, they look pretty dead again… staying completely still like this for long periods I’ve always viewed as an impressive form of torture. Being still is not conducive to tissue health or tissue life unless you’re a dandelion in the doldrums,  a well practiced human statue or a yogi who’s got nothing better to do than nothing with their brain.

While it’s mechanics that starts it off, it’s eventually what I call ‘botty-rot’ pain that results for any sitting still human-statue attempt-tee..  Tissues that don’t move don’t get any circulation…and soon get cranky.  Bend your fingers back and observe the tight skin in the palm of your hand. Note the colour, the white where there’s no blood and the blotchy bits where the blood is pooled and stuck.  Keep it there and keep staring.  No change in colour, no blood movement. All mechanical?  Sustained posture pain perhaps? The tissues like oxygen and nutrients fresh every few seconds and because they function like us, they need to run the sewer out regularly too.  Block these processes and the tissues start oozing inflammatory chemicals like prostaglandins and other eicosanoids…and then come the impulses to the brain…  Botty-rot results in the bum, and if the brain’s doing nothing much (Oh, focused on computer games… ahh! ) so it all starts to go bananas and you have to move.  Moral here: mechanics turns to chemicals turns to electricity and makes you move… aversive… psychology again… sorry.

Chronic pain can be precise and mechanically patterned….There are plenty more examples, but let’s have a thought for pain that’s beyond the Wrasse cut, the repeated hand-stands and the human-statue’s botty-rot problem.

All pain’s can have a mechanical pattern, even chronic ones.  Chronic pain, and I mean chronic maladaptive pain, can sometimes be incredibly precise and be clearly mechanically patterned.  I tear my hair out when I read papers that define ‘nociceptive mechanism related pain’ as having ‘mechanical pain’ , being well ‘localised’ and having clear relationship to movement and physical stress…, … and then ‘central mechanism related pain’ as being vague, non-mechanical, and poorly localised… I wonder if those who write this stuff and tell clinicians to believe it have ever really listened to patients.  Meow.

To assume that a pain of many years duration is still a tissue problem because it’s mechanically patterned and localised is OK ish to consider…,  but it’s mostly flawed and unhelpful overall.  Why can’t it be a meaningless pain, or a pain that is out of all proportion to the needs of the tissues (which granted may well be scar tissue or degenerate)?  My best argument follows… and comes from researchers with the rare qualities of having ‘listened’ to patients.

Here’s a quote from: Coderre, T. J., J. Katz, et al. (1993). “Contribution of central neuroplasticity to pathological pain: review of clinical and experimental evidence.” Pain 52: 259-285.

( – and note, the authors include Joel Katz and Ron Melzack, researchers who listen to patients!)

‘A striking property of phantom limb pain is the persistence of a pain that existed in a limb prior to its amputation.  This type of phantom limb pain, characterized by the persistence or recurrence of a previous pain, has the same qualities and is experienced in the same area of the limb as the pre-amputation pain.  Case studies of amputees have demonstrated pain ‘memories’ of painful diabetic and decubitus ulcers, gangrene, corns, blisters, ingrown toe nails, cuts and deep tissue injury.’

It’s the same for some unfortunate arthritic pain sufferers who then undergo amputation.  They get phantom arthritic pain, it may come and go with the weather and have feelings of stiffness in the joint just like it used to have… yet there’s no joint there anymore.  Pain related to arthroses in the knee joint is usually seen as a nociceptive mechanism… a fault or problem in the joint… get a new one… maybe we need to think again?

See: Haigh, R., C. McCabe, et al. (2003). “Joint stiffness in a phantom limb: evidence of central nervous system involement in rheumatoid arthritis.” Rheumatology 42: 888-892.

CBT approaches to patients with arthritis related chronic pain and disability have been shown to be effective…

Clinically you have to simply ask the questions … ‘Is this chronic mechanically patterned and well localised pain out of all proportion to the damage done?’  ‘Is it capable of being loaded and not being damaged?’  If you think its scar tissue or degenerate, so what, the key question is:- ‘Is it strong enough to start loading and get fitter?’  And, ‘Is it capable of being exposed to forces and movements that may help it to become less sensitive/desensitised, stronger and more functionally capable?’  The answer is most often yes and vast improvements can be made given the right top-down approach and top-down messages.

Fluid movement and discs.  Repeated movement causing pressure changes in tissues and forcing fluid out so they become less turgid may, in part, be a possible tissue reason to explain quick changes in pain and stiffness. Conversely, lack of movement provides an opportunity for fluid to return and become turgid and stiff again.  The disc, being the largest collagenous and avascular structure in the body, if intact, clearly demonstrates this fluid flow and changing stiffness phenomenon.

You might like to read the following paper about this very topic.  I wrote it way back in 1994…and hopefully note that I’m not the ‘neo-psychosocial’-tissue-hating-fascist that some would have me be.

Gifford, L S 1995  Fluid movement may partially account for the behaviour of symptoms associated with nociception in disc injury and disease.  In: Shacklock, M O (ed) Moving in on Pain.  Butterworth-Heinemann, Australia

In Part 2 to follow fairly soon…. I’m going to review the statement below from earlier and discuss another way of looking at centralization that I hope is reasonable and palatable, bring your shorts or wear sensible underwear… :-

‘Symptoms tend to centralize and eventually diminish as the displaced disk material is relocated and the deformity of surrounding tissues is reduced……’

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A final review of some of this… 

  • It’s my belief that the term ‘mechanical pain’ tends to make therapists think of a ‘mechanical problem’ that can only be fixed with ‘mechanical forces’.  I have criticised the notion that rapid improvement in pain while using exercise or mechanical techniques means that the mechanical problem, the tissue dysfunction, is improving.  I gave some examples from this profession as well as others and have attempted to show that this is much more likely to be due to changes in processing, but fluid movement may be involved too.
  • The preferred term: ‘Mechanically patterned pain’ allows the clinician to see that this ‘on-off’ with movement/manual therapy clinical pain presentation can be associated with tissue injury, tissue inflammation, scar tissue and healing, and many degenerative tissue or joint disorders as well.  The term allows pain mechanisms to be embraced and the broader dimensions that always accompany it in every patient every time. It suggests that movement may well help, not only with healing tissue recovery over longer time periods if graded well, but also in the desensitising process.

Centralisation or Centralization… follows in a while…

Louis.

Sex and leg length discrepancy

Anoop (pronounced ‘Anoop’ like ‘Snoop’) from Miami responded to the last blog and suggested I put the conversation we’ve had that’s at the bottom of the last blog… up as another blog… so it’s a blog of a reply to a blog?…I have a feeling he’s trying to help me get more ‘air’ time?  Anyway, I’ve edited it and added a bit about sex at the end because that puts you right off but leaves you wondering what it could be all about.

The trouble is I get side tracked from writing the book… and now I’ve found out that one or two Mckenzie supporters are off at me again in the depths of the CSP website… So, perhaps there’s a sensible blog piece to come soon on some recent thoughts on centralisation and how it might happen, any takers??  I tried to explain it once, but no one listened… They just say that I think that all McKenzie is extension…(well to most of the world, I’m sorry, but they do have an extension meme problem floating around…and I’ve explained that too…) .. I did one of the original UK courses with Robin McKenzie, at Royal Free Hospital in 1982..and even taught a few McKenzie courses until it stopped working for me…I liked the self management bit…  Now, if they’d only read what I said and follow the reasoning..

Right now though, I really should try to be more non-confrontational, so …..back to: Sex and leg length discrepancy….

(Anoop has a website: www.exercisebiology.com.  He’s an exercise physiologist and fitness/personal trainer with a strong evidence based focus in the fitness field… He writes, blogs and flogs..check him out!!)

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From Anoop….

Hello,
Just heard about your blog!! I have read your articles in peak performance online on treatment of chronic pain in athletes and a couple of book chapters. In there, you write about checking the patient for leg length discrepancy, asymmetry and hamstring length and ROM. My question is what do these measures tell us about the person’s pain or tissue condition? If a person has leg length inequality, what could it tell us?

Thank you so much, Anoop…

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Anoop, Can you point me to where you read this.. so I can see context…Thanks,
Louis.

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Here is the article: http://www.pponline.co.uk/encyc/biopsychosocial-pain-1107#ref‘. I have a lot of questions usually.

Anoop…

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Right, I had to re-read it.

That leg length mention was almost in there by reflex I feel…have to credit my colleague, good friend and co-author Steve Robson with it perhaps? No, we both did it…together…it was his fault…

You ask about the relevance of leg-length … well it’s absolutely no big deal, and what could be done about it anyway?… Tell the patient/sportsman and make them worry about it unnecessarily?…… Tell him it’s because of an SI joint upslip or something… Sorry, not my scene – it creates fear of structure, notions of weakness in the very people who want to feel invincible….. and it’s… well, bull-s**t?

A great many patients come in and say that the chiropractor /osteo/physio told them their leg length was out… so if they say this I always check it and 90% or more of the time it’s fine… So, patient lies flat, I ask them to wiggle the hips and back and get as straight as they possibly can … I bring their legs together at the ankles, both medial malleoli hit each other exactly, I get the patient to look and … they go ‘Ah it’s OK’…and I usually say… ‘They must have fixed it….!!’.. and laugh…(if appropriate)… Or if it is slightly different… I say – ‘If we took 50 people off the street with no problems at all we’d find a large number of them had small differences like yours…. Having a leg length difference is normal and very common and is of no consequence…. Anyway I can lengthen or shorten whichever leg you want… watch’….

I shift his hip slightly to one side… and hey presto… same length… or bring both legs marginally off to one side… or push one of the legs back through the heel…. all with the effect of slightly side flexing the back/pelvis and hence shortening/lengthening the leg.

‘Hey, I can make your longer leg even longer… and your shorter leg even shorter… party trick…. show your kids… get them to watch your feet and tell them one leg’s going to grow shorter….and just subtly and very slowly pull your hip up from the pelvis/back little by little…. do it sitting with your legs stretched out on a chair….do a bit of chanting at the same time…. even turn the lights down a bit to create atmosphere…

Chiropractors charge for this flim flam and faith healers make gullible worshippers think that a miracle has happened…Check out James Randi on faith healers..(http://www.youtube.com/watch?v=wsKBP1TOdYI) ….. he shows how they do it with the help of their Lord… Swing the legs to the side and pull the shoe off a little…. maybe even surreptitiously create a fearful trance like atmosphere… and while this is going on, push the leg so the knee bends a bit too….. they’re taking the piss,  making a load of money and they don’t pay any taxes… Shocking in my opinion.  Randi and his group of sceptics have been exposing them and showing the public the shams that they really are for many years now.  It’s unbelievable frankly.

Do Chiropractors’ really think they’re lengthening/shortening the leg?? Anyone want to be a whistleblower and afterwards go hide in an embassy somewhere???

Now, do I ever use a heel raise to correct it?  If it changes processing it may be worth it!! You try going round all day with a small heel cushion in your foot… Novel eh? Go for it… but don’t make the patient leg-length obsessed… they might just go see an orthopod for an osteotomy..
Any good??

Louis… (scpetic/skeptic and non believer with life spirit and annoying healing powers).

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This bit is where the sex comes in… I’ve just added this, so it’s ‘new’ to the blog….

Symmetry in nature is amazingly difficult to achieve. I’d like to quote Matt Ridley, author of ‘The Red Queen: Sex and the evolution of human nature’.  …. ‘It’s a well known developmental accident that animal bodies are more symmetrical if they were in good condition when growing up, and they are less symmetrical if they were stressed while growing. For example, scorpionflies develop more symmetrically when fathered by well-fed fathers that could afford to feed their wives….. Making something symmetrical is not easy… If things go wrong, the chances are it will come out asymmetrical..

Consider that most biological molecules, large as they are, twist and contort into the most fantastic shapes that are usually far from symmetrical. That we are all made of asymmetrical protein molecules makes it quite fantastic that, at least for the most part, we do end up pretty much symmetrical;  it has to be an incredible biological challenge.

I know this is rather politically incorrect, (please try to stay planted at the biological level) … but have you noted how attractive symmetry is?  And how unattractive asymmetry is?  Don’t have a short leg and look lopsided, or walk with a sway and a dip… and if you fly it’s not pretty to have asymmetry of your wings…. you really don’t look good, no one will want your genes… Sexual evolutionary selection has worked it’s wonders to produce a strong link between good genes and good looks  – and a part of that might just be symmetry!  Back to Matt Ridley again and his discussion of Møller’s study of swallows tail streamers (not the ones in the UK!).  Møller noted that swallows with the longest tails were the most successful at securing mates. He also noted that the longer the tails the more symmetrical they were too. ‘So Møller cut or elongated the tail feathers of certain males and at the same time enhanced or reduced the symmetry of the tails.  Those with longer tails got mates sooner and reared more offspring, but within each class of length, those with enhanced symmetry did better than those with reduced symmetry…

What girls make the boys do for a good time!!  But biologically it all boils down to advertising your good genes…..plus your good upbringing (well fed, stress free, and as a result, well developed)…and ultimately your fitness to sire the young lady swallow and be a good provider for the offspring.  Girls go for symmetrical boys and vice versa… plus, well, what about that human stallion driving a Rolls and controlling the Formula 1 Racing Empire, or that strangely symmetrical guy who won Wimbledon..? Oh, not for you…

So the moral of the story is to put that heel raise in, it might feel really weird but you’re much more likely to score!

It works, I’ve just tried it…

Thanks for listening and sincere apologies to any who may be offended.

Louis.