I’ve pulled out, scanned and uploaded all the material I’ve ever published on ‘Adverse Mechanical Tension’ (AMT) of the nervous system.  AMT became Adverse Neural Tension for a while before settling to ‘Neurodynamics’ – a term that I think Adelaide Physiotherapist  Michael Shacklock introduced and it stuck.  I always want to raise the flag for good old Bob Elvey here a bit…he died recently and he was one of the early pioneers of nerve movement and it’s examination, along with Geoff Maitland on the slump test….via good old fashioned clinical observation.  If you get a chance Geoff’s old article is well worth a read…. here’s the link (thanks to Blaise for finding this!)…

Maitland, G. D. (1979). “Negative disc exploration: positive canal signs.” Australian Journal of Physiotherapy 25: 129-134…..

(Tip…. I found it incredibly slow to come up on my computer screen from the AJP site, best to click on the download button and then view from there… works immediately! Louis)

AMT was the term coined by Alf Breig from his book – Brieg, A 1978 Adverse Mechanical Tension of the Nervous System, Almqvist and Wiksell, Stockholm.

It was where a great many of the slides showing nerve movement were lifted from in Dave Butler and my lectures and Dave’s writings, and many others since I’m sure.   I may be wrong but if I remember rightly, I think it was the clear demonstration of nerve movement in Briegs’ illustrations that Dave found so inspiring when he did his Slump research project on the Adelaide Manipulative Therapy course in 1985. During Dave’s literature search he came across Brieg’s book and saw the pictures.  His project was on slumping in the elderly..and he used some of the oldies from the RVS (Royal Voluntary Service) tea shop in the Royal Adelaide Hospital!   After regularly patronising the shop, chatting them all up a bit, buying loads of cups of tea and a great many of their famous ‘rock-buns’ he got them to agree to being slump tested!

Below are two of Breig’s famous pictures illustrating nerve movment during ‘cadaver’ straight leg raise!!  The position of the cadaver is shown in the bottom left of the picture.  It’s a view from anteriorly of two nerve roots emerging from the low/lumbar/ sacral? spine.  Tags have been placed on the roots.  The roots emerge and join becoming the lumbo-sacral plexus. The lower picture shows the cadaver in full SLR and you can clearly see the movement of the tags and the general increased tension of the nerves there, including the sympathetic chain if you look closely.

There you go. Pictures that have been round the world a great many times and inspired many a physio to caress, yank and twang pain patients’ nerves and earn money!

My clinical observations of ‘nerve root’ problems didn’t seem to always go with the flow of ‘Neurodynamics’ – or what I  call nerve ‘pulling’ or tensioning…. I kept seeing patients with nerve root pain who were flexed of deviated away from the painful side and who when they were brought up to neutral or extended the root pain got a whole lot worse… Some of the elderly with sciatica or brachialgia had full comfortable flexion often able to touch their toes, younger ones too occasionally, extension was invariably a key provoking movement.  It was obvious – nerve pinch… and something the ‘nerve-pulling’ fad seemed to have passed by, maybe it still does??

So, in the Neurodynamics chapter in Judith Pitt-Brooke et al’s book I lent 6 pages to ‘nerve compression’ dynamics, theory and reasoning.  Take a look… I hope the drawings there make sense… I highlighted this further in the cervical nerve root articles, – the OCPPP/In Touch one being the more comprehensive and the Manual Therapy one being the more recent.

Normal extension of normal spines tends to put pressure, even squash nerve roots and their vasculature. Remember, a nerve root in the intervertebral foramen or in the lumbar radicular canal is surrounded by vasculature and adipose tissue… Anything that tends to make the space smaller will compress the adipose tissue and therefore compress the nerves indirectly.    Add a bit of degenerative change, loss of disc height, disc bulge, disc protrusion/extrusion, osteophyte, enlarged facet, thickened flaval ligament…(ie. normal ageing!!)  to the ‘space’ there, and the potential for more marked root compression increases even further.  It happens to all of us as we age and for my logic, is a significant factor in explaining why the human spine tends to flex at the low lumbar/low cervical zones as it moves on in time… A bit of low lumbar or cervical flexion gives those important nerves of arm/hand and leg locomotion and co-ordiination, a bit more room!! Have you ever seen an 70 plus year old with a nice lumbar lordosis…??  Pretty rare!  Check out figure 4.12 in the Neurodynamics chapter, that shows how the superior facet comes together in opposition to the backward bulging disc during extension of a degenerate spine.  Lance Penning called it a ‘pincer’ movement and cadaver evidence from degenerative lumbar spines can often show actual indents in the roots from the facet and disc pinch! Roots are not uncommonly found to be flattened too.   It may not necessarily be painful, but it makes sense of why the elderly often have hard to get calf/triceps reflexes….

I hope you have a read of the chapter and articles, and think a bit more about nerve compression/pinch too….if you have already, fine, it’s merely my spin on it!

Ah, finally, those two early neural tension articles posted are of historical  interest more than anything.  You can see ‘where we were’ in 1989 and then later in the 1993 Olive Sands lecture arcticle,  that I was just starting to have a prod from the pain mechanism perspective… looking back it was really quite crude, but it was a great time!

Best wishes, and thanks for all your support.

Louis.

I didn’t sleep very well last night…

Anyway, in the depths of darkness feeling grumpy and restless I calm down a bit by thinking about my ‘heroes’.  I started with recent ones and quietly worked my way back in time to the 16^th century where I ended up thinking about Rene Descartes – who was a mathematical genius, ahead of his time, but has been much maligned by trendy pain researchers and lecturers of recent times.   I’ll come back to him later.

As I really like good debate about the human state – like, why we are the way we are and why we think and behave the way we do…. over the years I’ve read a great deal of what’s called the ‘new-atheist’ literature – For me it’s more about the clarity of thought, the quality and incisive bite and the pure logic of the writing that I love – and it fits with the way I feel about things too.  I guess that’s personal, but in reality it’s all about good reasoning based on sound facts, – something I spent a good deal of my teaching days trying to enthuse into those who listened to me.  The trouble is that humans have the capacity to be logic and sound reasoners one minute, then the next they go completely potty.  For the life of me I can’t understand why a highly trained research scientist, medical Doctor or anyone highly educated, can one minute apply exquisite rationality to a problem, yet peddle the creationist story of how we all came about come Sunday.  Yes, going outside with wet hair you’ll catch a cold…drinking Guinness cures teenage spots… sitting in a draught gives you a stiff neck…..Everyone does crazy reasoning – and good schooling hasn’t changed any of this stuff one jot….

So my first hero at around 2.00am is one of the so called ‘four horsemen’ (from the Four Horsemen of the Apocalypse –  the forces of man’s destruction as described in the Christian Bible in chapter six of the Book of Revelation) of neo-atheism, – who are: Richard Dawkins, Daniel Dennett, Sam Harris and the late Christopher Hitchens.  My pick for clarity of thinking, beauty of writing and brilliant logic has to be Richard Dawkins.  That he’s much hated and much maligned, even by some atheists, – is sad, and I believe most of those who criticise him probably haven’t read his books.  You don’t have to read ‘The God Delusion’ – remember this man is an evolutionary biologist and his best writings are on this very subject – which just happens to be a great hobby of mine.  While leaning on evolution, I’d recommend 2 books if you’re interested, – one by Dawkins himself:  The Greatest Show on Earth: The evidence for evolution; the other by Jerry Coyne – Why Evolution is true….   mmmmmmmm!

Then came pain Hero Pat Wall who died August 8^th 2001.  Several of us wrote little pieces on him for the PPA News issue 12.  Here’s mine:

 On Patrick Wall

I first met Pat Wall on June 22nd 1994.  It was the day, unbeknown to me, that the ‘Sun’ Newspaper featured on its front page a picture and story of a man who had willingly amputated his chronically painful leg by placing it on a railway line and having a train run over it.  Pat began our meeting by asking if I had read the ‘Sun’ newspaper that day!  Negative! I had to confess I hadn’t, and must have looked rather puzzled –  I wasn’t expecting a Professor Emeritus to be discussing the front page of the Sun, or the fact that the story continued on at length on page 3!  There was nothing stuffy here, I wasn’t a mere physiotherapist, I was someone who knew patients in pain, I was interesting to Pat Wall, I wasn’t a nuisance, I wasn’t wasting precious research time. Pat Wall made you feel comfortable, he watched normal human life, he had a most likeable twinkle in his eye that oozed rebellion. He relished findings and observations that did not fit expected patterns or standard dogmas, he was so refreshingly sceptical about the way Medical Students, and others like Physiotherapists, were taught and brainwashed by ‘unsubstantiated clinical twaddle’.  Mischievous and witty on the one hand, yet such a brilliant scientist and observer on the other.  It seemed to me that Pat Wall was the sole representative of real clinical pain, its mysteries and contradictions, in the world of research, the laboratory and academia.  His recent book, ‘Pain: The Science of Suffering’  is testament to his thinking, his observations and his devotion to the understanding of human pain and suffering.

Since that first meeting Pat Wall has seemed like a friend.  He has been very generous in his support for the activities and philosophy of the Physiotherapy Pain Association and at a personal level, with the content of the ‘Topical Issues in Pain’ books I have edited for the PPA.  It was through discussions with Pat Wall that I came to realise that Physiotherapists’ historically ‘subservient’ position to medicine was untenable. ‘We’ had something special and had a unique knowledge that could contribute and was needed.  For example, Physiotherapists have knowledge of pain states that no one has ever written up properly –  ‘Text book’ medical descriptions of pain states are mostly inaccurate and at best vague reflections of clinical reality.  I remember Pat Wall urging me to muster physiotherapists to record and publish unbiased accounts of the clinical pain states we see every day – and to present them to his laboratory based colleagues to unravel!

Most powerfully, he gave me the confidence to express my thoughts, relate my observations and freely discuss clinical interpretations of them in relation to the findings of pain science.   I will miss him, and I hope that future generations of Physiotherapists take the time to read his work and respect the impact he has had and the support he has given to us all.

After our meeting I went and bought a copy of the paper…. here’s the pic from the front page…it’s certainly a page of pain – ‘Charles: Truth about me and Camilla…. and in the top right there…. ‘Steffi is stuffed in first round’ (that was Wimbledon!)…..

For those of you unfamiliar with ‘The Sun’ newspaper it’s a right wing ‘tits and bums’ newspaper, page 3 usually being a topless model.

(‘Unsubstantiated clinical twaddle’ would be a good title for a blog sometime perhaps!!)

The other day my Philippa was on the Physiotherapy website looking at the forums and noted someone asking where to start with ‘pain’ – My recommendation will always be Ronald Melzack and Pat Wall’s classic penguin – ‘The Challenge of Pain’.  Everyone should read it and study it.

Well, (2.30am by now!) I then went back and back passing Hendrix, Bob Dylan, Robert Johnson, Oscar Wilde, Darwin and Wallace, Dickens… arriving with a doff of the hat at poor old Rene Descartes.  ‘Cartesian Dualism’ – is the assumption that mental phenomena are non-physical and that the mind and body are separate or ‘non-identical’.  For medicine it’s always been translated into this sort of reasoning: – If evidence for the symptoms a patient has cannot be found by reasonable investigation of the tissues of the body…. the symptoms must be coming from the mind – the patient is therefore blameworthy, is likely amplifying, exaggerating and manufacturing their problem….. best see a psychiatrist!

Then I started thinking about this desire for amputation – like the lad who used a train to cut his leg off – because I’ve recently be reading about ‘Body Integrity Identity Disorder’ or BIID – where seemingly perfectly normal people have a massive need to rid themselves of a limb.  Check out this sort of website: http://www.biid.org/ if you want to know more!  Then of course like the train kid there are occasional chronic pain patients in our own experience who ‘wish’ their limb were amputated – now called ‘Body Perception Disturbance’ or BPD.  Apparently all these folk know exactly where they want the limb cut off….

So here I am about 3am thinking about where the cut off is between ‘me’ my ‘mind’ and my ‘body’ if I were able to amputate it…. You try it… simply ask yourself where ‘you’ are anatomically and when you’ve got a rough idea hone it down a bit more and a bit more…

For me I’m somewhere behind my eyes and forehead, I’m definitely not in my chin and lower jaw and I’m not inside my ears, the back of my head is ‘body,’ so is my nose……. I reckon that I’m a 4 inch slice of head just behind eyes and forehead – frontal lobe area …. What’ve you found?

I even woke Philippa up to ask her… she’s roughly the same as me ( without conferring).

So, what’s all this about?– Simple, mind and body are naturally separate even though it’s an old wives tale!

One last thing, this sometimes useful analogy that chronic pain is ‘like an annoying tune playing in your head’ – isn’t quite right really.  Think about it and if you say this to a patient they could well come back to you and say…

‘No it’s not, when I’m aware of a tune in my head I know I’m imagining it, it’s not real…. My minds playing it to me…. But the pain I’ve got is in my body, its right here in my spine and my muscles, I’m not imagining it, it’s real.

Sort that one out!

Louis!

I’ve added some more material:

From the Journal Manual Therapy: ‘A Medical report to a solicitor’

From PPA News: The Vulnerable Organism

From Peak Performance: 2 articles by Steve Robson and Louis Gifford