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??

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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…

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

Louis.

I’ve uploaded two chapters:  A relatively young one…. from the 5th Edition of the tome that is the ‘Textbook of Pain’…. click to view and download….

Gifford L S Thacker M and Jones M 2006 Physiotherapy and pain. In: McMahon S, Koltzenburg M.  Wall and Melzack’s Textbook of Pain, 5^th Edn pp:603-617

and relatively dated one, but still quite relevant for the most part…..

Gifford L S 1997 Pain. In: Pitt-Brooke (ed) Rehabilitation of Movement:  Theoretical bases of clinical practice  Saunders, London 196-232

When I wrote the Textbook of Pain chapter I had in mind the likely readership!  Nerdy pain scientists and folk like me who really like reading heavy stuff and trying to understand pain..? In other words virtually no one!  I also had in mind the other authors who were mainly research scientists and also a few therapy research clinicians… who’d probably last seen a patient about 20 years ago, might they be interested!!  Unlikely.   Then I thought to myself, you know what I’d really like to write?  ‘Something I, or any physio colleagues, could photocopy and give to the local GP’s to read so they got a better idea of the state of the art and science of modern physiotherapy – rational, reasoned and well supported by good evidence…look how we practice, think and do!!!  Rather than how they mostly perceive us – as ‘modality’ applicators… doing a bit of ‘massage’, ‘joint wiggling’ ‘exercises’ (we can do that in 2 minutes anyway)..’ultrasound’, ‘acupuncture’  (there’s no evidence for it… hmm just a placebo…), ‘passive movement’… ‘walking practice’…. ‘stairs’…. You know what I mean?  It’s the old….. physio does a bit of rubbing and it’s all a placebo, waste of money, here’s a sheet of exercises, off you go…I wanted to put pain and physiotherapy in a good place and a respected and needed place, if I could..

That was the main thing in my mind then… and I hope you may find it useful to ply your GP’s with and follow-up with a tutorial on!!

The next thing I thought was that I wanted to write something so that budding physiotherapists, or any other practitioner for that matter, might read and see the ‘state of the art’ in physiotherapy for the treatment and management of pain.  I also thought it’d be good to try and persuade the most important people – physiotherapy tutors and the various ‘Schools of Physiotherapy’ round the country and even round the world – to see that maybe the pain part of their undergraduate curriculum needed a big shift, a revamp, and something a bit fresher than teaching modalities like TENS and some vague reference to pain-gate theory.

Well I know that’s all a bit arrogant of me, but that was the thinking and it was great that in writing the chapter I had help from my close friend – Dr Mick Thacker – one of the most pain knoweldgeable physiotherapists in the world.. (probably the most pain knowledgeable!!) and Mark Jones who many of you will have heard of in relation to his work on Clinical Reasoning.  Mark, has to be ‘the most clinical reasoning knowledgeable physiotherapist in the world’!! There you go.

The second chapter, the 1997 one, has a lot of basic nitty-gritty stuff that should fairly easily start anyone off on a ‘pain’ journey understanding. ( I’m quite OK if you hate it!! Don’t waste your time trolling me into a grave via Twitter though, I don’t go near that stuff, and I’m nearly dead anyway!).  My warning is that some of the clinical reasoning categories are old now and have since been updated… see the Textbook of Pain for the more or less current state of the art here…

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Over the years I get the odd communication asking me about how some of the stuff I used to do came about… like the story of the Mature Organism Model…some of the ‘explanation’ stuff like the ‘annoying tune’ and Colonel Bogey!  Recently the ‘Toblerone’ graph stuff came up.  Here’s the story, it’s an extract from the forthcoming book…(to be editied possibly!)

The toblerone Recovery story

The following is an extract from my forthcoming book…. Help! It has not title yet… how about….this… Gifford’s Aches and Pains – Essays, thoughts, swearing and patients!

 The Toblerone recovery…(excerpt)…

There’s a story behind why we call it the ‘Toblerone’ recovery.  It goes back to the mid 1990’s when Dave Butler and I were giving a 5 day course in Zurzach in Switzerland.  I was up the front teaching the group my way of explaining recovery for nerve roots… similar to what I have just described.  I was saying something like this……(I’ve got graphs of how pain goes up, along then down during nerve root recovery on the board)

‘Do you guys ever get a new patient in and you do a bit of treatment and they do quite well, their range of back or neck movement improves and there’s a nice drop in the level of pain… the patient kind of looks at you and says… ‘Wow, that’s good, we’re getting somewhere….’  The patient then goes home and comes back 3 days later and can hardly walk into your treatment cubicle, they look like death and they’re moaning in pain…. ‘I don’t know what you did to me last time but I’ve never been in so much pain in my life, I haven’t slept since I last saw you and I’ve been back to the Drs … and he says that you shouldn’t do any more of that manipulation…he said he was going to write to you…..’ 

‘You feel absolutely shit now and you’re wishing you were an office worker drinking a cup of coffee and sending jokes on the internet. Jesus, what’s the guy’s friggin’ Dr going to think of me, my reputation with him has now gone totally tits up.’

I pause and then ask the group…

‘Anyone been there? Does it piss you off as much as it pisses me off?  Come on hands up….?’

90% of them eagerly put their hands up and there’s a babbling and nodding of heads….

10% don’t put their hands up because they know that they cure everyone and that no one gets worse in their smart-ass clinic. They’re liars/faith-healers I reckon.

I go on…

‘Right, show them this recovery graph and explain that recovery is always up and down…and that up and down is normal and not to worry… and it’s especially up and down when a nerve is involved in the pain scenario…. one minute the pain’s quite OK, the next it’s agony again, you get several hours feeling good then for no reason it comes back again… you get good days occasionally, then later on it goes awful ….. etc…

Since I’ve been doing my little graph thing with my patients I don’t get the nasty ‘it’s-your-fault-look-what-you-did-to-me’ type reaction… I get…

‘Louis, I felt really good after the session so I went home and did a bit of gentle gardening and even felt so good that we had sex.  You know that pain went flying up after but I thought about that graph you showed me and it didn’t bother me.  I used the TENS and took the tablets like you said and it soon settled down…..’

As I was drawing the wavy up and down graph on the board Dave Butler piped up from the back…..

‘Hey Louis, that’s the ‘Toblerone’ recovery!’

Being Switzerland , the home of Toblerone chocolate, and Dave being Dave – it got a great laugh.  Ever since then the term has stuck and we always tell patients about the Toblerone recovery when appropriate The key for me, and why I came up with it and used it so often, was that it took the pressure off me – it stopped the patient blaming me for a natural fluctuation in symptoms and it kept them chill with what was going on, – especially if I’d given them some kind of ‘flare-up’ plan should the increase get too much for them to cope with.

….That’s the story!

Thanks for coming here, and thanks for following… I’ve had some wonderful comments and emails from folks!  You’re all amazing…

Best,

Louis