Apologies for being away for so long,.  The 2^nd 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.

26^th September 2013.

(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: https://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: –

https://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.

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

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

First up:

‘Re-writing ‘Colonel Bogey’ – can chronic pain be forgotten’

and second up:

‘Tricking Pain’

For any of you who like the  ‘tricking pain’ idea – you’ll probabaly enjoy this book:

‘Sleights of Mind:  What the neuroscience of magic reveals about our brains’  by Stephen Mackik and Susan Martinez-Conde with Sandra Blakslee. Profile Books 2011.

Hope you enjoy

Louis xx

Hi

Apologies for the rather tossy title of this post – ‘Post hoc,ergo propter hoc!’ –  it was actually the title of a PPA editorial I did back in December 2006.  I’ll come to ‘Pink flags’ in a moment…

I’ve posted the Post hoc editorial pdf up:

Gifford LS 2006 Post hoc, ergo propter hoc! PPA News Issue 22:3-7

The reason I’ve put it up is because David Collis posted the following…..

Wo! this is going faster than I ever imagined.  First up thanks to those of you who have signed up to ‘follow’ and an even bigger thanks to those of you who have posted such amazing comments.

I really wasn’t ready for this to go ‘out there’ but Adam Bjerre from Denmark found ‘me’ and left a message on the soma simple website… and off it went… I’ve thanked Adam very much but had to quickly re-tweak a few pages and realised I hadn’t quite included everyone in my story bit… particularly Ian Stevens from Dunblane and two very special American friends Bernie and Ellen Guth.  I’m also struggling a bit with sorting the ‘blog’ page and all the ‘reply’ stuff… I’m getting a hand with that from time to time and trying to be a patient patient.  Bloody widgets and side bars…..

Anyway, next up the 3 part series I did for the Organisation of Chartered Physiotherapists in Private Practice(now called ‘Physio First) journal: ‘In Touch’.  The articles are a bit of my 2001-2003 spin on biopsychosocial/multidimensional thinking and an introduction to the ‘Shopping Basket Approach’ – The way I think and reason with patients given all the evidence base meshed with my own thoughts with regards biomedicine, healing and recovery, pain mechanisms, disability, function, impairments, fitness and the the various ways of thinking about and dealing with pain.  Part 3 gives a patient example which may help!

I’ll also put up the clinical reasoning article I did with Dave Butler and a lengthy complex pain case history that was published in Mark Jones’ book ‘Clinical Reasoning for Manual therapists…. so you can see where I came from and where I ended up.  When you read the case history note how Mark Jones keeps asking and harping on about bloody abdominal muscles!  I love Mark to bits but he did seem to think I’d missed something with this lady… Anyway see what you think…

While on abdominal muscles, don’t forget their main function before we all went and sat down in front of computers and moved around in cars… – breathing! Panting! Shouting… Not…. tensing to pick a pen up from the floor, or doing sit-ups – unless you’re like me and have to get out of bed to have a pee 5 or more times a night….

Hope you enjoy and I really appreciate everyone who’s joined in… and made such encouraging comments..

Louis

I have now put up the full ‘McKenzie debate’ debate on the ‘Download’ page.  It’s here!

I would like to point out that the Mckenzie Institute did not publish any of my material or Mick Thacker’s article in their newsletter.  They only published the critiques from their own faculty and members, some of which called my stuff a ‘diatribe’. I was unimpressed but not surprised.  I got what I deserve I guess, but I thought I was being pretty reasonable!

Anyway, I hope this debate can still get you thinking, – even though it was printed in 2002 over 10 years ago…. The McKenzie operation seems as vibrant and as powerful as it always was…… or is it?

After the pounding I was given back then I’d like to point a few things out…. and look, the points below are general things that re-reading the McKenzie Institute replies to my original editorial have made me think of… they could be applied anywhere…

First up: Remember, good science should set out to try and disprove a given observation or hypothesis.  We should be testing to see that a given treatment doesn’t work, or that there’s no relationship between two observations, or ‘measured’ phenomena…..Start out sceptical and then if your results reject the ‘null-hypothesis’ the results hold far more power.

To me good science means that we should be sceptical about the many clinical ‘truths’ we are fed by treatment ‘gurus’ and that’s what I was and still am in the debate here.

Second, I’m interested in the common statement:- ‘no one gets worse with my treatment’!  Or, ….’in all the trials we did, no cases of worsening were reported…’

When I was teaching I used to get a class of 30-40 physiotherapists on the course to raise their hands if they’d had patient’s come to them who’d been made worse by other practitioners.  For example by forceful manipulation, forceful exercises, forceful end range extension, combined movements, hard pressures… even simple gentle stuff, whatever.  Every time I asked this question a vast majority raised their hands.  Many were keen to tell their stories. When I then asked if anyone had made any of their patients worse – hey, I was the only one to raise my hand!

My point is that patients often do get worse from seeing ‘other’ practitioners… for physio’s we like to blame chiropracters and osteopaths, but I bet if I’d asked the same question to a group of chiro’s or osteopaths I’d get the same show of hands… and they’d be blaming physio’s!!  This clealy needs researching and would make a great project for someone.  I’m mentioning it because in my clinical experience, not only did I make patients worse (sometimes a lot worse),  I frequently observed patients who’d been made worse by others – and I mentioned this in the McKenzie editorial, because I particularly saw patients with low back pain that had become sciatica following a strict regime of McKenzie repeated movement using the extension principle.

Third, I was lambasted by the UK McKenzie Institute for equating ‘McKenzie’ treatment with extension exercises to the vast majority of the world – but this is massively born out by the numerous Youtube vids and internet articles you can very easily find (e.g.this)…. plus… the McKenzie Institute’s International Extension Award – known within the Institute as “The Bronze Lady” –  is a bronze naked lady doing an extension in lying exercise….I know the method uses other movements like into flexion, side gliding in standing etc… I did the courses with Robin McKenzie himself back in the early 1980’s… but…!!  ….Please make sure you read my response ‘editorial’: ‘Memes dreams and dualism, the flexion extension debate and beyond’.

You must also make sure you check out the ‘Williams’ flexion exercises for acute low back pain too.

Fourth. Researchers who look at their favourite treatment (often their major source of income) and try and prove it are not to be trusted unless they are very open.  That’s why it’s always wise to check who the researchers are being paid by or who sponsors the research…….

Did you see the recent headline in the UK Daily Telegraph:  ‘Antibiotics could cure 40% of chronic back pain patients….Up to four in 10 cases of chronic lower back pain could be cured by antibiotics, research has suggested…..

and then comments like….

“Make no mistake this is a turning point, a point where we will have to re-write the textbooks,” says Peter Hamlyn, a consultant neurologist and spinal surgeon at University College London, as quoted by the U.K. Telegraph. “This is vast. We are talking about probably half of all spinal surgery for back pain being replaced by taking antibiotics … It is the stuff of Nobel prizes.”

Now do a little research (Thanks to my mate Ian Stevens!) –  about the authors and you find this….

A widely publicised study which claimed antibiotics could relieve up to 40% of lower back pain failed to disclose its authors’ potential conflicts of interest, it has emerged.  Three authors did not state they serve on the board of a UK company that receives money to certify doctors in antibiotic therapy.  The publicly-listed Modic Antibiotic Spine Therapy Academy, or MAST Academy, charges £200 ($310) to certify doctors in how to identify and treat modic back pain with antibiotics. Clinicians can alternatively take an online course for £100 ($155)….. The Danish study was widely publicised after it was published in the European Spine Journal in early May…. The authors claimed that the cause of up to 40% of lower-back pain was a common infection in the vertebrae that could be cured by antibiotics.

Many practitioners come wielding some expensive product for you to buy aswell…… care again!!

Fifth: Research that doesn’t give the results ‘wanted’ by the sponsors, drug company or Therapy Institute …. doesn’t get published, it gets binned. (That would be a good research project if it was possible to access all the research archives….)  Are there any whistle-blowers out there???  It’s a trendy thing to be one….!

Sixth. Make sure you look for a part of a ‘treatment’ or ‘intervention’  related research script or paper that has a ‘made worse’ column which gives the details of how and what was worse.  There’s no such thing as a treatment that doesn’t make some people worse, there’s also no such thing as a treatment that makes 100% of people 100% better either.  If you see results that suggest over 70% of subjects got 70% or more better… particulalrly for human musculoskeletal pain states…. get suspicious…. Also, sometimes bad figures can be made to look good because none of us are good enough at research stats to see through it…

Seventh.  As humans we tend to only listen to evidence that supports our stance or beliefs and avoid, ignore, reject, ridicule (call it a diatribe)…  evidence that might challenge it.  Buy and read Stuart Sutherlands’ book: ‘Irrationality’  In fact buy 2 and give one to your local Parliamentarian!

Eighth.  It might just be me, but in the last 4-5 years I’ve seen far fewer patients with the ‘fear of flexion/bending’ and ‘extension made them worse’ problem. – It maybe because  the population of Mckenzie therapists in this area moved out long ago, or, that the McKenzie ‘fad’ isn’t quite what it used to be here in the UK, well, here in Cornwall…. in other words, maybe clinical folk are being more ‘graded’ in their approach…like I suggested!!  Certainly the heavy- manipulating bone-setters, chiropracters and osteopaths seem to have virtually vanished and given way to far more gentle techniques..!.

Points done.

I was genuinely sorry to hear of Robin McKenzie’s death recently.  He was a great character, teacher and promoter of movement and self management – which was very refreshing back in the very passive therapy orientated days of the early 1980’s when I attended his early courses.

I think this ‘debate’ material, or stuff like it, should be mandatory reading for all McKenzie/physio/manual therapy courses.  I do have some further thoughts on the ‘centralisation’ phenomenon – but I’ll save that for another time!  There’s also a need for a discussion on this ‘mechanical pain’ thing too. Arghhh!

Anyway, good luck and enjoy! Remember, it’s fine to criticise, but do it nicely, no spitting!  I just want to get everyone thinking and using rational science.

Louis Gifford June 2013