Fish, guts and backs

Diverticulitis cured!
“Great news!” said my patient – “after those back treatments last week, I reckon you have cured my diverticulitis. I have had it for years. Thank you so much – you didn’t even tell me that you were working on it.” This was some years back, but I remember that at the time I wasn’t quite sure what diverticulitis was. I obviously felt quite chuffed about my hitherto unknown diverticulitis management skills while at the same time thinking, “what on earth happened there? Maybe I freed up some gut associated innervation when I got her back moving.”

I had forgotten this interaction till last week when I had a back twinge while lifting a large snapper onto a boat during my first week of self inflicted long service leave. The back was sore for a few days and I was getting a bit anxious about it, but it was also accompanied by what we technically call here in Australia, “the trots,” the kind we all get, but if it continued, the problem may acquire a label of irritable bowel syndrome.

Is irritable bowel much different to irritable back?
In many cases, probably not! While bowel and back are obviously different target tissues, the neurophysiological processes behind peripheral and central sensitisation are the same for all body parts. In many problematic states such as irritable bowel syndrome, chronic low back pain, fibromyalgia syndromes, post traumatic stress, chronic TMJ disorders there is a lot of overlap of symptoms and patients with one are often diagnosed with one or more of the others leading to the suggestion that there may be common drivers (Schur et al 2007). Around 10-15% of the population suffer from irritable bowel syndrome – a similar number to irritable back syndrome (I just made that title up – I mean chronic back pain).

The idea that irritable bowel syndrome, irritable back syndrome and other tricky to manage problems may, in many cases, originate from common pathways is not new, and although the notion that they occur together has been widely expressed by patients and some scientists, very little has been done about it. Different professions manage different parts of the body and support groups have grown embracing the notion that singular discreet problems occur.

The brain-gut axis

One critical element of the cognitive architecture of the NOI group is that in response to threat, interest, challenge and need, a number of homeostatic systems can be engaged to help us cope. One of these systems is the hypothalamus-pituitary- adrenal axis which is known to be perturbed in irritable bowel syndrome and in chronic pain states. It is also a key part of the brain-gut axis. Corticotropin releasing hormone is released in responses to threat and challenge, (including interoceptive stress such as colon distension). CRH receptors exist in most peripheral tissues and organs as well as many brain areas – its release has a general effect. Not just back OR gut.

Explain gut pain and other symptoms

Providing biological knowledge such as Explain Pain (Butler and Moseley 2003) to assist coping with more musculoskeletal associated problems is becoming quite acceptable. Similar knowledge, adapted a little for the gut, should now be applied for IBS type symptoms. It is known that patients with irritable bowel syndrome want more information than they are currently getting (Halpert et al 2008) and it is also clear that sufferers carry many misconceptions which are likely to enhance stress responses. For example, around 1 in 7 people with irritable bowel syndrome think it leads to cancer and many more think it leads to serious problems over time (Lacy et al 2007). Any unexplained pain is threatening to the brain and surely more so when it is associated with inconvenient, uncomfortable and distressing bowel problems.

And as for my patient with diverticulitis – I presume that whatever happened in the clinical encounter – technique, interaction, even a joke, calmed down an output system enough to have effects on body structures that were not in my original thought processes.

Help us
Tell us your thoughts and experiences. It may well be time to embark on Explain Pain type research and education in the irritable bowel syndrome world and the input from our readership helps. The notions of brain-gut axis and biopsychosocialism fit well together. Here, the best piece of writing comes from Wilhelmsen (2000).

References
Butler DS, Moseley GL (2003) Explain Pain Noigroup
Halpert A (2008) Dig Dis Sci 53: 3184
Schur EA et al (2007) J Gen Intern Med 22: 818
Wilhelmsen (2000) Gut 47 Supp14 iv5-iv7


Last week’s notes on nerve ordering
Thanks to all who wrote in last month with their story of novel positions and analyses. Kylie is the winner with her Aussie Rules football player’s tiny toe story and has been sent the NOI Neurodynamic Techniques DVD and handbook.

Quite some time ago a football player presented to me with severe pain in his 5th (little) toe when he kicked the ball on his right leg. He could not recall any incident of local injury, and had no focal tenderness around this area. After further testing I was able to reproduce his pain with a slump test, once knee extension and DF were added on that side.

Mobilising in this position with knee flexion and extension resolved his symptoms quite quickly, and he was once again able to return to kicking the ball without pain…

I found this case very interesting at the time and your topic reminded me of this patient! Kylie

Nice work Kylie – this could be as simple as a mid axon discharge from a branch of the tibial nerve in the foot. Give it some oxygen and remove mechanical constrictions (could even be a new pair of shoes) these can just disappear. It’s also a reminder that a tiny nerve can cause heaps of trouble.Find all other novel positions and analyses stories in here.


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