Archive for the ‘2008’ Category

Christmas pain

December 7, 2010

Well, this is the last newsletter of the year. We hope that you have a happy and successful Christmas holiday and thank you all for your great replies. We in the southern hemisphere now try and take a few weeks holiday, but still persisting with our snow covered Christmas cards, seemingly oblivious to global warming.

Can Christmas hurt?
Can this annual humanly constructed event actually change our physiology? And from what we have been teaching at NOI, especially with the notions of the brain representing our bodies, what is the cumulative effect of all those cues such as carols, men in red, presents, eating too much, ho-ho-ing everywhere, tacky tinsel, and candles?

Here are a few thoughts on pain and stress at Christmas…
The perils of Christmas in the UK: Last year in the UK, hospitals reported 4 broken arms after cracker pulling accidents and five people were injured in accidents involving out of control Scalextric cars.

Be also aware that three people die each year testing if a 9v battery works on their tongue and that nineteen people have died in the last 3 years believing that Christmas decorations were chocolate.

In 1998, eighteen people had serious burns trying on a new jumper with a lit cigarette in their mouth and even more scary, thirty-one people have died since 1996 by watering their Christmas tree while the fairy lights were plugged in… if there was ever a good excuse for a fake tree – that might be it (

Parental loss of Santa pain
Children usually discover the myth of Santa Claus at around 7 years and are usually quite positive about the finding. However, parents are usually very sad in reaction to their child’s discovery. (Anderson CJ, Prentice MN  Child Psychiatr Hum 1994 25: 67). I guess this is just about parents growing up too.

Christmas eye
In Australia, there is a rare syndrome known as ‘Christmas Eye’. It is thought to be due to activity of a mite which is only active in December and it seems it is associated with higher altitudes. Keep an eye out for this little fellow if you are downunder in December.

The neuroscience of pain at Christmas
But Christmas surely hurts many people more than the injuries in the physical domain mentioned above.

Christmas has to be the greatest memory sink of all time. Watch the widow, the widower, the one who has lost family or is just lost at Christmas. For many it is a ‘get through’ occasion which lasts too long and for which there are far too many cumulative cues (carols etc) which ignite and maintain levels of easily accessed sensitivity. And the sensitivity is maintained because it comes around at the same time every year without fail. ‘Neurones that fire together wire together’ (Hebb 1949) still provides our best understanding of memory retrieval.  Plus, the evidence for pain distress and social distress sharing common brain areas is growing (eg Eisenberger NI et al 2006 Pain 126: 132).

The Chistmas neurosignature and the pain neurosignature surely overlap (neurosignature = brain event space, which is a part of the neuromatrix or brain coding space). Key brain areas active in memory, planning, emotions and movements must be common to a Christmas experience and a pain experience in some people.

Simply the question “was Christmas OK?” might lead to a better understanding of ongoing pain and disability states.

Acute canine pancreatitis at Christmas
Last year my friend Jenny’s dog got up on the table and ate all the fat off the Christmas ham while no one was looking. She (the dog) got acute pancreatitis, had lots of pain and Jenny has the pain of a 2000 dollar vet bill. Keep your ham covered!!!

Wherever you are, we hope you can enjoy this time of year.

Your turn
Send in your most relevant ‘pain at Christmas’ story for the chance to win an Explain Pain audio CD pack.

Last month’s ‘Two pains at once…’
Here are all the great stories from last month’s contributors. Two pains at once sure doesn’t seem to be an alien experience…

We loved the dermatology and liver condition rendition from David in Canada but we found it tough to choose because the ‘Squash Bum’ from Sally in New Zealand came in top too.

Congratulations to both entrants, who will be sent a Pain Pack each.

Recognise updates
Anne Daly’s and Andrea Bialocerkowski’s recent systematic review suggests that graded motor imagery is currently the only evidence based physiotherapy treatment for CRPS1.

As the programme allows, we have updated Recognise™ Online with an extra 600 images of hands, feet, necks, shoulders and backs. With the programmes ability to automatically flip and/or rotate this allows for 4200 image possibilities so you will never take the same test twice.

Anderson CJ, Prentice MN  Child Psychiatr Hum 1994 25: 67

Eisenberger NI et al 2006 Pain 126: 132
Hebb, D. O. (1949). The Organization of Behaviour. New York, Wiley (Interscience).


Two pains at once

December 7, 2010

Can you feel two pains at once?
Instinctively the answer is, ‘yes!’ After all, haven’t we all filled in pain body charts over the years with pain #1, #2, #3, #4 and even more in the ‘pain everywhere’ presentations?

This is worth reflecting on. I don’t think you can feel two or more pains at once.  Pain is such a fast, even primitive, brain construction that is designed to make us take action and change the behaviour that the brain believes is related to the pain. Maybe the brain can only deal with one pain at a time?

There are many stories of people who have been badly injured in accidents, for example, with all the focus on a neck injury, and two days later their complaints of foot pain reveals a fracture in the foot. Pain is not such a good defender in this state.

The bite the lip experiment
Try this… bite your lip until it hurts – and at the same time pinch your tummy till it hurts – try to focus on both pain constructions and you will (probably/maybe!) note that the pain moves from one site to the other. But the key here is that the ‘threat value’ at both sites is the same. If you were biting your lip and I came along and pinched your tummy, there should be no doubt about where the pain will be.

If you really want to – try this… next time you are out in the middle of nowhere with nobody around and it’s all peaceful and quiet, pull both ears and you may feel a pain go from one to the other. Just don’t get caught!!

By the way, have you had the need to hit two biting mosquitoes at once?

Of course, I realise the error here – who am I to suggest what your personal pain constructions are like? Some of our readers may well be sufficiently evolutionary advanced to appreciate two pains at once.

Physical and emotional pain dualism
Reflect for a moment on the dualism of physical and emotional pain, still so prevalent in society (“he has got over the physical side, still needs time with the emotional” I often read in the local newspapers).

We know now of course, courtesy of the brain maps and cognitive psychology that it is impossible to have a pure ‘physical pain’ – there will always be brain areas related to emotional and cognitive events included. And pain states that are more emotional – the pain of bereavement, the pain of being told there is nothing wrong with you – will always have a physicality, evident for example in postural changes or cortisol levels.

Yet even here, the two pains at once issue arises. You can bite your lip at a really sad time and arrest tears for a time (shifting from more emotional to more physical perhaps).

So what could all this mean?
I think there is a lot in this, much related to the conceptual changes we seek in clinicians and patients. The obvious thoughts relate to the mechanisms of distraction and the importance of the threat value that the brain places on a body part. 

The notions of physical and emotional dualisms suggest that both domains need integrating and managing early on in patients. Education is the glue. I believe that the more pain sites a patient has, then the higher the likelihood that there is one major pain generator existing in the brain.

It’s a little graphic but this hollywood clip is a good example.

Your turn
Send us your best two pains at once story and the winner will receive our ‘two pains at once’ which we like to call the Pain Pack.

Last month’s Wall Street pain
Thanks Nick, Anne and Geir for your thoughts on Wall Street Pain and Anne especially with the details of your little experiment. You will be sent an Explain Pain audio for your contributions which read…

…You mean my $410 000 becoming a $41 000 – while my electricity was out from Hurricane Ike?

Ah… you mean my Financial Planner patient!

His neck ‘discs’ go out every time he reaches down to turn on his computer in the morning! It is so bad, that he has missed the opening quotes on Wall Street several times. It causes severe headaches and right arm paraesthesia, sometimes nausea and dizziness. Before being sent to me he had a full work-up. He’s had brain MRI, neck MRI – guess what – ALL the lower discs are ‘shot!’ But he hasn’t had a stroke and doesn’t have a brain tumour.

HE said it was as if he were allergic to Wall Street!

I am new to this Explain Pain stuff – sort of. After 34 years as a PT some has become intuitive. We talked about this and the article on Mirror Neurones was insightful. He was intrigued by there being a mind connection to this, but not in his case. I really need to fix his discs before he wants to deal with pain. He can handle the pain – but just fix the discs so he doesn’t have to have surgery (threatened by the neurosurgeon who sent him to me).

I’ve only seen him twice. I was miraculous in getting rid of arm pain with joint gapping and nerve gliding. For 1 day, it didn’t happen (do you know, that was the day after the market went up). So, he is going to chart morning pain and previous day’s stock price for me! I have no idea where this will go. He denies any relationship between pain and the stock market, but is willing to chart for me. Just so long as I fix his discs.

This should be interesting. 

Anne, TX United States

Wall Street pain epidemic

December 7, 2010

Duck for cover
A new and virulent pain epidemic known as Wall Street Pain is amongst us; It’s scary. If you Google it there are over 9 million entries so it clearly an international epidemic. Few have or will miss out. It seems to be closely associated with Financial Pain (2.3 million entries) and a new and growing allied problem called Mortgage Stress (400,000 entries). Some people may have contracted all three. The only good news is that a previous epidemic known as “Fuel Pain” (16 million entries) is thankfully waning. Like any pain problem, either personal or public it would be helpful if the sources could be found, thus blame apportioned. But with this Wall Street Pain, nobody is taking the blame and this will probably make it a lot harder to manage.

Onion rings to the rescue
Optimal pain management strategies will need to address this epidemic, but a framework will be necessary. John Loeser and Gordon Waddell’s onion skin model, a key feature of the biopsychosocial approach may help (see figure). This figure from ‘Explain Pain’ which is a slight variant on the original model has each ring of the onion as a contribution to your overall pain construction. Note the outside ring called ‘social environment’. The events of 9/11 provide a graphic example. I recall a study, reported in many newspapers about its effect on the pain levels of US east coast chronic pain sufferers. More returned to pain clinics, more sought treatment. One hypothesis at the time was that it could have gone the other way and created less pain but this was wrong. However, good clinicians now had a powerful and rare opportunity to educate patients (and themselves) about how pain is not just something constructed from within (such as nociception – the innermost ring on the onion) but something which can be influenced by world events. Wall Street Pain (now WSP) is the same.

Think of this next time you’re eating an onion!
WSP does not exist in the ether. It biologises itself. This means that the new environment created by the epidemic enters the brain in the form of increased synaptic activity in key brain parts such as the anterior cingulate, amygdala, frontal lobe, hypothalamus and insula among many other parts. These areas are often active in pain, stress and depression states. This is not a nice epidemic, but forewarned is forearmed.

Unfortunately there is no rapid cure. This is a slow process.
I noted however, that financial planners are beginning to biologise it – one in Canada’s National Post calling it a ‘life’ event which triggers a review of financial plans. Financial planners could well help in pain management.
We discuss paradigms like Onion Skins in ‘Explain Pain’. It may be very helpful for many people to know that world events can have physiological effects on their bodies, including pain production. The simple question of “what’s bugging you” may assist in the diagnosis of WSP. This educational experience of WSP may also provide a lifelong lesson to assist in coping with many other pains in future years.

Fantastic news (if you’re not Aussie or Kiwi)
There is some great news in the gloom. The Australian dollar has caught the epidemic badly and is now 35% weaker than it was a month ago. This is great time to stock up on Explain Pain – the book and the audio.

Your turn
We are absolutely loving all that you send. So this time write to us, here in Adelaide and tell of your closest experience – personal or clinical – to ‘Wall Street Pain’. The winner will be sent an Explain Pain Audio and an Explain Pain book!

Last month’s ‘Cool hand’ Moseley
Your thoughts on this topic are fantastic! Check them out, print them out – heck, sing them out aloud in the tune of another song!

Thanks Matthew, from London, for your prime example of altered body awareness – your Explain Pain audio is in the post. Here’s what you wrote…

It may interest you that I recently saw a patient who we practiced mindfulness with. This patient had been involved in an RTA and had lost her right lower leg. She was keen to improve her walking with her prostheses. Whenever she attempted to walk her pain increased significantly. She tried hard to distract herself from her leg although this did not work.
After assessment we looked at the workability of the distraction. We experimented with trying to distract from her leg (as hard as possible!) and she noticed it actually increased her sense of struggle, fraustration and her pain!
We then practiced a series of mindfulness meditation practices which involved resisting the tendancy to change anything and instead be openly receptive to the actuality of her present moment experience. She noticed that her mind went off to the fraustration about not having a leg, how things should have been, worries about how things might be in the future, and thoughts about not being ‘good enough’. She reported that during this time she was less aware of her body overall, although was more aware of her pain!
She then practiced a regular body scan which involves guiding the awareness through the body and ‘see what comes up’. Interestingly she reported less pain when she attended in detail to her right lower leg (which wasn’t there!).
We concluded that
1) when she was more in her head comparing and analyzing her situation she was less aware of her body yet more aware of pain.
2) When a non judgmental awareness was placed on her affected limb (in a balanced open way) her symptoms were less.
Therefore we planned for her to walk with her awareness placed within her feet both sides (big toe, little toe and heel) and every time she noticed she was up in her head she was encouraged to label this ‘thinking, thinking’ and guide her awareness back to her feet and then to widen her awareness to include her body as a whole.
Result: This increased her walking significantly and reduced her pain. Interestingly when ever she did it to decrease her pain it did not work (comparing mind perhaps?) however when ever it was performed out of a gentle curiosity and interest walking was better and pain was less!
Interesting stuff huh?
Matthew, United Kingdom

‘Cool hand’ Moseley

December 7, 2010

MY OLD MATE and co-author of ‘Explain Pain’, Lorimer (Lozza) Moseley comes up with some off the wall research, but one of the best was the recent “Psychologically induced cooling of a specific body part caused by the illusory ownership of an artificial counterpart” (PNAS 2008 105:13169-13173). I have attached the abstract at the end.

The rubber hand illusion
Lozza et al showed that skin temperature of the hand  decreases significantly if the person’s ownership of the hand can be altered by tricking them into taking ownership of a rubber hand. This can be done by using a well known rubber hand illusion trick – essentially hiding the subject’s  hand  behind a screen as in the image and  putting a rubber hand close by. If you synchronously brush the rubber hand and the real hand, people often perceive the feeling of brushing as coming from the rubber hand.  Try it yourself. It’s a weird feeling, but we believe every therapist should try it. Take care with your rubber hands though. Lorimer has been pulled up in customs with a rubber hand in his luggage and I have been accused of murder by hotel cleaning staff in Sydney. (Always hide your rubber hand to be safe!!)

The findings
The experiment is neat – six experiments with six different groups of volunteers (budding researchers take note). The change in temperature is limb specific i.e it doesn’t occur in the other hand or the foot. This is an important finding, meaning that it is unlikely to be related to a broad stress response and thus seems to be a specific cortically mediated adaptive response. Another finding was that the importance (weighting) of tactile information from the real body part is reduced when the person takes ownership of the rubber hand. Moseley et al summarise the findings succinctly… “ taking ownership of an artificial body part has consequences for the real body part; that the awareness of our physical self and the physiological regulation of self are closely linked in a top down manner; and that cognitive processes that disrupt the sense of body ownership may in turn disrupt temperature regulation in states characterised by both.”

So what does this mean?
I suspect many readers will think “well that’s interesting” and that will be it. But the study should provoke much discussion. (If you google it you will see that the world press was particularly interested)

  • As the authors note – many states such as anorexia nervosa, stroke, epilepsy, autism are characterised by altered body awareness and many of these also have altered temperature regulation as a feature. The findings help with explanations of symptoms to patients.
  • Perhaps we should all reflect on what body ownership is about and how we should include this in the clinic. Patients’ comments such as “it doesn’t feel right” or “it is not mine” or even the common “it feels swollen” may mean a distortion of body ownership. Here is a new research area, one that Moseley and colleagues have already exploited elsewhere, for example in the low back (Moseley GL 2008 Distorted body image and tactile dysfunction in patients with chronic low back pain. Pain doi:10.1016/j.pain.2008.08.001).
  • Somewhat on a tangent…if a person can take on an artificial rubber hand as their own, then what about collars, splints, taping and prostheses?  I have known a few patients where touching the collar hurts. Other clinical/research questions may be around how can we get a person to best accept a prosthesis and how can we wrest away a splint that a person has integrated into the representation of their body.
  • Practitioners utilising visualisation and  mindfulness should be interested in these results
  • These findings also support the worthiness of utilising a neuromatrix paradigm in every day clinical life. More knowledge about how quickly the brain can be changed and how cognitions can rapidly alter physiological processes in the body again challenges the still dominant biomedical approaches to chronic disease states. This research supports biopsychosocial approaches.

And remember – what you think you look like is very adaptable!

Your turn
This week’s prize of the new Explain Pain AUDIO, narrated by David Butler and Lorimer Moseley in their best Australian English goes to the best reply on either the potential clinical applications of the research or clinical story about altered body awareness.


Moseley GL, Olthof N, Venema A, Don S, Wijers M, Gallace A, Spence C. Psychologically induced cooling of a specific body part caused by the illusory ownership of an artificial counterpart.

Proc Natl Acad Sci U S A. 2008 Sep 2;105(35):13169-73. Epub 2008 Aug 25.

The sense of body ownership represents a fundamental aspect of our self-awareness, but is disrupted in many neurological, psychiatric, and psychological conditions that are also characterized by disruption of skin temperature regulation, sometimes in a single limb. We hypothesized that skin temperature in a specific limb could be disrupted by psychologically disrupting the sense of ownership of that limb. In six separate experiments, and by using an established protocol to induce the rubber hand illusion, we demonstrate that skin temperature of the real hand decreases when we take ownership of an artificial counterpart. The decrease in skin temperature is limb-specific: it does not occur in the unstimulated hand, nor in the ipsilateral foot. The effect is not evoked by tactile or visual input per se, nor by simultaneous tactile and visual input per se, nor by a shift in attention toward the experimental side or limb. In fact, taking ownership of an artificial hand slows tactile processing of information from the real hand, which is also observed in patients who demonstrate body disownership after stroke. These findings of psychologically induced limb-specific disruption of temperature regulation provide the first evidence that: taking ownership of an artificial body part has consequences for the real body part; that the awareness of our physical self and the physiological regulation of self are closely linked in a top-down manner; and that cognitive processes that disrupt the sense of body ownership may in turn disrupt temperature regulation in numerous states characterized by both.

Last month’s slippery sural nerve
Thanks for all of the interesting sural and other nerve stories – here’s the collection. We decided that Martin Spitzeck had the most suitable story as it best reflects a mondern-day version of Kamerad-Schnuershuh syndrome which was mentioned in the last edition.

“I had a client who was a keen fly fisherman. He spent 2 weeks on the South Island of NZ and ended up with tingling on the outside of his foot. The problem was the waders being tied up to tight. I did some research and found a case of an ice hockey player with bilateral sural nerve entrapment. His problem was putting tape around the laces of the boot compressing the nerve. This was good to show the client of almost an identical cause for him to getting a better understanding of his unusual symptoms.
Treatment involved sural nerve sliding techniques, massage around the calf, amongst avoiding tight fitting boots and waders.”

Thanks Martin! (We all love a good fishing story!!) – and we hope the Neurodynamics DVD and handbook comes in handy..


Did you know?
According to a Time magazine poll conducted over 3 years ago, in the United States, over 220 million adults average an hour and a half a day in their cars.

And figures published by the Work Wise UK initiative in 2007 revealed that the average commuter travels for 58 minutes a day and one in ten people have a daily journey of over two hours with 18 million of those travelling by car.

Granted, these are amongst the most congested countries around the world but that’s heck of a lot of time.

David and Lorimer recently got together and recorded their narration of Explain Pain onto a 3 CD set in beautiful Australian english; so it’s now available on backorder and will be available, hot off the press in mid October.

EP audio complements the text by offering a different learning medium. It also provides a way of getting the messages of Explain Pain out to those where reading is not an option.

Slippery, sensual, sural nerve

December 7, 2010

It’s time to get on your nerves!
Reach down to the outside of your ankle. Put your thumbnail on the lateral malleollus and slide it down under the malleollus. Go down about a centimetre and there it is! – the slippery sensual sural nerve, one of the best examples of a forgotten nerve in the body. Give it a little flick, feel how its slips around, you may even rejoice in a little zing on the lateral aspect of your foot.

Develop a feeling for a forgotten nerve
I have had a soft spot for the nerve since 1980, after I saw a student with a swollen lateral ankle. He said it was always swollen after he donated a segment of the nerve for a research study! These days, ethics committees may have spared more people this insult, although the sural nerve is still seen as a ‘spare’ as it is the usual nerve of choice for a nerve graft.

Arising from variable combinations of peroneal and especially the tibial nerves, the nerve runs lateral to the Achilles tendon. Here, you can sometimes see it in its glory in the dorsiflexed foot – a little string usually as  thick as a match stick –seems to poke out in cyclists and very noticeable near the Achilles tendons of Dutch people.  I admit to looking at calves (human) to see if I can see it and maybe this is where the sensual bit comes in.  At the ankle it turns 90 degrees and then senses various inputs from the lateral aspect of the foot.

Kamerad-schnuerschuh and other syndromes
If you delve into the sural nerve literature, there are snippets of information about its involvement in Achilles tendon injuries, post vein stripping and ankle injuries. Mumenthaler (1991) reports Kamerad-Schnuershuh syndrome (terrifying diagnosis!) where the lacing of a style of army boots with knots laterally may lead to compression of the sural nerve.

But this is a forgotten nerve. We teach examination of this nerve on the NOI courses and from the thousands of sural nerves that our instructors have examined, the clinical findings include:

•    frequent involvement post ankle sprain
•    involvement in lateral ankle ‘impingements’ i.e. a bony impingement may be a misdiagnosis with the problem due to mid axon sural sparking instead.
•    Involvement in many disorders with persistent swelling around the lateral Achille’s tendon
•    I have noticed involvement in a person who had to hike many kilometers on the lateral aspect of the foot after a bad cut on the heel
•    Lateral heel pain (the sural nerve often branches to supplying the lateral heel
•    And a favourite from one of our Canadian teachers who reported the nerve involved in a dancer who was tying the knots of her ballet shoes on the nerve. Easy to understand and remedy, but only if this little nerve is remembered.

The 30 second sural nerve checkout

You can test it via palpating the nerve (try with the ankle in dorsiflexion and inversion as in the image) Most mid axon nerve problems are mechanosensitive and you may be able to put your finger right on the problem. The neurodynamic test is ankle dorsiflexion, eversion and the straight leg raise. Problems may respond well to using this as a mobilization technique. Other techniques are described in our DVD and manual.

So don’t forget this little, distal and rather unloved nerve.

Your turn
Your sural or other foot nerve stories could win a copy of the Neurodynamics Techniques DVD and Handbook this month. We are interested in problems where the nerve was involved and how you managed it.

Thanks for all your replies. We got stacks and have put them together so have a look at some interesting heuristics stories…

The Gold Medal prize of an Explain Pain book goes to Kieran of the United Kingdom.

“I often use analogies to help patients understand some of the rubbish that I am talking to them about regarding core stability etc.

One that seems to be of particular use is the ‘Olympics analogy’. I describe phasic muscles as your ‘Linford Christies’ (or now Usain Bolts) and your postural muscles as your ‘Paula Ratcliffes’. Obviously with Linford as a sprinter he works for short periods of time and then generally switches off. He gets all the praise and glory just like a well-defined set of quads or biceps should. Your ‘Paulas’ are marathon runners who pride themselves on their stamina, hence they work quietly in the background and generally don’t get as much praise as the big phasic ‘sprinters’. If a dysfunction exists (i.e. a dynamic stability issue), i often tell my patients that the brain is a great cheat and if the ‘marathon runners’ are struggling to do their job, it drafts in the ‘sprinters’. Asking Mr. Christie to run 26 miles is not going to work; hence the development of overactive, fatigued, complaining and ultimately uncomfortable phasic muscles may well develop.

For the younger guys, drum and bass seems to work! Postural muscles are the rolling baseline in the background; phasic muscles would be the snare dropping in now and then. When they are working well everything sounds lovely (to those who like drum and bass – i.e. me!!), however having a baseline that doesn’t know when to come in and a snare that seems to be playing too loudly and for far too long makes the whole thing sound like a real mess!

These normally raise a smile and generally seem to get people on board when potentially undertaking a core stability/ Pilates-type approach to treatment.”

Nice one Kieran!

Put your hands up for video hands
Recognise™ Online now has video hands which you can test out as a demo on the Recognise™ website or consider it an added feature to your already existing Recognise license.

We are really excited about Recognise™ Online because as we have done with video hands, images and features will be updated as often as new research qnd progress allows making them immediately accessible by all current license holders so nobody misses out on anything.

Pamela’s lotion

December 7, 2010

‘Motion is lotion’ and ‘pace it don’t race it’ are sayings or ‘rules of thumb’ for some people. They are also called heuristics. We use them through life, (‘a bird in the hand is worth two in the bush’ or ‘it’s all water under the bridge’) and they are inevitably used in rehabilitation.

In educational research (a place that rehabilitation does not often look), the use of heuristics has been studied in terms of their role in students acquiring deep learning. Deep learning is knowledge which is elaborated throughout the brain and which can be used for problem solving and continued learning. This is opposed to superficial learning which is just the ‘parrot learning’ that many of us used to pass exams. In education, heuristics are not much use in achieving deep learning.

An obvious (though often not stated) role of rehabilitation is to help a patient to achieve deep learning – a deep understanding of their problem, so that their ‘brains can weigh the world’ and consciously/subconsciously decide whether pain or any other output is necessary. It is in rehabilitation that the use of heuristics may help (a) if the heuristic is ‘powered up’ and (b) if unhelpful ones such as ‘no pain no gain’ and ‘let pain be your guide’ and the downright crazy ‘pain is just weakness leaving your body’ are removed.

Thus ‘motion is lotion’ can be powered up with narrative about oiling joints, making blood flow better, pumping swelling out, refreshing the brain. A colleague, Peter Edgelow talks about ‘draining the swamp’ to get people moving in chronic thoracic outlet syndromes, a nice heuristic powered up by stories of using breathing to flush, nerves freely gliding and sliding, and postural change to empty the swamp of fluid and its alligators in and around the brachial plexus.

An oldie but a goldie in chronic pain management has been ‘your hurts won’t harm you’. Its easy to say, but effective use of this will require a lot of understanding about the science of chronic pain and how the pain constructed by the brain is usually not an indication of tissue damage but more the combined activation of memory, stress, motor, perceptual and other circuits in the brain all powerfully influenced by context. This is the main conceptual change story that Lorimer and I have tried to get over in ‘Explain Pain’. I picked up ‘I’m sore but I am safe’ on the prairies in Canada some years ago and it has become a favourite heuristic. A person in chronic pain who can analyse an evoked pain state and understand that although it hurts there is no tissue damage has undergone some deep learning.

‘If you keep backing away you’ll hit the wall’ can be useful for a person who is so fear avoidant that every pain or thought of activity alter function. But again, a person will need to understand something about the biological meaning of pain production.

Sayings attributed to celebrities can help but as long as the user can think past the celebrity. Michael Jordan said “I can live with failure, but I can’t live without trying” and Confucius says “A journey starts with a single step.” 

And let us finish with Pamela Anderson. I didn’t know she has this long multiple heuristic in her, but one of my students found it.

A little bit of pain is good for you. I feel alive. Everybody needs struggle. Once you overcome an obstacle, you springboard into the future. Life is interesting and short and it’s not supposed to be easy, and if it is, you’re probably just in denial and you’re existing here like a zombie.

Your Turn
So what heuristics do you use and avoid in the clinic and in life? What is you favourite and how do you power them up to achieve deep learning?

A prize of ‘Explain Pain to the best.

NOI Notes from last month: MIRROR NEURONES
Armfulls of thanks to all of the contributors for some stimulating thoughts! Readers took on the idea of emotional mirroring and how as an agent of change you need to stay level headed and positive and not get caught in patient spirals.

Many commented on the need to be more careful when demonstrating activity and exercise, and the importance of visualizing exercise, and after all, “the golfers have been doing it forever”. The “value” and meaning of observed activity will also be important. One writer suggested that we should perform the movement that hurt/hurts the patient in front of them.

There was one dear soul from LA who thought the monkey image was a touch erotic, but we put that down to LA!

We were reminded of a person who had a vasectomy getting pain when watching cricket and seeing someone hit in the testicles and another thought that mirror neurones could be responsible for your neck pain at night if you treat painful necks all day. Maybe.

It really does give a basic science empowerment to virtual reality and we had an interesting and personal letter about breathing patterns, reminding us that our mirror neurone activity will be unconscious and that our breathing style when we are with patients will be mirrored. It may be potent way to spread stress!

A writer touched on ‘free will’ ,the notion that premotor brain areas area are active 2 seconds before a motor output, something also known in pain, where somatosensory areas are active well  before pain is experienced. Mirror neurone activation may close this 2 second gap which may or may not be a good thing.

And how about  the witch story – I  never knew that “witches believe that all life is controlled by the mind”

A few readers picked up the role of mirror neurones in group therapies – some classes run well and some don’t. It just helps us understand  the level of success in classes and perhaps the need to pick group members with at least some commonalities.

“my mother and grand mother had arthritis so I was doomed” another readers reflects on a patient’s comments. She also added “of course – it is how babies learn”. 

And finally there was the suggestion that we may be able to develop  a questionnaire to assess mirror neurone activity and therefore enhance therapies. We are pondering this one now.

Congratulations June Trenholm from Canada – your story about working in groups and the implications of mirror neurones has won you a one year access to Recognise Online.
There was zero salivating at any ice cream stories though – we were seriously hoping for some more passion there!

You can read interesting responses here.

Mirror Neurones

December 7, 2010

Starting a wee
Just when we thought we were getting a hold on neurobiology and tricky things like central sensitisation, science produces mirror neurones. For 10 years or more we have been aware that approximately 25% of neurones in pre motor areas are mirror neurones, that is they fire when you watch or imagine an activity (25% that is a lot of neurones!). Some even act as predictive text, that is if the brain expects you to straighten your knee or turn right, the mirror neurones will set it up for you (Iacoboni and al. 2005).
It’s time to contemplate what this may be for rehabilitation practice. But first….why does water splashing seem to initiate urination, why are lip readers so fast, why can some sports stars read a game so well, why can group therapy be so effective, why does injury seem to spread though teams? Mirror neurones probably play a part.

Is pain contagious?
In Palma in Italy, in 1996, a monkey had some electrodes inserted into neurones in motor areas in its brain. These neurones fired when the monkey fed itself, i.e. hand to face activity. However, it was noticed that the same neurones fired when the monkey observed a person eating (legend has it that a person walked into the lab eating an icecream!). These neurones were called “mirror neurones” i.e. they reflected acts performed by another person (Gallese, Fadiga et al. 1996).

A similar situation occurs in humans. In conscious patients undergoing cingulotomy, cortical neurones responsive to noxious mechanical input (pin prick) have been noted firing when the person observed an experimenter pricking their finger. They will also fire if they think the person is about to prick their finger. (Hutchison, Davis et al. 1999)

These neurones also respond to sounds of an action such as splashing in the bowl and the sound of eating

Emotional mirror
If you watch someone vomiting you are likely to run a vomit in your own brain. There are emotional mirror neurones as well.

If you know that a person you love is in pain, then similar pain circuits in your brain will fire, much more than if the person in pain is unknown to you. (Singer, Seymour et al. 2006).

It is thought that dysfunctions in the emotional mirroring system may be a component of autism, perhaps related to empathy deficits due to failure of the mirror system

The suggestion is that these mirror neurones “encode templates for specific action” allowing basic motor procedures without thinking about them and comprehension of an act without thinking too hard, i.e. you can grasp what is going on because you are running the same action in your own brain. (Rizzolatti, Fogassi et al. 2006). 

So the sports star who can read the game brilliantly is actually running the opponents moves in his/her brain simultaneously; when you learn the guitar from Eric Clapton, your mirror neurones are beginning to play like Eric Clapton; the lip reader is perhaps almost entirely reliant on mirror neurones – instead of playing sounds back, its kind of playing movement back.

What do mirror neurones mean for clinical practice?
Its all a bit new. Help us out here. Here are my seven initial thoughts:
1.  The most obvious thing is not to hang around with idiots all the time

2.  If you are going to learn something like guitar, try and learn from the best

3. If you are demonstrating exercises, do it well and realise that the patient is actually “running a movie” of you doing the exercise in their brain

4. In the clinic, you can observe a person’s emotional state and form a cognitive assessment of it without feeling emotion. But sometimes the cognitive assessment will activate your emotional mirror system and you feel emotional as well ie the patient “gets you”. There are issues for your own health here.

5. If production and perception of motor action involves similar neruones in the brain, then it is quite understandable when a person says “it hurts when I think of moving.”

6. Working successfully in groups involves mirroring each other so humans perform complementary actions to achieve common goals.

7. These neurones are some of the targets of graded motor imagery (laterality recognition, motor imagery, mirror therapy). For those interested and also those currently using our “Recognise” laterality CD, we have just finished building an online streamed version of “Recognise™” including hands, feet, necks, shoulders and backs with video clips for hands to come.  Contact Tom for the codes for a free 2-week trial before the official release at the end of June.

Your turn
Sorry about the long NOI notes this month it ended up being quite a mouthful!

How do you think mirror neurones could be related to modern rehabilitation practice? Send in your most pressing thought to be in the winning for a full 6 months of unlimited access to “Recognise™” online.

And in honour of the discovery of mirror neurones tell us about your favourite ice-cream and why it is so! The most salivating answer will also win 6 months unlimited access to “Recognise™” online.

NOI notes from last month: FRED AND HALF A SHEEP

Thanks for the dozens of replies. Not everyone was fascinated by the sheep story, some wanted more science (yet the story of placebo remains a science issue up there with consciousness). The New Zealanders sent the story out to all their manual therapists (New Zealanders and sheep??) and the story was used in many therapy classes. But it is all about placebo something Pat Wall wrote about in 1992 “Placebo – an unpopular topic” (Pain 57:1-3).

Its still unpopular but the humour of some of the stories sent in suggests we are getting there. There were some toughen up and be brave stories, prescribing of B6 supplements, and the good old forget-to-turn-on-the-ultrasound-trick but the biggest congratulations goes to Janet Stevens from Great Britain who “…once told a farmer (like Fred) to continue wearing bailing twine around his waist for his low back pain because he believed it had worked for 30 years”!!! If it works – use it!

As for the gifts such as Fred’s half sheep, we are in awe here at NOI by the thought of a 6ft tall plastic apple tree and a bit weirded out by plastic cased kidney stones but the girls decided that definitely Sue Pritt had received the best gift whilst she was working in a private hospital in London a few years ago. The lady that she was seeing post THR noticed her shoes. Admittedly they were not flash as who has flash shoes when on your OE! The patient was horrified at how worn they were and asked if she had any others – Sue told her they were her only shoes apart from a pair of ‘flip flops’. The lovely woman gave her 1000 pounds to buy some ‘decent’ shoes. Sue had to take her the receipt for them to prove she spent the money on shoes! Man – you can get a lot of shoes for 1000 pounds!

Well done both of you – a set of shiny red posters are coming your way!
NOI is happy to announce the arrival of our new online streamed Recognise programme. It has been in development now for some months. We’ve taken on your feedback, resolved some issues from the CD version, and created new features only online can provide. This new online edition will provide a better Recognise experience as it doesn’t limit you to one computer, there are more tests available, it is quick and cost effective, everyone receives any upgrade all at once and you can choose to be involved in the front line research. As mentioned earlier, if you would like a 2-week sample of the programme, just send Tom an email and he’ll send you the access codes.

Gallese, V., L. Fadiga, et al. (1996). “Action recognition in the premotor cortex.” Brain 119: 593-609.

Hutchison, W. D., K. D. Davis, et al. (1999). “Pain-related neurons in the human cingulate cortex.” Nature Neuroscience 2: 403-405.

Iacoboni, B. and e. al. (2005). “Grasping the intentions of others with one’s own mirror system.” PLos Biology 3: 529-535.

Rizzolatti, G., L. Fogassi, et al. (2006). “Mirrors in the mind.” Scientific American 295: 30-37.

Singer, T., B. Seymour, et al. (2006). “Empathic neurall responses are modulated by the perceived fairness of others.” Nature 439: 466-469.

Fred & half a sheep

December 7, 2010

Meet Fred
Fred was a patient of mine. He was about 55 and came from the far north of South Australia and only came to the city once a year. He used to call in to see me for a bit of physio and he frequently brought a present – usually a piece of lamb, but occasionally a lump of beef that I am not really sure which part of the animal it came from.

Anyway, Fred used to say “the second and third are out in the neck, have been for a few months since I came off the motorbike; I reckon the L5 is out too and the hip might be going out too. Can you whack them back in. By the way, I have half a sheep in the truck for you. Mind you with the drought they are a bit dry, but you did say once that you liked mutton. And another thing – don’t give me any exercises, like you tried last year. I get too much bloody exercise on the place these days”.

Share my quandary
I take a breath and reflect….”but these days I am supposed to be evidence based and offer more self management, graded exercise and neuroscience education. I even wrote a book on what you are supposed to do. How did I get it so wrong with Fred? And what would my students be thinking now if they were watching this clinical encounter?”

Judge my therapy
I assessed Fred, I was interested in the motor bike accident so I checked him out as best I could for any contraindications to “whacking things back in”. There was a bit of stiffness in the upper neck and low back and I “whacked them back in” (grade 5 rotation for the lumbar spine, and lateral flexion grade 5 for the C2-3 joint or thereabouts). “Beautiful”, says Fred, jumping up and playing with his new neck movement. “Did you hear that neck go back in…still a bit out in the low back. Give it a bit more of a whack will you.” I did just that. Fred handed over the half a sheep, shook my hand and said “see you next year”.

What’s in a whack?
Was I wrong? I know that my therapy doesn’t follow any recent guidelines for chronic spinal pain and I know that the efficacy of manipulation is not that strong. I have got Fred addicted to me from years of successful annual treatment (at least I call it successful as I don’t know what might have gone on in the previous 12 months) and I have little chance of initiating an education and exercise based approach.

I don’t think anything goes out except fires and me on occasional Friday nights. Joints may get a bit stiff or rarely, locked, but that is about it. I am happy that I probably manipulated Fred’s perceptions as well as perhaps doing something to the joint structures. You could call it a placebo treatment but then again I am reminded by a Patrick Wall comment “In the end if many treatments are shown to be placebo, then we should work out what it was in the placebo that was the active ingredient.” There may have even been something helpful in the swapping of the sheep and the manipulative techniques.

Your turn
This month, four of the new shiny red NOI posters go to:
(a) The person who tells us of the most novel and interesting gift that a patient has given them.
(b) The person who tells us of their most novel placebo treatment and convincing rationale for it.

Email your response(s) to

The peripheral nerve stories from last month
Thankyou so much for your upper limb nerve injury stories from last month. There is clearly an endless number of ways to injure nerves. But there was also the realisation that people can have severe injury (eg Janet’s story of the patient whose whole arm was crushed to 3mm for two hours and they got away with a neurapraxia) and the nasty humeral fractures, yet with radial nerves spared – it makes you realize what a mechanically strong and resilient structure peripheral nerve is.

And what a sad story from Lyn – about a young mum working as a pole dancer and whose abusive boyfriend zapped her ulnar nerve with a cattle prod, eventually leading to an ulnar nerve problem and her falling off the pole ….and losing her job.

Thanks too for the descriptions of nerves and tendons hanging down like spaghetti after traumatic amputations (must be hand therapist contributors).

And Nic – who for the sake of science subjected himself to a sustained ULNT2 position for 15 minutes to see what would happen – well his shoulders went numb and he had burning pain in both arms for a week – thanks for this contribution to science Nic!

Nicola goes for the more exotic injuries – the water polo payer who put his hands in another player’s bathers to “restrain him” and ripped the FDP off and presumably the median nerve.

We have so many poets amongst our readers – the final two line of Deborah’s “loadaphone blues” about repetition strain injury from mobiles was:…

“the message on the screen read “text us”
Oh my poor brachial plexus”

This has a nice ring to it (sorry about that)

And other ways to injure nerves – serving ice cream cake (digital), leaning over the crib to sooth a crying baby (probably radial), untrained medical practitioners manipulating backs, strawberry picking and spider bites (median nerve), dancing and the femoral nerve, and tight caps and the occipital nerves.

We also have a “star wars” injury also. One of our valiant readers “Josh Obi Wan” sustained a radial sensory nerve injury following an epic battle with his 4 year old son “Anakin.” Read about this and therapeutic application of the neural force. Read the full story here…

And the winner comes from Canada!
Marie Ilowiecki from Alberta wins because she has described a previous unknown way to injure a nerve. So Marie, you’ve got a new NOI Mirror Box heading your way now – congratulations!

“One of my patients had a one sided true scapular winging after smoking dope and competing in a ‘who could sleep in the longest’ competition. He could not remember what position he slept in, how long he slept and he did not win the contest.”He obviously sustained a long thoracic nerve injury, in this case, probably from prolonged thoracic lateral flexion.

What’s new at NOI?
An international conference list which we’re maintaining as a resource for health professionals interested in relevant extended learning and participation.


A collection of short videos about some products from NOI. (No shoes!)


They’ll always be right here!

Now with a bright red look, these huge posters are A2 in size and come in a more sturdy, plasticoated finish.


All the squares have been kicked out of NOI! This triangular mirror box is easier to assemble, more durable and now comes with a larger mirror.

Peripheral Nerves

November 26, 2008

So many ways to injure a peripheral nerve – The upper limb

Traditional nerve injury classifications
Most clinicians would have learnt about grades of peripheral nerve injury ranging from the more minor neurapraxia, (conduction block with eventual reversal) to axonotmesis (axon severed, but connective tissues OK) and neurotmeses (neurones severed and connective tissue cut or badly scarred). These categories emerged post WW2 from the work of Sunderland and Seddon. Although we learned them, we rarely used them, unless perhaps you were working in peripheral nerve surgery. Sunderland and other peripheral nerve experts always talked about pre-neurapraxias (Sunderland called them perverted nerves). The pre-neurapraxis need a revisit.

A new look at nerve injury classification
Molecular biology has shown us that genetic and environmental forces combine to produce altered kinds and numbers of ion channels at mid axon sites along nerves, creating ectopic discharge – the basis of many syndromes such as carpal tunnel syndrome, tarsal tunnel syndrome and neurogenic tennis elbow. They may react to mechanical, temperature and emotional forces, but still not be picked up on a nerve conduction test. If Sunderland were alive today, I think he would be delighted to see his “perverted nerves” exposed.

A new view of peripheral nerve injury
Of course, nerves can be severely injured by traction, pinch and rubbing forces. The literature is full of exotic ways of injuring peripheral nerves, including grenade throwing practice (long thoracic), ‘love bites’ (accessory), handcuffs (radial sensory), cycling, taxi driving (ulnar), biceps exercise (musculocutaneous), injections (radial) and simple repetitive wrist flexion and extension (median). A whole range of familial and systemic states will also intervene. Some spider bites can be particularly mean on nerves too.

But a modern view is that it is not only the injuring movements which are critical, but the nerve owner’s responses and perceptions of the injury. Recent studies showing increased nerve adrenosensitivity (eg. more sensitive when stressed) and immunoreactivity (eg worse with the flu) with injury suggest the brain plays a big part in the clinical manifestations.

Your turn
Can you let us know a novel and exotic way of injuring an upper limb nerve, from your patient or personal experiences? This month’s prize to the most novel (and educational) nerve injury story is a new NOI Mirror Box!

Thanks for the beautiful poems on the anterior cingulate cortex from last month. The winner, Lorna Fox (NZ), sent us a lovely long poem, more of an ode really! – the first two paragraphs are here, but read the rest of the poem and the other anterior cingulate contributors.

Congratulations Lorna, a set of the New Explain Pain Posters are on their way over to you!

There’s a multi-use part of my brain,
involved in expressing my pain.
Examine my neck,
it’ll light up like heck,
and dim when distracted again.

My brain does this without thinking.
I guess it’s a little like blinking.
I wish I were dead,
I’m not swinging the lead,
I’m gonna go out and get drinking.

It’s actions are entirely unplanned…

NOI mirror box update
The mirror box has got a new slant to it! We recruited Pythagoras to help with the design and came up with a triangular mirror box that is sturdier, easier to set up, more durable and easier to post, while still using the same hygienic corflute material and quality perspex mirror. The original classic square box design still works well and some may prefer its more spacious box.

Mirror therapy forms a part of an evidence based graded motor imagery programme involving laterality recognition and motor imagery. It has become trendy recently, with claims for great successes in the literature. Lorimer Moseley’s recent article in Scientific American is a reminder that while initial results are encouraging, we need to be careful. Here at NOI, we would like to remind readers that the mirror is only a part of the management of complex pain states. Tailormade programmes, uses of other parts of the imagery programme, hard work, compliance, education and graded programmes are all a part of this exciting but embryonic therapy.


The amazing Anterior Cingulate

November 26, 2008

A trendy piece of the brain
A few centimetres above and in front of your ear and sitting on top and to the front of the corpus collosum is the anterior cingulate cortex (ACC). It’s a trendy piece of brain because it nearly always shows up as active in brain imaging studies, no matter what is being studied. Some examples are swallowing, pain, social interaction, stress, orgasm, problem solving, distraction, focused attention, doing “nothing”, obsessive compulsive disorder etc. etc. Remember that when “in action” the ACC could be inhibiting or activating and much action will be subconscious.

My best and bravest attempt of a summary of the function of the ACC would be…..a multiuse area of brain used when you need to work and sort things out, especially when you are really focusing on the task.

The clinical consequences
OK – so in comes a patient and you ask them to turn their head – it’s about one degree range all around, yet when they leave or dress, the head turns easily. Or they can’t bend forward during assessment (i.e. they are focussed on the movement and their brain is trying to work out what motor output to “show you”), yet they can bend over and put on their shoes.

Guilty bit
I admit that in the past I thought that there could have been a bit of “putting it on here” but an alternate view might be this hot little piece of brain (among many other parts) may be fired up when the focus is on a particular movement and “turned off” when the focused demand goes.

Use in management
Importantly, this variable finding means that the problem is real (as all pains are) and changeable. Distracted activities (ranging from “get a life” to “graded contextually variable activities”) are worthwhile, but maybe even more, the variable movements could be brought to the attention of the patient, the changeability emphasised and the patient told about this important piece of brain.

Sure – it is reductive, but the message should give hope….that there is a changeable brain and this small area called the anterior cingulate fires when you are stressed, focussed and panicky etc. and shuts off when you relax, work your problems out and distract should be good news to nearly all patients.

What about the scientists?
A brain scientist told me that sometimes ACC activity is not reported as it is a given that it will be in action. This multiuse is not surprising because it is linking area between cortical function and autonomic functions.

Those scientists still looking for dedicated functions for brain parts sometimes appear confused and the ACC is a good example of this.  Good recent writing for the more interested include Posner M et al (2007) The anterior cingulate gyrus and the mechanisms of self regulation. Cogn Affect Behav Neurosci 7: 391-5)

Explain Pain Posters
We’ve got the new look posters rolling out of here and they’re being approved by all! You can even watch David give his short, 5 minute perspective on the 4 posters which is great to see if you’re unsure about how they should be viewed or discussed and want to hear it straight from the horse’s mouth!

Last month’s carpal tunnel competition

Question – Why don’t pirates get carpal tunnel syndrome?
Thanks for all the answers, we enjoyed them all – plenty about answers about hooks and good aaaarrrghonomics and sharks and plank walking, healthy salt air, digging hands into the loot and lack of doctors and therapists to diagnose CTS and invulnerable brain cells die to all the treachery and pillaging.

Honorable mentions to:   “Parrots on shoulders modulating ascending afferent input”…… “They love their work therefore no need to grip the sword with excessive force”…. and “they drink rum, chase women and nerve glide the seven seas”

Dishonorable mentions to: “the warm poultice of parrot poop” ….and … misreading CTS for “Colorful Turd Syndrome”

And there was some nice poetry….

“There was a pirate Sparrow,
Whose sword was sharp and narrow,
Movements were swift
Pelvis did shift
And his trademark was like that of Zorro!”

And the more technical…

“Backhanded sword parlay reproduces median nerve glide: supination, wrist extension, elbow extension while rope swinging involves shoulder abduction, external rotation and elbow extension.”

Really interesting…

Did you also know that pirates wore a patch over one eye so that one eye was always dark adapted so that they could move the patch from one eye to the other when they moved from indoors (e.g., dark) to outdoors (e.g., light) and would not be temporarily blinded because their eyes were not dark adapted. A few second’s advantage could make the difference between life or death in a shipside battle!

But the winner is Ursula Crosby from the UK with..
“Pirates don’t get Carpal tunnel because they “swashbuckle” in a ZORRO like manner on a regular basis.( see page 47 of Neurodynamic techniques)”

and we couldn’t resist Hanna Lucas’ (Aus) answer either…
“Pirates don’t get CTS because they are really great ambidextrous sword fighters, they wear really cool shirts and never have to use a computer”.