Archive for the ‘2009’ Category

The conference and plasticity

December 9, 2010

Lumbarspinectomy
Here is a challenging thought – in most chronic back pains, if you were to do the radical and thankfully untried surgery of lumbarspinectomy i.e. cut the whole lumbar spine out, there would probably still be pain experienced in the hole that was left. Not recommended!

Neuroplasticity
It’s all about neuroplasticity, a terribly trendy topic due to tons of research and great books like Norman Doidge’s “The Brain that Changes itself”. Plasticity is a recurring theme throughout the NOI conference and it constitutes a true revolution requiring a paradigm shift in rehabilitation. We need to be a bit careful with this term plasticity – there is a lot of pop plasticity around on the net, there is a growing “brain fitness” industry and “is my brain made out of plastic?” is just another question all youngsters have to answer, whilst the oldies may be thinking “if my brain is so plastic as the scientists tell us then, why can’t I change my habits?”

The plastic revolution
Plasticity is a bit hard to define (like placebo and gene). But the essence is that plasticity is a change in the brain location for processing and constructing information.

As far as revolutions go in the world of biology, the brain mapping (plasticity) revolution is right up there with mapping of the human genome. Still – the impact of this knowledge is really yet to fully impress on some areas of rehabilitation and hard wired clinical conservatives may struggle or think ‘that’s interesting’ and go back to where they were. The revolution impinges on a number of areas – just like colouring in as a kid made you focus on the picture, all the new colour fMRI pictures of the brain demand a new awareness of the organ. The impacts are also on notions of a new changeability of sensory states, of new looks at once hard to alter states such as CRPS, post spinal cord injury pain, tinnitus and brachial plexus lesions, of liberation from outdated prognostic limits set by gurus and poor science, of how plasticity occurs right through the lifespan, and of just how distributed and how overlapping the neurosignatures related to function are in the brain which makes you realise just how set up the brain is to be plastic.

It all links so strongly to context, the thing that constructs rich representations in the brain and allows brain outputs such as love and anger and pain and performance to be so different in time and place. And so therapeutic too – for example the therapeutic power of doing an activity or even thinking of an activity in a different knowledge context comes down to neuroplasticity or in other words running neurosignatures in different ways.

Sticking with science and the impact on a conference
Plasticity permeates our teaching and the NOI conference.

Hailing from Heidelberg, Herta Flor is one of the most established and renowned researchers in this area and we are thrilled that she will be speaking on Day 1 on ‘Brain Plasticity – Friend or Foe’. Plasticity can become a friend – think of great responses post stroke, but a foe too – think of spasticity and chronic widespread pain. One reason we asked Herta is that on many of her papers, you will read “we cite animal and human studies and we derive suggestions for innovative interventions”. Elspeth McLachlan also talks of the immune system in peripheral and central systems and links the immune system to plasticity changes. Talks on the physical aspects of the nervous system (Michel Coppieters) inevitably touch on plasticity and link to Mick Thacker’s ‘Movement as Antigen’ talk. Many of the workshops have a central theme of plasticity such as the graded motor imagery workshops, the education workshops such as Adriaan Louw’s workshop on education changing post operation pain behaviours, Sam Steinfeld’s neurodynamics workshop plays with plasticity as do the lunchtime workshops on illusions where you can temporarily lose a limb.

In the Images of Pain and the Brain exhibition where noted English artist and printmaker Chris Gollon will be exhibiting – the curator Juliet Gore commented “he depicts hands as the most prominent part of his body – a homuncular clue which for me at least has the effect of wanting me to put my hands in the ink as well.” Though artworks are usually made without a brief and come from a ‘gut’ feeling their links to brain plasticity is perhaps undeniable, as this process often relies on happy accidents or going where the materials lead you – monotypes being one of the most notorious of processes for this as the ink on the plate or glass leads you to see new images and takes you to new places. Perhaps this is why Chris prefers not to talk about his work publicly.

Three weeks out from the NOI conference. It looks like we will have a full house but there are some places still available for the conference in Nottingham and for the master classes in Dublin. But be quick!

Stay plastic!

You are not your thoughts

December 8, 2010

…I’ve always enjoyed the music of Faithless and so it’s a great pleasure to have one of the band’s original members, Jamie Catto, come and open the NOI 2010 Conference in Nottingham and to share his thoughts on pain and music. In correspondence and in 1 Giant Leap Jamie talks about Ekhart Tolle and the notion of You Are Not Your Thoughts. This notion is worth a thought! I must have been the last person on the planet to read Tolle’s ‘The Power of Now’ and I think there is some really useful stuff in it, some links to modern neuroscience can be made although I admit to skipping over the more metaphysical parts.

Plenty of space for thought

One basic premise of Tolle’s writing is that our thoughts can consume us, make us make lists, keep us awake, focus attention on detail and unresolved issues. Thoughts can basically takes over and commandeer our brains. We have all had this experience, but it must be even more potent for those with unexplained pain or disease, especially with catastrophising. Yet you, the ‘self’, the ‘whatever’, are much more than this thought. Our ever changing brains with around 100 billion neurones, each with potential for 100,000 direct connections and an almost unlimited number of connections via gases and diffused neuromodulators, all tempered by around a trillion glial cells and a million activity gates on each neurone (give or take a few!) are capable of dealing with much much more than a dominating thought.

It might help to explore this idea with somebody in trouble (or tell yourself) that thoughts just take up a small part of your brain. You, the ‘self’ are much bigger than that. Explore with them the majesty of the brain. If you are bigger than your thoughts and can see this, you can probably deal with them. Try it next time a thought has you around the throat.

Hey, that’s me speaking!
Ever given a lecture or been raving on a bit and notice that you can distance yourself from the performance – you can hear yourself speaking and you are able to sit back and analyse yourself? It’s a bit scary and it may mean that you need to get out a bit more, but it’s also an indication that you, the ‘self’ can be dislocated from the thought.

The key conceptual changes
At NOI we are currently reviewing and arguing about what the five ‘big picture’ conceptual changes that a person in chronic pain would have to understand for the best outcome. Some are obvious such as “pain does not necessarily relate to injury or disease”. I am also pushing for “thoughts are real but you are not your thoughts”. More on this next year when we seek your views.

The conference and the art work
Four months until the NOI conference. If you plan to come book quickly as it is filling rapidly. A heavy duty speaker outline has gone up on the website and I have just seen the recent batch of awesome art submitted by pain sufferers for the “Pain and the Brain” art exhibition at the conference. The thoughts exposed by the art graphically reinforces that thoughts are very real and powerful, but somehow the art also suggests that the person who created it, by expressing it and voicing the thoughts, is much more than the thoughts that lead to the artwork.

Have a grrrreat Christmas break. We are really looking forward to seeing many of you next year.

Scary nerve stuff

December 8, 2010

Pinched nerves are everywhere
Google ‘pinched nerve’ and there will be about a million entries. The vast majority do not tell the full story and may make you worse if you think you have a pinched nerve.  ‘Pinched nerve’ is right up there with ‘heel spur’ and ‘degenerated disc’, maybe not quite as bad as the ‘obliterated thecal sac’, or ‘desiccated disc’, but it’s still pretty scary. The diagnosis itself usually needs more management than what is actually happening to the nerve.

Let’s go to the truth of ‘pinched nerves’ first.

The truth of pinched nerves

  1. When you look up at the stars you pinch nerves a bit. We do it all the time. They are designed to be pinched, squeezed, rubbed and wriggled. Most of the time, nerves love a good old workout.
  2. In autopsies, lots of dead people have been shown to have scuffed, squeezed, frayed, obviously pinched nerves, yet in life they may have never complained of pain (Neary and Ochoa 1975).
  3. It’s really hard to pinch and damage a nerve unless you take to the nerve with some pliers or there are some really significant arthritic changes in the spine, or you are the unfortunate victim of a nasty torture.
  4. And even when a nerve is injured (this takes quite a bit to do) it still may not hurt when physically handled or it may wait until you have the flu or are really stressed before it fires.
  5. Most of the time a person thinks they have a ‘pinched nerve’ it is usually a sensitive nerve, a non or minimally damaged nerve that moves quite well.

How do you treat a pinched nerve – talk, forget the pills and move.

Talk the nerve talk
First remember that you are usually treating a diagnosis, thus a concept, and conceptual change is the major therapy. The conceptual shift that you want is towards something like “OK it’s a bit sensitive but it will settle with a bit of brain and body de-stressing.

‘Pinch’ is a mean word. Do anything to me but don’t pinch me. A few years ago,  Michel Coppieters (Coppieters and Hodges 2008) showed that people move better when they think they are being tested for a muscle problem rather than a nerve – just the name – nerve compared to muscle. When you add ‘pinch’ to ‘nerve’ it has to be worse. So go through the truths above and put it into your own words.

Pills are not usually needed. There is a pill factory in your brain which should do the trick. Knowledge creates a flooding of happy hormones down the spinal cord. You can change the chemistry around the nerve by making it more physically healthy.

 

Move
No magic here. I am convinced that most undergraduate and postgraduate schools are no longer doing the science of neurodynamics justice (Coppieters and Butler D 2007). Get to a NOI course – watch for the new neurodynamics and neuromatrix courses coming near you. It’s easy to say get the nerves as physically healthy as possible and make sure the tissues around the nerve are as healthy as possible, but this can require special skills.

 

Nerve nips
OK – sometimes there is a ‘nerve nip’ (I quite like ‘nerve nip’ – much more friendly). I did focus too much on elongation in ‘Mobilisation of the Nervous System’ and there are occasions when a nerve can get nipped – most commonly the nerve root complex in the spine on extension (Spurling’s test) or the median nerve in the wrist on flexion (Phalen’s). ‘Nip pains’ may be sudden, even shocking, and if repeated may lead to fearful avoidance of the nipping movement. Management is the same…. remember it is nearly always a sensitive nerve not a damaged nerve.

Best of luck with your nips!

There will be heaps on nipped nerves at the rapidly filling Neurodynamics and Neuromatrix conference in Nottingham. There have been many research and clinical abstracts submitted such as the study by Takasaki et al which demonstrates the potential for nipping in the cervical spine from common activities of daily living. The workshops will include: Fine handling of the median nerve, Cranial nerve neurodynamics, and a workshop with Alan Hough, Andrew Dilley and Michel Coppieters on measurement of nerve movement.

Coppieters, M. W. and D. S. Butler (2007). “Do ‘sliders’ slide and ‘tensioners’ tension? An analysis of neuyrodynamic techniques and considerations regarding their applications.” Manual Therapy 13: 213-221.

Coppieters, M. W. and P. W. Hodges (2008). Beliefs about the pathobiological basis of pain alters pain perception in diagnostic clinical tests. IASP Conference, Glasgow.

Neary, D. and R. W. Ochoa (1975). “Sub-clinical entrapment neuropathy in man.” Journal of the Neurological Sciences 24: 283-298.

Movement as antigen

December 8, 2010

If you are involved in rehabilitation, the title of this newsletter should make you draw breath, stop and think. It’s also the title of a plenary lecture at NOI2010 in Nottingham by Dr Mick Thacker. Mick is a researcher, clinician, educationalist, international rugby player and dragonfly collector who started his PhD under the great Patrick Wall and finished it under the great Steve McMahon. I think his talk will have far reaching consequences.

Neurocentric to neuroimmune
Antigens are usually thought of as substances that stimulate immune responses. What is Mick Thacker all about? I interviewed him last week in his favourite coffee shop in London’s Borough Market.

Mick believes and knows that the traditional neurocentric view of pain, learning and performance is outdated without inclusion of the immune system. Neuroplastic activity and the responses of the acquired immune system have great overlap. I ask, “If pain is learning and learning is synaptic, then is pain an immune response in the brain?” Mick responds, “well it is, let’s not forget the nervous system, but the patterns and sequences of firing in synapses in cord and brain synapses are very strongly influenced by the acquired immune system. This is a glial response, producing cytokines and other immune associated molecules, essentially a sterile inflammatory response. In Mick’s view, much chronic pain could be conceptualised as an ‘inflammation in the brain’. Mick scoffed a chocolate truffle and I thought “this is right on the edge.”

The system that knows who you are
A definition of the immune system that I picked up from a Thacker lecture some years ago is “a system that can identify self”, or “a system that knows who you are”, and will respond when the self is challenged. The definitions inspire deep contemplation. This is easy to follow with infection – the innate immune system will respond and usually be a saviour. But there is a deeper issue here. I ask Mick, “what happens when a person’s self is challenged, perhaps with a loss of meaning in life, searching for meaning, or with the mass of demanding and invasive thoughts so characteristic of people with chronic pain?”
“Same thing”, he says. “The immune system will respond, synaptic activity will be influenced by the immune system.”

Movement as antigen?
“So Mick, tell me more about movement as antigen – that’s a bit novel”, I said with yet  another truffle devoured and he went on… “well motor synapses are immunosensitive too and there has to be a way we can influence them. It’s about applying the right amount of antigen, in this case movement. Too much input can make athletes and patients sick as we know, but graded and contextually variable movement (graded antigens) would provide beneficial immune responses. Take kinesiophobia – the fear of movement, I suggest that this is a immunosensitivity to movement, even an immune response to the thought of movement. I admit to thinking “holy shit!” at this stage. I thought of writers such as Eckhart Tolle who always emphasized the place of destructive thought and the need to separates our “self” from thoughts.

“So where do the pain literacy strategies that we use to decrease threat so effectively fit in?” Mick scoffs his fourth chocolate truffle and continues. “Aha, while strategies like Explain Pain were based on neurones and synapses, education is actually a stimuli (antigenic), like appropriate movement to providing more appropriate immune responses.” I thought with better knowledge of the immune system we can improve these strategies, not only from improved pharmacology – but including public education about the immune system and reinforcing the place of known immune healthy behaviours such as laughter, multiple coping strategies, exercise in management.

Time was running out. I ask, “If we injure our back, we know that there will be rapid immune responses which contribute to the inflammation?” Mick nods. “And we know that these responses will also be in the brain, perhaps in the form of a neuroimmune distortion of the back representation in the brain. So how does my back tell the brain area that it is in trouble?” Mick thought, lovingly fondling the last truffle on the plate and said, “Dave – we will discuss that and a lot more at the conference.”

It will be such a pleasure to welcome Mick Thacker in Nottingham – a true intellectual and humanist in the world of rehabilitation. I believe his work will permeate many of the scientific talks and presentations at the conference, including the art, music and poetry which will be an essential part of the NOI2010 conference experience.

PS Mick Thacker has recently lost 10kg in weight.

Last month’s notes on Hashish pain
Thanks for your stories of placebo response from last month’s notes on the Hashish view on Jaw Pain. Congratulations to Adam from the United States who has been sent a copy of Explain Pain. He wrote…

I had a retired psychology professor as a patient. He was very interested in hypnosis, which when you think about it, may be the placebo effect at full throttle. He told me the story of a dentist that would hypnotize a patient, then perform a tooth extraction or something that would normally be painful and require novacaine.

He claims to have witnessed a procedure where the patient had no pain and was even able to control the amount of bleeding throughout the procedure. This may be embellished, it may not. Regardless, those people that can be hypnotized can feel no pain just like someone who gets worked up into some sort of frenzied, adrenalized, or spiritual state.

The Hashish view on jaw pain

December 8, 2010

The Hashish view on jaw pain
Our group, like many, have pondered the meaning and place of placebo. Here are a couple of ‘golden oldie’ pieces of research that are worth a rethink.

In 1988, a remarkable experiment with results that clinicians who use electrotherapy should ponder (as well as those who don’t) was carried out by the Hashish group (true!).

The researchers set different levels of ultrasound intensity to see what was best for pain and jaw stiffness after extraction of wisdom teeth. The patient and therapist were blinded to the level of ultrasound intensity. There were benefits for all intensities and remarkably (then!) the best was when the machine was turned off. If the patients used the ultrasound on themselves there was no effect. It had to be a clinician doing it. Note also that the beneficial results were not only pain reduction but in jaw stiffness and swelling. Thoughts can change stiffness?

Ultrabullshit?
I have often been in trouble for using the above word; an electrotherapy distributor once boycotted a national physiotherapy conference when they heard I was to be a keynote speaker. But clearly, in these cases it was not what came out of the ultrasound transducer head that had an effect, but belief, enhanced by therapeutic interaction. The message is if the patient believes it will work, then use it if it is safe, but use the opportunity to introduce more evidence based tools.

Sham heart surgery
Fifty years ago, the now ethically impossible Cobb and Dimond studies (1959, NEJM 20:1115) revealed that sham internal mammary artery ligation, a common operation then for angina worked as well as actual ligation of the artery. This operation was done to supposedly shift blood from the pectoral muscles to the heart. The improvements were in walking distance, consumption of drugs and even ECGs with some improvements maintained at 6 months. A thought can have significant physiological effects at 6 months?

These two stories were often told by Pat Wall of gate control fame, who wrote very eloquently about placebo. Wall died 8 years ago – remarkable in itself as it still seems as though he is with us. Pat made a comment on placebo, something like this:

“if it shows that a particular treatment which works is actually a placebo, do not despair, but seek what it was in the placebo that made the person better”

(I can’t find the actual quote, but I am sure that was pretty close).

These days as we take Wall’s work further with pain definitions along the lines proposed by Moseley (2003, Manual Therapy 8:130-140) of pain as a brain event constructed more by perceived threat than actual tissue damage, placebo makes a little more sense. And if we add this to notions of pain as an output of the brain not dissimilar to motor, inflammatory, sympathetic and other outputs, the reduction in jaw stiffness and changes in ECG have a paradigm to fit into. Don’t hang up your ultrasound just yet!

At the NOI2010 conference in Nottingham as we merge neurodynamics with the neuromatrix, there will be plenty of brain stories. And you can be sure that the wonderful placebo will raise its head many times.

Your turn
Send in your best story of a placebo response  (inadvertent or not) in the clinic for a chance to take home a copy of ‘Explain Pain.’

Last month’s notes on neurodynamic research
Thankyou for all the research suggestions. They have been noted and we do have quite an army of undergraduate students looking for research projects. There were suggestions for asessing the role of neurodynmaics in multiple sclerosis (never previouly attempted), the role of neurodynamics in exertional compartment syndrome in the leg (a big problem in the defence forces), the possibility of identifying early laterality problems in wrist fractures, a call for shared data amongst small pain clinics, the need for measuring how other health professions view neurodynamics and a call to measure and therefore create awareness of the importance of therapists beliefs and values in therapeutic outcomes.

It is extremely hard to select one – they’re all valuable and need doing. We simply picked the winner out of a hat and the winner is Jon from Australia with his curious thoughts on the role of neurodynamics in patients with exertional compartment syndrome in the leg. Congratulations, you will be sent a copy of The Sensitive Nervous System.

Neurodynamics and neuroscience

December 8, 2010

 ‘The tiger by the tail’
I recall that over 20 years ago, one of my old lecturers at The University of Queensland said, “putting the nervous system into manual therapy – you will have a tiger by the tail.”  I didn’t quite understand it then, but I know the neurodynamics tiger has been pulling in many directions ever since.

Meet Michel Coppieters and his team
Many of our readers will have heard of Dr Michel Coppieters – clinician, educator and the world’s leading researcher in the area of neurodynamics. That’s him in the red t-shirt. Michel, and several members of his neuropathic pain research team at The University of Queensland (Bob Nee and Nina Schmid) will be presenting at the NOI 2010 Neurodynamics and The Neuromatrix conference in Nottingham. Michel will present a plenary lecture, be a part of a median nerve hands on workshop and a workshop on measuring nerve movement.

His research team conducts both clinical and basic science experiments. The basic science experiments aim to better understand the implications of peripheral nerve pathology on the peripheral and central nervous system. The clinical studies aim to optimise the diagnosis and treatment of patients with peripheral nerve entrapments. You can check out Michel’s long list of research publications at noigroup.com. Among the most well read by clinicians are the research articles supporting notions of structural differentiation, for example, and the popular sliders and tensioners article.

The big challenge for neurodynamics
Whilst it would be easy to leave neurodynamics in the world of biomechanics and metaphysics as most educators do, this would be short changing a remarkable concept. It has to be put into a bigger picture. While there will be chances for hands on techniques, a much bigger and more controversial picture will be presented at NOI 2010 in Nottingham. For example, these issues will be raised:

  • If a person has a positive neurodynamic test, it is likely that the brain representation of that part and that movement in the neuromatrix will have altered. What do we do about it?
  • A positive neurodynamic test may be due to stress related chemicals creating sensitivity and inflammation in the nervous system. What do we do about this?
  • It is quite possible, with skilled interaction and education, that the sensitivity in neurones can be altered. While touch and skilled movement are important, there are other linked ways to improve movement and function.
  • Can we see nerves moving with imaging techniques and how can we measure the movement?

Hope to see you in Nottingham. Bring plenty of neurones. It’s going to be right ‘out there’.

Your turn
NOI likes to help with research projects. Send in your best idea for a neurodynamics research project for the chance to win a copy of The Sensitive Nervous System.

Mirror box therapy
If you want to know more about it, watch, listen and learn as David Butler runs you through a brief but thorough 7 minute talk on mirror box therapy. From box construction to neuroscience to techniques and related therapy – he’ll try to answer all of your questions.

 

Images of pain and the brain

December 8, 2010

Images of pain and the brain
Pain has always been the most powerful inspiration for creativity, and it’s not hard to think of famous examples that prove this point. For example, Frida Khalo, throughout her entire life, painted about her tram car accident and its disastrous effects on her health and life and Gustav Mahler wrote that his music must have surely been influenced by his poor health.

The brain and mind have also been the source of much artistic creativity over the years, often linked to pain and feelings and attempts to describe how it all works. Neuroscience is now providing its own art with the multicoloured brain images now in many journals.

As part of the Neurodynamics and the Neuromatrix conference in April 2010, Images of Pain and the Brain will represent many aspects of these creative and unique personal explorations of pain and the brain – in the form of paintings or other 2 or 3 dimensional artworks like photography, sculpture, movement or even music.

Electronic PowerPoint displays are planned, as well as an exhibit depicting some of the creative outpourings of those who have been somehow effected by pain, or inspired by the workings of the brain.

Can you help?
We want to involve people in pain, clinicians and their colleagues in this challenge. We know that most clinicians out there at the ‘coal face’ will have patients who paint or draw or who write songs or dance in relation to their pain experience. We know that there are many people who are attempting to represent the brain and mind in various artistic forms.

If you are in pain and express your pain somehow through art it would be great to receive your contribution.

If you are a clinician, look out for some of these people among your patients and let them know about this opportunity. They come in many guises:

Some pain sufferers want to forget their pain, so they paint about other things. People make art or music as a coping mechanism – creativity can distract from pain, can sometimes desensitise a part or objectify what they are feeling.

The creative process can also provide a portal for feelings, a medium to communicate to others so the artist doesn’t feel so alone in their pain. Pain is a lonely thing and isolation is just one of the potential bedfellows of the pain sufferer. Fears and disability help to create walls between sufferers and their friends, life aspirations and meaningful involvement in the wider community. Art may be the only way of expressing this.

The first Images of Pain was an exhibition that ran as part of the ‘Moving in on Pain’ conference in Adelaide, 1995. It was a similar concept and some amazing stories emerged as the exhibition took on a life of its own. One such poignant story illustrated the artist’s isolation, loneliness and anger beautifully.

John’s story
John (I’m not using real names here) had suffered Non Hodgkins Lymphoma when he was 14, and was isolated from the world, his friends and school activities for several months. During this time he began to paint about his isolation and loneliness and his paintings reflected this in empty landscapes and buildings, all completely devoid of life. His parents decided not to tell him his diagnosis, so it wasn’t until long after his recovery when he went for a medical exam for a job in his late twenties that he was told by a doctor. He continued to paint, and became increasingly isolated and angry with his family. At the exhibition his family came and for the first time read and understood his story next to the paintings and they came together and spoke about the illness for the first time.

This story also illustrates the power of creativity – how it can present even the artist with surprising insights that they might not be aware of, nor want to face.

Debbie’s story
Debbie, a sculptor had created an installation where she made a pile of bones in the bush and set fire to them and this was displayed on a banner in Images of Pain. She said she felt empowered by this experience and it made her feel released from the grip of her pain.

Irene’s example
“It is 2am. I had a migraine yesterday and had to have two injections, one of dihydrogot and one of phenergon which made me feel as though I had an electrical charge running through my body, which in turn made me feel rather unable to sleep although I was very tired. I feel it was the phenergon that made me feel this way as I had not had the drug before. This drug also made me extremely thirsty.”

Art, empowerment and neuroscience
The act of painting about a pain or a feeling may give the artist a more complete understanding of it, and it may allow them to feel more in control over it. Putting words or a face to pain can externalise it in a way that potentially enables you to look it in the eye and come to grips with the demons it brings with it, and to actually play with the endings or outcomes in an external space.

In a neuroscience sense, the act of creating material associated with a painful problem requires a representation of the pain and the materials to be activated in the brain – a high energy synaptic activation involving many parts of the brain.  However, the use of art material provides a powerful contextual variation to the brain activity, thus allowing the brain activity to occur without a conscious appreciation of the pain. It essentially exercises the pain associated neurones in the brain in a very healthy way.

 

Last month’s notes on the problem sprained ankle
Thanks to all of you who sent in some great stories last month. They were so numerous and well written that once again we couldn’t choose a winner between Penny from the UK and Roderick from the US. So congratulations – you have both been sent a Neurodynamics Pack. Here is Penny’s scenario….


Patient: 10 year old girl with a history of 2-3 years of left ankle pain. She complained of it continuously “turning” and swellling with pain. Her response was to protect it and rest it for a few days. A pattern was thus established of her behaviour around pain. She is a very active young lady and loves all sports plus ballet.

She did not complain of any other painful joints. She had become increasingly frustrated about her problem and the ankle pain had begun to effect her level of activity. The mother had not been given any appropriate advice on management apart from RICE. She was now turning her foot several times a day…

Continue to read Penny’s, Roderick’s and many other fascinating, simple neural mobilisation stories.

The art of the sprained ankle

December 8, 2010

The art of the problem sprained ankle
A common clinical presentation is a patient with a 3 month (or thereabouts) history of an inversion ankle sprain, with persisting symptoms of pain and swelling and reports of altered function. We think it is so common, that in many cases it is not even clinical – i.e. that person has not bothered to turn into a patient. Using the world of clinical experience, backed by some neuroscience, here is how to help the patient or person fix most of these problems.

The problem ankle findings
On the problem foot, there may be a slight range limitation and symptoms evoked on plantar flexion and inversion. ‘Giving way’ is common. The ankle probably still has some pitting oedema. On the neurodynamic test for the fibular (peroneal) nerve (ankle plantar flexion and inversion plus SLR) symptoms are typically worsened with pains and pullings along the peroneal tract at around 40 degrees. Frequently, there are limitations in the tests of sural (dorsiflexion and inversion and SLR) and the tibial (dorsiflexion and eversion plus SLR). On the other ‘good’ side, symptoms are much less and the range considerably higher.

How to fix – five key points
These ankles are easy to manage and are very appropriate for self management.

1. Tell the ankle owner (AO) and anyone else interested, what is probably happening. That a peripheral nerve is a bit irritated and sticky in the swelling and maybe it has had a slight sprain as well. That an ankle sprain is no insignificant event and a bit of swelling and pain is normal as the brain tries to fix the final few problems. Tell them there are little sensors in nerves and they report the chemicals, the pulls and pressures and even stress and temperature. These calm down when the brain is satisfied that the ankle is OK. Tell them that the whole central nervous system is aware of the ankle and keeping an eye on it and that’s why all ankle movement may hurt a bit. But make sure they know its all good and normal and a part of the healing process in a healthy individual. In fact they should be proud of their nervous system for looking after them, but it needs a bit of advice. Check and tell them the ankle is stable but sensitive.

2. Tease and wriggle the peroneal and other appropriate nerves. Find three or four ways to wriggle the nerves, for example, the technique shown below (easy to do actively) or others in ‘The Sensitive Nervous System’ or the “DVD handbook”. Wriggle in and out of some discomfort as long as the ankle owner knows that it is a good pain – maybe 6 times a day with 20 or so mobilizations until you come to an ideal baseline. It won’t need much.

3. Keep up the graded proprioceptive input. Wobble boards are OK but we don’t use wobble boards in everyday life. Walk on uneven surfaces, rocks etc. Let the ankle reconstruct its role in the brain by reducing fear of use.

4. Most ankles will improve in a few days with range restored in perhaps 2 weeks or less. Much of it can be done actively. Wriggle it into a little bit of pain if the owner understands that it is an OK pain. The ultimate ankle technique will be to take up the ankle movements first, then SLR and then wriggle the ankle.

5. But the brain won’t forget. These are novel movements superimposed on a disturbing injury. It is likely, even normal, that there will be a response of increased pain, even some swelling and perhaps disturbed sleep during the treatments. Movement improvements will usually still be obvious. No panicking please– tell the AO that it is normal, its the brain checking out what is happening and probably creating a bit of a response to seek more input and knowledge on which to base actions. And at the ankle itself there is a bit of excitement with the refreshment of new tissue movement as the sensors adjust. It’s all good – these ‘flare-ups’ will only last a day or so.

Your turn
Send us your clinical experiences of simple neural mobilisation rapidly helping a problem such as the persistent ankle. A Neurodynamics pack will be sent to the person with the best answer.

Graded motor imagery 101
Take a crash course in Graded Motor Imagery by watching and listening to David Butler give a 40 minute presentation at the recent Denmark Fysioterapeuten Conference. It’s a very valuable resource for clinicians and also particularly beneficial for patients who can develop an understanding about what their rehabilitation process is based upon.

Comprehensive one-day Graded Motor Imagery courses are now available in the United Kingdom.

NOI goes to Brazil
With a rockstar reception and a constant shake of his hips, David Butler has been teaching Mobilisation of the Nervous System and Explain Pain courses in São Paulo, Brazil as NOI released the Explicando A Dor book (Explain Pain) for the Portuguese speakers.

Adrenaline junkie nerves

December 7, 2010

Peripheral nerves are not like the cord on the telly
Many people (professionals and the public) think that a peripheral nerve is a connector, a reporter of the senses to the central nervous system and the electricity conduit to the muscles, sort of like the cord on the television set. They are wrong. A typical peripheral nerve could have 100,000 fibres in it, each fibre may have a million ion channels embedded along it, all reactive to various stimuli. And paradoxically, when a nerve is damaged or cut, it doesn’t shut down, but can react violently leading to chronic pain states. In particular, neurones may become reactive to adrenaline.

This adrenoreactivity and the power of neuroplasticity in the peripheral nervous system was emphasised in a remarkable study in 1993 by Elspeth McLachlan et al, published in Nature.


Plastic adrenoreative nerves
McLachlan et al. reported that in rats with a ligation of the sciatic nerve , noradrenaline reactive neurones would sprout into dorsal root ganglion and form ”baskets” around large diameter sensory neurones which would then be fired by sympathetic stimulation, essentially stress. It is known that neural sprouting will occur into denervated tissues, but this is an aggressive sprouting into intact nerve fibres, creating new synapses. The sprouting was noted within a few weeks but was also noted 10 weeks after the ligation, suggesting that it is an ongoing process. Even the contralateral dorsal root ganglion had increased sprouting.

 So what could it mean?
The same processes that occur in rats will most likely occur in us. Our nervous systems are similar and although we don’t usually tie ligatures around our peripheral nerves, we squeeze them, stretch them and dribble noxious chemicals on them. While the reactivity of peripheral nerves was known before this paper, this research shows the clear power of peripheral nerve plasticity and when linked to knowledge of central sensitivity it becomes obvious that these DRG changes have a great potential to upregulate the central nervous system. If a person has a highly adrenoreactive area of peripheral nerve and if they are in a state of persistent elevated stress then repeated firing into the CNS will occur. And if the person is stressed, central inhibitory controls will probably be lifted anyway and a persistent neuropathic pain state may ensue.

We presume that as a defense, when stressed by persistent  injury, ligatures, pain and all sorts of contexts, that it makes sense for us to make ourselves as sensitive as possible, and what better way than to have a nervous system which can be reactive to stressors. Nerves probably become adrenoreactive before the remarkable invasion by neurones, and readers who perform physical tests on nerves may reflect on findings, that stress will influence the range of SLR (McCracken, Gross et al. 1993)

Most readers do not have access to exogenous drugs, we try and access the remarkable endogenous drug cabinet in the brain. We entertain the hypothesis that anything which can dethreaten the situation will have the potential to limit the nervous system’s need to heighten its sensitivity. This could involve reduction of nociception, provision of dethreatening knowledge and alteration of personal contexts. It means that the receptionist who greets your patients and says goodbye to them may have a powerful role in reducing the sensitivity of peripheral nerves.

Readings
Mclachlan EM, Janig W, Devor, M, Michaelis M. 1993 Peripheral nerve injury triggers noradrenergic sprouting within dorsal root ganglia. Nature 363: 543-546

McCracken, L. M., R. T. Gross, et al. (1993). “Prediction of pain in patients with chronic low back pain: effects of inaccurate prediction and pain-related anxiety.” Behaviour Research and Therapy.

Your turn
This month’s prize of an Explain Pain book authored by David Butler and Lorimer Moseley goes to the person with the best story of the power of a receptionist in de-threatening a pain state.

Last month’s notes on ‘Freud’s tingling thighs’
Thank you for your overwhelming response! Freud would have had a great time analysing you all. It was very difficult to choose a winner so congratulations to Hannah Lucas, a copy of The Sensitive Nervous System is heading your way! Click here to see the shortlisted poems and here is the winner;

Oh me oh my
my tingling thigh
The plural, meralgia paraestheticae
Alas alac it’s not my back
My lateral femoral cutaneous is trapped
My loin, my groin,
It needs some rest
Or best
A rub to my anterior superior iliac crest.

Hanna Lucas

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Wir hoffen, es gefällt Ihnen. http://de.noigroup.com

 

Freud’s tingling thighs

December 7, 2010

Where do Freud’s thighs fit in?
Sigmund Freud was diagnosed with a meralgia paraesthetica (MP) and hence the link. MP, the well described ‘entrapment’ of the lateral femoral cutaneous nerve of the thigh (see the image below) was one of the first described nerve entrapments back in 1878 by Bernhardt. We can learn a lot about the behavior of a peripheral nerve problem from MP.

Back to Freud’s thighs… his self observations in 1895 were translated by Schiller. At the time of writing he had a MP, occasionally bilateral, for 7 years in a zone similar to the image. Freud complained of a ‘furry sensation” and ‘alien skin’. He also mentioned that the rubbing of his undies caused a ‘disagreeable sensation’ and that if he ‘pinched the skin on the painful side it was worse than on the other’. It is tempting to suggest that Freud may have had a bit of central sensitisation as well (allodynia, long duration, bilateral sensations, more cold reactive than heat). It feels quite strange trying to diagnose a problem in Sigmund Freud!

What causes Meralgia Paraesthetica?
Up to 100 causes have been suggested, so it is best to keep it to a case by case discussion. The usual problems which contribute to peripheral neurogenic troubles such as diabetes, thyroidism, alcoholism, are in the literature, but problems in this nerve are likely to have mechanical contributions as well. It emerges from L2-3, travels around the iliac crest and then contends with the inguinal ligament a few centimeters below the anterior superior iliac spine. Here it can turn nearly 90 degrees to enter the fascial planes of the thigh (Mumenthaler and Schliack 1991).

Diagnosis of Meralgia Paraesthetica
The nerve is purely sensory, so there should be no motor changes, such as the reflex changes or weakness in the hip flexors and knee extensors which may be characteristic of a root lesion. (Freud checked this out as well). These days, with our new knowledge of injury to peripheral nerves (Nee and Butler 2006) a term such as ‘entrapment’ may not be that helpful. The nerve may not be stuck, but still sensitized anywhere along its pathway. Symptoms may not necessarily be in the entire zone, but be ‘zings and zaps’ in part of the zone, especially when the hip is in extension.

What do you do for it?
There are no large clinical trials on the management of Meralgia Paraesthetia, but the syndrome needs a good application of modern neurobiology and neurodynamics to provide ideal management. The advice in the literature is usually to leave it, or if bad enough, attempt surgery. Education and appropriate movement rarely get a mention in the literature where the advice is usually to wait or try surgery.

Education should help
This must be a worrying syndrome. Everyone thinks of the horrible neural diseases with a few tingles and groin area pain may be a bit more worrying than most. Freud has three patients with MP describing them as “healthy anxious people who consulted me for the very reason that they were taking the harmless affection for something grave”. Threat reducing education could include “this should go, we understand it, it’s not a serious disease, informing that anxiety can excite the nerve, and there are things you can do for it yourself.” Get rid of the term “entrapment”. It’s scary! An “excited nerve” may be more relevant to many cases. A good examination as Freud did, is also helpful to reduce anxiety.

Secondly, get moving
All the sitting that people do these days, bunching up the front of the hip – the nerve probably just needs a good airing in many people. How long has it been since your hips have been in extension? The test for the nerve is hip extension, adduction, knee flexion (Butler 2000). This is not new. Mumenthaler and Schliack described a similar test in 1991.

Thirdly…
Some targeted manual therapy to structures around the nerve. Sites of ectopic (mid-axon) discharge could be anywhere along the nerve. Known candidates could be within the psoas, thigh fascial structures, where the nerve exits just medial to the anterior superior iliac crest and where the nerve has its origins at L2-3.  Removal of tight belts, some weight loss and the completion of pregnancy may help in some cases. Most writers agree that surgery should be the last resort. 

Readings
Butler, D. S. (2000). The Sensitive Nervous System. Adelaide, Noigroup.
Mumenthaler, M. and H. Schliack (1991). Peripheral Nerve Lesions. New York, Thieme.
Nee, R. J. and D. Butler, S. (2006). “Management of peripheral neuropathic pain: integrating neurobiology, neurodynamics and clinical evidence.” Physical Therapy in Sport 7: 36-49.

Your turn
In the name of tingling thighs, we want to give away a copy of The Sensitive Nervous System to the one who sends in the best poem on Freud’s tingling thighs.

Last month’s notes on being individual
We had two favourite contributors from last months newsletter on individualised assessment and treatment. Thanks Manuel and Helen – you will both receive a Graded Motor Imagery pack.

Read Manuel and Helen’s stories here…

Sprechen sie deutsch?
Falls sie zu dieser Kategorie gehören, schauen Sie sich doch die neue deutschsprachige Website der NOI Gruppe an! Darauf finden Sie den aktuellsten Newsletter, die Details zu den NOI Kursen, Sie können mehr erfahren über die Deutsche Instruktorengruppe und auch über NOI Produkte- und das alles auf Deutsch!

Wir hoffen, es gefällt Ihnen. http://de.noigroup.com The electricity we felt after recently meeting up with the dynamic UK team is enormous! They are highly motivated and are probably running a course near you.

NOI erupts in the UK
If you want to buy NOI products in the UK, you can. This price list includes VAT and postage and handling within the UK – don’t pay Aussie prices if you don’t have to!