Archive for the ‘2011’ Category

Brain gifts for Christmas

December 15, 2011
I was thinking about gifts and was reminded about a public lecture I heard in Oxford by Sir Paul Nurse, a Nobel Laureate. It was called ‘Great Ideas in Biology’ (here is a similar talk). Nurse talked passionately about great ideas such as the cell – the simplest unit exhibiting the characteristics of life, the gene – the basis of who we are, evolution by natural selection and ideas of bringing it all together – a notion which we would perhaps put under the heading of the neuromatrix.But these are more than ideas – these are gifts from science and in particular from the world of neurobiology. And the gifts keep rolling in. We often say “we know more about how the brain works, and how pain is made in the last 10 years than in the thousand years before.” The gifts of knowledge include:

  • Mirror neurones – neurones which fire when watching, and imagining activity.
  • The remarkable role of glial cells in the cord and brain making us ponder that pain is a sort of immune inspired, sterile, inflammation in the brain.
  • The astonishing brain plasticity that we kind of thought was there but had no idea of its magnitude.
  • The daily arrival of new neurones in our brain, also in the elderly (neurogenesis).

And it goes on and on. My favourite gift was always the synapse – a delicious knowledge gift only 100 years or so old.

Power-up these knowledge gifts
If you take the gifts, but also take some time to think, chat with a few mates and maybe open a shiraz or cabernet, then these basic science gifts will power another level of gift – neurophilosophy and paradigm shifts. Examples like the brain as a neuroimmune organ, mirror neurones underlying a universal consciousness as we feel what others feel (empathy), a neuroscience powered-up, biopsychosocial approach and the neuromatrix as a critical paradigm to engage the neuroplasticity gifts.

And the gifts are special – nothing is asked in return, but my feeling is that the rehab community can always do more to take and reshape the gifts in the form of therapy for those who need it.

I do still want brightly coloured socks and a new fishing rod though! Happy Christmas all, David

Come along to share NOI’s 21 years!
Noigroup.com is now 20 years old – we’ll be back next year and for those making the trip to the NOI 2012 conference there will be heaps of knowledge gifts for you – check the programme!

Links
Paul Nurse ‘Great Ideas of Biology’ Lecture [1 hr separated into chapters]
NOI 2012 Conference Programme [initial release, Dec 2011]
Keep healthy, keep moving! A great short factanimation
A PT petition you should probably sign

 

Health workers can save the planet

November 3, 2011

Health workers can save the planet!!
Most of the public consider that health costs are a necessary financial drag on society and few health workers pause to consider their job as an economic driver or an invention which may be critical to the continuation of a way of life. Health as an economic driver in the format of labour markets, insurance and building new hospitals is quite obvious (imagine the unemployment if there were no health care jobs), but something deeper beckons if health workers are to be saviours of the planet…read on if you wish – it’s time for a slightly heavy noinotes!!

Waves of economic activity – meet Nikolai Kondratieff
It is quite obvious in society, especially capitalist societies, that economic activity and prosperity often go in waves – the 10-12 year waves are most obvious, though many people in Europe and America are looking anxiously for the next wave! Other waves of economic activity have been described. Nikolai Kondratieff (Russian of course) proposed 60 year cycles of economic activity focussing on a particular invention which has led to enhanced productivity. Note the six waves of inventions in figure 1. Note also that the invention which underpins the current 6th Kondratieff wave is suggested as health and in particular biotechnologies and psychosocial health. The 5th Kondratieff was information technology. While the impact of IT is still strong, it is dwindling, at least in the West, where most people have access to a computer. Although, various estimates suggest that only 10% of the world population have access to a computer.


Image adapted from http://kondratieff.net/11.html
Health as economic driver?
Health as invention or economic driver may seem a bit odd. It is not really tangible like railways and steel which underpinned the 2nd Kondratieff wave. A good example of advances in biotechnologies includes the recent major steps towards a vaccine for malaria but it is the psychosocial health (perhaps it should be rephrased as biopsychosocial health) which is of interest here. Psychosocial health in regard to the 6th Kondratieff involves “attempts to better understand and tap into humans’ internal information processes, and the wide field of mental and social potentials” with the suggestion that future successful economies and companies will rely on the health of their people and the health of the public health system as a whole – spiritually, bodily, socially, ecologically and mentally. [1] Wow! All this suggests, supports and encourages a powerful information medicine.

You have to think a bit laterally here to grasp it. Those of us who were not born with computers had to think in a different more systematic way to manage computers, but we seemed to manage. It will require quite a shift (eg resources to appropriate education, fair distribution of societal wealth) to access the untouched reserve of human mental potential to restructure a health care system into one where repairing disease continues but the focus is on health. This “information medicine” must be powerful.

The 6th Kondratieff, information medicine and the power of biology
We believe that the information medicine underpinning the 6th Kondratieff will emerge mainly from neurobiology and in particular recent neuroimmune science. For example, here is a pathway of knowledge that has only been available in the last decade… We know that altered use and pain experienced in a body part will lead to changes in the representation of that part in the brain. We know that this is a neuroimmune event most likely related to the activation of groups of glial cells which are essentially immune organs. We know that the immune system is, as Mick Thacker states, is “a system which can identify self from non self”, i.e. it is a system that “knows who you are and will respond when you are not you”. Responses could be fighting infection or altering the way the body is in the brain. However “you are not you” is not only a state which exists with a disease or injury, it also exists when you are socially dislocated, feel meaningless, have pain that you don’t understand or don’t have the means (cognitive, knowledge, finances etc) to even begin self-management of a problem. You “may not be you” if you are in a society yet to deal with ageism, racism, sexism and every other “ism”. There must be neuroimmune effects leading to pain, disease and altered cognitions and emotions, all of which we now know that the immune system has a hand in [2].

Isn’t it a bit too capitalist?
My dear friend Mick Thacker, responsible for much of the neuroimmune mutterings above (and who now owns a stuffed badger) suggested a danger with the “health invention” falling into the hands of the capitalists, and he may be right. Growth theories don’t appeal to everyone and well-being is not necessarily related to economic productivity and dollars. Nikolai Kondratieff certainly fell out with the Trotskyites in Moscow and he ended his days cooling his heels in a Siberian labour camp. But notions of linking a person’s existing mental and spiritual powers to information medicine have great links to the health literacy movement, and you would hope that an awakening of these powers would limit misuse.

Some recent projects in Scotland have links to the 6th Kondratieff. (Scottish politics are usually left of the English) Here, the Chief Medical Officer [3] has launched an Assets Alliance for Scotland – health assets being any factor or resource which maintains the ability to sustain and maintain health and well-being. One of the greatest health assets is the still untapped productivity that we all have as part of our mental/spiritual/psychological makeup. Knowledge is the key to unlocking it and thus there are enormous links to the information medicine underpinning the 6th Kondratieff.

Will you come on the trip?
One way to contribute to and benefit from the 6th Kondratieff is to reduce our own knowledge gaps as biopsychosocial knowledge races away from standard practice. So I am pushing the NOI conference here, a proactive conference on neuroimmune backed biopsychosocialism which pushes health as an economic driver. Check out the list of remarkable plenary and invited speakers – perhaps the best ever list of speakers at an Australian Rehabilitation conference and the massive “what to do about it” list of workshops and lunchtime events. There is a deep underlying theme here of informed self-management, professional and personal empowerment, information medicine and the critical neurobiology, in particular the engagement of the brain, which we see a vital to health as a successful 6th Kondratieff. -David www.noi2012.com

References

Nefiodow, L.A.; Available from: http://kondratieff.net/11.html
Fields, R.D., The Other Brain. 2009, New York: Simon and Schuster.
Burns, H.; Available from: http://www.scdc.org.uk/assets-alliance-scotland

Last month’s notes on little fishing lines in the knee

Thanks again for writing in with some thoughts on how knowledge about the infra patellar branch of saphenous nerve plays its role in day to day healthcare.

Congratulations to VPS from India with your ‘twang’ like a guitar string, we will post you a copy of the NOI Neurodynamic Techniques DVD and Handbook. [4 minute preview]

Read some of our favourite comments here [pdf]

Links
David Butler on biopsychosocialism [4 mins]
Assets Alliance Scotland
Videos by NOI
Recognise App (for hands)
NOI 2012 International Pain Change Conference

Little fishing lines in the knee

September 27, 2011

Little fishing lines in your knee
If you take your finger nail and rub across either the femur or the tibia on the medial side of your knee cap you may feel a twang as your nail flicks across what feels like fishing lines. These are likely to be branches of the infrapatellar branch of the saphenous nerve. Now that is a mouthful – and did you know that the saphenous nerve is the longest nerve in the body. These little nerves may well be responsible for a range of problems such as medial knee pain and swelling, post arthroscopy pain and fat pad problems. Check out the picture of them – there are usually two branches, and see if you can give them a twang. Next time you see me ask me to get on your nerves!

Is the brain too trendy?
These days the brain is trendy to research, who would want to focus on the knee when there is a brain to explore? It’s sexy to link yourself to a gadget that peers into the workings of the brain and even the word ‘neuromatrix’ has a Keanu Reeves feel about it. It’s all good stuff in our view but it may be at the expense of clinical consideration of the body. We are serious here about the reciprocal interactions between brain and the rest of the body.

One of our guiding philosophies at NOI is that the pain mechanism has a physicality. What this means is that pathophysiology is nearly always linked to movement. For example, in a pain state where nociception contributes, say a good knee sprain, the clinical findings, assessment and treatment are linked to movement. In pain where there is contribution from a peripheral nerve, the clinical findings are often linked to movement of the nerve. Even in centrally generated pain, the meninges, neural and glial cells still have a physicality, i.e. they can move and stretch and this may well be a necessary feature for neural health. But let’s take another look at the infrapatellar branch of the saphenous nerve (IBSN).

The IBSN – A very slidey little nerve?
Think what happens when you squat – the saphenous branches really move like worms in the skin fascia and soft tissue as we move. If your knee is extended the nerves run 45 degrees across the knee joint but when the knee is flexed it will be parallel to the joint line and it could glide a centimetre (Tifford, Spero et al. 2000). I occasionally marvel at its physical abilities when I squat (doesn’t everyone!). It is worth remembering that the nerve still has to function electrically and chemically despite this extraordinary movement and worth reflecting on the possible role of this nerve in people with painful squatting and/or kneeling.
Image from Butler, D.S., The Sensitive Nervous System, Noigroup Publications, 2000

Problems with the IBSN
Knee surgery seems to be the biggest challenge for this little nerve. Meniscal surgery used to regularly ‘wipe out’ the nerve. Of course, it is all done arthroscopically these days but 25 years ago, up to 44% of people reported discomfort in the IBSN zone as late as 6 months post-surgery (Mumenthaler and Schliack 1991).

Most researchers agree that surgery such as total knee replacements, the insertion of arthroscopy portals and incisions for cruciate surgery place the nerve at risk with the incidence of sensory changes in the distribution of the IBSN reported as “common” – between 25 and 70%. Of course, this may be inevitable and it often resolves but some do go on to neuropathic pain states which may be inconvenient (problems squatting) or very painful such as CRPS. There is a good summary in Tifford et al (Tifford, Spero et al. 2000) for those who want to read further.

Adding some pain sciences
Involvement of the IBSN may be more common than we realise. It should be considered a possible contributor to any anteromedial knee pain. This may make us look afresh at patella fat pad problems or patella tendinopathy – could they be neurogenically inflamed by the nerve injury (antidromic firing causing a substance P initiated mast cell degranulation, bleeding and immune reaction in the fat pad)?

And of course some patients with knee problems will have brain changes in the representational meaning of the knee (Woolf 2011) and it is likely that as the brain tries to rearrange its notion of body that further immune based swelling and nerve sensitivity is possible. This may well be minimised if patients are told prior to surgery that they can expect some sensory changes and that it is likely to go.

Checking it out
It’s rare that fancy electrodiagnosis will be needed. Just do a sensory examination, touch the nerve to see if there is any difference in sensitivity compared to the other side. Palpate it in knee flexion and extension. Local tissue snags and thickening may well benefit from some soft tissue work and simply identifying and explaining the problem for patients may dethreaten the situation enough to calm it right down. Maybe some knee taping could unload the tissues around a discharging area of nerve.

So in summary
Let’s not forget the body, and remember that even minor nerves can cause heaps of trouble. Get your fingers off the keyboard and go twanging.

Send in your best clinical story involving the infrapatellar branch of the saphenous nerve and the winner will get a NOI Neurodynamics DVD and handbook.

Neurodynamics and the Neuromatrix conference
At NOI 2012 we will have sessions on neurodynamics, although there is not as much research as there is on the more trendy brain. One of the sessions will be a lunchtime display where you can watch movies of nerves sliding and have someone ultrasound your own nerves – what a lovely way to review your anatomy and come to grips with how much even the small nerves glide.

References
Mumenthaler, M. and H. Schliack (1991). Peripheral Nerve Lesions. New York, Thieme.
Tifford, C. D., L. Spero, et al. (2000). “The relationship of the infrapatellar branch of the saphenous nerve to arthroscopy portals and incisions for anterior cruciate ligament surgery ” The American Journal of Sports Medicine 28: 562-567.
Woolf, C. J. (2011). “Central sensitization: Implications for the diagnosis and treatment of pain.” Pain 152(3Suppl): S2-15.

Winners on the female homunculus
We’re all winners with these new maps! But seriously, thanks so much to everybody for sending in your thoughts and sharing your personal experiences. The three winners will be sent a copy of Explain Pain (book, audio or ebook in English, Spanish or Portuguese).

Huge congratulations to Melissa from the United States, Emily from Australia and Carolyn from Canada for answering the three questions in that order.

[PDF of responses from August 2011 – Females reclaim the homunculus]

There are also more comments you can read on the blog page where the NOI Notes get posted each month.

Links
Explicando a Dor ebook
Explicar el Dolor ebook
Explain Pain ebook

NOI 2012 September scientific update

A
recap on the recent Australian GMI tour
Handstands in your day

New Flashcards – back, neck and shoulder

NOI Neurodynamics video

NOI Research

Females reclaim the homunculus

August 25, 2011

Females reclaim the homunculus
I have been teaching undergraduate physiotherapists for many years in a semester long pain sciences course at the University of South Australia. A key paradigm that we teach is the neuromatrix and this is supported with stories of phantom pain and changes in somatosensory and other homunculi. There is quite a prominent penis on most somatosensory homunculi [1], perched precariously near the toes, and this is usually pointed out as a variant of the somatotopic organisation (the neuronal map of the body in the brain in the central nervous system). Many have pondered on this relationship and foot fetishes.

One semester, I had just finished my lecture on the neuromatrix, phantoms and the homunculi and was about to go when a concerned looking young female student approached me and said “do I really have a penis in my brain?”. No I stuttered, “you probably have a vagina, but no one has really researched it”. “Why not?”, she demanded. “This is important.” I had no answer.

Women have been badly treated in research. Male animals are easier to research and often women miss out on accolades (think of Rosalind Franklin the British X-Ray crystallographer whose contribution to the exposure of the DNA helix in 1953 was hardly recognised by Watson and Crick) But I am digressing…

The virtual vagina
Finally, the location of the human vagina, cervix, clitoris and nipples has now been mapped in the brain [2]. While it might seem obvious in hindsight, the findings are as follows:

1/ The clitoris is in the same place as the penis
2/ Vaginal stimulation activates different areas of the brain to clitoral stimulation
3/ Nipple stimulation not only activates the chest on the homunculus it also activates the genitals.

Not really surprising…

This activates that?
I wish the scientists (including those writing in “New Scientist”) would not talk about “this activating that” as though the brain works in a linear way and A turns on B then turns on C. All this linear thinking (another example is the notion that pain affects movement when, in the brain, activation of movement related neurones is a part of a pain construction) is overlooking the fact that we are just a bit more complex than reductionist scientists and clinicians make out sometimes. The pelvic representation in the brain is likely to already be activated at the thought of being in a study that involved stimulating it – it’s all occurring at the same time.

The virtual vagina – so what?
The first thing is that I have already updated my lecture notes in the pursuit of completeness. But it is tempting to say “so what” or even that such research is waste of money. And as the New Scientist review points out, women have been telling us about nipple stimulation and the difference between vaginal and clitoral stimulation for ever.

But lateral and thinking therapists can take this further. We can assume that with pelvic pain and lack of normal pelvic activity, that the entire pelvis and genitals are probably ‘smudged’ in the brain. The scientists should be able to show this soon, and the images – with appropriate education – should be helpful for many patients. (i.e. “yes, it’s real, measurable and changeable”). We now know that breast stimulation is probably a way of pacing for pelvic pain). Aspects of the graded motor imagery programme, which have shown some success for chronic neuropathic pain [3], should be trialled in pelvic pain states. We could hypothesise that the yoga lotus position (sitting with the feet pressed together in the groin) could help sculpt the clarity of the foot/genital representational boundaries in the brain.

Pelvic pain is a problem for men and women – some estimate the prevalence as similar to back pain [4]. We want to address it at the NOI 2012 Neurodynamics and the Neuromatrix conference. The information from plenary speakers such as Lorimer Moseley (the body matrix), Sandy McFarlane (PTSD) Fiona Wood (thinking yourself whole), Frank Keefe (coping with disease related pain) and the plenary session from Michel Coppieters’ team on peripheral neuropathic pain will filter to two workshops directly on pelvic pain and many related others (eg Mindfullness, Feldenkrais, Latin dance for the pelvis). And I feel as though we are doing something for the student miffed about the sexist homunculus! -David

Do you want to contribute?
We would love to hear your thoughts on this one in terms of scientific benefits (or not) and the future implications of this particular news. For each question answered below we will post a copy of Explain Pain (book, ebook or audio) to the person with our favourite answer.

1/ Is this research worthwhile?
2/ What are some alternate ways this information could be utilised?
3/ Where to from here?

References
Kell, C.A., et al., The Sensory Cortical Representation of the Human Penis: Revisiting Somatotopy in the Male Monunculus. The Journal of Neuroscience, 2005. 25(25): p. 5984-5987.
Komisaruk, B.R., et al., Women’s Clitoris, Vagina, and Cervix Mapped on the Sensory Cortex: fMRI Evidence. Journal of Sexual Medicine, 2011. July 28.
Moseley, G.L., Graded motor imagery for pathologic pain. Neurology, 2006. 67: p. 1-6.
Howard, F.M., Diagnosis and treatment of persistent pelvic pain, in Pain 2010. An updated review, J. Mogil, Editor. 2010, IASP Press: Seattle.


Links

The Neurodynamics and the Neuromatrix Conference 2012
Women’s Clitoris, Vagina, and Cervix Mapped on the Sensory Cortex: fMRI Evidence
Sex on the brain: What turns women on, mapped out
Graded motor imagery
Explain Pain *ebook*

A week of pain?

July 27, 2011

A week of pain?
It’s Pain Week in Australia, an initiative of Chronic Pain Australia. The aim is to “create awareness, to shine a light on the dilemma and work towards creating a hopeful message about living with pain”. We think it is a great idea – chronic pain is such a hidden and deeply invasive epidemic in society. The term ‘pain week’ is also a reminder of how pain is medicalised – we don’t see ‘love week’ or ‘jealousy week’ for example, yet love and jealousy are brain constructions as well and thus not that dissimilar to pain. This should remind us that the answers to chronic pain are not all medical either. Maybe “living with pain” for many could be a bit defeatist – like “managing pain”. Pain is a biological event – all biological events cycle. Perhaps we could add more hope and say – “living with and treating pain”, notwithstanding the nastiness and horror of it for some.

A time for reflection
National Pain Week has made us reflect at NOI – what is the essence of our teaching and philosophy – are we on track? When someone says “tell us what are the most important things that you teach, summarise the key philosophies in a nutshell”, it does make you reflect. The two things I have selected are firstly that pain is an output of the brain, not an input and secondly that pain is just one of many outputs our brain makes to defend us.

We would like clinicians and patients to be aware of these philosophies as part of our contribution to National Pain Week.

1. Pain as an output
If you pinch yourself hard enough, it hurts and it is so intuitive to think that pain kind of goes into your body and brain. Biologically this is not correct. First, if pain was entirely an input it should be easy to stop it by turning off inputs such as the pinch or a thought. This may work for some pains but it clearly doesn’t work for most people with chronic pain. One billion plus people in the world can’t be wrong! Of course it is nociception* which goes in – it is up to the brain to weigh everything up and decide whether the nociception is worth a pain experience. So many health professionals still don’t get the difference between pain and nociception. (You can tell they don’t when they say things like “pain signals into the brain” and “pain nerve endings”.) If pain is regarded as a brain output experienced in a body part, it simply makes you take on the biology of the brain, all that is in it and all that can influence it.

2. Pain is just one of many brain outputs
This is a precious neuroscience base to our teaching. When we are in trouble, threatened, injured, curious or learning, there are numerous brain outputs which could be constructed to protect, defend and help us. These include the immune, sympathetic, motor and endocrine systems, but also pain, language, emotions, cognitions, respiration, inflammation and many more. It is good to have some of these turned on for a short time to help us learn and to protect and defend us, (eg being anxious can protect us, cortisol level changes can help healing, pain makes us change behaviour) but if there is non-resolution of the inputs that set off these outputs, then the outputs may become pathological in their own right. If a tiger starts following you around the suburbs, you will turn on defence systems (outputs) which will become pathological if ‘the tiger’ continues to follow for months and months. For example – pathological sympathetic, endocrine and immune responses, pathological muscle changes and ‘pathological’ thoughts and emotions. Early intervention is obviously the key. The tiger might simply be a lack of knowledge.

Freedom of the output systems
If a person has numerous outputs turned on it can become taxing for the body. That is, it takes an enormous amount of energy to run multiple systems. A typical patient with chronic pain may have unusual cortisol levels, muscle tightness, a labile sympathetic nervous system, an unbalanced immune system, and produce inflammatory immune compounds. There is not much energy left for the rest of life.

A patient, with a bit of knowledge, may be able to identify the outputs systems turned on and then perhaps the issues (could be body structures, thoughts, contexts etc) which need resolution to turn the outputs off. Just knowledge about why we hurt can give so much freedom to the output systems.

‘Control’ is a bit of a buzz word out there – pain control, motor control, control of your emotions and on it goes. But there are problems with the control doctrine. Brains don’t construct by control, they construct by freedom, creativity, curiosity, testing the edges of homeostatic behaviour. ‘Pain freedom’ and ‘motor freedom’ sits better with our teaching (acknowledging that sometimes you need control to get freedom), but ultimately it is freedom and choice, much of it subconscious, of construction which is critical for brain health.

Our aim here is to give patient freedom of choice of the output systems, essentially by movement and education so that they have brains that can weigh the world when challenged and not automatically default to a pain, motor, endocrine, language or other habit.

Promoting awareness of these issues is our contribution to National Pain Week. – David

*Nociception
There are some neurones in your tissues that respond to all manner of stimuli, if those stimuli are sufficient to be dangerous to the tissue. Activation of these special neurones sends a prioritised alarm signal to your spinal cord, which may be sent on towards your brain. Activity of this type in these nerves is called ‘nociception’, which literally means ‘danger reception’. We all have nociception happening nearly all of the time – only sometimes does it end in pain.

Butler DS & Moseley GL, Explain Pain, Adelaide, Noigroup Publications, 2003, p32

NOI 2012: early birds get a sweet deal and a chance to win!

NOI 2012Early bird registrations for NOI 2012 end this week. All early birds get a sweet deal and will also go in the draw to win a weekend for two in the South Australian wine region of your choice.

All conference delegates will receive three days of highly intellectual and clinically relevant information including the large range of workshops, an invitation to the opening drinks, the gala dinner on the second evening and involvement with the Nerdy Passions.

Get in early and save heaps, we would love you to come to our festival of clinical neuroscience! See www.noi2012.com for all current conference details.

Links
Explain Pain resources
Chronic Pain Australia
NOI 2012 brochure [1MB]
NOI 2012 Masterclasses
Lorimer Moseley – Pain. Is it all just in your mind? [49mins]
Facebook
Twitter

NOI Notes on spirituality and nerve root pain

July 6, 2011

Nasty nerve roots
Nerve root pains can be downright nasty, sometimes tricky to identify and they often last a long time – shooting pains in the leg, sleepless nights, latent pains, weird behaviour, and impaired quality of life. It may well be hard for a patient to give meaning to it, especially with the unfamiliar symptoms. “It just eats into my soul” commented a recent sufferer.

If this is the case, perhaps you should hope/pray that your patient is the spiritual type. On an analysis of basic sciences, the spiritual type may do much better than the non-spiritual person when faced with a nasty and unfamiliar nerve root problem. And you can be a spiritual assistant!

Spirituality
Differences between spirituality and religion have been argued for years and I don’t really want to get into that hot potato. Spirituality is usually defined as a personal quest for seeking meaning and purpose and a connectedness with the world. It includes a willingness to accept transcendence i.e. things that cannot be objectively demonstrated (Emblen 1992; Maliski et al. 2010). You don’t have to be religious to be spiritual although there is often overlap. Faith is a manifestation of spirituality and in the health care context this could be faith in the health care provider, self, family and the system. High levels of spirituality may be really important in getting an acute nerve root problem to calm down and to minimise the number and effect of reoccurrences. Health professionals should be aware of the spiritual needs of patients and the fact that the spiritual person will be more likely to have biopsychosocial mental frameworks to tap into.

What is so spiritual about a nerve root?
While the brain is a far more trendier part of the of the nervous system to experimentally probe, a recent revival of interest in the peripheral nervous system is noted, especially the nerve root, the ‘brain’ of the peripheral nervous system. No doubting anatomically that nerve roots (referring here to the rootlets, roots and dorsal root ganglion) are in a tricky place for modern life and surgery can be spectacularly successful for some, however the common mechanistic ‘pinched root’ and nerve root ‘compression’ thinking needs a challenge.

When a part of the peripheral nervous system is injured, immune cells such as glia, Schwann and T cells in the dorsal root ganglia, spinal cord and brain produce pro and anti-inflammatory cytokines – a sterile inflammatory response. The pro-inflammatory cytokines include interleukins 1, 6 and TNF alpha. The anti-inflammatory cytokines include interleukins 4 and 10. These two groups kind of balance each other out, with the balance ultimately contributing to how the injury plays out (Austin and Moalem-Taylor 2010). For example, people with painless neuropathies have heightened levels of anti-inflammatory cytokines and patients with painful neuropathies have heightened levels of pro-inflammatory cytokines. Other linked processes related to nerve root sensitivity include altered sensitivity to mechanical, adrenaline and ischaemic stimuli (Devor 2005). Inflammation does not necessarily show on imaging and the spiritual person may readily accept that their pain does not have to have an objective measure.

Searching for a sense of self in a nerve root?
Those more spiritual may see the nerve root problem as a microcosm of self. The inflammatory component of the nerve root problem, which will be mimicked in the cord and brain is driven in part by mind status. The ‘out of balance’ notion of mental disorders, increasingly seen as unbalanced glial activity (Fields 2009) may apply to the peripheral nerve injury. For some there may well be ‘goodies and baddies’ or ‘angels and demons’ in the inflammatory response and heightened spirituality enhanced by biological knowledge may tip the balance in favour of the anti-inflammatory immune response.

For example, catastrophisation which is known to have immune inflammatory effects (Edwards, Kronfli et al. 2008) could be minimised by a spirituality which encourages a search for meaning and knowledge, and perhaps a ‘go with the flow’ thinking. You can help the person seek meaning. For example, knowledge of the pain referral zones, that immune based ‘sympathy pains’ in the other side are common, and that immune based responses for months after are expected and normal as the system slowly balances. And in particular, the knowledge that neuroinflammation is influenced by unhelpful thoughts like catastrophisation and emotions such as fear should be welcome by the spiritual person. Ultimately early movement with minimised fear may be a beneficial outcome.

The religious discussion is inevitable here. Cusick, a minister writing in the American Pain Society Bulletin (Cusick 2003) noted five spiritual religious interpretations of pain – pain as punishment, pain as a test, pain as an opportunity for transcendence (i.e. a little pain is good for the soul), pain as atonement (i.e. experiencing pain to help other people) and pain to gain control. However, as Cusick  notes, the social meanings of pain are now changing rapidly with improved pain medications and increased understanding of its biology – that pain, like other brain constructions is a protective coping strategy to help us change behaviour and is not necessarily a voluntary and potentially harmful experience.

Assessing spirituality
Given that most people report having a spiritual life and that spirituality may well have an influence on the potency of neuro-inflammatory soup, it seems worthwhile asking about it. Questions such as “what helps you get through tough times” and “to whom do you turn when you need support” (Mueller, Plevak et al. 2001) may well be obvious questions to a health professional with a biopsychosocial framework.

More on spirituality
These are complex issues ripe for discussion. This perplexing topic of the relationship between spirituality, pain, immune and other systems will be up for discussion at the second Neurodynamics and The Neuromatrix conference in Adelaide, Australia, April 2012. The Reverend Dr Andrew Dutney, next head of the Uniting Church in Australia will talk and present a workshop with Professor Frank Keefe who has researched in the area of spirituality and arthritis and Mick Thacker, immunologist and spiritual atheist.
Keen to have your thoughts here – David

References
Austin, P. J. and G. Moalem-Taylor (2010). “The neuro-immune balance in neuropathic pain: Involvement of inflammatory immune cells, immune like glial cells and cytokines”. Journal of Neuroimmunology 229: 23-60.
Cusick, J. (2003). Spirituality and voluntary pain. APS Bulletin 13(5)..
Devor, M. (2005). Response of nerves to injury in relation to neuropathic pain. Melzack and wall’s Textbook of Pain. S. McMahon and M. Koltzenburg. Edinburgh, Elsevier.
Edwards, R. R., T. Kronfli, et al. (2008). “Association of catastrophizing with interleukin-6 responses to acute pain.” Pain 140: 135-144.
Emblen, J. D. (1992). “Religion and spirituality defined according to current use in nursing literature ” J Prof Nurs 8: 41-47.
Fields, R. D. (2009). The Other Brain. New York, Simon and Schuster.
Maliski, S. L. and e. al. (2010). “Faith among low-income, african american black men treated for prostate cancer ” Cancer Nursing 33: 470-478.
Mueller, P. S., D. J. Plevak, et al. (2001). “Religious involvement, spirituality, and medicine: Implications for clinical practice ” Mayo Clinic Proceedings 76: 1225-1235.

NOI 2012: early birds get a sweet deal and a chance to win!
NOI 2012Early bird registrations for NOI 2012 end this month. All early birds get a sweet deal and will also go in the draw to win a weekend for two in the South Australian wine region of your choice.

All conference delegates will receive three days of highly intellectual and clinically relevant information including the large range of workshops, an invitation to the opening drinks, the gala dinner on the second evening and involvement with the Nerdy Passions.

Get in early and save heaps, we would love you to come to our festival of clinical neuroscience! See www.noi2012.com for all current conference details.

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Frontal lobotomy meets neuromatrix

May 12, 2011

It’s sobering to ponder the story of frontal lobotomy every now and then and reflect on how far we have come.

Brain mashing
For those who have come in late, frontal lobotomy is a psychosurgery which was widely carried out in the US and Europe in between the 1930s and 1960s. “The lobotomy was not a procedure on the fringe of science. It was a mainstream treatment advocated by many highly-educated physicians and prestigious institutions. Praised in breathless news articles, and touted as an amazing neurosurgical advance” (Psychosurgery 2009). In 1948 the New York Times called it “surgery for the mind”. While some techniques involved drilling into the skull and mashing brain with a bit of wire, (little different to stone age trepanning), the most widely used technique was to push a small knife under the eyelid, hammer it into the brain through the cribiform plate and then wiggle the knife, essentially cutting or mashing connections to the frontal lobe.

WARNING – graphic content, it made us feel sick
Here is a video clilp of the operation performed by the US lobotomy protagonist, Dr Walter Freeman. It is worth watching as you ponder how far we have come or not come.

The “lobotomobile”
The operation become famous as Egas Moniz, the first performer of lobotomy on humans, won the 1949 Nobel Prize. It is estimated that 40,000 Americans have had frontal lobotomies. Freeman travelled the West Coast of the US in his “lobotomobile” and “cured” delinquent children (Freeman performed 19 lobotomies on patients under 18) and housewives who had lost their passion for domestic work. We couldn’t find a picture of the lobotomobile but I envisage one of those scary big cars with a big bonnet that kind of smiles at you. The most famous patient was President Kennedy’s sister, Rosemary Kennedy, a moody, if not depressed 23 year old girl who was lobotomised in 1941. She spent her remaining 64 years incapacitated, incontinent, and staring at walls. Howard Dully was diagnosed by Freeman (a non-licensed psychiatrist) with schizophrenia after 4 visits at 12 years of age. Howard was one of the youngest lobotomy victims. Western movie aficionados may be interested to know that the “Cisco Kid” was lobotomised (I always thought he was a bit slow on the draw!).

Forty years on – what have we learnt?
It’s revolting of course, and it wasn’t that long ago the practice of lobotomy generally ceased (1970s). I was studying biology in high school when Walter Freeman was forcibly stopped from performing lobotomies (patient number 3000 haemorrhaged on the operating table during her third lobotomy). Remember that science was advanced enough to send a man to the moon around the same time.

Medical omnipotence: neglect of basic sciences
No matter how you look it, lobotomy does not make sense, then (operating blindly on something you don’t know about) and now. These procedures were continued without follow up and were supported by anecdote a fawning media and surely an omnipotent surgeon. Such practitioner arrogance persists – the “operation went fine, it must be your fault you are not better” or “we have shown you how to tighten your tummy muscles, it’s your fault, you are not trying hard enough”. Are we still guilty of continuing techniques and research without asking the question “does it make sense from broad basic sciences?”. Does it make sense to invest in studies of techniques like single muscle activation or prolotherapy for chronic pain? Not if we were giving out the research money.

The lobotomised patients had chronic problems. It should be clear that most chronic problems such as chronic pain have multiple causes and are often related to what the person thinks and does about the initial issue. Cutting one bit will not help. The relentless hunt for single causes for chronic pain persists in society, a feature which probably makes many worse. I can’t help seeing a MRI on a truck, and think of the relentless searches for the disc bulges in chronic pain states at the expense of a wider psychosocial search, and I think back to the lobotomobile.

Easy in hindsight?
But then again, there wasn’t much else back then. The daughter of an apparently successful lobotomy patient made the comment . “That’s the thing, people who are looking at it now don’t understand, they didn’t have anything else and nobody was coming up with anything.” Have we haven’t advanced that much past Thorazine – the chemical lobotomy that signified the decline of the surgical lobotomy- ? We still overmedicate (biomedical) and de-humanise medical conditions. The non-pharmacological and surgical community do not stand up and sprout loudly enough about what they can do in terms of education, movement therapies and brain retraining therapies. The public still doesn’t know and the media still lead – once a month, a “new” pain treatment will appear on my television.

Looking forward
I believe that watching the lobotomy clip now should evoke more repulsion than it would have ten years ago. This should be a sign that some progress has been made. “That is incredibly useful brain being mashed and it has many other uses other than to contribute to a pain or psychosis neurosignature, its changeable, its plastic, stop, stop you nutter”: went through my brain. We are now aware that the strict modular views of the brain are not correct and that various areas of the brain can have overlapping function or take over the role of another part. Brains consist of mainly association neurones, not neurones dedicated to a singular function. Destroying a brain part will not necessarily remove a neurosignature such as pain. There should lessons here about how the neurosignature works.

Surgery for pain still persists despite limited evidence. In 2001 there were, for example, 70 lobotomies performed in Belgium, even 15 per year at Massachusetts General Hospital in Boston. However, today surgeries like the lobotomy are most commonly used to treat severe obsessive compulsive disorder.

With a view that pain is an output of the brain, like love, we are perhaps fortunate that surgery for love is not commonplace.

Finally – at least the lobotomists were ahead of their time in one area – pain is ultimately in the brain.

References
Psychosurgery: Remembering the Tragedy of Lobotomy, 2009 [online]
Kessler, R. (1997). Sins of the Father: Joseph P. Kennedy and the Dynasty He Founded. Warner Books, New York.
French National Consultative Committee on Ethics, opinion #71: Functional neurosurgery of severe psychiatric conditions 2002, 04-25.
Dully, H. and Fleming, C. (2007). My Lobotomy. New York, Crown Publishing Group, division of Random House Inc, New York.
Atkins, L. (2009). A radical treatment for obsessive compulsive disorder patients. The Guardian. London. [online]

NOI 2012: the countdown begins
NOI 2012 It is now less than 350 days out from the NOI 2012 Neurodynamics and the Neuromatrix conference at the Adelaide Convention Centre on 26-28 April 2012. Registrations are open, and starting to roll in.

The NOI conference is bringing neuroscience revolutionaries from around the world to the beautiful city of Adelaide for three days of essential brain food in a unique opportunity for health practitioners. See www.noi2012.com for all current conference details.

Submitting?
Workshop, platform and poster presentation submissions are now open. Please visit the submissions page to send in your contributions. All submissiosn close on 31st October 2011. >NOI 2010 scientific programme.
>NOI 2010 workshops and lunchtime activities

Coming?
The first 200 people to register before July 31st this year will be eligible for an early bird price of $990. This includes the three days of highly intellectual and clinically relevant information including the large range of workshops, opening drinks, the gala dinner on the second evening and involvement with the nerdy passions.

Masterclasses
Before the conference we will be offering four of the most popular NOI courses as Masterclasses – presented by world renowned researchers, clinicians and educators in rehabilitation and neuroscience.

Get in early, save heaps and register for NOI 2012 here. We would love you to come to our festival of neuroscience!

By George!

March 31, 2011

Meet George, his once dicky aorta, and his veering problem.

My brother in law George, youthful at 67, has a problem with walking. After about 10 steps he consistently veers to the right and to keep walking he corrects himself by limping on his left leg. This is not a pretty look and such veering can be embarrassing in the supermarket. But George is lucky to be with us. About a year ago he had an aortic valve replacement, a reasonably standard operation these days, but unfortunately the aorta split two hours later and he began to bleed out. Simply the heart had no blood to pump. The chest was quickly pulled open in intensive care and they managed to stabilise him, before another 12 hours of surgery. He lived to tell the tale (very few do) and remarkably, has no cognitive changes. His story even made the local paper.

Treating the rellies
I have never liked treating the rellies (see noinotes). But a year after his aortic event, George mentioned his veering and his limping. I happened to have my computer with me and on impulse, I checked his laterality.

Testing laterality means measuring the ability of a person to identify whether a body image is left or right. Both accuracy and speed can be measured. We are aware that this sense of laterality can be disturbed in some ongoing pain states such as CRPS1 and phantom limb pain and that restoration of laterality is a part of the effective graded motor imagery (Moseley 2006). George had no pain but I still tested him using Recognise Online.

A missing squirt of blood?
His results from hands, neck and shoulder laterality tests were all good- meaning he was getting left/right accuracies of over 80% and speeds per image of under 2 seconds without any left/right bias. The back was the same, but the feet laterality scores really surprised me. The time taken to make a decision on whether he was looking at a left or right foot was nearly 4 seconds for the left and 2.5 for the right. He was accurate in only about 60% of the left feet (i.e. not much more than chance) and about 75% for the right.

So I thought “oh dear, maybe that last squirt of blood destined for the foot laterality appreciation network in the brain didn’t quite make it and ended up on the floor of the intensive care ward.”

A GMI workout
George started on a laterality workout using the Recognise Online programme. He does at least an hour a day and although he found it exhausting initially, it is now getting easier and easier. He focuses on the feet but also includes some back and hand training. Within a week his average time to identify left and right feet dropped down to under 1.5 seconds and his left/right accuracy became equal and above 80%, although every now and then there were a few lapses with the left. He has been on the programme now for over six weeks.

Functional outcomes of the laterality exercises
There have been benefits (maybe treating rellies isn’t so hard after all!). George is not limping anywhere near as much and he is also walking more upright. He no longer has to look at his feet while he walks and he feels far more confident in moving around. George also commented that his “brain was clearer”. Last week he made the comment that he is “now remembering a few things that he didn’t know he knew – things about the hospital stay.” He was unconscious for over a week. I guess the exercises may have awoken a few memory networks?

The joys of anecdote
This is an anecdote of course. Anecdotes are particularly useful when novel therapies such as the graded motor imagery develop. Anecdotes are perhaps not as useful when the evidence about a therapy is well established (e.g. miracle cures after lumbar traction). But at the moment we welcome anecdotes at NOI – they can guide research and create healthy discussion. In George’s case it creates an awareness that GMI may have a place in perturbed motor states.

Can you help?
We are doing a project on laterality and low back pain with the University of South Australia. We are seeking back laterality responses in a group who are asymptomatic and a group who are suffering back pain. It takes less than 15 minutes to do. Here is the link.

You may have contributed to the Sarah Wallwork neck laterality study last year. We managed to get 1500 subjects and the results have been submitted for publication. We hope to get 1500 subjects again, so if you can do it, and get people with back problems to do it, it will really help. Here is the link again.

References
Moseley, G. L. (2006). “Graded motor imagery for pathologic pain.” Neurology 67: 1-6.

Last month’s notes on “Tattoos losing the ashes for Australia”
Last month’s notes on “tattoos losing the ashes for Australia” certainly stirred the pot.

Here are some of the responses. There were a few we had to exclude (!) especially from the English fraternity who were most disparaging of Australia’s sporting abilities (how short memories can be!).

There were lots of delicious thoughts – For example, many discussed the meaning of the tattoo, we were reminded that people with alopecia sometimes get tattooed eyebrows with a resultant increase in well being and thus the meaning and the location of the tattoo could be important. Others queried the influence of ink in the system. Many picked holes in the hypothesis citing world class cricketers and basketballers with tattoos and my n=2 sample. But others reminded us of sportstars whose performance dwindled with the advent of ink, but suggested that maybe the tattoo was about looking more of a bad boy, thus the athlete may have had low self esteem, which could affect performance.

We were also reminded that in the Australian Football League, Collingwood is well known as the most tattooed team, yet they won the grand final in 2010.

And the challenge to the hypothesis can be on pure science grounds. It was argued that a tattoo may well augment the embodiment of the limb – a facilitation of the motor response via visualisation.

Hard to pick a winner as always. For the best support of the hypothesis the prize goes to Cameron. For rejection, Edel.

NOI 2012
The NOI Neurodynamics and the Neuromatrix Conference is coming to Adeliade! Registrations are opening in April. There will be 200 early bird tickets available until July 31 2011. Don’t be a late old chook! Keep www.noi2012.com bookmarked for all scientific updates, workshop outlines, art and abstract submissions, sponsorship opportunities, information about Adelaide and other great 2012 opportunities and events.

Plasticity Mirror neurones Pain and stress literacy Neuroscience-backed psychology Neuroimmunology Neurodynamics and movement Brain sciences Intellectual nourishment Education as antigen Movement as antigen Spirituality and pain Information download Art Meditation Neuroscience updates Dance Social media applications for health care and research Hands on workshops Nerdy passions…

Links
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WWW.NOIGROUP.COM/COURSES
1 – 3rd Apr Mobilisation des Nervensystems, Kassel, DE
2 -3 Apr Mobilisation of the Nervous System, London, UK *FULL*
2 -3 Apr Mobilisation of the Nervous System, Liberty MO, US
8 – 10th Apr Mobilisation des Nervensystems, Fellbach, DE
9 – 10th Apr Neurodynamics and the Neuromatrix, Chicago IL, US
9 – 10th Apr Mobilisation of the Nervous System, Red Deer, Alberta, Canada *FULL*
9 – 10th Mobilisation of the Nervous System, Las Vegas NV, US
9 – 10th Apr Mobilisation of the Nervous System, Hillsboro OR, US
15 – 16th Apr Neurodynamics y la Neuromatrix, Valencia, ES
15 – 17th Apr Mobilisation des Nervensystems, Saarbrucken, DE
29th Apr – 1st May Applicazione Clinica: Arto Superiore, Milano, IT
29th Apr – 1st May Movilización del Sistema Nervioso, Pontevedra, ES
30th Apr Graded Motor Imagery, Chicago IL, US (FIRST EVER IN THE US!)
6 – 7th May Explain Pain, Adelaide, AU
8 – 10th May Mobilisation des Nervensystems, Wien, AT
14 – 15th Mobilisation of the Nervous System, Toronto, CA
14 – 15th Mobilisation of the Nervous System, Minneapolis MN, US
14 – 15th May Explain Pain, Fairbanks, Alaska AK, US
17th May Explain Pain (1 day course), Bristol, UK
20 – 22nd May Klinische Anwendungen: Obere Extremität, Thorax und HWS, Saarbrucken, DE
21 – 22nd May Neurodynamics and the Neuromatrix, London, UK
21 – 22nd May Explain Pain, Lake Tahoe CA, US
25 – 27th May Mobilizacao do Sistema Nervoso, Florianopolis, BR
25 – 26th Mobilisation of the Nervous System, Ottawa ON, CA
27 – 29th May Mobilisation des Nervensystems, Munchen, DE
28 – 29th May Explicando a Dor, Florianopolis, BR
1 – 3rd Jun Mobilizacao do Sistema Nervoso, Brasilia, BR

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noi notes

Tattoos lose the ashes

February 23, 2011

Tattoos lose The Ashes for Australia (a hypothesis)
England has just soundly beaten Australia, on Australian soil, in a 5 game series of test cricket. This is the first time this has happened for nearly a quarter of a century. For our non cricketing audience, this competition is known as “The Ashes” and each game can last for 5 days. While deep down, we are quite fond of the “poms” as we call the English, we don’t like losing to them at all, especially in games they invent such as cricket and rugby, even darts.

There has been quite a bit of clinical reasoning going on in Australia about this loss, but while watching a recent match I couldn’t help ponder on the possible role of tattoos in Australia’s dismal performance.

Tattoos and performance
Two poorly performed and inconsistent players in the Australian team during the test matches were the batsman and vice captain Michael Clarke (left) and the strike left arm fast bowler Mitchell Johnson on the right. They both have recetattoos.

noi notes on tattoos lose the ashes
Clarke has a number of tattoos including one with the initials (LB) of an ex girlfriend tattooed on his shoulder. Johnson has a “sleeve” on his right arm and an abdominal tattoo.

Clarke and Johnson are world class cricketers with world class statistics but in recent years their form has suffered. Note in the graphs below, how their performance approximately relates to when the players had recent tattoos.

noi notes on tattoos lose the ashes

What is it about a tattoo?
Any hypothesis should be made on a foundation of basic sciences. Our suggestion is that a tattoo may alter the representation of the tattooed body part in the brain, essentially the” meaning” of the body part in the brain, leading to a motor sensory incongruence resulting in perturbed motor output. Clarke and Johnson have had perturbed cricket motor outputs this season which may well have recruited mirror neurone complexes in teammates and perhaps altered their performances.

Tattoos are usually done with great meaning, thought, expense and prior contemplation and they usually hurt, especially in areas that have large representations in the brain. Tattooed feet hurt more than shoulders. Large tattoos can take weeks to finish. No doubt the tattoo owner will have altered emotions and thoughts about the tattooed limb – perhaps, proud, excited, hypervigilant ,maybe a bit ashamed later on. The limb is surely embodied a little differently in the brain. Altered emotions and thoughts about the limb will be also be affected by other people’s attitudes to the tattoo. While tattoos are increasingly regarded as cool, especially by younger people (Rooks et al 2000), a dragon tattoo on a young woman will still evoke more negativity about the person than if she was not tattooed (Resenhoeft et al 2008).

Tattoos, the brain and perturbed motor outputs
When a person plans and executes a motor output such as bowling a cricket ball or playing a cricket shot (and there is an infinite variety of both which could be executed by these elite athletes) the brain calls on various sources of reference to execute the most appropriate output. References could be considered external such as state of the pitch, state of the match, opposing cricketers’ actions and current climate. They could also be internal such as memories, cognitions, fatigue, and pain. The cricketer will not even be aware of some of references called upon and the brain will be continually seeking feedback from the references (How is that sore elbow, what is the opposing team doing, will it rain?) One of the references will be the somatosensory maps –i.e. the sensory neurotags representing the arm in the brain. Most readers will be aware that these brain maps change continually but may alos change significantly with altered inputs (Pascual-Leone and Torres 1993; Flor 2000; Duffau 2006). The suggestion here is that the altered inputs into the embodiment schema of the tattooed body part of the cricketers may be enough to create a sensory motor incongruence leading to perturbed output in cricket. It may only be minor to lead to significant perturbed output in a high performance athlete when dealing with a cricket ball travelling at 150Kph. Perturbed outputs may not only be altered motor performance, they could be sensory disturbances, even inflammation (?bursitis) which again impact on the embodiment of the arm in the brain.

I would even suggest that the current state of happiness with the tattoo and its meaning, may reflect on the sports performance at that moment. I also suggest that a much loved and integrated tattoo may even enhance the finery of the representation of the limb in the brain and even improve motor outputs. -David

Your turn
Of course – this is all hypothesis. We are keen to hear reader’s comments and also we will give a prize of an Explain Pain to
(a) the person who picks the best hole in the hypothesis and
(b) the person who provides the best supportive evidence for the hypothesis.

PS
There is an ‘out there’ conference coming up called NOI 2012, in Adelaide, and you can expect to hear more. You’ll have the chance to see live tattooing in action and contemplate its meaning.

References
Duffau H. Brain plasticity: from therapeutic mechanisms to therapeutiuc applications. Journal of Clinical Neuroscience 2006;13:885-897.
Flor H. The functional organization of the brain in chronic pain. Prog Brain Res 2000;129:313-322.
Pascual-Leone A, Torres F. Plasticity of the sensorimotor cortex representation of the reading finger of braille readers. Brain 1993;116:39-52.
Resenhoeft A et al. (2008) J Am Coll Health 56: 593
Rooks JK et al (2000) Minn Med 83: 24

Another legendary NOI Instructor
Bob Johnson NOI InstructorBob Johnson is based in Chicago and has been a ‘nerve-head’ for a really long time. He has taught with David Butler and the NOI team since 1999 and teaches all NOI courses in numerous places around the world.

On top of organising continuing education courses, he is co-owner and clinical director of Achieve Orthopedic Rehab Institute which has seven out-patient offices and focus on manual therapy & exercise interventions for acute/chronic pain of the spine and extremities. Bob has been practicing since 1979 and currently directs an APTA credentialed Orthopedic physical therapy residency program.

Bob is a former faculty member of Northwestern University Medical School and past Chair of the Orthopedic Specialty Council, American Board of Physical Therapy Specialties. Bob is also a current adjunct faculty member for the University of Southern California Spine Fellowship program.

Bob has just returned from a 5 week trek in Nepal. He loves ribs (with extra sauce), likes to get to work on bike and bus and is inspired with every new morning.

Achieve Orthopedic Rehabilitation Institute

Bob next instructs:
Clinical Applications: Lower limb and lumbar spine on 26th March, Chicago, US
Neurodynamics and the Neuromatrix on 9th April, Chicago, US
Enquire about and find more of Bob’s courses here

Links
NEW WEBSITE SECTION: NOI Likes
NEW WEBSITE SECTION: NOI Videos
THE STRANGE POWERS OF PLACEBO 3 MIN VIDEO