Archive for the ‘2013’ Category

The Cabbie Cortex

December 17, 2013

It’s nearly Christmas and due to the festivities many of us are likely to be in a taxi in the near future. I love talking with taxi drivers and for some years, I have been asking them the question, “How do you think the brain works?”. After all, scientists don’t really know- but maybe people in this unique profession have an insight.

Taxi drivers have a unique job – they are nearly always moving and they deal with an enormous variety of customers – happy, sad, angry, anxious, talkative and non-talkative. They could have a CEO in the car one moment and the next customer could be a youngster who has had too much to drink and needs a bit of care. Your taxi driver could be a student, professional driver, actor waiting for a break, a doctor or physicist waiting for registration for their desired profession.

My questioning goes something like this:
After a bit of chitchat – “Can I ask you an odd question? You guys see a lot of life and talk to a lot of different people. I am interested in the brain – no one really knows how it works. How do you think it works?”

Expect to be surprised by the answer! In Australia, at least, 4 out of 5 will give you an answer other than “no idea”.

I now have about 25 responses to what I call The Cabbie Cortex series, presented at the Pain Adelaide conference in 2013. Here are three responses to “How does the brain work?” to give you an idea.

Samir: Adelaide airport to Adelaide city $22
“Well sir, I think it is quite clear how the brain works. There are definitely three compartments. The conscious, the subconscious and memory and there are parts within each part. The difference between a smart and a dumb person is how many bits you can use at once. Say a genius could use 10 and a dumb person 5. Will you be quoting me in a scientific paper, Sir? I tell my kids to never, never think they are dumb. Everyone’s brain starts off the same we just have to try harder. Like you can exercise a muscle, you can exercise the brain. Books are really important.”
I thought “that’s quite poignant, but Samir is right on with notions of distributed processing, changeability, and environment influences”.

Ahmed: Sydney airport to city $38
Now you will notice I am in Sydney – this is a multicentre study!
“I will tell you one thing – taxi drivers have terrible bodies but wonderful brains. If we worked our bodies as hard as we worked our brains during the day, taxi drivers would have the best bodies. I am exhausted at the end of the day and that is from the brain not my body. It must be one hell of a machine.”
I thought – while there is a bit of brain body splitting there, I bet he would love a story about mirror neurones. He is ripe to take on modern brain science and get rid of the machine notion”.

Bob: Adelaide casino to the University of South Australia $7
“What are you, mate? A shrink or something. I don’t bloody well know”… (very long pause followed). “That is the weirdest thing I have been asked in 24 years of pushing a cab.”
I thought – probably not my best interview! But at least he has been thinking of it. I bet if I asked him in a week or two he would have an answer.

Your turn
We would love our readers to ask their next taxi driver “How does the brain work?” and let us know the result. In the interests of good data collection, we would like it in the following format:
1. Taxi driver name, 2. pickup site, 3. drop-off site, 4. cost of ride.
This could all be important data! Send your responses in to or comment on NOIjam.

I will periodically publish your taxi driver experiences on our NOIjam blog as they come in. We would love to create a world-wide snapshot of how people think the brain works. The top five published responders will be announced at the end of next month and will receive a copy of the Explain Pain Second Edition eBook. Let’s see if we can build a Cabbie Cortex!

And a very happy (taxiing) Christmas from all at NOI.

David Butler, Noigroup

Last month’s NOI Notes The Rollercoaster of Professional Life received so much feed-back. It was so lovely to hear from everyone, your feedback and treatment tales. I will be addressing these responses in the new year!

What’s happening on NOIJAM?
Education for all
Great Minds – Nelson Mandela
The potential perils of specialisation
Mind your mirror neurones

2014 courses – first quarter

Adelaide, Mar 21-22: Explain Pain, David Butler
Melbourne, Apr 4-6: Explain Pain 3 Day, D.Butler, L.Moseley & Prof Mark Jensen
Sydney, May 9-10: Explain Pain, David Butler
Plans in train for Perth and Brisbane, and open to further invitations.

Montreal QB, Jan 24: Graded Motor Imagery, Sam Steinfeld
Montreal QB, Jan 25-26: Mobilisation of the Nervous System, Sam Steinfeld
Guelph ON, 8th Feb 8-9: Neurodynamics and the Neuromatrix, Laurie Urban

Warsaw, Poland, Feb 28 – Mar 2: Mobilisation of the Nervous System, Irene Wicki
Saarbrücken DE, Mar 21-23: Mobilisation des Nervensystems, Irene Wicki

Doorn, Jan 17-18 : Graded Motor Imagery, Tim Beames
Arnhem Jan 18-19 : Mobilisation of the Nervous System, Michel Coppieters
Arnhem, Jan 25-26 : Neurodynamics and the Neuromatrix, Michel Coppieters
NOI in the Netherlands Facebook page

Frimley, Jan 25-26: Mobilisation of the Nervous System, Stephanie Poulton
Colchester, Feb 1-2: Mobilisation of the Nervous System, Stephanie Poulton
Doorn, Feb 7-8: Explain Pain, Tim Beames
Oxford, Mar 15-16: Explain Pain, Stephanie Poulton
Middlesbrough, Mar 22-23: Mobilisation of the Nervous System, Ben Davies
London, England Mar 23-24: Mobilisation of the Nervous System, Stephanie Poulton
Dublin, Ireland Mar 29-30: Explain Pain, Ben Davies
NOIUK Facebook page

Berkeley, Jan 11-12: Pain, Plasticity and Rehabilitation, B.Haslam (NOI AU) & S.Schmidt
Portland, Jan 18-19: Pain, Plasticity and Rehabilitation, B.Haslam
Chicago IL , Jan 25-26: Pain, Plasticity and Rehabilitation, B. Haslam
Boston, 8th Feb 8-9: Explain Pain, D.Butler & R.Johnson
Atlanta, Feb 15-16: Explain Pain, D.Butler & R.Johnson
Dallas, Feb 22-23: Explain Pain, D.Butler & R.Johnson
Madison, WI, Mar 8-9: Explain Pain, R.Johnson
Buffalo, USA Mar 22-23: Graded Motor Imagery, T.Beames (NOI UK) & R.Johnson
NOIUS Facebook page

Search for and enquire about NOI courses here

The Rollercoaster of Professional Life

November 14, 2013

The first wave
Forty years of practice beckons – what a rollercoaster! When I emerged proudly with my degree in the late 70s, all packed with Maitland style manual therapy, I was convinced I could fix all and sundry and I often opened a clinical conversation with “what can I fix today.” ( I feel ill saying it now!) Anyway, it all worked well for a few years but then I noticed that “it” was not delivering the goods so well. Unbelievably some patients dared not get better. Things were feeling professionally grim, career changes were pondered, but then, proud and erect, fresh from New Zealand, Robin McKenzie rode into town, maybe even on a white horse!

The second wave
Wow – this was it! How silly was I to miss the disc and the novel notion of actually getting people to treat themselves and to give your thumbs a good rest. People started getting better again, my practice was full of lumbar rolls, the “Treat your Own” books and models of discs and I was on a roll too. This McKenzie approach worked wonders for a few years, but then the outcomes began to taper off, some patients wouldn’t improve, some wanted the old fashioned hands on that I had given away and a now familiar professional grimness emerged again.

The third wave
I heard about a year-long Maitland course in South Australia and I reasoned that there must be more to it than I’d first thought, so I signed up for the year. That was intense! I made it through a bit wounded but the old “I can fix anything returned” and I went into the outer suburbs of Adelaide to ply my trade, wriggling and cracking joints and doing the new teasing nerves stuff. People got better again! and complex problems seemed to dissolve. But would you believe it – it happened again – the clinical outcomes tailed off with what I now recognise as centrally sensitised states, overuse syndrome and complex regional pain syndrome.

The fourth wave
By now I was becoming a bit older and wiser and thinking deeper about things- so I thought –”stuff the others – I’ll work it out myself” And so I went off on the “neural tension” bandwagon – the idea of the physical health of the nervous system and mobilising nerves. I did some reading, had a few thoughts, stood on the shoulders of a few others and even wrote a couple of books. This was it I thought! Life will be easy from now on as we wriggled and glided and teased nerves from head to toe. Patients flocked in…… but the old diminishing outcomes emerged again, even for something I had helped to invent. Grim days – coffee was coming into fashion I pondered becoming a barista and I investigated what it would take to become a marriage celebrant.

The fifth miniwave
I was getting very wary now – the early work of Vladamir Janda was being updated and researched, particularly at the University of Queensland and once obscure bits of anatomy such as transversus abdominis, obturator internus and short neck flexors were now the new targets and the “with it” practitioners had ultrasound machine to view muscles. I went to the courses and gave it a go but my heart wasn’t in it. The outcomes were eluding me again. I tried the taping too but like a focus on a single muscle, it just didn’t make enough sense.

I drifted off into the world of pain and neuroscience and am still happily there. No magic, just a lot of hard work using neuroscience to fuel educational and imagery therapy and the good parts of the historic waves I’ve ridden. I thought I may have reached nirvana with the brain, but now I realise that neurones are only 10% of the brain and as the rest is immune cells, so there is long way to go.

Two thoughts:
I look around now at the course advertisements in the back of the journals and it seems the new roller coaster is driven by dry needling and someone called Pilates. No doubt some people are flying with it, and good on them, but not me – I am too war weary to get on the roller coaster again but I am sure there is something in it like there is in everything and if your professional paradigms are wide enough and trending towards biopsychosocial then there is a rational place for everything. The waves are not a loss if you can absorb them.

What bugs me is that it took so long to realise that it was I myself who was probably the main variable in outcomes – not the techniques. I am not saying that massaging patients with a wet salmon will help. However the interactional power needs better analysis and understanding and as Pat Wall would say ‘in the end, if the majority of the outcomes are based on placebo, do not fear, but work out what it was in the placebo which gave the outcome”.

To finish off, here’s a bit of Love Rollercoaster for you.

David Butler, Noigroup


What’s happening on NOIJAM?
Nudity and the clinical scientist – can there be therapy for pain by going nude?
Snoring in Afghanistan
Hunger pains in the US
‘Back infection’ mop up
Louis Pastuer
Here’s to whistleblowers and tiny testicles


Faculty travelling the world…

Brendan Haslam (AU)
USA: Inaugural presentations of Pain, Plasticity and Rehabilitation
Berkeley CA, 11-12 Jan 2014, with Steve Schmidt | Chicago IL, 25-26 Jan 2014
Michel Coppieters (AU)

South Africa: Presenting Mobilisation of the Nervous System – Cape Town 22-23 Nov | Durban 24-25 Nov | Pretoria 30th Nov -1 Dec
Netherlands, Arnhem: MOTNS on 18-19 January and N&N on 25-26 January
David Butler (AU)
USA: Presenting Explain Pain with Robert Johnson – Boston 8-9 Feb| Atlanta 15-16 Feb| Dallas 22-23 Feb
Tim Beames (UK)

Netherlands, Doorn: Presenting GMI on 17-18 January and Explain Pain on 7-8 February.
USA, Buffalo: Presenting Graded Motor Imagery on 22-23 March with US lead instructor Bob Johnson.
Denmark: Presenting MOTNS and GMI courses in 2014!
Irene Wicki (DE)
Poland, Warsaw: Presenting MOTNS on 28 Feb – 2 March

COURSES BY REGION… next six months
DENMARK 2014 With Tim Beames
Arhus: Mobilisation of the Nervous System, 3-4 May
Arhus: Graded Motor Imagery, 18-19 October

Warners Bay: Graded Motor Imagery, 16-17 Nov, David Butler
Melbourne: Graded Motor Imagery, 23-24 Nov, David Butler
Sydney: Explain Pain, 9-10 May, David Butler
Perth: EP, PPR, GMI courses – details to be confirmed.
With Sam Steinfeld and Laurie Urban
Montreal QB: Graded Motor Imagery (one-day), 24 January
Montreal QB: Mobilisation of the Nervous System, 25-26 January
Guelph ON: Neurodynamics and the Neuromatrix, 8-9 February
Toronto: Mobilisation of the Nervous System, 5-6 April
Fredericton NB: Graded Motor Imagery (one-day), 18 August
USA 2014 – a great year for guest lecturers…

David Butler presents in Explain Pain course in Boston, Atlanta and Dallas February 2014 (see him also at at the APTA CSM)
Tim Beames presenting the Graded Motor Imagery course in Buffalo on 22-23 March.

NOIUS Facebook page
EUROPE German speaking courses:
29-30 Nov, Schmerzen Verstehen, Zurzach DE, Martina Egan-Moog
16-18 Dec, Clinical Applications: Upper limb, thorax and neck, Hamburg DE, Harry Von Piekartz
21-23 Dec, Mobilisation des Nervensystems, Bad Zurzach CH, Hugo Stam
21-23 March, Mobilisation des Nervensystems, Saarbrucken DE, Irene Wicki
25-27 Apr, Mobilisation des Nervensystems, Zurzach CH, Hugo Stam
25-27 Apr, Mobilisation des Nervensystems, Hamburg DE, Irene Wicki
NETHERLANDS 2014 with guest lecturers:
Tim Beames (UK) in Doorn:
GMI on 17-18 January and Explain Pain on 7-8 February
Michel Coppieters (AU) in Arnhem
MOTNS on 18-19 January and N&N on 25-26 January
ITALY Mobilizzazione del Sistema Nervoso:
Belluno, 23-24 November, Ruggero Strobbe
Warsaw: Mobilisation of the Nervous System, 28 Feb – 2 March, Irene Wicki
Tim Beames
Lincoln: Explain Pain, 23-24 Nov
Bournemouth: Explain Pain, 30 Nov – 1 Dec
Netherlands, Doorn: Graded Motor Imagery, 17-18 Jan
Netherlands, Doorn : Explain Pain, 7-8 Feb
Tim also travels to the USA to present Graded Motor Imagery, Buffalo, 22-23 March.
Stephanie Poulton
London: Mobilisation of the Nervous System, 30 Nov – 1 Dec
Frimley: Mobilisation of the Nervous System, 25-26 Jan
Colchester: Mobilisation of the Nervous System, 1-2 Feb
Ben Davies
Dublin, Ireland: Mobilisation of the Nervous System, 23-24 Nov
Carlisle: Graded Motor Imagery, 30 Nov
Middlesbrough: Mobilisation of the Nervous System, 22-23 March
Stockport: Mobilisation of the Nervous System, 29-30 March
NOIUK Facebook page

Nudity and the clinical scientist

October 2, 2013

Somehow, on holidays and being invited to visit long lost friends in France, my wife and I found ourselves in the world’s largest nudist colony at Cap D’Agde. Not being a nudist (other than the odd skinny dips some years back when I had abs) but happy, albeit wary and a bit panicky early on –(talk about graded exposure!) to go along with our dear friends, I suddenly found myself on the beach, pink from the Australian winter, surrounded by 20,000 very brown, tightly packed nudists. I am sure you could have spotted me from Mars!

Lying on the beach and observing the passing parade, the clinical scientist in me quickly emerged. “What good posture nudists have and how happy and freely mobile they seem to be”, were my first thoughts. And such body confidence too, despite all shapes, sizes, ages, scars, missing bits and extra bits. I noted people with what appeared to be MS, stroke, and Parkinson’s. A quick on- beach Google brought up an old study suggesting that nudists have better body concepts than non-nudists (Story 1984). Another Google search found support for this and also the finding that college students who were more pro-nudity were more accepting of other religions, gays and lesbians than those who were less pro-nudity (Negy &Winton 2008). Well at least I am scientifically safe I smugly thought.

It’s a well- known saying in these parts that without clothes everyone is equal and that you can’t be judged with your clothes off. In fact, the study cited above (Story 1984) reported that body judgements made by male nudists were based more on function than attractiveness. My wife disagreed with this finding. 1984 is a long time ago and it may well now be “lovely hips” rather than “gee those hips work well”. But are we equal? It seems that, even in the wearing of a tiny piece of jewellery, a piercing or a tattoo, the inevitable augmentation, or the waxing or style of waxing of body hair, an element of judgement, discrimination and potential inequality is reintroduced.

But readers – what a fabulous feed for the mirror neurones! Imagine if you had a sore shoulder and you let it escape from all those clothes and straps and all around there were thousands of naked shoulders doing all sorts of activities “with you”. There is a freedom, a liberation of the senses in removing one’s clothes, it appears, that allows also a freedom of movement, and probably an adjustment/liberation of the brain representation of body. What of the body ‘force field’, the space around our body encoded in our representations of self that appear altered in some pain states and with the arms crossed. Do clothes and fashion alter the extent and potency of this space? Should Moseley, Gallace and others (2012) involved in this research area run some trials in a nudist camp and include the nudity variable? They’d have to be in the nuddy as well! Sometimes variables turn into treatments. Once again, talk about graded exposure! Maybe there is something in showing the world your sore, missing or misshapen parts and then realising that the world doesn’t care as much as you thought they did.

And gosh! Whatever happened to body hair? A lot of people wax these days, or is this sampling error judgement? Is it healthy?

I am not sure if a return visit is on the cards, but I am sure our readers have some good thoughts, stories and experiences to add here. Best to add the stories over on the NOIjam blog.

Moseley GL. Gallace A 2012 Body illusions in health and disease: physiological and clinical perspectives and the concept of a “cortical body matrix” Neurosci Biobehav Rev 36: 34-46
Story M 1984 Comparison of body Self-Concept between social nudists and non-nudists. Journal of Psychology 118:99-102

What else is happening on NOIJAM?
Hunger pains in the US
Back infection mop up
Louis Pastuer
Here’s to whistleblowers and tiny testicles

Michel Coppieters (AU)
South Africa: Presenting Mobilisation of the Nervous System – Cape Town 22-23 Nov | Durban 24-25 Nov | Pretoria 30th Nov -1 Dec
Netherlands, Arnhem: MOTNS on 18-19 January and N&N on 25-26 January
Tim Beames (UK)
USA, Buffalo: Presenting Graded Motor Imagery on 22-23 March with US lead instructor Bob Johnson.
Netherlands, Doorn: Presenting GMI on 17-18 January and Explain Pain on 7-8 February.
Irene Wicki (DE)
Poland, Warsaw: Presenting MOTNS on 28 Feb – 2 March.
David Butler (AU)
UK, London: Presenting Explain Pain on 12-13 October
USA: Presenting Explain Pain with Robert Johnson – Boston 8-9 Feb| Atlanta 15-16 Feb| Dallas 22-23 Feb

All NOI courses

She crumbled like a biscuit

September 4, 2013

This is an ontological metaphor – use of language to describe/express something which can be difficult to lay words on – things like life, and love and anger or in the case of my friend – sadness and loss. The metaphor theorists have discussed this in detail (Lakoff and Johnson 1980; Kövecses 2010) though not particularly in regard to pain. Of course, pain is another “thing” that often defies language, even analytical thought, especially severe acute pains and many chronic pains. Pain related ontological metaphors such as “I am falling apart at the seams” or ‘I’ve got my Mum’s painful knees” are attempt to objectify pain, to make sense of it, to convey it to others, to help construct a blame source or to set up an escape route – “I need to pull myself together”.
Perhaps we want pain, more than anything, to be objectified. We want to find the non-private parts of pain and share it. It makes you realise how people hang onto the health practitioner’s words or the suggestion of something odd in a scan, even though the image may have been taken years ago – “I might have a little disc bulge in there” says a 75 year old.
Next time someone says to you “I am going to pieces” or “I just feel so fragile today”, or something similar, pause a moment and consider these ontological metaphors and what they may mean. Perhaps the “pieces” allow links to a jigsaw or something broken. Perhaps “fragile” to a glass object or something that does not travel well. These are attempts to objectify.
We have informally sampled around 300 therapists, asking for the metaphors that patients are using. Dozens of ontological metaphors based on a “journey” emerge such as “it’s been a rocky road”, “the pain is dragging me down”, “I was cruising last week”, “I am at a cross road” or “there is light at the end of the tunnel” or more blatantly “I didn’t realise this operation would be such a journey”. The “journey” as discussed by Lakoff and Johnson provided an avenue for verbalising.

But I am a manual therapist not a linguist!
Most of our readers are manual therapists, but not all. More so than our medical colleagues, therapists have time with patients and are also in the unique position where we often talk to patients without looking at each other – this always offers a chance to say things you may not have said face to face. A key part of the Explain Pain work is giving understanding and assisting the emergence of self- explanatory language – an individually tailored description of how the brain works in pain may make someone aware that they are not “coming apart at the seams”. However, there is a risk involved…

A possible problem with Explaining Pain
What I am suggesting above is that we should try to objectify pain and help the patient take it further than their initial attempts. There is no other way than physical imagery (both in our therapeutic stories and in delivery methods) to allow the mind to form a view of pain. But herein lies the problem – if we objectify it, we risk making it an entity i.e. THE pain, MY arthritis, as opposed to a process of which changeability is the most powerful component. We know that many patients come away with the wrong message and, despite our/your best efforts allow their existing mental concepts to twist your message into a flawed concept. (“He thinks it is all in my head, he clearly doesn’t know, makes me sure that the problem is my unstable vertebrae.”)
Our words lead us to what we might become – and that may be all we have. I am left with the “broken biscuit” entity rather than the complexities of an emergent process such as sadness.
These are complex issues – the answer is perhaps to assess existing mental concepts first so that knowledge can be tailored to these neurosignatures. We need help and discussion here – it’s all part of the next phase of Explain Pain and the issues are increasingly appearing in Explain Pain courses.
Further clinical discussion on this topic, a forum to share your patient’s ontological metaphors and a place to discuss the rather complex issue of explaining pain without harmfully objectifying is at the NOIjam blog.

Kövecses, Z. (2010). Metaphor. New York, Oxford University Press.
Lakoff, G. and M. Johnson (1980). Metaphors we live by. Chicago, University of Chicago Press.
Explain Pain – A Second Edition!
The highly regarded book Explain Pain, written by pain specialists Dr David Butler and Professor Lorimer Moseley, sparked the introduction of neuroscience education as therapy a decade ago. The second edition of this book, which is available now, contains the most up-to-date scientific information to help pain sufferers understand and overcome pain.
David Butler, founder of the Neuro Orthopaedic Institute, says that “it is no longer acceptable that pain be just managed: we must expect that it can be treated, and sufferers can alter it themselves through education.”
Explain Pain Second Edition is AVAILABLE NOW at


Have a painful yarn to share? Well we want to hear it! In 150 words or less tell your best painful yarn to for your chance to win a Painful Yarns eBook.

“Moseley is pain management’s answer to James Herriot. This book captures that illusive ability to both educate and entertain.” Dr Michael Thacker

“…this is clearly the best book about clinical pain that I have ever read.” Dr John Keltner

“Painful yarns are about life. The way Moseley turns them into metaphors about pain is brilliant. This is a real gem.” Diane Wilkinson

For further clinical discussion on this topic, and others, head over to NOIjam

What else is happening on NOIJAM?
Different Cracks
A problem Shoulder
Kahlo’s Cracked Column
Bob and Neural Tissue
Everyone Needs a Break, Right?

Where will David Butler be?
London UK 2013
– Explain Pain: 12-13 October
Australia 2013
– Explain Pain: Perth 19-20 October | Melbourne 9-10 Nov (FULL)
– Graded Motor Imagery: Warners Bay 16-17 November | Melbourne 23-24 Nov
USA February 2014, Explain Pain courses with Robert Johnson
– Boston 8-9 Feb| Atlanta 15-16 Feb| Dallas 22-23 Feb

Search for and enquire about NOI courses here

Explain Pain and the hunt for better outcomes

June 26, 2013

Some people instantly understand and run with the powerful therapeutic benefits of pain stories – for some, the stories are easy to deliver, gratefully received and a useful knowledge enrichment follows.
But for others, the stories are rejected, the patient looks confused, and angry, saying things like “how dare you suggest it has something to do with my brain” or “yeah, but my pain is different to the one you are telling me about”.  At NOI, we try different metaphors, stories, educational applications and contemplate variables impacting on whether they “get it” from multiple domains – that of the deliverer, the learner, the message and the social context. Prompted by recent work from educational psychologists (Chi, Roscoe et al. 2011), we are increasingly aware that an important variable may be whether the learner and the deliverer have emergent neurosignatures in their brains.

Emergent neurosignatures?
A neurosignature (schema, mental framework) is a body of knowledge in the brain constructed by a pattern of brain cell activity.  Emergence is something which “just happens” or appears to just happen – examples are applause, consciousness, diffusion, traffic jams, ants’ nest activity, bankruptcy, and erosion. Emergence, or emergent patterns are things that occur, often surprisingly, when a collection of objects interact with each other in complex ways.  The ‘objects’ might be water molecules, neurones, insects, animals, humans, cars, or clouds.  The patterns or phenomena that emerge could be a snowflake, a thought, a swarm, a herd, a crowd at a water fountain during a music festival in summer, a traffic jam or weather.

The players or agents (eg cars in traffic jams, neurones in consciousness) in an emergent pattern have reasonably equal status, the overall outcome emerges from the combined and simultaneous activity of the agents and just a small action of one of the agents can have disproportionate effects. For example, the actions of just one car may set off a massive traffic jam, but it still requires all agents (e.g. all cars, road conditions, weather, drivers, time of year etc.)  to make the traffic jam. Take erosion – many factors contribute, but then the whole bank of a river could give way with normal water flow.

Love, fear and movement are emergent. So is pain – sometimes a tiny event, perhaps a thought, can kick off a nasty and chronic pain. Some historical events like the fall of the Berlin Wall are also emergent. To deeply understand emergent patterns, you probably require emergent neurosignatures (schemas, mental frameworks) in your brain.

I would like to suggest a hypothesis that patients might never understand the pain process because they (and maybe you) may not have emergent neurosignatures in their brains. Why is this worrying? And how do we fix it? Read on.

Sequential and linear patterns
Other patterns and processes in our lives are more sequential and linear – moon phases, the circulatory system, tissue healing, mitosis, the digestive system, and most childhood stories. There is often a dominant initiating process and the sequential nature means that something has to happen and perhaps be completed before the next phase. You eat then swallow then digest. You sprain a ligament, it inflames, swells and remodels. Sequential patterns are usually more easily understood than emergent patterns.

Did you “wipe out” in high school science?
Conceptual change theorists and researchers such as Chi (Chi, Roscoe et al. 2011) have studied emergence in high school science students. Such students are known to have problems when they learn about processes that are emergent (diffusion, electricity, natural selection) – sequential patterns are usually less problematic (apparently nearly 10,000 papers exist on this topic!).  It has been suggested that these students may not have emergent neurosignatures/schemas in their brains, or that perhaps their emergent signatures may be dormant. If you try to understand and problem-solve processes that are emergent by using linear/sequential neurosignatures you will have trouble. Now I know why some parts of high school chemistry and physics were disasters for me!

Emergence and “Explain Pain” as therapy
This is likely to have great relevance for our pain education.

Do you ever wonder about patients (and colleagues) who just can’t get it? When a patient is totally fixated on a singular cause (perhaps a single piece of anatomy – “the bloody disc” or blame one person, “the bloody supervisor”) for a complex chronic pain state?

Or those who seem to know a lot about a lot of things, but can’t pull it all together, i.e. can’t ‘see the wood for the trees’?? Maybe they don’t have emergent schemas. When I mark assignments where the question requires some understanding of emergence (e “Describe pain as a brain output rather than an input”) some students are all over the place with piecemeal answers, others can pull it together – maybe they have emergent schemas?  With pain, of course, there will be many agents and contexts which simultaneously merge for the emergent output.

Did you ever think how sometimes you are educating about tissue healing (a linear sequential process) and then jump to a discussion on pain or cognitions (emergent) and as we mentioned earlier, see the patient’s eyes glaze over. Again, think about the patient who insists there is a singular cause/blame for a complex problem and can’t see any other possible contributions?

Maybe we need to teach our patients about emergence? Maybe we need to try to work out if they have emergent schemas first?  Emergence modules are now being trialled in the “Explain Pain” course.

Tim Cocks and I have discussed emergence, pain and education in greater depth in the blog post on

We are very keen to hear your thoughts there.

Chi, M. T. H., R. D. Roscoe, et al. (2011). “Misconceived causal explanations for emergent processes.” Cognitive Science 36: 1-61.

The Linguistic journey and pain

April 5, 2013

”It’s bone on bone at L4, mate”

If you have your brain thinking in a neuromatrix and neuroplasticity mode you could probably see that a limp output that is making someone hobble around is not much different to a language output such as “it’s bone on bone in my back”. Both are made by the brain, both are repeated innumerably, and both exist in widely distributed brain neurosignatures with probable overlap. There is no doubt that a limp would be a therapeutic target for any reasonable therapist. Get your patient to see what is happening in a mirror, stretch this bit and strengthen that bit etc. etc. And you could expect that better gait could decrease pain through a combination of altered limp circuitry in the brain, and healthier and more appropriate use of the body structures. But an alteration of the language output may be as clinically potent in desensitising pain neurosignatures and it certainly has not been considered as deeply in rehabilitation.

Nearly all readers would aim for full and best expression of motor outputs, but many patients are left with a limited linguistic expression of their injury and therapeutic journey. For example, left with language neurosignatures such as “I have a popped disc” or “it’s bone on bone in my neck/lower back”. I am sure you can think of many more. It’s like leaving someone with an uncorrected limp – any educationalist will tell you that what is uncorrected one semester will show itself magnified the next semester or year.

Metaphors in a diagnostic sense

Modern, high quality, clinical skills require assessment and delivery of neuroscience knowledge in both narrative and metaphorical forms, but it is metaphor in particular which dominates patients’ descriptive language and our education.
Metaphor has had limited study in the pain area, but a way to start viewing metaphors in a diagnostic sense is to listen to the patient’s stories and to try to categorise them.
On the NOIjam blog there are posts seeking information and feedback on various metaphor categories to help our research. We welcome your help. Here are some suggested categories adapted from Lackoff and Johnson’ classic work on metaphors (1980).

‘Pain in the arse’ to ‘it’s totally stuffed’

We all use simple equalising metaphors all the time (‘he is a pain in the arse’, ‘she has a heart of gold’, ‘it hurts like hell’) – these are common, useful, colourful, open ended ways to express yourself.

Many patients use invasive metaphors (‘like a knife in there’, ‘my head is in a vice’) and sometimes therapists give them to patients ‘it feels like something is out of place’, ‘your pelvis has slipped’. X-ray findings – ‘degeneration, compression’ etc. – also create a perception of invasion, which these days we are aware could have potentially unhealthy immunological ramifications with glial cells on alert for challenges to the representation of the part in the brain. These metaphors need softening, reframing, removing.

Ontological metaphors are when people try, often desperately, to verbalise and objectify abstract notions such as pain and emotions (‘I feel as though I am going to pieces’, ‘It’s so fragile’). Just like new movement is precious post injury, so is emerging language as patients try and objectify and grasp what is often not objectifiable – i.e. pain, especially chronic pain often has nothing to link it to as smell has coffee, touch has texture and hearing has The Bee Gees. Patients want to grab this thing ‘pain’ inside then take it by the scruff of the neck, give it a damn good shake and have a look at it. No wonder they cling to a mere mention of ‘disc bulge’ if it gives it some object. This emergence of language needs to be helped and guided.

Some metaphors are orientational as in ‘my back is out’, ‘it goes up to my head’, some are static (‘something is wedged in there’) or mobile as in ‘it moves from back and goes into my groin’. I have no ideas what it might mean – maybe it will show up as a diagnostic in some smart study, but the change in language to a more normal output would be ideal.

Yet other metaphors suggest a separation of body and mind or ownership, as the problem gets labelled ‘it’, or even ‘my back is killing me’ suggests a separation of ‘back and ‘me’. ‘I want to cut it off’ or ‘give me a new one’ are also suggestive of disembodiment and the need, where possible, to get that person to take back and love the body part again.

Yet others are prognostic. ‘It’s stuffed’. ‘It’s completely ruined’ are common, but it’s not all bad as another metaphor could be ‘there is light at the end of the tunnel’.

So what?

I think that analysis of metaphors, based on the clinical question of ‘why are they saying this at this particular time’ and then considering whether the language could be diagnostic or need change/reframing, or is it just the local vernacular? This discussion continues on NOIjam and we would love to get your input.

Lakoff, G, Johnson M. (1980) Metaphors We Live By, Chicago, University of Chicago Press.

Blackberry Thumb

February 1, 2013

I have self-diagnosed myself with ‘blackberry thumb’ (BT)! Bear with me and my personal minor health story. This is quite exciting as I have never owned a blackberry but I admit to being a recent convert to texting, perhaps tripling the amount of texting that I do in the last month. Blackberry thumb is basically pain in the thumb from excessive texting. Isn’t it the most delicious diagnosis? You imagine a bruised black thumb and you kind of want to lick it and I much prefer the label to others suggested such as ‘teen texting tendonitis’ ‘wii-tis’ and ‘playstation thumb’. I thought it was quite exotic until I read that 1 in 6 British teens complain of hand pain while texting. With iPhone sales alone around 120 million a year and even more androids, there will be more aches and pains. It is predicted that there will be 2 billion smartphones in use by 2015. Blackberrys were invented before iPhones otherwise it might have been called iPhone thumb which sounds weird.

What is it?
If you read the various case studies in the literature, most refer to a thumb tendonitis or a joint arthritis. Maybe I am biased but my Blackberry thumb is a nerve irritation (an abnormal impulse generating site) in the dorsal nerve of the radial nerve (on the radial side). I think this is the first description of neurogenic blackberry thumb. I suspect (as in many other parts of the body) that peripheral neuropathic problems are often missed. Check out the image of my thumb in Figure 1.

The spotted part is where the thumb is slightly numb. I know numb is numb, but this area is slightly numbish. If I press the spot where the arrow is, the numbness increases and it can zing into the base of my nail – more of a thudding feeling than a pain. Of course I tried out an active radial nerve neurodynamic test – reaching down with an internally rotated shoulder and with my thumb flexed. This gives a real thudding feeling into the nail and I was wondering if it could neurogenically inflame the nail bed. However, it doesn’t do it always when I try and finds the thudding position again. This made me a bit frustrated at first and then I remembered that peripheral nerve problems often present with this unpredictability. The thumb looks exactly like the other thumb i.e. no swelling or colour changes.


Did my fat thumbs cause it?
I think it is from texting with a firmly flexed thumb interphalangeal joint with ulnar deviation pressure. Because my thumbs are bigger and fatter than most, I flex, ulnar deviate and almost rotate the distal phalange to get a more angular edge of the thumb, ie near the nail to hit the right key. Check out my texting style in Figure 2.

I think it will take a while for our thumbs to evolve to handle texting and by then there will be sure to be a better way of communication. Such flexion will give quite a local stretch of the nerve and it is the repeated unusual tweaking of the nerve that I think has caused this. Older peripheral nerve entrapment books mention that compressive forces such as scissor use could cause a similar neuropathy, but this is more a repetitive traction injury which has not been mentioned before in regard to blackberry thumb.


Peeking inside
I would love to peek inside the thumb, take a look at the nerve and then peek inside the nerve. Tiny nerves, especially in the extremities are very mobile – they have to be so we can move so much. Look at the dorsal side (back) of your thumb. Flex it and imagine how much the nerves just under the skin have to glide and stretch. I think I overdid this a little and I may have stretched a bit of myelin, maybe peeled some of the Nodes of Ranvier in outerlying fibres apart, there must be a little bit of intraneural inflammation and perhaps a bit of ion channel upregulation.

So what?
The main issue here is that peripheral nerves and their injuries and problems are missed ‘out there’. The brain is now so trendy – peripheral nerve research or even clinical consideration, is rare these days. Many people still think a peripheral nerve is like the cord on the television set, i.e. if you cut it, it stops working. Yet peripheral nerves are reactive, adapting, mobile parts of our bodies which deserve to be included in a wider view of the neuromatrix.

Does my BT need treating?
Some of these minor problems can go onto chronic problems. I think as long as you know about it, and don’t panic that you have some rare neurological disease this should be OK. I have adapted my texting techniques, in particular to using my index fingers which are more designed for dextrous work. I am trying some active radial nerve mobilising techniques which include the thumb and I am expecting that it will slowly go away in a month or so. Or you could take on texting with a sausage – an adaptation that has spread throughout South Korea and Russia to stop frostbite in the winter time.

Light blackberry relief
Ronnie Corbett also has an issue with a Blackberry – check it out 🙂

Last NOI Notes responses…
In last month’s NOI Notes we asked “Who is missing out on modern pain treatment?”. We had an overwhelming response, some detailed, and some pleading for help. Thank you for your responses. We can’t answer all of them, but there is no doubt that stroke, pelvic pain, face pain, post hepatic neuralgia, radiotherapy pain, post mastectomy pain, and fibromyalgia all need an outing.

NOI JAM BLOG – get amongst it!
There are nearly two billion people in the world with an ongoing pain state – we hope this blog provides a connection point for clinicians to discuss and brainstorm their cases. NOI jam is about:
•    providing an open liberal discussion forum led by experienced clinicians, focusing on the treatment of ongoing pain states via nervous system changing therapies based on movement and education
•    facilitating findings from science into clinical decision making,
•    enhancing links between clinicians and researcher,
•    bringing researchable ideas from the clinic to the fore.

We can’t take questions from individual sufferers nor can we provide individual treatment advice, however, patients may find reading the clinically orientated stories helpful and we hope that you can see that by providing these stories we are helping clinicians and indirectly helping you.

All posts submitted are monitored and, in most cases are put up within one business day of posting on noijam. Some delays due to time differences may be encountered. We welcome:
•    clinical commentary
•    patient treatment issues
•    the integration of both basic and clinical science into clinical practice
•    discussion on novel therapies based on science
•    discussion of pain problems that most clinicians have given up on.

All helpful, respectful, constructive and reasoned comments are welcome. If you are not sure, submit your proposed noijam post to for a friendly chat.

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