Archive for the ‘2014’ Category

Shin splints, relieving the tension

October 22, 2014

‘Shin splints’ are a real problem out there – common, painful, activity limiting and often treatment resistant. A bit of research on ‘shin splints’ (or the more recent, awkward, and I am not sure helpful term, ‘medial tibial stress syndrome’) in the medical databases, won’t provide much clarity in aetiology or agreement in treatment and you will find there are probably many different kinds of shin splints. If you Google ‘shin splints’, in-line with the growing trend, you’ll get lots of diagrams with multiple strips of brightly coloured tape applied in complex patterns.

Sometimes you need to be aware of the science, and move on. Move on to what you see in front of you – clinical scientists are often years in front of desk scientists.

Here is a clinical pattern I have seen many times over the last 30 years.

The history
I recently caught up with an old friend while teaching a course in Brisbane, Australia. She is a keen golfer, mid 40s, and had a left tibial fracture 3 years ago – it healed well and she was back to good quality golf within months. Six months ago she began to experience medial tibial pain radiating to the posterior medial malleolus in her left leg during and after golf. She had a medical check up – there was nothing sinister and no complications from the fracture. She also saw a number of therapists who proposed muscle imbalances in the leg, ‘switched off glutes’, trigger points and biomechanical issues in her feet – she had been told that both her feet were ‘flat’. Various therapies had been diligently applied and adhered to, including strengthening, stretching, suctioning, needling – even a bit of ‘core stability’ (perhaps this last one was thrown in as a ‘just in case’).
The end result for my friend was that she was avoiding golf and if she did play, used a cart to minimise the amount of walking. Especially, as she had been warned, on uneven ground.

Reported area of pain for shin splints

Reported area of pain for shin splints

The examination
I checked her out. There was nothing exceptional in the leg at the time of examination – nothing surprising at all for a 40 year old, active woman who had been fully functional for a number of years post fracture.

However, there was a clear neurodynamic finding which had not been examined in the past. In the slump position, with left ankle dorsiflexion/eversion and knee extension, the tibial area pain was recreated. Releasing knee extension released the tibial symptoms, as did releasing neck flexion. The same test on the right side revealed hamstring tugging and a better range of knee extension. I reasoned these to be relevant findings.

Post examination thoughts
I thought that there were two critical elements in the clinical presentation of the person in front of me. Firstly, and most importantly, an avoidance behaviour based on the (erroneous) fear that playing golf or exercising and experiencing any pain meant that there was further damage occurring and things were getting worse. One comment from my friend went something like ‘If I keep playing golf with my muscles all out of balance, the trigger points will come back and I’ll just make it worse’. Secondly, there was the relevant neurodynamic finding. If I was trying to be a bit smart, I might suggest that a third clinical element was a positive feedback loop between these first two, with the fear-based ‘though viruses’ helping to drive a sensitive nervous system which in turn provided erroneous evidence for the thought viruses to be maintained.

The treatment
We treated it. First I suggested not calling it ‘shin splints’ – this metaphorical diagnosis suggests that the problem needs support or outside help – aching shin, even just sore shin is better.
Secondly we moved her nervous system around a bit with the idea of restoring its sliding and gliding function and maybe flossing and flushing out some areas that had been a bit ‘sticky’ for some time.

We have recreated the assessment and treatment in the video below:

Thirdly, we chatted. I suggested that there may be a bit of an increased ache for a day or so post stretching as this sometimes happens but not to worry about it ‘It’s your body adjusting to the treatment’. I suggested that the problem now was a ‘bit of nerve and soft tissue irritation, it sometimes happens, even a few years after an injury as the brain holds memories of serious injuries and can react over time* – almost trying to heal it again so it puts a bit of useful swelling there which can irritate things. It gets a bit compounded when treatments don’t work or make sense and you start to worry – worry can make things more sensitive too. But this is all good – it will go. Go back to golf – there’s nothing that can be damaged – play 18 holes – a few aches and pains are fine and normal, continue the post game gin and tonic ‘

She played 18 holes of golf 2 days later – no problems. It’s now 3 weeks later, and with much golf and regular stretching there are no reported problems.

My thinking
Not all ‘shin splints’ are the same of course – some acute presentations may be serious medical emergencies** and should be treated as such. But my example is a common and repeated scenario and I believe that this problem is not often treated in this way.

This is not intended to be some crowing about a ‘miracle’ – there was no miracle cure, no quick-fix, no tricks, no secret technique performed by magical hands. There was just some basic clinical reasoning powered up by a modern, neuroimmune understanding of how pain works – or at least the best understanding available to us right now.

The kind of pattern reported above is common and will usually ease with the simple principles showed in the video. If I had to have a go at the pathology, I would suggest some tibial nerve irritation, perhaps even a minor compartment syndrome in the posterior compartment which houses the tibial nerve. How simple it would be to suggest that the nerve and its connective tissue sheath were sticky, perhaps with limited oxygenation, some local immune inspired inflammation perhaps also related to slightly altered anatomy post fracture. But more than that – I suggest that the person’s perception of the problem has also added to the sensitivity both locally and in neuroimmune territory representing the meaning and the function of the leg.

I rang my friend today and asked how she was going – ‘I am doing fine. Golf is no problem at all. It’s good to know I couldn’t hurt this paying golf and its good to have some stretches that I know are getting at it’.

Sometimes our game can be deceptively simple?

David Butler,

*We are talking here about a temporal brain glial response ? microglia and astrocytes have a danger surveillance function which may last for many years. If activated they may encourage responses in other systems such as the endocrine and sympathetic systems leading to swelling and increased local sensitivity.

**If you ever see or experience lower leg pain that commences suddenly, is associated with rapid and significant swelling of the lower leg, changes in blood flow, tingling and or loss of sensation don’t hesitate, seek appropriate medical assistance immediately.

Comment over at


The joy of anatomy

July 29, 2014

Can you recall the exquisite delight of your first anatomy class? The wonder and respect as you peered into a body and saw bits that could be linked to names and function; the muscles and tendons, nerves and joints that linked to the structure of your own body like a life-size jigsaw? Anatomy is such an important basic science behind rehabilitation. If there was a ‘rehabilitation guild’ responsible for keeping the secrets of the profession, anatomy would be the most carefully guarded knowledge.

Anatomy has its own language with echoes of the ancient past and at times seemingly impenetrable grammar and syntax – extensor carpi radialis, flexor digitorum profundis, substantia nigra and so on. For better or for worse, more than any other basic science, health language is constructed around anatomy ? it’s deep in our bones.

Anatomy offers much for technique and understanding. Interestingly, I’ve spoken to many clinicians over the years who have remarked that they wished they had learnt anatomy after they had started touching and treating people – to be able to move a joint or glide a nerve in a living body and then go and check it out in the lab to see what was happening on the inside. With university cuts to anatomy classes, such knowledge may truly become secret.

This noinotes is about two pieces of forgotten anatomy – bits of us that may be very relevant for the next person you see…

Ruff Ruff
Quick, which muscle in the body can contract to 10% of its length? There is only one and that is the iris of the eye (actually 2 muscles). The inner ring of the iris is crenelated with about 70 folds like an accordion. This ring is known as the pupillary ruff. Your pupils are probably around 3mm across right now, but they can get to almost a centimetre across – this was a real secret until flash photography. Google pupillary ruff and check out the great ruffs.









I have always observed pupils for odd shapes and sizes – I couldn’t help it after I once noted that a person with severe low back pain had a pupil completely flat on one side and rounded on the other – their ruff was in spasm. If I do an Upper Limb Neurodynamic test, I can’t help looking into the eyes – the pupil flares with pain and sometimes seems to flare in anticipation of pain. The pupil is a part of an integrated defence detection and response system as the organism works out “what is going on”. I wonder how much the shape, size and responsiveness of the pupil could be a measure of what else might be going on in a person’s life? So many things are now known to influence pupillary size –intellectual reading material, cognitive demand, emotions, lateral gaze, light of course, and pain. Movements may too – there are reports of neck flexion causing pupillary flaring, but otherwise there is not much in the literature.

Next time someone is in pain, peer into their eyes, check out their ruff and let us know if there are any odd pupil shapes or marked left right differences. It may well be a novel research area. Plus looking into someone’s eyes evokes a healthy oxytocin release for both of you.

The myodural bridge
What a name! I was always intrigued by the difference between a group of patients who could quite easily elongate their upper cervical extensor muscles (“pull your chin in”) and another group where upper cervical flexion was particularly sensitive and easily evoked headache. The repeated clinical anecdote is that the second group can flex their upper cervical spines more easily in sitting or even better, in supine with their knees flexed. This may well unload the myodural bridge.

myodural bridge

Enix DE et al 2014 J Can Chiropr Assoc 58: 184

Myodural bridges are connections between the cervical dura mater and the cervical extensor muscles. These connections probably anchor the dura and stop it folding in on the cord when you look up and extend your head back (Hack et al 1995, Rutten et al. 1997) – this may have been an evolutionary advantage to our ancestors as they gazed up in awe at the firmament! There is a great recent review out by Enix et al (2014) updating the anatomy of the bridges including sub occipital bridges and proposing clinical implications. Think of it next time you’re having a look at a patient’s posture as they sit in front of you with their worries and concerns – or ask someone to tuck their chin in. It also remind us that everything is kind of joined up in the body – discrete anatomy is for the textbooks.

Hack GD et al 1995 Spine 20: 2484
Rutten HP et al 1997 Spine 22: 924
Enix DE et al 2014 J Can Chiropr Assoc 58: 184

David Butler,

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Time for motor freedom

May 22, 2014

Motor control to motor freedom
A recent study published in one of the world’s premier medical journals (The Lancet) on treatment for whiplash using motor control principles has attracted a lot of attention (Michaleff et al 2014). A number of Australia’s best known researchers and clinical physiotherapists were involved in the study. 172 chronic whiplash sufferers (grades 1 and 2) were given a booklet to read and put into two matched groups. One had 20×1 hour sessions of treatments based on motor control principles and graded activity, the other group had a 30 minute educational session during which they read the educational booklet, could ask questions, were given advice to move and were offered two phone call follow ups. Both groups improved but the key finding was that the comprehensive motor control programme was no more effective than the 30 minute educational session. Essentially it doesn’t work for this particular group and probably for other groups in chronic pain.

I hope that people see this as a positive result – for patients, researchers, clinicians and for those who pay. These results may well be causing some angst in communities teaching and using the motor control philosophies which have dominated rehabilitation in Australia and elsewhere for the last 20 years. If not it should be as it strikes at the core of current practice and the findings are strong enough to influence practice.

Time for personal and professional reflection
Maybe those who had practice foundations based on motor control philosophies can admit they were not quite right. But that takes guts and sometimes a loss of years of clinical mileage which can be hard. Yet most clinicians in practice have had to do it at least once in their professional life. A vast amount of resources over two decades, and more than a little hype have gone into education, research, marketing and promoting the approach. These resources need urgent diversion elsewhere. The 12 month prevalence of chronic pain is around 39% (Tsang and 2008). Chronic pain is more prevalent than heart disease, diabetes and cancer combined (Jensen and Turk 2014). We should move fast. These findings may well lead to a professional redefinition. Maybe the main drivers of this approach could even apologise for hogging the conferences, agenda and research dollars?

There is a tough question that must be asked – Why did we ever think this approach would work? The philosophy of therapy used here assumes that chronic whiplash syndrome with its stigma and inherent biopsychosocial aspects is a motor control issue – as such it is therefore a focus on epiphenomena, on one brain output only, that of altered muscle activity, perhaps an example of pareidolia. Lost in the mass of research motor control minutiae is a simple question – what is the biology of ‘whiplash associated disorders’? A parallel view in existence for 20 years, based essentially on neuroimmune based plasticity and neuropsychology, suggests that reciprocal and adapting perturbations of input, processing and multiple coping systems of which the motor system is just one, should be entertained. In other words, the paradigm of motor control is just not big enough for a disorder such as chronic whiplash.

Time to stop bastardising ‘education’
Despite similar results, the therapist training in this study was heavily biased towards the intensive exercise group. The therapists involved were ‘experts’, had a one day pre-trial workshop, a mid-programme one day workshop and an audited treatment and advice session. There was involvement of Physiotherapists deemed specialists by the Australian Physiotherapy Association.

Nothing so detailed for training in the education group – this was 30 minutes which included reading the handout, answering questions and access to two explanation sessions. We have no information on the core educational competencies of the therapists, or whether they were even aware of and trained to answer the most common questions. Education is belittled – it is as though it is an accepted intervention which we are all competent and equal at!

The booklet itself is a biomedical booklet. It has been known for many years that biomedical styles of education do not help chronic pain states. (Cohen, Goel et al. 1994; Gross, Aker et al. 2000; Maier-Riechle and M. 2001) There is nothing in this booklet on the kind of education which is known to work – that of Explain Pain type education, something with an ‘A’ evidence grading on the National Health and Medical Research Council’s grading, i.e. – “the body of evidence can be trusted to guide clinical practice”. The Explain Pain style of education is not just advice to move or telling someone that the presence of pain may not signify damage, it is explaining the benefits of activity on all systems and it is explaining why ‘hurt’ does not necessarily equal ‘harm’. It is not saying that you have central sensitisation or other nervous system changes, it is explaining how the nervous system has become overly protective and what you can do about it. There are considerable competencies to achieve to be efficient at this form of education. Simply, in chronic pain states there will be multiple causes, structural and motor changes may well be one, but critically the symptomatology and disability depends more on what a person thinks, does, says, believes, who they meet and where they go.

And more bastardisation occurs. A Reuters report of the educational component of the study says it was ‘counselling’. Counsellors should be appalled. We need to get serious about how we define education and how we research it. If the education group in the study considered educational competencies and modern pain biology educational interventions known to work, I hypothesise that the outcomes would be better than that of the 20×1 hour group work. Education based on motor freedom principles may be better and a realisation that that includes immune, linguistic, emotional, cognitive, creative, autonomic and endocrine freedom as well.

Explore the second last line in the Lancet paper – “Last, how to successfully deliver simple advice needs to be established”. Advice is never simple. A Steve Job’s quote comes to mind “Simple can be harder than complex. You have to work hard to get your thinking clean to make it simple. But it’s worth it in the end because once you get there, you can move mountains”. A start would be to use the word ‘curriculum’, something rarely used in our clinics. If you are educating seriously you would have considered the notion of curriculum, both one-on-one or in a group. The word should instantly bring up content, delivery, timing and measurement. Perhaps educational psychology may be a new and better path to follow rather than health psychology.

This review is not a call to ‘down tools’ as has been suggested by one commenter in a lengthy, discussion in response to a Body in Mind blog on the same article. It is not a call to stop healthy expression of movement, but it is a call for urgent change and revision of the paradigms which we work under. It is a call to adapt and alter tools; to use the best evidence from basic sciences and clinical trials to develop new tools, and it is a call for a serious understanding of education as an intervention.

Many thanks to the authors for publishing this and congratulations on the quality of study which made it to one of world’s premier medical journals. This is useful use of taxpayer money if the findings alter and refine research and clinical practice.

Michaleff ZA, Maher CG, Chung-Wei CL,Rebbeck T, Jull GJ, Latimer J, Connelly L, Sterling M (2014) Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial. The Lancet
– Cohen, J. E., V. Goel, et al. (1994). “Group education interventions for people with low back pain. An overview of the literature ” Spine 19: 1214.
– Gross, A. R., P. D. Aker, et al. (2000). “Patient education for mechanical neck disorders.” Cochrane Database Systematic Reviews CD000962.
– Jensen, M. P. and D. C. Turk (2014). “Contributions of psychology to the understanding and treatment of people with chronic pain.” American Psychologist 69: 105-118.
– Maier-Riechle, B. and H. M. (2001). “The effect of back schools – a meta-analysis.” Int J Rehabil Res 24: 199.
– Tsang, A. and (2008). “Common chronic pain conditions in developed and developing countries. Gender and age differences and co-morbidity with depression-anxiety disorders ” The Journal of Pain 9: 883-891.

Help for pelvic pain
Millions of women around the world suffer from pelvic pain. Are you one of them? The University of South Australia is running a survey to develop a tool to measure the impact of pelvic pain on women’s lives. If you think you may be eligible and are interested in participating, visit the survey, or contact the primary researcher, Jane Bowering by email.

David Butler, Noigroup


April 10, 2014


In this world of brain plasticity and the excitement it engenders we may sometimes forget the complexities of the rest of body and maybe also, the rest of the nervous system.

The T6 area in the clinic
What is it about the T6ish area? The middle of the back is a very popular place to experience pain and tightness. About 30 years ago, as the neurodynamics thinking emerged, I was intrigued with this area. A repeated clinical pattern exists where many people with positive straight leg raises (SLR) or slump tests often complain of pain around the T6 area. Additionally, if someone had a positive SLR or passive neck flexion, suggesting some alteration of meningeal biomechanics, palpation around the T6 area often revealed tenderness and stiffness, usually unbeknown to the owner of the back. People, post whiplash, often have this finding and indeed whiplash sufferers who complain of pain in the mid thorax may have a worse prognosis (Maimaris, Barnes et al. 1988). Many clinicians reading this blog are well aware that if you gave the mid thorax a bit of a wriggle and shake, the whole body movement can improve and SLR and slump test findings will often improve, sometimes markedly.


The science
Intriguingly, some science on neuromeningeal biomechanics emerged at the time of developing neurodynamic theories. With an extrapolation from a 24 human cadaver study by Louis (1981), supported by earlier work by Breig (1978) and painstaking monkey dissections by Smith (1956), the year I was born! I came up with the image below from “Mobilisation of the Nervous System (1991). The spinal canal could be around 9 centimetres longer in flexion than extension – somehow the contained cord and meninges have to adapt. Check out the T6 area – it doesn’t move that much in relation to the surrounding canal – kind of like if you pull a piece of elastic from both ends, there is a bit in the middle that doesn’t move much in relation to its surrounds.

If there was something special about the area then you would expect that the anatomy would express something about the function. While there has been minimal study (and few would bother today), the major blood vessel for the thoracic cord and meninges comes in just under T6 – so it’s probably not a good place to have a lot of sliding around, and in addition, the canal here is quite narrow and the dura mater is thicker than anywhere else along the neuraxis. Maybe it is designed to be like the middle of a piece of elastic?

T6 today
Pause a moment and marvel– the spinal cord in the thorax may only be a little over a centimetre in diameter with the surrounding canal maybe around 1.4 centimetres and also containing meninges and cerebrospinal fluid (CSF) whose freshness is necessary for cord nutrition. This tiny area has a lot of work to do in representing the low back, pelvis and legs. I think it is best to add the cord into modern concepts of representation and neuromatrix which are often all brain based.

I think that no matter what, if central sensitisation is considered, then the physical health of the nervous system including the cord should be entertained. Is the T6 area a place that is perhaps biomechanically more at risk than other parts of the nervous system especially when you consider what humans do with their bodies these days? Physical problems with physiological consequences could result in significant nociception from the meninges, peripheral neurogenic contributions from sinuvertebral nerves innervating the meninges, and nerve roots plus mechanically induced contributions to sensitisation. The slump test, especially in long sitting may be useful to check it out and I am sure the area loves inputs such as yoga, dance, martial arts and just a good old roll around on the floor.
In conclusion, there is a place in the biopsychosocial framework for T6.

Tell us your T6 stories

Breig, A. (1978). Adverse Mechanical Tension in the Central Nervous System. Stockholm, Almqvist and Wiksell.
– Louis, R. (1981). “Vertebroradicular and vertebromedullar dynamics.” Anatomia Clinica 3: 1-11.
– Maimaris, C., M. R. Barnes, et al. (1988). “‘Whiplash injuries’ of the neck: a retrospective study.” Injury 19: 393-396.
– Smith, C. G. (1956). “Changes in length and position of the segments of the spinal cord with changes in posture in the monkey.” Radiology 66: 259-265.

David Butler, Noigroup

Upcoming NOI courses

Melbourne April 11-12 Mobilisation of the Nervous System [FULL] Michel Coppieters
Sydney May 9-10 Explain Pain [FULL] D. Butler + L. Moseley
Perth June 14-15 Explain Pain David Butler
Perth June 20-21 Pain, Plasticity & Rehabilitation Brendon Haslam &David Butler
Winkler MA April 26-27 Mobilisation of the Nervous System Sam Steinfeld
Fredericton NB August 18 Mobilisation of the Nervous System Sam Steinfeld
Montreal Sept 18-19 Explain Pain Sam Steinfeld
Zurzach CH April 25-27 Mobilisation of the Nervous System Hugo Stam
Hamburg DE April 25-17 Mobilisation des Nervensystems Irene Wicki
Århus DK May 3-4 Mobilisation of the Nervous System Tim Beames
Ljubljana SI May 9-10 Graded Motor Imagery Tim Beames
Freiburg DE May 9-11 Mobilisation of the Nervous System Irene Wicki
Bad Zurzach CH May 9-11 Der “Problematische” Schmerzpatient Martina Egan-Moog
Saarbruecken DE May 16-17 Schmerzen Verstehen Martina Egan-Moog
Rheinfelden CH May 16-18 Mobilisation des Nervensystems Irene Wicki
Winterthur CH May 24-26 Mobilisation of the Nervous System Irene Wicki
Athens GR May 24-25 Explain Pain Tim Beames
Winterthur CH June 30 July-1 Graded Motor Imagery Hannu Luomajoki
Dublin June 7-8 Mobilisation of the Nervous System Tim Beames
London UK May 30-31 Graded Motor Imagery Tim Beames
Dublin IE June 7-8 Mobilisation of the Nervous System Tim Beames
Oxford UK June 21-22 Mobilisation of the Nervous System Ben Davies
Bournemouth UK June 21-22 Mobilisation of the Nervous System Tim Beames
Derby UK June 25-26 Explain Pain Ben Davies
London UK July 12-13 Explain Pain Tim Beames
London UK July 15-16 Mobilisation of the Nervous System Tim Beames
Derby UK July 17-18 Mobilisation of the Nervous System Ben Davies
Chicago May 10-11 Graded Motor Imagery Robert Johnson
Los Angeles May 17-18 Explain Pain Steve Schmidt
Los Angeles May 19-20 Clinical Applications: Lower Limb Robert Johnson
Philadelphia, PA August 9-10 Explain Pain Morten Høgh
Chile, US Sept 7-8 Mobilisation of the Nervous System Robert Johnson

Just one word

March 14, 2014

I was in New Zealand on the west coast two years back and a friend took me to see a rugby match between two Maori teams. What a rough match! It made me think “no wonder New Zealand has the best rugby union team in the world”. Anyway, I somehow ended up in the dressing room of one of teams before the match and was called upon to help strap ankles. I hadn’t strapped ankles for some years but the old skills quickly returned. A young shy limping lad came up to me and said “my ankle makes a funny crackling noise, is it OK?” I took a quick look, did some routine ankle stability tests, put some strapping on, “one extra piece for you” I told him, and then said “it’s safe” and “off you go”. The whole thing just took a few minutes and it was onto the next ankle.

I watched the game and noticed the youngster, playing on the wing. He ran, tackled and performed beautifully. I caught up with him after the match and said “How was your ankle?” He looked at me quizzically as if to say why are you asking and said, “it was safe” and just wandered off.
“Safe” – the incredible transformative power of one word, I thought. Readers will have many examples of course and we would love to hear them. And it can go the other way of course – just one word – “be safe with your bulging discs”.

Sticky words
From a neuroscience perspective, the word “safe” had quickly become ‘sticky’ in the young footballer’s brain. ‘Sticky’, meaning brain activity that is sensible, welcome, easily elaborated throughout the brain and accommodating and anchoring to other brain neurosignatures, in other words the word was neuro-modulatory. It makes me think – why can’t we achieve this in everyone and the processes that allowed this stickiness should be explored more.

Theta waves for best stickiness?
I am looking forward to a three day explain pain course with Lorimer Moseley and Mark Jensen in Melbourne next month. Mark is a psychologist, a professor at the University of Washington and among other things, the editor of the Journal of Pain.

Explain Pain courses are evolving quickly and one direction is the translation of words/information/story to peoples’ brains in ways that are sticky, useful and lead to more appropriate behaviours. Mark Jensen is involved in some intriguing research that may shed some more light on this. Brain activity assessed by electroencephalogram (EEG) shows brain waves in various frequencies – alpha, beta, theta and others – all much beloved by alternative health movements, but clearly needing more research. There are some correlations with rhythm activity and pain – for example with intense pain, beta frequencies increase more than other bandwidths and less pain is associated with a lessening of beta activity and increases in slow wave activity (eg. delta, theta). For a review see (Jensen, Hakimian et al. 2008). One basic hypothesis is that theta brain oscillations reflect a physiology of brain state that is ready to accept and process new ideas as opposed to the zoning out of alpha waves and information processing of beta waves. States of relaxation, mindfulness, and safety are likely to lead to theta brain waves and thus more stickiness and acceptance. This opens up a new world of clinical research that is instantly clinically relevant – neurobiofeedback, new research measures, allied therapies for explain pain, and contexts to improve explain pain outcomes.
Meanwhile, I do wonder what radical reconceptualisation and change of brain waves may have occurred in the footballer who now reasoned his ankle was safe.

Jensen, M. P., S. Hakimian, et al. (2008). “New insights into neuromodulatory approaches for the treatment of pain” The Journal of Pain 9: 193-9.

David Butler, Noigroup


The glory of traction
What are you reading?
Roentographical love
Festival therapy
Flashback Fridays – Zings, Zaps, Sliders and Tensioners
This video is going to hurt
A brave new (virtual) world
Routine therapy
Facing the pain
Flashback Fridays – What is a neuromatrix?

NOI courses around the world

Melbourne April 11-12 Mobilisation of the Nervous System Michel Coppieters
Sydney May 9-10 Explain Pain David Butler
Perth June 14-15 Explain Pain David Butler
Perth June 20-21 Pain, Plasticity & Rehabilitation Brendon Haslam & D.Butler
Winkler MA April 26-27 Mobilisation of the Nervous System S.Steinfeld & L.Urban
Fredericton NB August 18 Mobilisation of the Nervous System S.Steinfeld & L.Urban
Zurzach CH April 25-27 Mobilisation of the Nervous System Hugo Stam
Hamburg DE April 25-17 Mobilisation des Nervensystems Irene Wicki
Århus DK May 3-4 Graded Motor Imagery Tim Beames
Ljubljana SI May 9-10 Graded Motor Imagery Tim Beames
Freiburg DE May 9-11 Mobilisation of the Nervous System Irene Wicki
Bad Zurzach CH May 9-11 Der “Problematische” Schmerzpatient Martina Egan-Moog
Saarbruecken DE May 9-10 Schmerzen Verstehen Martina Egan-Moog
Rheinfelden CH May 16-18 Mobilisation des Nervensystems Irene Wicki
Winterthur CH May 24-26 Mobilisation of the Nervous System Irene Wicki
Athens GR May 24-25 Explain Pain Tim Beames
Middlesbrough March 22-23 Mobilisation of the Nervous System Ben Davies
Dublin June 7-8 Mobilisation of the Nervous System Tim Beames
Chicago May 10-11 Graded Motor Imagery R.Johnson
Los Angeles May 17-18 Explain Pain Steve Schmidt
Los Angeles May 19-20 Clinical Applications: Lower Limb R.Johnson

The Professional rollercoaster and burnout

January 22, 2014

NOI Notes always generate responses which we all enjoy but there has never been a response like the one to the recent Rollercoaster of Professional Life. There were hundreds which included many first time responders and they are still coming in. The Rollercoaster NOI Notes was an observation of the ups and downs of my professional life as I took on new ways, systems and gurus then discarded them, taking the good bits and finally belatedly realising that much of the outcome depended on features of me, not a system or technique. My rollercoaster is summarised below.


I want to summarise the responses and share some of the words of wisdom that came back. It occurs to me that the rollercoaster may well be linked to professional burnout – a problem in all professions and one where research is limited.

Most of us are on a rollercoaster
Most respondents said “hey that’s me too”. Even some recent grads were noting it too, but were pleased they weren’t alone. It makes me realise that this should be mentioned in undergraduate education. And I am glad the story made a few laugh! But when you do get sucked in by something and you realise it, it is probably healthy to laugh. Some thought I was at the end of the rollercoaster and retiring, thus the odd mini obituary (thanks for the nice words) but this is not true, I have a few potential waves still left in me!

Some younger respondents were relieved that there probably is no holy grail. And some too became aware of colleagues stuck on just one wave (eg “all they do is needle” or “they just go straight to iliopsoas”). A couple had found happy and fulfilling waves along the way with Feldenkrais. I think it helps to contemplate the waves – and as Mike says – “many thanks” and “I will remember this, the next time I become disheartened and want to be a plumber”.

Rollercoaster awareness and unpleasant memories
The notes did evoke unpleasant memories for some who recall visiting gurus as patients and being shouted at because they didn’t get better. I too recall lectures where you felt you could not question a particular guru. No wonder things cycle!

The notes got regular responder Cameron going – he asks “did any of my lecturers at university ever question a single assumption about any of these so called treatments?”. Being a lecturer back then, I guess, the answer is “probably not – sorry Cameron, we were sucked in”. Cam goes on to say “people are afraid of the truth – that the mind not only creates pain and injury and illness but it literally creates the whole world”, but that is a longer discussion we can have later on NOIjam.

Advice on flattening out the bump and limiting burnout
Positivity presented in the responses. As many respondents noted, as long as we are still curious, our jobs will be a pleasure. (Remember to evoke curiosity in your patients as well!). Nicole has a lovely line – it is the challenge of not always being right and thus having to think about and dive into the ever larger wealth of knowledge that helps.

Ernst comments that if rollercoaster recognition helps us sense our role and the power of the patient therapist relationship, new ways to treat should lead to reframing of patients’ behaviours and novel coping styles should emerge.

I enjoyed Allyssa’s rollercoaster – from transversus exercises to muscle energy to nutrition medicine to the visceral world and how just like in my experiences, each new approach initially appeared to be the answer. “Is it that I convey the placebo response to the patient because I am so newly overconfident after each course but after it is apparent it’s not the whole answer, they pick up on my doubts and the placebo is no longer transmitted.” Probably yes if placebo is taken as brainpower.

Craig has had a rollercoaster too but his physiotherapy practice has been helped by studying an MBA – leadership, ethics, marketing, motivation, teamwork, sales etc. Much like Allyson who has found support in Napoleon Hill’s “Think and Grow Rich” and Cameron in Jed McKenna’s “Theory of everything”. Professional improvement and burnout buttressing may not necessarily emerge from yet another rehab course.

The rollercoaster notes made some think quite laterally and deeply – Lezanne comments “it is clear my own wellbeing has an effect on patients” and coins the useful phrase “therapeutic use of self”. Deena brings up the issue that the rollercoaster context has changed and we now have to deal with pain systems increasingly bullied and tormented by policy makers. She asks whether bullying has any influence on pain (I don’t know but it probably does).

Perhaps Helen sums it all up by suggesting our job is essentially one of being a facilitator of change.

A final wave
I have been on my final wave for nearly 20 years now. A few people asked me what my next wave is. There is none. I am convinced that treatment foundations which combine modern neuroimmune science, education science, reasoning and evidence based movement enhancing strategies are the go – all what we teach at NOI.

Thanks again for such a response and messages of support. We have enjoyed them all here at NOI. These NOI Notes are also on NOIjam if you wish to comment.

David Butler, Noigroup


Adelaide March 21-22 Explain Pain David Butler
Melbourne April 4-6 Explain Pain 3 Day D. Butler, L.Moseley &
Prof Mark Jensen
Brisbane April 5-6 Mobilisation of the Nervous System Michel Coppieters
Sydney May 9-10 Explain Pain David Butler
Perth June 14-15 Explain Pain David Butler
Perth June 20-21 Pain, Plasticity & Rehabilitation Brendon Haslam & D.Butler
Montreal QB January 24 Graded Motor Imagery Sam Steinfeld
Montreal QB January 25-26 Mobilisation of the Nervous System Sam Steinfeld
Toronto April 5-6 Mobilisation of the Nervous System S.Steinfeld & L.Urban
Arnhem NL January 25-26 Neurodynamics & the Neuromatrix Michel Coppieters
Doorn NL Feb 7-8 Explain Pain Tim Beames
Warsaw PL Feb 28-Mar 2 Mobilisation of the Nervous System Irene Wicki
Saarbrücken DE March 21-23 Mobilisation des Nervensystems Irene Wicki
Frimley January 25-26 Mobilisation of the Nervous System Stephanie Poulton
Colchester February 1-2 Mobilisation of the Nervous System Stephanie Poulton
Oxford March 15-16 Explain Pain Stephanie Poulton
Middlesbrough March 22-23 Mobilisation of the Nervous System Ben Davies
London March 23-24 Mobilisation of the Nervous System Stephanie Poulton
Dublin IE March 29-30 Explain Pain Ben Davies
London April 5-6 Explain Pain Tim Beames
Crewe April 5-6 Explain Pain Ben Davies
Derby April 8-9 Mobilisation of the Nervous System Ben Davies
Las Vegas Feb 3 *FULL* Graded Motor Imagery David Butler
Boston February 8-9 Explain Pain D.Butler & R. Johnson
Philadelphia February 13 Graded Motor Imagery David Butler
Atlanta Feb 15-16 Explain Pain D.Butler & R. Johnson
Dallas Feb 22-23 Explain Pain D.Butler & R. Johnson
Buffalo March 22-23 Graded Motor Imagery T. Beames (UK) & R.Johnson
Doylestown April 5-6 Mobilisation of the Nervous System Robert Johnson