NOI Notes on the golden click

THE GOLDEN CLICK
The lure of the "golden click" has been with patients and manipulators for ages – the idea that there is a way of manipulating the spine, thus providing a panacea for many conditions. Those who manipulate have experienced tantalising hints of it – the instant removal of a headache with upper cervical manipulation, relief of gut symptoms with a thoracic manipulation, the almost magical instant effects on an "OA hip" with a properly executed lumbar manipulation. However, we all know that it doesn't always work.

THE CLUNK BETWEEN THE SHOULDER BLADES
My patient walked in slowly to the outpatients department in an English hospital. She looked ill and drawn. "What is wrong with you" I said. She replied "I rolled over in bed about 5 years ago and something went clunk in between my shoulder blades and I have been the same ever since… constant pain, dizziness and headaches." "What is life like?" I said. "Well I do a bit of part-time work for my husband, I am stuck at home most of the time, I don't like to travel far as I get sick and dizzy quickly, I can't sleep very well and there is not much happening in the social world as you can imagine." "Has your thorax been treated?" I asked. "Only with heat – most of the treatment has been aimed at the neck – they said it was referred pain."

THE EXAMINATION AND TREATMENT
I examined her. I noted that any neck and thorax movements were very limited and evoked pain and made her dizzy. In sitting, if she extended either her left or right knees it pulled in her thorax and evoked nausea and pain "I am used to that - carry on" she said. There were no hints of serious pathology and she had been through a medical workup recently "we can't find anything wrong except a stiff back." I could find no hard neurological signs with my testing. I gently touched her mid thoracic area. She recoiled instantly. A straight leg raise of 20 degrees also made her recoil and feel ill. I suddenly realised that I had no idea what to do. I reached for the ultrasound and gently sounded the back. There was silence (nothing worse than a lonely ultrasound!). I put a hot pack on. (This was some years ago!) "I don’t think that will help" she said. In my heart, of course, I knew it wouldn't either.

THE MANIPULATION
She returned two days later. "Absolutely no different" she said. I don't know what came over me. I got her to stand up. I stood behind her on the London Phonebook, grasped her by the elbows, put my ribs in around T5 and gave an almighty lift. Well……..she gasped, there were about 50 huge cracks, maybe more and then I had the unusual experience of a heavy unconscious female sliding down the front of my body onto the floor. It was my turn to gasp! – there was a student therapist following me for the week who was now all eyes and hand on mouth and all I could think to say was "quick, let's pick her up and put her on the bed before the boss comes!" I got her on her side, remembering my first aid…. she seemed OK, unfortunately just unconscious. A long 45 seconds later, just before I was about to call emergency she opened her eyes, looked at me and said "thankyou" and lapsed back into unconsciousness. I was trained by Geoff Maitland and he always insisted that we seek a reassessment but right now I thought "that's the best reassessment I will ever get."

She came to, I let her lie for while and rang for her family to come and pick her up. I half carried out this bedraggled patient, lipstick smeared all over her face, hair in the air, and handed her over to her family. As she left I remembered to say "By the way, this may be a bit sore after, you may feel a few odd things, it's quite common after such a treatment, just let me know and I'll see you in four days". Phew…. back I went to work, with a very wary student and somewhat limiting my manipulation treatments that day.

THE FOLLOW UP!
Four days later, there she was in the waiting room (at least she came back I thought). With some trepidation I asked her how she was. "You were right about me being sore and sick. I vomited for 2 days and couldn't get out of bed for 4 days. I was in terrible pain. My husband kept wanting to ring you but I stopped him because you said it might be a bit sore after." I wiped my brow and she went on …..yes it was awful, but you know in the last couple of days I reckon I am bit better, I don't get as sick and I can move a bit more." There was hint of a smile. I felt a sense of pride almost, but then I looked at the student who had been following me around and she looked down and just shook her head. It dawned on me that she didn't want to go through the shock again, a "please don't do it again look".

I didn't manipulate her in the same way again. We started some gentle graded neural mobilization and some mobilisation and gentle "screw type" manipulations to her thorax. She slowly improved over 3 weeks. I had to leave the country for various reasons so I had to pass her on to another physio. On parting she said "thanks for doing what you did on day 2." I often think of her and in particular – would I do it again, would I do it differently these days and if so how? Is there a golden click worth chasing, could I have harmed her and what was the response due to? Has manual therapy moved on?

I am leaving it open – what would you do with such a patient, would you manipulate and what are your thoughts?

A HAPPY CHRISTMAS BREAK TO ALL OUR READERS
Thanks for the massive response to last month's "NOI Notes on Central Sensitisation" It was so reassuring to get so many emails about how you integrate it, use it and are challenged. And I realise that the note was a bit of a rant, perhaps inspired by dealing with too many over the top biomedicalists during the week.

Some readers rightly pointed out there were others who were pushing a barrow for central sensitisation in rehabilitation around twenty years ago and I would like to acknowledge them. In addition to Pat Wall and Clifford Woolf there were others such as John Loeser and John Graham in Adelaide. A very influential read for me, encouraged by Judy Waters, editor at Churchill Livingstone was the British Medical Bulletin (1991) Vol 47, No3, with contributors such as McMahon, Bowsher, Main, Wall and Dickenson. Perhaps the article which influenced Louis Gifford and I, more than any, was by Benjamin Crue (1983) The peripheralist and centralist views of chronic pain. Seminars in Neurology 3:331-339, still a brilliant read and worth hunting out. In the physio world, my interactions, either clinically or by writings with Louis Gifford, Peter Edgelow, Mark Jones and Max Zusman, the warrior from West Australia provided the confidence to get out and teach as many undergrad and postgrads as I could about central sensitisation. Max's article in 1992 Central nervous system contributions to mechanically produced motor and sensory responses in the Australian Journal of Physiotherapy 38:4; 245-255 and the follow up with Structure orientated beliefs and disability due to back pain AJP 44: 13-20 certainly stirred the interest of local and international physios though not everyone was enamoured in those days. We estimate that NOI has taught around 50,000 therapists at least something about central sensitisation and are keen to keep doing it.

ANOTHER LEGENDARY NOI INSTRUCTOR

Adriaan Louw completed his first tertiary studies at the University of Stellenbosch in Cape Town, South Africa, where he graduated in 1992 from an extensive physiotherapy program, including a very stringent manual therapy based training. He has since completed his graduate certificate in Research Methodology from the University of South Australia and more recently has finished his Masters degree in research into spinal surgery rehabilitation at his alma mater, the University of Stellenbosch.

Adriaan is one of the keenest NOI instructors and seems to be constantly flying all over the US to teach both the Explain Pain and MOTNS courses. He is currently well into his PhD under the supervision of Dr Ina Diener and Dr David Butler which is all about therapeutic neuroscience education for patients undergoing lumbar spinal surgery and is anticipating some great research results.

Adriaan is an adjunct faculty member at Rockhurst University, where he teaches spinal manipulative therapy as well as guest lecturer for several universities in the United States and South Africa and has been a NOI instructor since 1998. He is a part-time clinician and spine specialist and has taught numerous post-graduate courses and conferences throughout the world on topics related to spinal disorders and pain management. Adriaan and his wife, Colleen, own and operate International Spine and Pain Institute and organise numerous NOI courses each year within the United States. www.ispinstitute.com

Adriaan next teaches:
Explain Pain in Clearwater, FL (Feb 19-20, 2011) Enquire here

HOT COURSES IN THE NEXT 2 MONTHS18 - 20 Dec Mobilisation des Nervensystems Bad Zurzach, CH
15 - 16 Jan Mobilisation of the Nervous System Chicago IL, US
22 - 23 Jan Mobilisation of the Nervous System Mo i Rana, NO
29 - 30 Jan Mobilisation of the Nervous System Glasgow, UK
29 - 30 Jan Schmerzen verstehen Münchenstein, CH
29 - 30 Jan Schmerzen verstehen Basel, CH
4 - 5 Feb Mobilisation of the Nervous System Montreal, CA
5 - 6 Feb Explain Pain Chicago IL, US
10 - 11 Feb Schmerzen verstehen Lausanne, CH
18 - 19 Feb Explain Pain Brisbane, AU
19 - 20 Feb Explain Pain Clearwater FL, US

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NOI Notes on central sensitisation

DECADES OF DENIAL
We have known about central sensitisation (CS) for at least 20 years, since Patrick Wall, Clifford Woolf and others published seminal papers suggesting that some pain and altered sensory states may be due to synaptic and membrane excitability changes in the central nervous system and not necessarily due to processes in tissues. This should have been a great relief to health professionals, but attempts to introduce the notion into rehabilitation, especially the manual therapy world (Butler 1994; Gifford and Butler 1997) were met with slow acceptance and often derision. I can recall introducing it in a conference in Scandinavia in the early 90s with the following speaker saying "well that's well and good but we have to get on with the treatment", and so the next session was on muscle stretching. "You are turning into a counsellor" was another comment. Many prominent physiotherapists and anatomists still deny the state and the current level of integration in most undergraduate and postgraduate programmes appears little more than lip service. Central sensitisation underpins modern biopsychosocial holistic management, yet we have a long way to go to integrate it. It deserves core curriculum status. A hot off the press review article by Clifford Woolf (2010) makes me believe that there may be a growing knowledge gap between science and practice.

ADMITTING THAT THERE IS MORE TO THE STORY
For health practitioners to take on central sensitisation, they usually need to accept that the old peripheral story is not complete. A trigger point may have little to do with issues in the soft tissues, the palpably tender C2-3 nothing to do with processes around the joint, and the irritated gut only partly related to the gut, but are now known to be more due to a central nervous system which has lost the ability to "feature extract" from input and defaults quickly to a pain construction. The pathophysiology of this state is now well described. See Latremoliere (2009) and Woolf (2010) for updates. Of course this can be a challenge – many successful practitioners have a lot of clinical mileage at stake and large investments in continuing education. While many readers of these notes will have embraced it, most of the rehabilitation community is yet to integrate it.

A WORD FROM A BIG PICTURE EXPERT
Gordon Waddell (1998) summed it up nicely when defending modern holistic biopsychosocialism "it is all very well to say that we use science and mechanical treatment within a holistic framework, but it is too easy for that framework to dissolve in the starry mists of idealism. We all agree in principle that we should treat people and not spines, but then in daily practice we get on with the
business of mechanics."

"BUT WHAT ABOUT CHRONIC KNEE OA AND OA HIPS THAT RESPOND
TO HIP REPLACEMENT?"
The hard core biomedicalists often bring this out as evidence of the tissue base of chronic pain. Of course, these are peripheral diseases which are often amenable to peripherally directed management. But even here, the degree of pain does not match radiological finding or degree of inflammation, suggesting a central mechanism as well (Bradley, Kersch et al. 2004). In OA knees (Arendt-Nielsen, Nie et al. 2010) and OA hips, there is impaired central inhibitory controls. This key feature of central sensitisation will improve with hip replacement (Kosek and Ordeberg 2000). This and other data summarized by Woolf (2010) strongly suggests central sensitisation should be a consideration in all acute and chronic pain states.

BUMS INTO GEAR
This NOInotes is unashamedly all about getting readers to update, reconsider and read the Woolf update – here you can read all about CS in rheumatoid arthritis, osteoarthritis, TMJ disorders, fibromyalgia, headache, miscellaneous musculoskeletal disorders, post surgical pain, irritable bowel syndrome etc. etc.

Central sensitisation is treatable, though currently predominantly by medication. The NNT (number of people need to treat to get one with 50% pain relief) in fibromyalgia for a drug like pregabelin is around 6 (Russell 2006). This simply reinforces the fact that the conservative forces of management need to get their bums into gear, review current paradigms and get CS evidence based management strategies including neuroscience education (Butler and Moseley 2003), graded activity and exercise, imagery, mindfulness, and appropriate manual therapies out there and heard. Central sensitisation is so liberating in the clinic – the relentless and often disappointing searches for sources of nociception in the clinic becomes less important and it supports the critical notion that functional restoration can processed even in the presence of pain.

And there is a little bit of muted satisfaction seeing the research emerge which supports the importance of central sensitisation in all acute and chronic pain states.

REFERENCES
Arendt-Nielsen, L., H. Nie, et al. (2010).:"Sensitization in patients with painful knee osteoarthritis." Pain 149: 573-581.
Bradley, L. A., B. C. Kersch, et al. (2004)."Lessons from fibromyalgia : abnormal pain sensitivity in knee osteoarthritis" Novartis Found Symp 260: 258-270.
Butler, D. S. and L. S. Moseley (2003). Explain Pain. Adelaide, Noigroup Publications.
Butler, D. S. (1994). The upper limb tension test revisited. Physical Therapy of the Cervical and Thoracic Spines. R. Grant. New York, Churchill Livingstone.
Gifford, L. and D. Butler (1997). "The integration of pain sciences into clinical practice." The Journal of Hand Therapy 10: 86-95.
Kosek, E. and G. Ordeberg (2000).”Lack of pressure pain modulation by hetereoptic noxious conditioning stimulation in patietnns with painful osteoarthritis before but not following surgical pain relief." Pain 88: 69-78.
Latremoliere, A. and C. J. Woolf (2009)."Central Sensitization: a generation of pain hypersensitivity by central neural plasticity." The Journal of Pain 10: 895-926.
Russell, I. J. (2006)."Fibromyalgia syndrome: Approach to management" Bull Rheum Dis 45: 1-4.
Waddell, G. (1998). The Back Pain Revolution. Edinburgh, Churchill Livingstone.
Woolf, C. J. (2010)."Central sensitization: Implications of the diagnosis and treatment of pain." Pain (in press).

LAST MONTH'S NOTES ON WOMEN RULEThanks for your overwhelming and most comprehensive thoughts last month on why women rule. Here are a few of your thoughts in no particular order..

Our brains are 'wired' differently
Women can think outside the box
Women are more emotive by nature and men are more mechanical
Women might struggle with fly fishing
An upbringing with art, music and creativity may play a part
Women like to fix things verbally while men prefer to do it manually
We should consider tone of voice, touch, perfume or aftershave
Women are generally superior in general when it comes to talking, networking, sharing, discussing, socialising and communicating than men. (From a man).

ANOTHER LEGENDARY NOI INSTRUCTOR
Tim Beames is officially the equal baldest member of the NOI teaching faculty. He has been teaching with NOI since 2006 and has recently gained his Masters in Pain: Science and Society at Kings College London in 2010 under the legendary truffle thief, Mick Thacker.

Tim has an interest in nerve injuries and is researching the correlation of neurological assessment techniques in rugby players. Clinically he works in private practice as a physiotherapist treating patients with complex pain presentations using both traditional and more novel treatment techniques. He gets invited to speak at various conferences around Europe and aims to bring a better understanding of pain and the interaction of biological, psychological and social elements with an individual's pain experience to patients, clinicians and the public.

Beames in name and beames in nature he landed in Australia earlier this week to take a look around the country over summer, teach a couple of courses and be there in the flesh to shake his fist as the dual for the ashes (cricket) continues.

Tim next teaches:
Neurodynamics and the Neuromatrix in Brisbane, AU (Dec 3-4)
Graded Motor Imagery in Adelaide, AU (Dec 10)
Enquire here..

NOI Notes on women rule

A recent discernable shift in the search for better outcomes with patients who have been troubled with pain for some time is to view the clinician as a possible variable in the outcome (Houben, Ostelo et al. 2005). Traditionally it has been features of the patient such as chronicity and catastrophisation which have been the key focus. On this issue, it is quite interesting to consider that in education the teacher is known to be a critical variable in outcome, as well as the student, but this notion hasn't really entered the world of health.

WOMEN WIN!
I have been studying clinician based variables which may lead to knowledge of best evidence based practice for chronic pain in my home state. With modern neuroscience backed biopsychosocial management taken as best evidence, I have sampled about 20% of the workers in the state. One clear finding is that females are significantly more evidence based in their knowledge of chronic pain management strategies than males. Their quality of knowledge is better. The women clearly win! Congratulations and well done. What could we boys be doing wrong I ask myself.

A CLOSER LOOK AT THE GENDER WIN
I admit to checking this finding a few times and to trying novel statistical approaches but the women still won. I also measured the quality of knowledge about the processes which may relate to how a person travels from an acute injury to a chronic pain state (for example, knowledge of yellow flags) but here there was no gender difference. This superior quality of knowledge in females about chronic pain management may be even more pronounced because women are more likely to work in rural areas which is known to have a negative effect on knowledge of evidence based chronic pain management.

WHY IS THIS?
I need some help in writing up this finding. My female friends say "but of course, how long has it taken you to realise that" but that is of no help in a scientific paper. Sure, females experience more non pathological pain than men with menstrual associated pain and childbirth but is this enough to educate oneself about evidence and scientifically based strategies such as self management, education, appropriate medication, pacing and exposure to painful activities at a deeper level than the boys? Girls are known to have a greater prevalence of musculoskeletal pain as well and perhaps these experiences have been educational.

Why do you think this could be (or could not be)? We would love to hear your most interesting, valuable and expert opinions.

REFERENCES
Houben, R. M. A., R. W. J. G. Ostelo, et al. (2005). "Health care providers' orientations towards common low back pain predict perceived harmfulness of physcial activities and recommendation regarding return to normal activity." European Journal of Pain 9: 173-183.

ANOTHER LEGENDARY NOI INSTRUCTOR
Here is a classic 'women rule' story. Martina Egan-Moog is practically an acrobat. She has a family of four young children and a loving husband. She teaches undergraduate and postgraduate courses about Physiology of Pain and Pain Management, is involved with clinical supervision, and publishes in various German and English speaking journals and books.

One of Martina's amazing achievements was cycling in 2003 alongside her husband 4500km on an unassisted tour across the entire length of Australia, from Sydney to Perth. That's  Malaga to Moscow, or New York to San Francisco with a gruelling, long and hot desert in the middle!
The wonder woman completed her Postgraduate Diploma in Manipulative Therapy (1996) and a Masters by Science degree (1999) at Curtin University in Perth, Western Australia. From 1999 to 2003, she worked with an interdisciplinary team in a Cognitive-Behavioural-Therapy (CBT) program for chronic pain patients at the Pain Management and Research Centre (PMRC), University of Sydney.

Martina has since returned to Europe, where she currently lives at the Swiss/German border, near Basel. Her main interest is to bridge research findings from pain sciences and behavioural medicine with clinical practice. For this she is an active member of SIG Pain and Movement (IASP) and SIG Physiotherapy and Pain (DGSS).

She is teaching Schmerzen Verstehen (Explain Pain) in Saarbrucken this month.

NOI Notes on the dodo in rehabilitation

TRANSVERSUS ABDOMINUS UNDER INTERNATIONAL ATTACK
In a recent magazine section of Australia's widely read national newspaper, 'The Weekend Australian' (August 21-22) the validity and usefulness of core stability training was strongly challenged and in particular, the rapid international shift of the research from the physiology laboratories to personal trainers, pilates and gym instructors was criticized (Bee P, Core promises, The Weekend Australian Magazine Aug 21-22, 2010). As is well known, during the last decade, Paul Hodges' team based at the University of Queensland has provided data showing that activation of transverse abdominus was inhibited in groups with back pain and that training offered protection from further injury. As The Weekend Australian says "it wasn’t a clear link and the evidence wasn’t conclusive."

The article included quotes from a number of overseas experts, such as Thomas Nesser (US), Stuart McGill (Canada), Peter Gladwell from the UK and Eyal Lederman (UK), author of the article "The myth of core stability", all supporting the notion that initial research claims were overinflated by the exercise industry. There were no Australian responses to the article, but perhaps it wasn't solicited. It's good to see this challenge and appropriate that it is in the lay literature.

KNOWLEDGE IN THE WRONG HANDS
I have always had some trouble with the idea of core stability and could never get past the fact that the body core is actually the aorta. I am no fan of specific exercises… it's all too biomedical for me, nor am I a fan of the still widely held notion that pain is related to the "instability" detected by many core stability practitioners. This is one of the concepts which prevents acceptance of central sensitisation. However, I am in awe of the experimental process, vigour and output at the University of Queensland, unmatched in physiotherapy anywhere in the world.

There is nothing much wrong with the research findings – it's how they have been used by some physiotherapy teachers and the research industry to the point of almost cult like acceptance. There is always a problem with knowledge. Carl Sagan in "The Demon Haunted World" expressed great foreboding about "awesome technological powers in the hands of the few and when those representing the public interest have difficulty grasping the issues or are unable to knowledgeably question those in authority". This statement is also related to health, for example, self medication where people repeatedly take potent pain killers and the bastardisation of the transverses abdominus research by the exercise industries and some educators.

THE DODO IN REHABILITATION
The specific muscle activation movement will be up for many and stronger challenges in the future, but we do this to ourselves in the world of rehabilitation.  The "dodo effect", (Rosenwieg 1936) is well known in psychology circles. It basically says that therapeutic orientation does not matter as all orientations work, as long as the single factor of faith that it will work is held by patient and therapist. Those who can remember their reading of 'Alice in Wonderland' may remember the dodo handing out prizes after a race where distance and time were not measured and saying "everyone has won and all must have prizes." In the physically based rehabilitation world in addition to the more established professions of physiotherapy, chiropractic, occupational therapy and osteopathy there are subgroups and groups based on technique (eg. massage therapists, acupuncturists), geography (eg. Australian and Norwegian approaches), singular tissues (eg. focus on isolated muscles, craniosacral, disc lovers) and people's names (eg. Feldenkrais, Maitland, Mulligan). Everyone must be getting a prize or these various groups would have evaporated. The core stability movement is currently one of these groups.

A CORE CANNOT STAND ALONE
But is it faith or a little more than faith? Or has something additional been isolated by each group. I'd like to think so. Core stability may well provide something special for a particular group in a particular circumstance and this will need clever research to show, but it is clearly not something to be done at the exclusion of other exercises or strategies. It, as well as the other groups desperately need integration into biopsychosocial assessment and management strategies for effectiveness , expansion and to encourage rational debate on its place. The divergent approaches listed above may well converge when this happens and common factors in the approaches are established.

Big picture neuroscience is the basic science essence of biopsychosocialism. We will try our best to present this view at the second 'Neurodynamics and Neuromatrix conference' in Adelaide 2012.

LAST MONTH'S NOTES ON TREATING THE RELLIES Wow! Treating the rellies is definitely a common chord and we got piles of stories. Thanks to everybody who wrote in with their own, but particularly to Alyssa of Australia who can struggle to help rellies with their pelvic floor issues..

I have a complete phobia of treating friends and family. This may partially stem from the fact that I mainly do pelvic floor rehabilitation, and when someone starts telling me about their weak bladder and how they need to see me I break out into a cold sweat thinking "do they realise what is going to be involved when they come to see me? It ain't no regular treatment couch!!"...

Congratulations Alyssa, we will send you an Explain Pain Combo for your brilliance!

LEGENDARY INSTRUCTOR OF THE MONTH Laurie Urban is one of Winnipeg's great assets. He has a handful of diplomas, a tidy bachelor and is currently completing his MSc. Rehabilitation where he is looking at the possibility of using the Slump Test as a screening test for neuropathic pain.

Laurie is a Co-Director at the Sports Physiotherapy Centre in the Pan Am Clinic and lecturer at the University of Manitoba, both in Winnipeg.

The cuddly Canuck is an accredited instructor and Chief Examiner within the Orthopaedic Division of the Canadian Physiotherapy Association. He is a Fellow of the Canadian Academy of Manipulative Physiotherapists and is currently on the planning committee for the upcoming IFOMPT conference being held in Quebec City in the fall of 2012.

Laurie has published articles on the Straight-Leg-Raising-Test in The Journal of Orthopaedic and Sports Physical Therapy and in Greg Grieve’s Modern manual Therapy of the Vertebral Column. When they're not guzzling gallons of maple syrup, together with Sam Steinfeld, he teaches all NOI courses in Canada.

Laurie next instructs: Mobilisation of the Nervous System 23 - 24 October Regina, Canada. Enquire here
LINKSWHAT IS NOI? (..baby don't hurt me..)
NOI RESEARCH
FIRST AUSSIE GMI COURSEGILLIAN'S WALK FOR CHRONIC PAIN
SIGNIFICANT MUSCLE IMBALANCE - AN AUSTRALIAN STUDY

NOI Notes on treating the rellies

I had dinner with a distant relation last week. She moaned about how she could no longer play tennis because she said, "I have two bulging discs and the sciatic nerve is really jammed in between them…. it doesn’t hurt all the time but when it does it is really bad – the doctor says I must not play tennis again." I groaned internally as I pushed my roast lamb and peas around in the gravy. The story is familiar of course, but a relly*…..is it really worth going there and do our standard treatments "work" with friends and rellies? I don’t think so. * relly is a usually fond term for a relation NOTABLE FAILURES OF RELLY/FRIEND TREATMENT All clinicians have surely treated their relations and friends in the past despite the mantra "never treat friends or family". I have heard of some great disasters. I do recall a colleague of mine who manipulated the neck of his accountant wife and set off what appeared to be a nasty long lasting nerve problem, eventually requiring surgery. I hate treating my wife and have left her back and leg pain as 'hipkneeankleattca' (the diagnosis satisfied her for a few years until Google emerged!). I must admit that the greatest failure of reading 'Explain Pain' was my brother with his chronic post traumatic neck pain…. "I read it twice Dave but my chronic pain is different to the ones you talk about, this has got nothing to do with me." OTHER FEATURES OF RELLY/FRIEND TREATMENT There is another side to this story. A third year physiotherapy student approached me once and said, "my granny got bitten on the big toe by a large ant 6 months ago and she keeps saying that it still hurts and could I come and check it out….could the pain from an antbite last that long?" Highly unlikely but the pain of not seeing your blossoming grand daughter may last longer. And a colleague of mine, a very evidence based physio, will travel some distance to ultrasound his mother's shoulder. What is it all about? What are these stories telling us? IS THERE A MESSAGE IN ALL OF THIS? Dentists can fill, surgeons can cut and GPs can give scripts to friends and family and there is no evidence that it is detrimental (although some professional associations have warnings of potential dangers such as avoiding necessary questioning and shortcuts). For physios, OTs, chiropractors, psychologists, massage therapists etc, there is nothing to stop you treating friends and rellies except that it just doesn't seem to work as well. Why is this? I think it is because the problems that the professions involved in rehabilitation deal with are more related what people think and do about a problem or perceived problem than the actual problem. The dentist doesn't really care about what you think about the hole in your tooth, the surgeon about your thoughts on the nature of appendicitis – for them it's find it and fix it and there are clear, often sole mechanical or biological targets. But in the world of chronic problems it's different. Simply we usually don't really want to go to the depths of the problem with our friends and relations. Also, does having to pay money for a treatment make it work better? Does having it for free mean that it’s somehow taken for granted? AND MY RELATIONS? I no longer bother. Other than listening to a story for hints of something really serious and the comment "you should challenge that sentence you have been given" and referring them off to someone who I know will follow a biopsychosocial line of thinking, that's it. YOUR TURN An Explain Pain book and audio book to the person who sends in the best story (sad, humourous, whatever) about treating a relation or friend which reveals something of the therapeutic interaction. NEW NOI RESEARCHWe have two new projects starting using Recognise online - they are collaborative studies involving NOI, the Body in Mind research group at Neuroscience Research Australia, the University of South Australia and The University of Western Sydney. One project focusses on how the ability to make left-right judgments develops as we do. For this project, we want kids to get onto the computer and have a go. We have used photographs of kids' hands and we ask a few questions beforehand. One is about pain, so it is fine to do this even if you have a sore hand or arm (in fact, it would be great to see how performance might change in this situation). Depending on the age of the child (we are after 5 - 18 year olds), mum or dad or a responsible adult might have to walk them through it.  It should take less than 20 minutes. Although we are after kids, it might be interesting to see how adults perform when the images show kid's hands, so we have opened it up to anyone.  The lead researcher on this project is Shikta Dey, who has called it OMIT - On-line Motor Imagery Task. The second new project is being led by Kathryn Nicholson Perry at the University of Western Sydney. This one is focussed on getting data from people with lower limb problems, in particular those with a spinal cord injury. So, if you know anyone with a spinal cord injury, tell them about this study! Again, there are a few questions to answer and then the tests. It will take about 20 minutes.  Please help us to cover new ground - we look forward to welcoming you to the Cutting Edge. LEGENDARY INSTRUCTOR OF THE MONTH Max Zusman is a (nominally) retired former private practitioner (30yrs) and university lecturer (20yrs) who is now occupied by a busy national and international post-graduate teaching programme. His long standing interest is in pain mechanisms and their realistic management with physical treatments - chiefly movement based. He is one of the profession's pioneers in this area, and continues to act as an information source and advisor to researchers and colleagues in different parts of the world. He publishes reviews of appropriate topics, as well as original thought-provoking and potentially clinically relevant science based models aimed at informing our clinical reasoning and decision-making skills. Max instructs The Problem Pain Patient (Der 'problematische' Schmerzpatient) with Martina Egan-Moog which is an advanced 3 day course aimed to benefit medical professionals (therapists, doctors and scientists) in their clinical reasoning and decision making processes. He turns 76 on the weekend, and his hobbies are [still] golf, billiards and Barbie. We wish him a wonderful day and are sending over some big hugs so they get to Perth in time. Zusman M (2009): Ubersicht uber Schmertzmechanismen: Implikationen fur Diagnose und physiotherapeutische Behandlung "problematischer" Schmertzpatienten. Manuelletherapie 13: 167-173. HOT COURSES IN THE NEXT 2 MONTHS 2 - 4 Sept Mobilisation des Nervensystems Vienna, AT 10 - 12 Sept Klinische Anwendungen: Obere Extremität, Thorax und HWS Saarbruecken, DE 11 - 12 Sept The Sensitive Nervous System Toronto, CA 11 - 12 Sept Neurodynamics & the Neuromatrix Bournemouth, UK 16 - 17 Sept Mobilisation of the Nervous System Derby, UK 17 - 19 Sept Applicazione Clinica: Arto inferiore Silea, IT 18 - 19 Sept Mobilisation of the Nervous System Pittsburg KS, US 23 - 25 Sept Das sensitive Nervensystem Zurich, CH 24 - 26 Sept Klinische Anwendungen: Obere Extremität, Thorax und HWS Kriens, AT 25 - 26 Sept Mobilisation of the Nervous System Baltimore MD, US 1 - 3 Oct Mobilisation des Nervensystems Hamburg, DE 2 - 3 Oct Explain Pain Dallas TX, US 2 - 3 Oct Mobilisation of the Nervous System Middlesex, UK 7 - 9 Oct Mobilizzazione del sistema nervoso Silea, IT 9 - 10 Oct Explain Pain Boise ID, US 15 - 17 Oct Klinische Anwendungen: Untere Extremität und LWS Bad Neuenahr, DE 16 - 17 Oct Explain Pain Portland OR, US 16 - 16 Oct Graded Motor Imagery London, UK 17 - 18 Oct Schmerzen verstehen Fellbach, DE 22 - 24 Oct Applicazione Clinica: Arto superiore Pavia, IT 23 - 24 Oct Mobilisation of the Nervous System Singapore, SG 23 - 24 Oct Explain Pain Melbourne **FULL**, AU 23 - 24 Oct Mobilisation of the Nervous System Omaha NE, US 23 - 24 Oct Mobilisation of the Nervous System Regina, CA 27 - 29 Oct Mobilizzazione del sistema nervoso Sant'Angelo Lodigiano, IT 29 - 30 Oct Schmerzen verstehen Saarbrucken, DE 29 - 31 Oct Mobilizzazione del sistema nervoso Milano, IT Search for more courses LINKS So... what is noi? NOI research NOI Portuguese The PT Project Body in Mind - a must read Lorimer Moseley in the USAInsane Australian car crash Gillian's big walk for chronic painDon't forget twitter and facebook

NOI Notes on fish, guts and backs

DIVERTICULITIS CURED!
"Great news!" said my patient – "after those back treatments last week, I reckon you have cured my diverticulitis. I have had it for years. Thank you so much – you didn't even tell me that you were working on it." This was some years back, but I remember that at the time I wasn't quite sure what diverticulitis was. I obviously felt quite chuffed about my hitherto unknown diverticulitis management skills while at the same time thinking, "what on earth happened there? Maybe I freed up some gut associated innervation when I got her back moving."

I had forgotten this interaction till last week when I had a back twinge while lifting a large snapper onto a boat during my first week of self inflicted long service leave. The back was sore for a few days and I was getting a bit anxious about it, but it was also accompanied by what we technically call here in Australia, "the trots," the kind we all get, but if it continued, the problem may acquire a label of irritable bowel syndrome.

IS IRRITABLE BOWEL MUCH DIFFERENT TO IRRITABLE BACK?
In many cases, probably not! While bowel and back are obviously different target tissues, the neurophysiological processes behind peripheral and central sensitisation are the same for all body parts. In many problematic states such as irritable bowel syndrome, chronic low back pain, fibromyalgia syndromes, post traumatic stress, chronic TMJ disorders there is a lot of overlap of symptoms and patients with one are often diagnosed with one or more of the others leading to the suggestion that there may be common drivers (Schur et al 2007). Around 10-15% of the population suffer from irritable bowel syndrome – a similar number to irritable back syndrome (I just made that title up – I mean chronic back pain).

The idea that irritable bowel syndrome, irritable back syndrome and other tricky to manage problems may, in many cases, originate from common pathways is not new, and although the notion that they occur together has been widely expressed by patients and some scientists, very little has been done about it. Different professions manage different parts of the body and support groups have grown embracing the notion that singular discreet problems occur.

THE BRAIN-GUT AXIS
One critical element of the cognitive architecture of the NOI group is that in response to threat, interest, challenge and need, a number of homeostatic systems can be engaged to help us cope. One of these systems is the hypothalamus-pituitary- adrenal axis which is known to be perturbed in irritable bowel syndrome and in chronic pain states. It is also a key part of the brain-gut axis. Corticotropin releasing hormone is released in responses to threat and challenge, (including interoceptive stress such as colon distension). CRH receptors exist in most peripheral tissues and organs as well as many brain areas – its release has a general effect. Not just back OR gut.

EXPLAIN GUT PAIN AND OTHER SYMPTOMS
Providing biological knowledge such as Explain Pain (Butler and Moseley 2003) to assist coping with more musculoskeletal associated problems is becoming quite acceptable. Similar knowledge, adapted a little for the gut, should now be applied for IBS type symptoms. It is known that patients with irritable bowel syndrome want more information than they are currently getting (Halpert et al 2008) and it is also clear that sufferers carry many misconceptions which are likely to enhance stress responses. For example, around 1 in 7 people with irritable bowel syndrome think it leads to cancer and many more think it leads to serious problems over time (Lacy et al 2007). Any unexplained pain is threatening to the brain and surely more so when it is associated with inconvenient, uncomfortable and distressing bowel problems.

And as for my patient with diverticulitis – I presume that whatever happened in the clinical encounter – technique, interaction, even a joke, calmed down an output system enough to have effects on body structures that were not in my original thought processes.

HELP US
Tell us your thoughts and experiences. It may well be time to embark on Explain Pain type research and education in the irritable bowel syndrome world and the input from our readership helps. The notions of brain-gut axis and biopsychosocialism fit well together. Here, the best piece of writing comes from Wilhelmsen (2000).

REFERENCESButler DS, Moseley GL (2003) Explain Pain Noigroup
Halpert A (2008) Dig Dis Sci 53: 3184
Schur EA et al (2007) J Gen Intern Med 22: 818
Wilhelmsen (2000) Gut 47 Suppl4 iv5-iv7

LAST WEEK'S NOTES ON NERVE ORDERING
Thanks to all who wrote in last month with their story of novel positions and analyses. Kylie is the winner with her Aussie Rules football player's tiny toe story and has been sent the NOI Neurodynamic Techniques DVD and handbook.

Quite some time ago a football player presented to me with severe pain in his 5th (little) toe when he kicked the ball on his right leg. He could not recall any incident of local injury, and had no focal tenderness around this area. After further testing I was able to reproduce his pain with a slump test, once knee extension and DF were added on that side.

Mobilising in this position with knee flexion and extension resolved his symptoms quite quickly, and he was once again able to return to kicking the ball without pain…

I found this case very interesting at the time and your topic reminded me of this patient! Kylie

Nice work Kylie – this could be as simple as a mid axon discharge from a branch of the tibial nerve in the foot. Give it some oxygen and remove mechanical constrictions (could even be a new pair of shoes) these can just disappear. It’s also a reminder that a tiny nerve can cause heaps of trouble.
Find all other novel positions and analyses stories in here.

LINKS
LORIMER MOSELEY IN THE UNITED STATES
DAVID BUTLER IN NEW ZEALANDTHE PT PROJECT - A GREAT BLOG
SOMETHING FROM NOTHINGSEND THESE NOTES TO A FRIEND
NOI - EXPLAIN PAIN
NOI - BRAIN TRAINING
NOI - NEURODYNAMICS
NOI - PORTUGUESES
NOT SIGNED UP?

NOI Notes on nerve ordering

ORDERING NERVES
A patient with a carpal tunnel syndrome once mentioned that if he put his hand under his chin with his wrist extended, he could move his head and alter an evoked pain in his hand without moving the hand. "It's really freaky mate" he said. Most clinicians have stories of pain states being produced in odd positions (we'd like to hear about these - more later). Anyway, these clinical findings, along with the fact that a peripheral nerve is anatomically different along its course, became a part of the order of movement principle (OOM) thinking in neurodynamics, something we hold quite dear.

The principle is that for the best clinical exposure of a peripheral nerve problem, take up the part that you think holds the problem first and then progressively add tension to the nerve via the limbs. So for example for a carpal tunnel syndrome, you would start with wrist extension with the rest of the arm in a neutral position and then progressively add elbow extension, shoulder abduction and lateral rotation and finally neck lateral flexion to the other side. It made sense, and it seemed to make it easier to 'find' nerve problems.

TWISTED CLINICAL BEHAVIOURS
Using the OOM principle in the clinic could be useful, fun and even give the clinician a workout! So for a proposed nerve entrapment around the buttocks, you would take up hip flexion first, perhaps add a bit of rotation and then progressively add knee extension, ankle dorsiflexion, spinal lateral flexion away from the test side and even neck flexion. For me, the most spectacular uses of the principle were in the foot problems such as 'plantar fasciitis' and 'heel spurs' – here you would start with the patient's knee flexed (i.e. nervous system slack) then you dorsiflex and evert the ankle, extend the knee and flex the hip, thus taking the leg into a straight leg raise with the distal end of the sciatic/tibial/plantar nerve complex loaded first. Hidden little foot problems that may well have had their origin in mid tibial nerve discharge would often be exposed and this position could be used to mobilise.

If you listened to the patient about the sequence of movements which aggravated them, you could replicate the sequence. So during the heel strike phase of running, the ankle is usually in dorsiflexion/eversion followed by knee extension as the phase continues – it fits the position described above.

The order of movement principle could be used for the really sensitive hot nerve problems. Why stir something up by starting at the problem site when you could 'sneak up' on the problem by starting movement elsewhere? Hot shoulder with overtones of neuropathic pain? Start movement from the wrist and then the elbow – you may not even have to move the shoulder if these movements reproduce symptoms.

Great theory we thought.

THE RESEARCHERS TAKE A LOOK VIA THE SILENT MENTORS
Researchers can sometimes call closing time on clinical behaviours or encourage adaptation of the behaviour. Bob Nee and associates from the Neuropathic Pain Research Group at the University of Queensland did some research on the OOM principle in Taiwan at the Tzu Chi University Medical Simulation Centre using seven fresh frozen cadavers, known as 'Silent Mentors'. Fresh cadavers for experimental purposes are hard to access and clinicians can be grateful for this research access to this remarkable place.

Nee et al. (2010) demonstrated in the median nerve in the distal forearm, that order of movement changes such as starting with the wrist first or the shoulder first, does not affect the strain or position of the nerve in relation to surrounding structures at the end of the test. Basically on first reading, our much loved OOM principle has been blown out of the water and the first thought from any clinician must be "stuff the researchers".

TAKE A CLOSER LOOK AT ANY RESEARCH
All research needs a careful read. So many people take just one phrase of the findings and leave it at that.

The researchers still recommend that the OOM principle is kept. They suggest that the clinical finding may be due to the starting position simply held for longer than the finishing position. They suggest that the clinical finding may be because certain orders of movement can apply increased levels of strain to a part of the nerve for a longer time period. They also noted that the median nerve glided differently depending on the order of movement. Lastly, likely differences between sequences in ranges of joint motions may still influence nerve biomechanics at the end of a test. In discussions with Bob Nee, the suggestion was made that clinicians can take advantage of these differences in ranges of joint motions. For example, neural tissues can still be tested in highly sensitive or stiff body parts by starting movements away from the painful area. Moving the sensitive or stiff body part last in the neurodynamic test sequence means that it will not have to go through a full range of motion. Bob also said that the study only addressed biomechanical issues and that the different sequences may have different impact on brain circuitry. If the test sequence closely replicates a painful movement it is conceivable that the neural circuitry that represents those body movements in the brain would also be sensitised. It may also be that the movement you apply first, places attention on that part and therefore it is the somatosensory part represented in a pain neurosignature.

The message is: Keep playing with order of movement. Further research will reveal more.

Butler DS 2000 The sensitive nervous system, NOI, Adelaide

Nee RJ et al. (2010) Impact of order of movement on nerve strain and longitudinal excursion. Manual Therapy 15: 376-381.

LINKSNee RJ et al (2010)
NOI NEURODYNAMICS
WE ALL JUST WANT TO PARTYEXPLAIN PAIN - ENGLISH, PORTUGUÊS, ESPAÑOL
UNPUBLISHED NECK LATERALITY NOI RESEARCH RESULTS
NOI 2012 - KEEP IN THE LOOP