-
-
-
We aim to facilitate and disseminate good clinical science research. We love comments that engage with the research and are constructive and respectful. No self-promotion please (these comments get filed in the recycling bin). We do not prescribe treatments. 
All blog posts should be attributed to their author, not to BodyInMind. That is, BodyInMind wants authors to say what they really think, not what they think BodyInMind thinks they should think. Think about that! Blog networks
{ 52 comments… read them below or add one }
Dear Lorimer and David,
I have been working with several CRPS in a unilateral upper extremity with quite severe and easily exasperated symptoms. I have had to limit the number of images seen at each session. In trying discern what was provoking their increase, two of the patients stated that as they moved their eyes to focus on the image, their pain increased. With each of these patients I then tested unidirectional repetitive eye motions. Eye motions, without head movement, toward the side of pain would rapidly provoke the symptoms within a few reps. other motions did not provoke the symptoms and the same movement with eyes closed did not provoke the symptoms. I have started patients on non symptom productive movements and symptom provoking directions with eyes closed. I also used palpation of the side of the face below symptoms. I have seen improvements in thier tolerance of eye movement in the past 10 days and some tolerance for other activities. Do you have any insight ( no pun) on what may be going on here?
[Reply]
Lorimer Reply:
December 10th, 2009 at 11:40 am
Great work John. I am particularly interested in symptoms in CRPS that seem to be related to space. what i mean by this is we know that people with chronic CRPS seem to neglect the space in which their limb normally resides [see our recent Brain paper: space-based but not arm-based shift...]. I don’t know why this happens. It seems feasible to me that, for some patients, that whole side of space becomes ‘dangerous’. If so, it would seem sensible to prevent oneself from having anything to do with it. The best way to do this would seem to be to make it painful. That is, perhaps even looking in that direction is regarded as dangerous by the brain and hence increases brain.
I love your clinical response to this. I would love to be kept in the loop of how it goes and I encourage you to take good notes.
[Reply]
I’ve just been introduced to Painful Yarns through my husband attending intensive rehabilitation for his back at Salisbury Hospital, Wiltshire, UK. Whilst pondering the tales in the book in relation to my husband’s experience of pain (not necessarily easy as an interested bystander – perhaps that’s another book for you), I wondered if you thought that the same might be true of people who experience emotional pain. In that, historical experience/tangible examples of a lot of emotional pain would result in someone lacing situations with a greater amount of emotional content and therefore reacting in a more extreme manner than others might. And so, rather than learned behaviour and mimicing others, the brain’s evaluation of ‘emotional danger’ delivers an emotional wound which then leads the individual to display more extreme emotions than a situation warrants.
Just a thought….
[Reply]
Lorimer Reply:
December 10th, 2009 at 3:41 pm
Hi Diane. Nice thoughts. Your wondering seems sensible to me – there is no doubt that our brain remembers anything that is important to our survival. That said, I dont make a distinction between physical and emotional pain. I reckon that if it hurts somewhere in the body then it is pain. If it doesn’t, then it is not. I am very comfortable with the idea of, for example, an aching heart, but if one doesn’t feel the ache then it is probably most accurately called something else, for exmaple anguish, grief, despair etc etc. this sounds simply semantic but I think it is important if we are to accept that pain is produced by the brain and doesn’t need input from the body even though it feels exactly like there is. Anyway, that is a Cab Sav conversation, which is a conversation best had while sharing a bottle of south Australian, preferably Coonawarra, Cabernet Sauvignon. I am not sure if you can get them in Wiltshire.
[Reply]
Many thanks for your response, that is most helpful. Good news! Coonawarra, Cabernet Sauvignon is available in Wiltshire, sadly we’ve a bit too much weather at the moment for the ideal situation, but I could light a fire…………
[Reply]
The 2009 non pain study by Mizuguchi et al (Influence of touching an object on corticospinal excitability during motor imagery) showed that the excitability of the corticospinal pathway can be increased during ‘ball squeezing imagery’ if real touch of the ball is also involved during this imagery exercise. Furthermore, this increased excitement occurred along the corticospinal pathway (including the primary motor cortex), and not along the afferent pathway to the primary somatosensory cortex.
This raises a possibility that graded motor imagery (GMI) and actual touch of the imagined object (‘combination GMI and touch therapy’) may be an alternative for CRPS treatment, instead of GMI treatment alone?
Studies may be warranted to determine whether ‘combination GMI and touch therapy’ results in increased activity along the efferent corticospinal pathway. If yes, this may result in increased benefits for some CRPS patients, and may even benefit CRPS patients that may not respond to GMI therapy alone.
Neuroimaging may be useful to confirm any increased activity along the efferent motor pathway in CRPS patients.
[Reply]
HI Lorimer
My personal good friend always challenge me to give her more scientific evidence that her lower back is not the typical chronic lower back pain that other patients have (we both work in rehab where we see chronic back pain patients). SHE believed and argued with me that her pain is purely “physical”. She had spondolysis and had 2 back surgery to stabilise the joints from slipping forward. She tried everything under the “medical” sun. She is a Yoga teacher and believed that when she is doing her yoga, she is in no pain, extremely flexible and mobile. But when it comes normal standing, she needs to use her sit/stand stick. So …using all the bible text including Explain Pain, Painful Yarns and the Brain that Change itself….eetc…to illustrate to her that pain is in her brain and she can change her mind about believing that her pain is purely physical and that nothing works for her…any suggestions please? She’s a good friend and I feel like I am arguing with her. But she has a point. It is physical isn’t it?
[Reply]
Lorimer Reply:
January 4th, 2010 at 4:53 pm
Tricky. Except that ALL pain is of the brain. I can’t tell you if you should argue with her or not – it sounds like she is quite the formidable opponent – however, i can tell you that it is, ultimately, her call. If she believes she is human (which clearly you believe she is) and that she is not a freak of humankind (which you clearly think she is not), then the fact remains that her back wouldn’t hurt if her brain didn’t make it hurt and her brain will make it hurt if her brain thinks it in her best interests and her brain almost certainly considers more than spinal input in high threshold neurons when it makes this call. If your friend believes that the only determinants of her back pain are the forces, chemicals and temperature fluctuations that are occurring at particular tissues of her back, then i think she should apply exactly the same principles to training it that one would always apply – remove those factors and then gradually expose the tissues to those things again. This is, as it sounds, probably impossible. If one was to abide that hypothesis of course, then one would have to deal with the sticky issue of why larger forces, more concentrated chemicals and bigger temperature fluctuations don’t necessarily hurt. We are, i am convinced, fearfully and wonderfully complex…….
[Reply]
lloyd Reply:
February 3rd, 2010 at 9:38 am
hi Alice and Lorimer,
interesting. your friend is so like me. i’ve an L5 spondylolithesis caused by doing a particular yoga extension pose that i used to rest in for 10 minutes at a time regularly over a period of 18 months almost 10 years ago now. buttock and lateral shin pain with standing any sort of prolonged time.i’m not a longe lizard for nothing.about 3weeks ago i went again to see a consultant re a fusion cause i was fed up with the pain and limitations felt there was nothing i could do to solve it feeling very like what you described for your friend. Interestingly since i’ve now got 4 months till surgery i decided that i’d better get serious cause i’d be well cheesed if i fused it and then discovered a couple of years later that there were processes i could have used. i’m now using a combination of feldenkraise type exercises meditation and yoga and reading Anat Baniels fab book- the nine esentials for lifelong vitality. basically trying to enrich the cortical realistate that relates to my back and body, the way it moves and feels. in the process i’m beginning to uncover all sorts of ways my nervous system needs to increase its sensitivity , relax ,increase its activation. the breath shows up alot of old fight and flight patterns stored with in this nervous system.
i still had a bunch of pain doing the washing up this evening but i’m not so bothered because i see a way forward and am excited by my discoveries. we’ll see over the next couple of months but i’m not going to get a fusion. if i can get the surgeon to decompress the root without stabalizing i might go for that.they automatically think the segments unstable and needs fusing. i can deal with the degenerative symtoms. i maybe i can live with the “nerve” pain in a better way
anyway.it is very difficult when you percieve probably very rightly that there are major nocioceptive drivers present and the reality of a graded exposure approach when you have a complex life to lead just seems ridiculous.
Lorimer i hope to catch you at the nottingham gig. i’ll try not to get to flustered by the presence of such a megastar and relate to you as a person ok!
i presume that would work better for you as well.
regards
lloyd
[Reply]
mike Reply:
April 29th, 2010 at 12:49 am
Yoga is lovely and becomes a way of life . The danger, particularly around L4-L5 is that people tend to hinge on this area so their extension postures are only coming from flexibility in a small are of the spine. It may be worth having a friend check which parts of your spine are moving in extension and modifying the pose to concentrate on other areas/going easy on the spinal extensions in the sun salutation warm up especially.
Hi Lorimer,
I am an Occupational Therapist in Green Bay, Wisconsin/US. I have been reading some of your articles for Graded Motor Imagery, and have tried out the 3 phase program with 3 participants (2 are active patients). I am looking for clinical guidelines with developing our program. I meet with participants once a week but have them completing the program mostly through home program. It looks as though the research suggests 3 times an hour, but was wondering if you see results still with reduced frequency. (My patients are struggling with getting the program in this frequently). Also, I am going to be creating laminated pictures for them to use, and plan to do Right/Left and Male/Female, but how many images would you suggest to be effective but as cost effective as possible for us to make?
I really appreciate your input as I try to complete Evidenced Based Practice, but also make it as practical as possible to fit in with patient’s daily routines.
One more question: do you think that the limb laterality recognition would also work by identifying right and left on people around them (instead of paper copy?). I have a hair dresser that has little time with the pictures, but states she is constantly observing her clients hand postures and mentally identifying Right/Left.
I find your work fascinating!!!
Thank you,
Jamie
[Reply]
admin Reply:
January 28th, 2010 at 11:19 am
G’Day Jamie- noigroup already sells laminated pictures of hands and feet i think. Check them out – http://www.noigroup.com. Re guidelines – we are a bit short of that but that is where we would like to go. These things take time and much effort. Re your idea about observing on others – GREAT! Makes complete sense according to cognitive neuroscience but, of course, we haven’ tested it in a clinical trial! Thanks for your support and input.
[Reply]
Hi Lorimer
I have watched a very good DVD from Discovery Channel production regarding Pain and chronic pain. I used it in my Pain Management workshop with my patients from all sorts of ethnic background. They seems to understand the concept more so in a video format than in a written format (partly due to language but also i guess it’s pretty boring to talk about pain, isn’t it? Of course, you always makes chronic pain topic so much more interesting and intriguing.). In the video, they interviewed Dr Mackay’s research regarding using fMRI scan to retrain the brain to reduce the “volume” of pain. What do you think about that? Is that something we can have in Australia at some stage for those pain patients who are willing to use their brain power to control pain? Interested in your views about that.
Alice
[Reply]
admin Reply:
January 28th, 2010 at 11:16 am
Hi Alice – Sean Mackey does some really groovy stuff and i reckon the real time biofeedback using fMRI is cool+++. Will it be something we use clinically any time soon? I don’t think so because there is a large amount of research – clinically and experimentally – that we would have to do first. As well as that – the gear is really really expensive. My final thought on that one is that i can’t see that it solves the problem. I guess it could address it in some form because patients would realise that their brain is the main player, not their body. Still, I am open minded about these things – it certainly is very groovy research.
[Reply]
Sorry. It’s Dr Mackey’s research.
http://paincenter.stanford.edu/press/video_discovery.html
Alice
[Reply]
Hi Lorimer
Just finished reading my new book for my little one on Brain by Rita Carter. Got me also reading her book on mapping the mind. I know she is a medical writer not a researcher but found her book easy to read and explain quite nicely how the brain is so powerful in controlling so many things including pain and chronic pain. Just thought you might have met her somewhere in your career paths?
Alice
[Reply]
I’m treating a patient at the moment who has developed CRPS in her hand post colles fracture.I have been treating her for two months now and her PIP joints of the 2-4th digits are held in fixed flexion ~ – 40 degrees extension which is irreversible with a passive stretch. I was wondering if anyone has any clinical tips for treatment or how long such can take to resolve? Thanks
[Reply]
Lorimer Reply:
February 11th, 2010 at 2:28 pm
Hi Maria –
I am not sure i understand the exact nature of the motor pattern, but that it affects passive and active range is consistent with a fixed motor dystonia. The best people in the world on that stuff are in The Netherlands – look up Bob (Jacob) van Hilten and the Trend Consortium. I will pass on your thingie to Bob as well in case he can comment on it with more than i can. Anyone else out there feel free to suggest something to Maria…
[Reply]
Lorimer:
Big fan of you & David Butler. I have read many of your articles, etc. but my favorite?? …..“Painful Yarns ”… what a hoot! Anyway, I’ve had CRPS type symptoms for 15 years or so. My PT and myself are going to engage on graded motor imagery path, using NOI Groups cards, etc… I have a question:
…. I have never seen a visual image in my “mind’s eye” in my life. I just cannot visualize. Do you have any recommendations concerning how to try to kinesthetically imagine movements without actually engaging the neuromuscular system?……….
[Reply]
Lorimer Reply:
February 15th, 2010 at 5:55 pm
Gday Tim – thanks a million for posting, and for your encouragement – much appreciated indeed! I am not sure of the answer to your question – however, the good news is that the idea of graded motor imagery is, after the initial phase of left/right recognition, to NOT imagine what it looks like but just imagine doing it. Does that make sense? That is, you don’t visualise the movement, you just imagine doing it. I will have an ask around and if i find something will let you know.
thanks again Tim, Lorimer
[Reply]
Gday Lorimer…
thank YOU a million for a reply!!
you said, “the idea of graded motor imagery is, ….. to NOT imagine what it looks like but just imagine doing it. Does that make sense?
Frankly — no — this does not make sense to me.
How do people imagine? I think most people when they imagine trying to visualize don’t they?? When people ask me to imagine… I really can’t… because I can’t visualize.
I maybe can think about moving my arm, but I’m wondering if that actually engages the mind and the nervous system a little bit and if that is good or bad???
So, ‘m still confused.
I checked out some definitions of, imagine….. and they all say something like this:
Imagine: To form in the mind a notion or idea of; to form a mental image of; to conceive; to produce by the imagination.
Most definitions of imagine use the word root, imagine, in its definition or refer to visual mental images….
Still treading water…
Timv
[Reply]
Lorimer Reply:
February 20th, 2010 at 12:41 pm
hey Tim – I don’t think that imagine means ‘visualise’, but i am v. open to being a dufus on that front. I think we should try to feel what it feels like, not what it looks like. perhaps this is illustrated by imagining you have chocolate in your mouth – you don’t visualise that because you don’t know what it looks like (presumably….). make sense?
[Reply]
l’m the dufus. so, What I’m understanding is that the “motor imagery” part of “Graded Motor Imagery” does not involve any visualization, I should just simply watch others do motions that are painful for me (or look atRecogniseTM cards etc) and just concentrate on what is happening………… nothing else. The mirror neurons et. al. will do their work..
thanks for taking the time to respond to me. I think the word “imagery” leads to confusion with me ( and probably others). Please keep on posting!! some of us find it your work as interesting as you do!
timv
[Reply]
this is a facinating conversation. its so interesting to hear ?? you say?? that lorimer
but i have to say i feel like a dufus.
i always thought of imagine as visualise as well
but have to say i like imagine the feeling more than the image
and really engaging activly your mirror neurons whilst watching someone else do something that is difficult or painful for me is absolutly brillant
nice one tim
what a bunch of dufus’s
high regards and peace
llolyd
[Reply]
Hi Lorimer,
i have read Explain Pain and almost all books from Wall and Melzack and I now really understand the physiology of pain and no pain, no brain ( atleast of what i read). I had low back pain and just by understanding pain physiology, my low back pain is 90% better. I know that’s just n=1 and doesn’t say much about anything.
i am in the exercise field and the field is so influenced by the biomechanical model of pain. I have been trying to tell people how there is very little correlation between pain and structural pathology and i haven’t come across any studies which shows this to change in athletic population. For example, the scapular dysfunction in shoulder pain is just correlated and not causative. Or is it?
But I like to keep an open brain. Do you think in athletic population chronic pain can have a greater biomechanical component that the lay person. If so, have you come across any research? For example, can tight hamstring contribute to back pain and so on.
Thanks for your work and a great blog!!
[Reply]
Lorimer Reply:
April 1st, 2010 at 4:08 pm
G’day Anoop –
these are great things to contemplate. Do athletes, sportspeople etc have a greater biomechanical component? I don’t know – they certainly place more demands on their structure but I guess we would expect them to have structure that is better suited to demand – so perhaps they cancel each other out. Regardless, i am sure that they are not simply skin and bones and muscles……
[Reply]
Hi
Thanks for the reply.
Sometimes I feel the threat level in their brain is much much higher than a lay person. Mainly because they are an athlete and they worry so much about their low back and ankle and other joints and also they have been well taught that pain is a result of structural dysfunction which put them in the mentality of pain always means damage.
[Reply]
Looks like the email subscription for budyinmind is playing up..
I get a message from google feedburner
http://feedburner.google.com/fb/a/mailverify
saying
“The feed does not have subscriptions by email enabled”
or am I being dim ?
[Reply]
THANKS MIKE – we’d reset the feeds and hadn’t picked up that the email subscriptions wasn’t working. Glad you told us! Should be fine now.
Heidi
[Reply]
Can you give me a lead…Pain and the brain as the receptor and generator through “memory” (forgive my novice nomenclature) must also apply to antigen response within the body and brain controlling skin symptoms of exczema and the itching cycle. Are there studies, readings on the brain centered control of this issue?
[Reply]
Lorimer Reply:
May 31st, 2010 at 4:47 pm
Hi John – so sorry this one got under the radar and it has taken us a while to respond. Your idea sounds nice – I don’t have much of an idea on that stuff – but I know who does – a guy called Dr Mick Thacker at King’s College London – you could easily find him via Professor Google – tell him I sent you ok?
[Reply]
Hi Lozza, I really enjoyed the lecture you presented at the NZ Physiotherapy conference here in NZ. I never knew that apin could be so funny.
Sweet as bro
[Reply]
Both my parents had arthritis, low back pain, from as far back as my memory goes. I remember a day when I was walking out of the house, nine years old, and ‘felt’ low back pain for the first time. In my mind I was saying, “Oh, me aching back…” the same words I heard my Dad repeat at least 20+ times a day. I had not hurt my back previously. What I think now, was I realized, in my family, to get any type of empathetic, loving attention, we were not a touchey family, I should place that stiffness and soreness in my back. Perhaps my nine year old brain had finally developed enough connective powers to come upon this realization to get my emotional needs met. I am 60 now, still have chronic low back pain. A life time of holding those muscles in a certain way doesn’t go away very easily!!
[Reply]
We have been treating CRPS for the past 5 years with EEG Neurofeedback with excellent results. There are too many cases to describe, but one was referred to us with no bowel or bladder control,and problems with a range of other internal organs and was wheelchair bound. He recovered bowel and bladder function quite early in the piece and over 3 years progressed to crutches, walking stick and now can walk unaided and feels well. He is re-training to return to work. He may have recovered quicker but has a loose screw in his foot from failed surgery which actually caused the CRPS and each time he weightbears the screw hits a nerve. His doctors are still hesitant to take the screw out as they are worried surgery may flare up the CRPS.
The majority of CRPS sufferers whom we have treated improve in a range of areas.
Essentially we are targeting the reversal of central windup and affecting central nervous system dysfunction by raising the pain threshold. We train the brain waves to produce optimum frequencies to effect this and to inhibit other frequencies at the same time.Through this method of operant conditioning the brains learns to be able to move flexibibly between the states of arousal, and not remain ‘stuck’ in heightened arousal ( high beta waves) or stuck in low arousal ( slow wave).
EEG Neurofeedback has been very effective and I wonder why more clinics are not using this method to treat patients?
Sue Stern
[Reply]
Sue – thanks a million for posting. This sounds very interesting indeed. Have you published it, or has anyone else? If so, where? Send me a copy? If not, you should – this is the key actually. If it has really been tested, it needs to be published. If it hasn’t, then it needs to be testd. I always say: ‘If this is as good as you think it is, then we all need to know about it. If it is not as good as you think it is, then you need to know about it’. Let us know?
[Reply]
Hi PT out there
I have a client have been searching for physio who knows/ can do mirror box therapy for the recovery from a stroke. She is not able/not willing? to use her affected upper limb. When I mention to her about mirror box therapy, she lights up and asked me if I can find her a PT who can offer that. Any suggestions? Thanks a million in advance.
[Reply]
Heidi Reply:
July 23rd, 2010 at 9:13 pm
Hi Alice
Thanks for posting – I am wondering, along with asking here, you might want to ask the same question on the BodyInMind facebook page and see if you get any responses. NoiGroup also has a facebook page, and it may be that a PT will get back to you?
Heidi
[Reply]
Hi Lorimer
I am so passionate reading about pain and brain …i am wondering is there any avenue that I can get my hands “dirty” by volunteering somewhere where I could get more opportunity to learn more? (other than reading your blogs and read all the moments on the blogs and google search….)
Thanks
Alice
[Reply]
hey BIM folks:
any comments on this study?
http://genome.cshlp.org/content/early/2010/08/02/gr.104976.110.abstract
I think the authors are implicating that there is a genetic predisposition to chronic pain.
curiously awaiting your reply!
timv
[Reply]
lorimer Reply:
August 12th, 2010 at 4:22 pm
Nice pick-up Tim. we have now done a post on it, so watch out for it……
[Reply]
Hi Lorimer
I have been doing a lot of catch up reading into pain research, which is an absolutely fascinating topic!! I am a mere beginner but am enthused by it! I was speaking to a colleague of mine who is a pain specialist and we were discussing central sensitisation. As I understand it there is a genetic change in the cell nucleus which causes an increase in the embedding of NMDA receptors in the cell synapse, oh that’s already complicated writing that?? This is permanent, so if it is a permanent change and not reversible then how is it possible that this can be modulated and information that is coming from that synapse to the brain will not set off the pain signals?? Is it down to reconceptualisation of the information coming to the brain from the synapse, as in are we training the patient that although they may be getting an increased stimulus we have trained the brain to reconceptualise the information as in the brain has final say??
Phew, that was hard but actually after having read that again that kinda makes sense if the brain has final say??
Feedback would be good
Paul
[Reply]
Lorimer Reply:
October 21st, 2010 at 1:06 pm
Hi Paul –
Great contribution. I would argue that it is not permanent. If it is a genetic switch on, we do not know that it can’t switch off. Regardless of whether it is permanent or not, we must remember that it is in the nociceptive system, not pain. Having profound spinal cord changes does not necessarily mean one has pain. Keep pursuing this stuff because it only gets better……
[Reply]
Hi Lorimer,
I read your book explain pain. I think it is ok. You are basing your conlsuions on too much hypothesis and basic science. If it is evidence based, it needs to be shown in an RCT and I dont think there is many out there. Melzack’s Neuromatrix theory is still a hypothesis!
[Reply]
Hi Lorimer
I have recently been introduced to your work and that of NOI. I have a patient I am ‘experimenting’ with using some of the concepts. He is an upper limb amputee, amputated at the shoulder. He has been experiencing significant amounts of PLP which can include cramping of the fingers and thumb and burning through the limb. At times he can move his fingers but his thumb consistently feels as if it is blocked by an object which stops him extending it. His elbow is also fixed although he doesn’t get pain from it. Acupuncture provides instant relieve to the fingers for about 20 min and they feel as if they are floating, but the thumb and elbow remain fixed. The OTs started him with mirror therapy, but he found this increased his pain. I have got him registered on ‘recognise online’ and I thought we could attempt to reproduce the approach used in the RCT – so 2/52 of laterality then moving towards mental imagery and if required introducing mirror therapy after this. Do you have any tips or suggestions with regard to us using this approach especially with respect to whether we should focus on getting the thumb and elbow moving or is it better to go with what moves more easily first (ie fingers) and hope that the elbow and thumb start to free up in time?
Many thanks for you help.
[Reply]
Great question. Right. I would see how it goes with Recognise. As we learn more about graded motor imagery, our gut feelings that practice practice practice is important are being confirmed – so get him to do it as often as possible without doing it for too long each time. I would have him do the context pictures as well as the vanilla ones. I would also get him to watch footage of fingers and arms moving in a pain-free manner – piano playing, guitar playing, cards, cooking shows perhaps – watching the hands. This might seem odd to him but you could explain that the idea is to just watch and, this is the tricky bit – really attend – to the hands and arms. You could progress this to imagined movements and you could make these functional too. I would do sensory discrimination training on the stump – particularly if acupuncture gives such an excellent response. I would explain explain explain that, even when an arm is ripped off and there is a bucket load of obvious noxious input from the tissues of the body, it is still the brain that makes the final call and the GREAT thing about the brain is that it is the best learner we’ve got. Still, we have to practice practice practice. I hope this helps – keep us informed on this one?
[Reply]
Hi Lorimer
I had a conversation with a Physio yesterday regarding my client. The client has sustained a “level II whiplash injury” apparently. The Physio has asked me to see if I can get more approval for physiotherapy treatment for symptoms management. This client had about 50 sessions of physio 12 months ago. I have asked the physio what other evidence that the client would benefit more for ongoing physiotherapy (she said the client needs to see her once a fortnight for symptoms management and it would be likely ongoing given it is a level II whiplash injury). She said that if i was familiar with the whiplash injury hierarchy, i wouldn’t need to ask that question. Anyway, I asked whether the client has had multidisplinary pain management clinic such as one at Westmead Hospital or North shore. She said the client had already tried pain clinic and it doesn’t work so she suggested that I shouldn’t bother with a second try. Anyway, the conversation ended with me saying that I could try asking for more approval.
Now the above conversation really got me a bit sleepless last night. I feel like I was talking to a brick wall (well the client was a brick wall, that I know) but the therapist as well? Anyway, please enlighten me about the whiplash injury hierarchy as really have no idea even after consulting Dr Google.
Thanks heaps. Sorry for the long winded post.
[Reply]
Alice Reply:
October 23rd, 2010 at 2:05 pm
Oh btw, it is Grade II whiplash injury (I meant) not Level II
I just don’t see how the grading would justify ongoing treatment and that multidisciplinary program is not recommended.
[Reply]
Hello,
I just wanted to let you know that Body In Mind was mentioned today in an Internet radio programme. Fashion Moves is the Fashion portal to provide a meeting place between the Fashion / Garment and Textile Industries and the clothing desires of People with disabilities. We will explore designs for Business Professionals, students, athletes, parents and kids. Fashionable clothing that fits, for everyone’s chosen lifestyle. Fashion Moves will interview garment designers, textile designers, musicians, athletes and everyone wanting Fashion with the right fit. We will also mention industry organizations and news notes we feel will be of interest to our listeners.
Please listen to today’s and previous shows. Feel free to post this on your website and to share this information with others. I am also looking for guests for future shows and would be pleased to speak with you about any suggestions you may have.
Bye for now.
Ruth J. Clark
Fashion Moves
http://www.fashionmoves.blogdog.com
http://www.blogtalkradio.com/fashionmoves
fashionmoves@earthlink.net
250-314-1849
[Reply]
Hi,
I am working with young children with CRPS. Do you think there is a lower age limit for children to benefit from the Laterality retraining. At what age is laterality clearly established?
[Reply]
BiM Reply:
November 10th, 2010 at 9:02 am
THIS IS A great question, to which we don’t know the answer. YET. We are starting to find out by first assessing left right judgments in kids – see our OMIT study, link here
Any personal experience re minimum age you would care to share?
[Reply]
Woah! Having just watched shutter island even pain is being referred to in the movies! Have a look, people!!
Paul
[Reply]
After recently discovering that George Bush launched the “Decade of the Brain” with a somewhat infamous proclamation 20 years ago it seems only fair to acknowledge that the evolution in this field has been monumental -with or without George’s contribution. A recent rewiew of the ” Decade after the Decade” here http://www.sharpbrains.com/blog/2010/02/23/brain-neuroplasticity-implications/
is a useful read. Enjoy.
David
[Reply]
Dear BiM
Firstly……thanks, you guys are monumental
Second, as current Chair of the PPA (Physiotherapy Pain Association in the UK) would there be any way in which we could collaborate on getting the pain management message out there. One of our limitations is cascading info in a timely fashion to our membership (nearly 700) and the wider Physio profession. We produce a Journal six-monthly but this whilst stimulating debate does not lead to rapid dialogue and discussion in a timely and immediate way. We also host the iCSP site and have ten times the number of registered members who log on intermittently. We as an Exec think we may have a lot to learn from you in terms of making info accessible (as well as so much more)
Do you have any constructive advice or suggestions
with very kind regards
Martin Hey
[Reply]
Heidi Reply:
February 2nd, 2011 at 9:03 pm
Thanks Martin! Getting the message out there is certainly something close to our heart. We’ll have a think and get back to you by email.
Heidi
[Reply]
Hi there fantastic BiM team and friends!
You have probably already picked this up, but just in case… check out: “Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome” published in PLoS One (link to pdf below). They show that even when patients know they are receiving placebo, it can still improve symptoms. Hmmm, might have to re-think the interpretation of those active V placebo trials….
http://www.ihfglobal.com/education_documents/Placebo%20IBS%202010.pdf
Julia Hush
[Reply]
Heidi Reply:
February 2nd, 2011 at 9:05 pm
Nice Spot Julia, thanks for taking the time to share it – I’m sending the link to the BiM team!
Heidi
[Reply]
Neil O'Connell Reply:
February 2nd, 2011 at 10:39 pm
Quite a neat (but unflinching) deconstruction of this study can be found here:http://www.sciencebasedmedicine.org/?p=9339
If you sell folk the idea of powerful minbd-body effects then they get a placebo response. Of course if you told people that estimates of placebo effects size are generally marginal (see Cochrane review) then you might not get the same effect.
[Reply]
Hi and help!
Apologies if this is not the right forum (I’ve subscribed but not contributed to bodyinmind before) but I would like your help. Have I missd out on Upper limb tension tests and slump and neurodynamics and things for all these years? I’ve probably been not very competent in the past ( well 15 years or so ago) when I last tried them, but I never found them very reliable, so I gave up. Ok I use an SLR as more of an ‘expected’ and standard, ‘traditional’ test when What are we testing when we do an ob I’m thinking nerve rooty thnigs, but would not necessarily rely on it alone. I always thought if some part of the body / system is indicating ‘pain’ then a test lik that would be posive anyway – does it tell us what we alrady know. That and there are alot false positives (an article i read recently said there are false positves even in asymptomatic test subjects) anyway and it could vary, day to day mood to mood. Is it a bit like ‘Waddell’s inorganic signs’ and tells us that the person is in distress somehow and not much elseor have I really been missing out? What are testing when we do an objective assessment anyway eg for a medial collateral knee ligament strain if it isn’t particualrly lax but the patient reports pain. How ‘subjective’ are our ‘objective’ tests? When I was having this discussion in our journal club, I stated that I didn’t find ULTT etc very helpful, but I got lost whe i tried to explain why. Do I need to eat humble pie? Many thanks Pete
[Reply]
Michel Coppieters Reply:
February 16th, 2011 at 9:32 am
There is a lot of stuff in this post… Let me comment on a couple of things:
1) Like any other clinical test, neurodynamic tests have their strengths and weaknesses. I believe they have merit if applied in the right circumstances. A recent Delphi study (by Keith Smart, published in Manual Therapy (2010)) revealed that expert physiotherapists and pain consultants consider movement tests, such as SLR and upper limb neurodynamic tests, the most significant clinical indicator for peripheral neuropathic mechanisms of musculoskeletal pain. Obviously, the response of a neurodynamic test (like any other test) has to be considered in terms of the pathobiological processes in operation. Neurodynamic tests, like many other clinical tests, may appear false positive if there is widespread sensitivity due to central sensitisation. Hence the importance of the patient interview…
2) False positive tests deserve further consideration… it depends obviously to a large degree on the criteria that are used… In my view, reproduction of symptoms and a change in these symptoms with structural differentiation remain the key criteria (despite some other suggestions). If these criteria are applied, it is impossible to have false positive tests in asymptomatic people… Per definitions, asymptomatic people have no symptoms let alone that a test could reproduce them. Obviously, neurodynamic tests will elicit sensory responses in most healthy people, but that does not compromise the test’s validity (note the differences between ‘symptoms’ and ‘sensory responses’ – many people, including researchers, often confuse them). On a personal note (this is a blog after all), I believe neurodynamic tests are probably useful to assist to determinate whether there is a contribution of the peripheral nervous system to the pain state, but the tests are probably not of so much value to determine where along the course of the nerve the problem might be. Let’s bear in mind though that we don’t have a single clinical test or technical investigation that has a good enough validity so that it can be used in isolation to diagnose a peripheral neuropathic pain state. Hence the need to combine the results of neurodynamic tests, with the findings of other tests, patient interview, technical investigations, etc…
3) Regarding reliability of the tests, there is increasing evidence (check out PubMed) that commonly used outcome measures of the test can be reliability measured – not just in experimental conditions, but also in clinic. These are relatively difficult tests though – to paraphrase David Butler: ‘Handle well, or don’t bother – try another branch of physiotherapy’. Sounds somewhat rude, but poor handling will indeed compromise the usefulness of the test…
4) Of course things can vary with mood – use it to your advantage rather than as a limitation – Isn’t it a great teaching tool to show your patients the multifaceted nature of their pain experience! And again… consider the pain mechanism before conducting and interpreting clinical tests…
Hope this makes sense – Hope you will have that journal club again; regardless of what the final conclusion might be…
Cheers, Michel Coppieters
[Reply]
Sorry for the misspells I was in a rush, Pete
[Reply]
David Fitzgerald Reply:
February 6th, 2011 at 11:49 pm
Hi Pete
I suspect that this may not be the right location for detailed discussion on this topic but I think it’s appropriate to at least make some suggestions.
“Upper limb tension tests, slump and neurodynamics – but I never found them very reliable!.
I can’t speak with any authority on the normative data which has been collected for these tests other than to point you to David Butler’s book “The sensitive nervous system” which was the sequel to his classic “Mobilization of the nervous system”
However, from a clinical perspective I would certainly suggest that these types of treatment approaches have direct relevance and appear to be effective (at least by test-re-test within session, sequential re-evaluation over time and correlation of objective signs with subjective improvement).
I would qualify this with the acknowledgment that my almost evangelical enthusiasm for these techniques 25 years ago has been somewhat tempered over time – but more on the basis of patient selection rather than any criticism of technique.
This then raises the necessary discussion of selecting appropriate patients for this type of intervention. There is some discussion on this here
http://www.physiodigest.com/621/nerve-sensitivity-altered-neurodynamics/
“I always thought if some part of the body / system is indicating ‘pain’ then a test like that would be positive anyway – does it tell us what we already know”
Trying to ascertain pain mechanisms and selecting appropriate interventions based on this is the big clinical challenge facing physiotherapy, I think. An overview of this type of approach can be found here.
http://www.physiodigest.com/371/pain-pattern-recognition-in-primary-care-%E2%80%93-mechanism-driven-management-strategies-in-physiotherapy/
“Ok I use an SLR as more of an ‘expected’ and standard, ‘traditional’ test when What are we testing when we do a test – I’m thinking nerve rooty things, but would not necessarily rely on it alone”
I would concur that frequently clinical testing confirms what we are ready know (or at least what we think we know) and rather than shedding any miraculous new insights simply fits into the category you describe. However, it’s no harm to have our clinical hypothesis confirmed by tests or to use these clinical signs as markers in assessing response to treatment (for better or worse).
“there are alot of false positives (an article I read recently said there are false positives even in asymptomatic test subjects) anyway and it could vary, day to day mood to mood.”
Maybe so, But I doubt very much if that is unique to neurodynamic testing.
It’s probably in the category of “un-modifiable variables” that we can’t influence.
How ‘subjective’ are our ‘objective’ tests?
We’ll Pete I draw the line on that one but I’m sure there are others in this forum better positioned to comment on this issue.
PS I’m sure you’re aware of David Butler’s faculty website at
http://www.noigroup.com/en/Home
The history of Neurodynamic ‘s is a prime example of the evolution of integrating contemporary pain sciences to explain mechanisms of effect (allbeit speculative, but at least contemporary). Some readers here will be old enough to remember the original terminology for Nero dynamics which was “ANT -adverse neural tension” – shocking and all as it may seem now.
David
[Reply]
Many thanks for your thoughts and ideas! I did read, many years ago David Butler’s ‘ ‘Mobilisation of the Nervous System’, but I haven’t read ‘The Sensitive Nervous System’ as I gave up on ‘ANT’ as it was then, probably because I wasn’t veyry good with it and to me it just didn’t make ‘sense’. I wasn’t too worried though because along came Louis Gifford’s ‘mature organism model’ and Max Zusman’s ‘Fear Avoidance’ work and from then on…
I think it was louis who said or wrote somewhere about not worrying if a technique doesn’t work or feel right for you and do things that you are comfortable with as any treatment (technique or exercise) in its mechanisms is multi-dimensional, genetic through physiological through neurological, emotional, psychosocial etc etc. That’s my excuse for not pursuing neurodynamics – it’s his fault! Maybe I gave up too soon!?
I think louis’ ideas chimes in with Neil and Benedicts’ thoughts in thier recent article ‘Chronic non-specific low back pain – sub-groups or single mechanism’ (www.biomedcentral.com/1471-2474/9/11 – reviewed with Frederic Wellens’ piece ‘The mechanistic paradigm in the teaching and practice of manual therapy; time for a reality check.’ http://www.physioaxis.ca/realitycheck.pdf, in the recent PPA Journal). It seems to me that one of their points is that for all the diversity of techniques and concepts, from acupuncture, through core stability (it stills gives me nightmares…) and then CBT, their success (limited in LBP) may be because they work through similar neuro-physiological pathways /mechanisms. So if I’m going to change my ways I need to know do neurodynamic techniques (ULTT etc) stand out as being particularly useful / valid? and why? May be they are for a particular patient (and a particular ‘therapeutic relationship’) but for the general population? I don’t just need to read the book, go on the course, I need to know the results.
I’m wary, because like most of us in the past I guess I have liked the theory, but the results / evidence / research (usually a decade or two later!) of how it works in practice has often been disappointing or made more complex to analyse. Examples – electrotherapy (we are down to 2 U/s machines now in our department), the biomechanical (roll and glide) of joint mobilisations, muscle (im)balance, acupuncture and so on. We’ve all been there!
Granted it will be very different in a private setting (lots of non-specific effects for one) but in the cruel, harsh world of the NHS where evidence – based – medicine is becoming synonymous with ‘cost effectiveness’, where extended treatment time in departments means an extra cost (and then possibly a pressure on jobs), how would ‘neurodynamics’ be rated / recommended? What does it add to an assessment or treatment? For example what does an ULTT tell us when it can be positive in an asymptomatic subject, likely to be positive with an acute impinged shoulder or someone with trigger points? Is it not similar to what Wellens reminds us of a specificity issue where we can find (biomechanical) dysfunctions (with or without neurodynamic signs?) even in asympomatic populations?
As you can see, I can’t help but be sceptical, but hopefully willing to change, if the evidence is there in terms of not just good theory, but one tried and tested and seasoned in practice, which might just be one definition of evidence- based – practice.
[Reply]
i know of someone who came off benzodiazepines and opiates and when he came off the benzo, his chronic pain for which he neede opiates went away. really.
so what role did the drugs have in this pain perpetuation?
[Reply]
http://www.bbc.co.uk/iplayer/episode/b00ybvz6/Horizon_20102011_The_Secret_World_of_Pain/
You can also download the episode on you tube.
Excellent 1 hour on Pain and the updates research on pain. I am blown away.
Alice
[Reply]
Hello,
I am Spiros – reflexologist from Athens, Greece.
I have been enjoying and sharing information from your blog on my blog for a while now.
I read this in the news and thought you might find it interesting.
Colorado Doctor Finds Foot In Newborn’s Brain
Infant Recovering After Surgery
http://www.thedenverchannel.com/health/18297954/detail.html
Spiros
[Reply]
David Fitzgerald Reply:
March 2nd, 2011 at 11:01 pm
Thanks Spiros
certainly will make me think of the Homonculus in a different way from now on!
David
[Reply]
Hi Guys, great site and great info, so thanks for all that. Quick question for Lorimer…I recently listened to your ABC classic radio interview and in the first section you discuss the experiment with the violinist and how their string fingers have a lower pain threshold compared to the fingers on their bow hand. You then state that your interpretation for this difference is a psychological one based on fear/anxiety relating to the ability to successfully continue playing the violin. While I obviously have no doubt of the role psychological factors play in the pain experience, how confident can you be that this is the case in this instance? How likely is it that these research subjects actually felt that much fear in a controlled laboratory setting? Maybe this is mentioned in the actual paper, but is it possible that the lower pain threshold is more of a property of injuring highly represented sensory maps? Have you done or are there any comparative studies on pain thresholds on highly represented maps (but not of a skilled/”important” finger like a violinist, but more so of just a very frequently stimulated finger doing a mundane task) and then compare pain threshold to normally represented maps of the other hand. I imagine this would negate much of the psychological factors that could confound any differences.
So I guess basically, does the size of the representation correlate with pain threshold? It would seem to make sense that if something is highly represented then the default assumption of the brain is “this is important, protect it from danger”. And then the reason why it’s important (I need this finger to be a successful musician) is more of an after the fact rationalization, and can potentially increase pain, but is not necessary to account for any difference in pain threshold. Just curious what you think. Thanks for all the great work and look forward to a reply.
Best regards,
Jason
[Reply]
Hi, i recently heard Lorimer speak on pain at the FILEX fitness convention and was quite blown away.
This also lead me to a question about Chrionic Fatigue Syndrome.
I have a very close friend who is battling with this and as you probably know or could imagine, it is a very challenging and life changing illness.
I have not been able to find anything clarifying on this subject, so was wondering if someone on this site could provide me with anything helpful in thinking through management or healing processes or at least a scientific understanding of what is happening with this type of syndrome? Any/all information or advice would be more than helpful.
Thanks!
[Reply]
BiM Reply:
April 19th, 2011 at 3:06 pm
Hi Robert
Glad the talk was helpful. Sorry to hear about your friend. We don’t have anything specifically on Chronic Fatigue – you could try (if you haven’t already done so) the Chronic Fatigue Society – there is one in each state – and that might be a good starting point.
[Reply]
Robert Abboud Reply:
April 19th, 2011 at 3:20 pm
OK, Thanks!!
[Reply]
Robert
A fantastic historical text is “The stress of Life” by Hans Selye. Widely accredited as the father of stress medecine I believe and a field which has now evolved into psychoneuroimmuniology. The common element of fatigue in conditions like CFS, Fibromyalgia, RSI and neuro-degenerative conditions attracts interest in these fields. Judging by the diverse combination of therapies (usually a bad sign) offered this appears to be work in progress.
David
[Reply]
Robert Abboud Reply:
April 20th, 2011 at 10:02 am
Great thanks so much David, I’ll do some searching for his work!
[Reply]
Came across this excellent Radiolab programme on placebo – popular New York science programme – lots of neuroscience stuff – careful it’s quite habit forming
http://www.radiolab.org/2007/may/17/
all the best
Steve
[Reply]
Hi,
A couple of your researchers presented at an osteopathic conference I was on on the weekend. I spoke to one afterwards, who suggested that I post on this site. I seem to be able to treat CRPS-type conditions with some degree of success. I’d be interested in participating in a research project using these sorts of techniques (as the clinician, not as the researcher), if anyone is interested.
The types of things I would normally look at for one of these patients are:
1) Manual lymphatic drainage. The lymph is often locally congested, and some of the pain seems to relate to over-stretched lymphatic vessels. One of the good things about treating the lympathic system is that you start working proximally to the site of pain, and can reduce the swelling and inflammation without making direct contact with a painful site. This in term lets you gradually work from proximal to distal, until it is possible to introduce some normal manual stimulus to the site of pain, and often to do further manual work to decrease pain locally once it is possible to touch the area.
2) Find and manually releasing sites of nerve entrapment and irritation proximally to the site of pain. Again, this allows you to make a change without having to directly contact a sensitive area.
3) Ensuring adequate rib excursion. (The proposed model is that this facilitates good blood flow to, and therefore normal functioning of, the sympathetic chain, through the effect of rib excursion on the azygos system.)
4) Seeking other potential sites of noxious stimulation that may be keeping the nervous system in a state of heightened arousal without quite registering as conscious pain. One classic site for this is a gall bladder which is painful to light touch, but is otherwise not registering on the person’s conscious awareness.
5) Testing for an unidentified thyroid dysfunction. Thyroid dysfunction seems to increase the level of musculo-skeletal pain, and to increase congestion in the lymphatic system. The chemical pathways between thyroxine and the mitochondria do not seem to be well understood by the medical profession, which means that may people with a dysfunctional thyroid mechanism seem to be told they are normal just because their TSH and T4 are normal.
6) Providing an increase in normal stimulation (such as massage) to non-painful areas, to increase the level of parasympathetic stimulation and to provide more normalised input to the CNS.
I hope this is helpful. Please let me know if you are interested in discussing any of these issues further.
[Reply]
Flavia Reply:
October 26th, 2011 at 1:08 pm
Hello John,
I remember speaking to you at the Conference and I really appreciate your feedback. I’m glad you’ve posted on our site; we aim to maintain a forum for researchers and clinicians to stay on top of what the other lot is getting up to!
At the minute, we are not running any clinical treatment trials in CRPS and as such aren’t in a spot to embark on any formal collaborations. But your ideas are nonetheless informative for us to see and other clinicians to comment on and add to.
It’s interesting that several of the techniques you mention may in fact be used by other clinicians from across different disciplines; only sometimes people may have varying rationales behind why they chose that particular method, or what may be the underlying cause of the problem.
All things worth debating! Thanks again for you input
Kind regards
Flavia
[Reply]
As an occupational therapist and pain researcher, I confess to being somewhat annoyed that your current poll about who is using the site allows aliens to self-identify, but not OTs!
[Reply]
heidi Reply:
October 20th, 2011 at 9:12 am
Oh My! You are quite right Tara, OT’s should definitely be included. Thanks for letting us know. They have been added to the poll.
[Reply]
Congratulations on your innitiative for the current poll, i am sure all you people at BiM will be in for a surprise. I admit, as did Tara the OT, to feel left out because whoever researcher added the options to the poll forgot Reflexologists! Ok we are a small group, even though we are working in a hospital pain clinic in Athens, how about adding CAM, you know complementary – alternative methods. What if priests are reading your blog, have you considered that!!!!!
[Reply]
Hi Spiros. Another good suggestion – thank you. CAM has been added. Because of the way the poll is set up I can’t move questions that people have already voted on (maybe in the next version of the widget they will enable that) – so the order the questions are coming up in is a little illogical, but CAM is there !
Heidi
[Reply]
thanks Heidi!
[Reply]