Explain Pain Section 5: Modern Management Models

This is a summary of section 5 of “Explain Pain” by David Butler and Lorimer Moseley.

So Many Clinicians

There are several people who would like to help someone in pain, with each person offering a different explanation and solution for someone’s pain. Research has shown these conflicting explanations can often make things worse. The one who has the most power over pain is the person who is in pain.

Here are some general guidelines for someone dealing with pain.

  1. Make sure any injury or disease which requires immediate medical attention is dealt with. All ongoing pain states require a medical examination.
  2. Make sure any prescribed help makes sense and adds to your understanding of the problem.
  3. Get all your questions answered.
  4. Avoid total dependence on any practitioner.
  5. Make sure your goals are understood by you and the clinician.

The clinician’s ultimate job is to assist you in mastering your situation.

Teach you to master your pain, we will.

Models of Engagement

There are 5 interchangeable models which enable both the patient and the clinician to identify the processes underlying pain.

  1. The orchestra model – Pain is a multi-component process that manifests itself in the brain and goes through many pathways. There are many players involved in the pain experience, hence the orchestra, with the brain as the maestro.
  2. The Onion Skin Model – Helps describe all the factors that go into the pain experience; including nociception, attitudes and beliefs, suffering, pain escape behaviors, and social environment.
  3. Fear-based models – Fear of pain and reinjury are major forces behind the development and maintenance of chronic pain.
  4. An evolutionary model – Pain protects the tissues in order to ensure species survival.
  5. A clinician decision-making model – Pain is very personal, and therefore a plan of care should be developed exclusively for that person.

When working with a healthcare provider, they should be able to answer the following questions:

  1. What is happening in my body?
  2. How long will it take to get better?
  3. What are all the options for management?
  4. What can I do for it?
  5. What can you do for it?
  6. Is there anything that requires special attention?
  7. What do my physical findings really mean?


Coping aims to reduce the threat value of the stimulus and the associated emotions and altered biology.  There are various ways coping can be done, with some better than others. Generally, active copers manage pain and other health issues better than passive copers.

The active coper…

  • Learns about the problem.
  • Explores ways to move.
  • Explores and nudges the edges of pain.
  • Stays positive
  • Makes plans.

Whereas the passive coper…

  • Avoids activity.
  • Does nothing.
  • Waits for something to happen.
  • Believes someone else has the answer.

Relating to Pain

There are several patterns in which we react to pain.

  • Hurts don’t do it – Pain kicks in at a certain amount of activity, then we stop once it starts. Over time we can perform less and less activity before pain occurs, leading to disability, disuse, and likely depression.

pain graph 1

  • Boom-bust – Pain comes on but you push through it and ignore it until suddenly the pain becomes unbearable. Here, your nervous system busts. A cascade of danger chemicals floods the nervous system leaving you completely wiped out for days to weeks.

pain graph 2

The commonality between these two patterns is that both lead to eventual activity limitation. We want to be somewhere in the middle.

DNS B Course Notes

Whew, I recently finished (and still trying to process) the B level DNS course from the folks at The Prague School. Instructors were Martina Jeszkova and Dr. David Jeurhing. There were a lot of things covered during this 4 day course and I definitely learned a few things. Here are the highlights.


Developmental Principles

The focal point of DNS is the concept of joint centration, a static and dynamic maximal joint surface approximation.  When joint surfaces achieve optimal bony congruency, the muscles surrounding the joint achieve optimal activation and highest mechanical advantage.  The reverse is also true. If muscles coactivate properly, then joint centration occurs.

Conversely, if optimal joint centration is not achieved then muscle imbalances occur. The reverse is also true. This change becomes very problematic, as decentration at one joint effects centration at all the other joints. This may lead to decreased performance at best and at worst increased wear on joint surfaces.

Take lower crossed syndrome (or open scissors if you are a DNS fan) for example. Let’s say we had a problem with our lower back. In order to cope with this trouble, we increase lumbar lordosis and decentrate the lumbar spine. See how it affects the surrounding structures. The pelvis anteriorly tilts, which affects length tension relationships to glutes, hamstrings, and hip flexors. Thoracic kyphosis increases as well, affecting the shoulder girdle and cervical muscles. Basically, play with one body region or joint position and see how it affects the others, and you can develop a decent understanding of joint centration’s implications.

We can argue all day if posture is relevant, but can we at least agree this it’s not a good look?

Developmental Milestones

The Newborn

  • No optical contact due to holokinetic movements, which basically means movement due to lack of stability.
  • Mass extensor pattern in supine.
  • Mass flexor pattern in prone.
  • Able to turn head, but cannot lift head off of table.

6-8 weeks

  • Optic fixation is constant.

3 months

  • Begins sagittal plane stabilization.
  • Can begin feeling with arms.
  • Able to lift the head.

4.5 months

  • Able to stabilize in sagittal plane.
  • Functional joint centration of all joints.
  • Rotates head 30 degrees each direction independent of other spinal movement.
  • Grasp as far as midline.
  • Ulnar grasp.

5 months

  • Active grasp across the midline occurs, which leads to turning from supine to sidelying.
  • Radial grasp.

6 months

  • Radial grasp
  • Chest breathing combined with abdominal/diaphragmatic activation.
  • Turn from supine to prone.

7 months

  • Can oblique sit onto forearm.
  • Pincer grasp.

9 month

  • High oblique sit.
  • Crawling.
  • Unsupported sitting.

10 month

  • Side walking.
  • Independent steps between surfaces.

14-16 months

  • True gait

Here are a couple vids of the developmental process.

The Integrating Stabilizing System of the Spine

Much of where joint centration begins at the spinal level, and involves the following functional muscle unit activating in a feed-forward subconscious fashion:

  • Short intersegmental spinal muscles.
  • Deep neck flexors
  • Serratus anterior
  • Diaphragm
  • Abdominal wall
  • Pelvic floor.

Developing proper function of this group is what allows for movement.  However, if one of these muscles becomes dysfunctional, the entire complex becomes dysfunctional. Stability is then achieved by substituting with other muscles groups and/or passive structures.

Stabilizing system function is very important as we develop, as lack of this mechanism may lead to abnormal bone structuring. Examples of this would be anterior pelvic tilt, femoral anteversion, spinal kyphosis, etc. These would be deemed utilizing passive structures to increase stability for function.

There are 3 reasons for which stability becomes disturbed.

  1. Culture, sport, habit.
  2. Abnormal early development.
  3. Protective pattern due to pain or pathology.

DNS tests

There are general compensatory patterns that are evident in almost all the DNS tests, so watch for the following:

  • Excessive scapular winging, retraction, elevation.
  • Poor diaphragmatic breathing & lateral expansion.
  • Excessive lordosis or extensor tone.
  • Rib flares.
  • Diastasis or rectus abdominis hyperactivity.

These patterns are results of poor punctum fixums, which are fixed points to which muscles pull. For example, with supine cervical flexion the fixed point would be T4. If mobile, you may see excessive movement there, hence poor centration. The tests themselves unfortunately require a lot of subjective interpretation in terms of what you see, so I will not give you a demonstration. Here is a brief description of each.

  • Diaphragm test – seated breathing.
  • IAP pressure test – Supine breathing.
  • Trunk & head flexion test – max flexion of cervical spine in supine.
  • Arm elevation test – Shoulder elevation in supine.
  • Extension test – Prone head lift.
  • Oblique trunk flexion – Somewhat cross between an armbar and get-up.
  • Quadruped rock forward – Watching for winging.
  • Squat – Duh.
  • Low kneeling – See below exercise.
  • Bear position – See below exercise.

Three Level of Motor control

The three levels of motor control are as follows:

1)      Spinal/brain stem – neonatal. Think primitive reflexes that we see in babies such as rooting, moro, etc.

2)      Subcortical – The first year of life.

3)      Cortical – 2-4 years of age.

I will not go into details regarding all the different reflexes; much of these are what you learned in school. This section was one I had some qualms with after recent discussion (i.e. me listening in awe) with Bill Hartman.  I do not know that science agrees with maturation in the first year of life being subcortical and reflexive. In order for movement to occur, motor learning and motivation are required. These two are both cortical phenomena. If there were reflexive changes, then should not all babies develop optimally?

Reflex Locomotion

Then we went over the “voodoo” aspect of DNS—reflex locomotion (RL). What occurs with this technique is evoking partial motor patterns via afferent stimulations (i.e. pressure) at specific points. These specific points correlate to the support zones that occur throughout the developmental cycle. By pressing on these points, joint centration can be established allowing for motion.

Typically these movements occur more readily with younger children and babies, and sensitivity differs amongst adults. Here are some of the changes typically looked for in RL.

  • Breathing patterns
  • Muscle fasciculation
  • Partial/whole movement patterns
  • Autonomic responses

Realize that RL is not a learning/training process and does not teach normal movement. RL achieves muscle activation, stereognosis, and body awareness—prerequisites for movement.

Here are some videos of the positions that I learned in the course from someone who is obviously way better at this modality than I am.

Reflex Turning 1

Reflex Creeping

Reflex Turning 2

1st position

The group at my course was generally very reactive and elicited some movements. Even I had a reaction elicited in reflex turning 2. However, it is important to understand that everyone in the course knew what was to be expected; hence I wonder if there is some “Ouija boarding” occurring when we perform these activities.

My guess is you will spell D-N-S.

We did have a couple kiddos come in for treatment as well who had neurological problems. Some “responses” got elicited, though these were very minor and I could not tell very well if these were responses or if the kids were just fidgety. Now, seeing pre and post gait everyone thought there were improvements. Of course, I try to battle confirmation bias somewhat (but it is so damn hard), I had some of my PT colleagues check out the videos. They could neither see a difference nor could they tell which were the pre and post videos. Moreover, it does not help when much of the testing had subjective interpretation. We have to be mindful seeing changes that may not be there, or else you starting looking like the video below.

Now, is there some efficacy in RL? I don’t know. I haven’t seen enough of it to say either way, nor am I good enough at it to elicit regular responses. There is also the time factor that is required to elicit changes, which I have many other techniques that may be just as effective at faster rates. I think the selling point for me will be if I can see nice changes in people with marked neurological deficits. So if anyone has stories, please comment below.

Active Exercise

To the instructor’s credit, they state that you will use the active exercise way more than RL. This is good because this is where I think the DNS bread and butter lies. The exercises have been an excellent adjunct in my practice. Here are the big principles regarding exercise that DNS advocates.

  • Develop sufficient body awareness by feeling correct and incorrect movement.
  • Quality over quantity
  • Perform movements slow and pay attention to how one is moving.
  • Keep centration throughout.

The exercises utilize correspond with the various developmental positions, so here are some examples that I have been utilizing and playing with.

4.5 month breathing with band pulldown courtesy of my man Bill Hartman with the wonderful Eric Oetter.

3 month prone with head turns

4.5 month reach

6 month supine breathing

7 month low oblique sit with press

Roll to 8 month oblique sit.

Low kneeling plank

Tripod to bear to squat

Bear crawls

TRX sit to ½ kneel

Squat Cues

We also learned a great way to cue squats to increase pelvic floor activation, which I describe in the video below.

Quadruped Foot

We also had some off-topic discussion with quadruped foot versus tripod/short foot, which I outline in the below video.

Final Verdict

Now I realize that there were some DNS concepts that I knocked, however I will say that the exercise portion of things is very good. Our nervous system is looking for novel input, and I feel the exercises are a great way to provide this. We all developed too, so neurologically these positions are somewhat familiar albeit challenging at time. What is more, DNS exercise does an excellent job of integrating all the body segments into moving as one unit as opposed to training/rehabbing specific body segments. I can appreciate that the folks at the Prague School have taken many different concepts and tied them together into one unit.

So should you take their courses? I say yes. I still learned a great deal in both A and B despite my gripes, and I plan on taking C this fall. So check out the Prague school and learn some good skills.

I also would like to shout out my good friend/fellow mentor PT/cameraman/all around good guy Scott Passman for taking some of these videos, as he put in great effort to make them look good.

Explain Pain Section 4: Altered Central Nervous System Alarms

This is a summary of section 4 of “Explain Pain” by David Butler and Lorimer Moseley.

CNS Alarms

While much of talk in rehab deals with tissue injury and tissue pain, realize that the brain always makes the final decision as to whether or not you should feel pain. No brain, no pain.

This sentiment does not mean that pain is not real. All pain is real. However, pain is a construct that the brain creates in order to ensure your survival.

Spinal Cord Alarms

When an injury occurs and the DRG receives impulses from peripheral structures or the brain, the spinal cord neurons must adapt to better uptake all these signals. In essence, the DRG becomes better at sending danger messages up to the brain. This change leads to short term increases in sensitivity to excitatory chemicals. Those stimuli that didn’t hurt before now do (allodynia) and those that used to hurt now hurt more (hyperalgesia).

In persistent pain, this change continues occurring to the point where neurons that do not carry danger messages start growing into space where danger messages are taking place. Now innocuous stimuli such as grazing the skin begin hurting. The pain may be normal, but the underlying processes become abnormal.

When these spinal cord alarm systems become unhealthy, the brain no longer receives an accurate message of what is going on. The alarms become magnified and distorted.  The brain is told there is more damage in the tissues than is actually present.

What is good is that this increased sensitivity can change once damaged structures are under control and/or the underlying physiological processes are understood by the person in pain.

The Animals may have been onto something.


Another change that happens in the brain is termed smudging, in which brain areas devoted to body parts or functions begin overlapping. This process is why some body parts may become difficult to use or other areas become sensitive compared to the injured area.

Fortunately, since the brain homunculus frequently changes, these effects are reversible. The homunculus must be trained just like any other muscle or skill.


It is now understood that thoughts are powerful enough to maintain a pain state, known as thought viruses. These viruses are known to cause and enhance a low back pain experience, and likely have an effect at the whole body. Here are some examples of thought viruses.

  • Pain means something harmful is happening to my body.
  • Stopping social activity because of pain.
  • It is bad if no one can find out what is wrong with me.
  • Pain scares me.
  • Refusing to move until all pain is gone.
Given many medical treatments, I can see why.

Central Sensitization

Central Sensitization is when the brain and spinal cord become overly sensitive to processes. This change occurs in chronic pain states.  Diagnoses such as fibromyalgia, chronic fatigue syndrome, and non-specific low back pain are often given out. The diagnosis given often depends on where you live and which health professional you have seen. Here are the characteristics of central sensitization.

  • Pain persists past normal healing times.
  • Pain spreads.
  • Pain is worsening.
  • Lots of movements hurt. Even imagining movement can hurt.
  • Pain becomes unpredictable.
  • There are other past, present, and future problems in life.

The Autonomic Nervous System

The sympathetic nervous system helps us cope and stay protected from threat. It does so by sending adrenaline to all the tissues among many other processes.

In chronic pain states, there are increased levels of adrenaline, though in some cases adrenaline can become depleted. Adrenaline does not itself cause pain, but does increase alarm system sensitivity.

On the other hand, the parasympathetic nervous system is what slows us down and helps shift us out of a sympathetic state. This system is why relaxation and meditation can help with the healing process.

Bonus points if you meditate in a cave…and go bald

The Endocrine System

Chronic pain states are often associated with high levels are cortisol as well. Cortisol often gets a bad rap despite its role as a protector. What cortisol does is slow down unnecessary body processes which are not needed for immediate protection and enhances those which are.

The Immune System

The immune system has a major link to the autonomic and endocrine systems. The immune system works by releasing pro-inflammatory cytokines, which can create lethargy, loss of appetite, sensitive movements, etc. Even old pains can come back because of cytokines. Here are some fun immune system facts.

  • Immune system becomes more involved in serious or chronic states.
  • Immune system responses can become learnt.
  • Long-term stress and pain can lead to altered activity which leads to more cytokine production.
  • Immune stressors can be major or multiple minor events.
  • The immune system may underpin pain states such as mirror pain and loss of fine sensibility.
  • The immune system can be activated by the brain.

There are also several ways you can boost your immune system to counteract pain causing behaviors.

  • Improve your quality of life.
  • Be in control of life and treatment options.
  • Have strong family and medical support.
  • Have strong belief systems.
  • Humor.
  • Exercise.
I just boosted your immune system. You’re welcome….Unless you don’t like kids.

Movement (Not Gray Cook, that’s coming later)

In threatening states, big mover muscles become primed. This change occurs evolutionarily so your body can escape potential threats. In injured states, prime movers can act as splints.  If this state occurs for the long term, muscles can start to feel stiff and achy. Even if pain is gone, sometimes these muscles do not return to their normal activity levels.

Really big splints.

Explain Pain Section 3: The Damaged and Deconditioned Body

This is a summary of section 2 of “Explain Pain” by David Butler and Lorimer Moseley.

Tissue Injury 101

When a body is damaged, pain is often the best guide to promote optimal healing. Sometimes it is good for us to rest, other times it is better to move.

A similar healing process occurs for all tissue injuries. First, inflammation floods the injured area with immune and rebuilding cells. This reason is why inflammation is a good thing in early injury stages.

A scar forms once the inflammatory process is over. The tissue then remodels to attempt to become as good as the original. Blood supply and tissue requirements determine how fast the healing process occurs. For example, ligaments heal much slower than skin because the former has a lower blood supply than the latter. This may also be a reason why aerobic exercise may speed up the healing process.

If present, pain usually diminishes as the tissues heal. However, pain may persist if the nervous system still feels under threat.

Acid and Inflammation

The alarm sensors described here constantly work and often get us to move. Movement keeps our system flushed. When we don’t move or a physical obstruction is present (e.g. sitting), acid and by-products build up in the body tissues. Oftentimes we will start to feel aches and pains when we stay in a prolonged position, which is our body’s way of saying “get up and move.”

Much like the alarm system, inflammation is a primitive way for our body to continue the healing process. Inflammation is designed to hurt so the injured area has time to heal. There is no need to fret when swelling, redness, and pain are present; our internal systems are merely repairing us.

Not so bad after all!

We call swelling and its corresponding cells the “inflammatory soup.” This soup is a by-product of blood and chemical transportation, and sets off our body’s alarm system to increase sensitivity. All of these changes are essential to facilitating a healing environment.


Everybody be hatin’ on muscles nowadays as the source of our aches and pains. However, the authors put muscles in perspective for us with the following points.

  • Muscles are loaded with sensors, so can impact the pain experience.
  • Muscles can become unhealthy and weak.
  • Muscles are very difficult to injure, they are just very responsive structures.
  • Muscles are well vascularized which allows for quick healing.
  • Muscle activity alters in response to threat and injury.
  • Muscles reflect what our brain is thinking.

The Artist formerly known as disks – LAFTs

The reason the authors wish to change the name of these structures is because anatomically they do not resemble a disk at all. The new name is “living adaptable force transducers,” or LAFTs.

LAFTs are made up of the same material as your ear, and contain some very strong ligaments. In the medical world, we have many different treatment modalities that target the LAFT. We have McKenzie, traction, surgery, and injection to name a few. Because there are so many different treatments for these structures, it is fair to say that LAFT injuries are still not fully understood.

LAFTs also come with very strong language: slipped, bulging, herniated. Using such strong language can stop someone from moving, which is far from the ideal regarding low back pain.

Here are some LAFT facts.

  1. The LAFT outer layer has a nerve supply, so danger sensors can become activated easily. If the LAFT becomes injured, the surrounding structures will likely set off danger sensors as well. You want a lot of danger sensors if something is occurring near the spinal cord. It is kind of a big deal.
  2. LAFT injuries usually do not cause instant pain. Pain usually occurs 8-12 hours later.
  3. LAFTs naturally degenerate and do not have to contribute to a pain experience. At least 30% (and potentially up to 80%) of people without low back pain have LAFTs bulging.
  4. LAFTs never slip.
  5. LAFTs heal slowly, but they will always be a bit tatty around the edges. This attribute makes it hard to distinguish aging from injury.
  6. LAFTs, spinal joints, and nerves are built to withstand high forces.

Skin and Soft Tissues

Our knowledge of pain is based predominantly on the skin. The skin mirrors the nervous system’s state. Rarely is the case that skin injury leads to chronic pain however. On the flipside, painful skin zones; changes in skin health; and altered sweating or hair growth can all be indicators of damaged nerves.

How often have you seen or had your skin become increasingly sensitive to touch after an injury? This is a common phenomenon that occurs because cutaneous nerves increase sensitivity in order to protect an injured area. Here are some other skin and soft tissue facts.

  • Damaged skin heals very quickly.
  • Skin has a high danger sensor density.
  • Skin is very mobile and loves movement.
  • Fascia is a strong tissue that lies under the skin and also contains many danger sensors.
  • Massage moves tissues and sends impulses to the brain. Therefore, movement and touch are great ways to refresh the virtual and actual body.
Love skin, just not too much.

Bones and Joints

Most joints have lining known as synovium which keeps the joint contained and lubricated. This lining is loaded with danger sensors. Here are some other facts.

  • Joint pain seems to be dependent at which the speed damage occurs. Slow changes usually do not make the brain think there is danger. A dislocation however may lead to severe pain. Most people with worn joints never know about it.
  • Everyone has worn joints as we age. They are the wrinkles on the inside.
  • Joints love movement and compression.
  • Broken bones heal and are often stronger than before.
  • Joints in the back and neck can get injured, but may be too small to see on imaging. This may or may not set off the alarm bells.

Peripheral Nerves

Most of today’s neuroscientists agree that peripheral nerve problems are far more common than we think. Here are some fun facts regarding nerves.

  • Nerves have danger sensors.
  • Neurons can contribute to pain.
  • If a nerve becomes injured, it may become more sensitive to ensure you survive.
  • Nerves slide as we move. If a nerve cannot slide well, pain may occur while moving.
  • Nerves change as we age, just like everything else in our bodies.
  • Scans and nerve conduction tests cannot easily identify a damaged nerve.
  • Nerves can be injured but may not create a danger message for days to weeks.

The Dorsal Root Ganglion (DRG)

The DRG is like the brain of the peripheral nervous system. This is the first place that tissue messages are evaluated. Here are some facts for DRGs

  • Peripheral nerves have their nucleus in the DRG. It is here that sensors are made.
  • The DRG is extremely sensitive and changeable.
  • The DRG is very sensitive to blood chemicals, especially stress chemicals.
  • Sometimes the DRG fires just because. It is like your body’s car alarm. Sometimes the DRG can be hurt without having any pain too.

Backfiring Nerves

When a nerve is injured, oftentimes it will backfire. The reason for this is like a domino effect. If a nerve is stimulated at one end, it will send messages up the system to go to the other end.

Backfiring may not be an issue for the short term, but its persistence can lead to sustained inflammation. A less sensitive nervous system may lessen the amount of inflammation in the tissues.

Nerve Pain

Here are the common symptoms associated with peripheral nerve pain.

  • Pins & needles.
  • Burning.
  • Night pain.

Here are potential locations

  • Skin zones supplied by the damaged nerve.
  • Small sensitive hot spots known as trigger points.

There are also some other potential qualities

  • Movement often makes it worse, so you may adopt abnormal postures for relief (upper cross, elevated shoulders).
  • Stress makes it worse.
  • Unpredictable zings may occur.
  • Movement or a sustained posture may ignite an injured nerve which keeps ringing.
  • May not hurt for a few days or weeks.
  • Skin zones may become itchy.
  • Might just feel weird.

Just because you feel these symptoms does not mean it is the end of the world. Understand that nerves are just responding to signals from the brain that tell them to increase sensitivity and improve warning capacity.

Explain Pain Section 2: The Alarm System

This is a summary of section 2 of “Explain Pain” by David Butler and Lorimer Moseley.

Alarm Signals

Our body’s alarm system alerts us to danger or potential danger. This alarm system is composed of sensors throughout the body, the eyes, nose, and ears. It is these sensors that are our first line of defense against harm. If one sensor fails the others take over.

Most of these sensors are located in the brain and respond to various stimuli. Some to mechanical movement, some to temperature change; the sensors in the brain particularly respond to chemical activity.

What is important to know with sensors is that they have a very short life expectancy of a few days. This cycling means our body’s sensitivity is constantly changing. It is with these life cycles that there is hope for those with chronic pain.

Well, at least most of us can change how sensitive we are.

Moreover, the rate at which sensors are made is normally stable but can change very quickly in regards to a particular stimulus. So if we take for example one with persistent pain, the rate at which pain sensitivity occurs can be changed.


We lack pain receptors in our bodies. Instead, the various tissues have special neurons that respond to different stimuli. These receptors are called nociceptors, which translates into “danger receptors.” Nociception is occurring all the time, but only sometimes will it end in pain.

Nociception is neither necessary nor sufficient for pain.

The sensors correspond to particular neurons. In order for these neurons to become excited and send signals to the brain, an action potential must occur. An action potential is a spike in which nerves relay messages. These spikes require a certain amount of stimulation to go over a certain threshold. Think of it the same as if someone were doing many things to make you mad. Eventually, that person will cross the line and may cause you to get very angry. Action potentials act very much the same way.

These nociceptors can become very active very quickly depending on resting stimulation. If at rest these sensors are stimulated high enough, then small changes could cause the action potential threshold to more quickly be reached. This happens in acute injuries for example. Suppose you scrape your leg. The skin sensors along the scrape have increased sensitivity. This change may lead to even a slight touch to the injured area creating a nociceptive response.

No touching! Even if there is money in the banana stand

Notice that above I have been neglecting to say pain. This is because the brain and spinal cord have to analyze the incoming nociceptive information prior to pain being felt. This processing is why not all nociceptive responses are painful.

The Pathway

When nociceptive fibers activate, a signal is sent to the spinal cord. Here at the cord, chemicals are released to activate surrounding neurons. The various neurons are built to respond to particular chemicals and not to others.  This is called the Lock and Key Principle.

From the spinal cord, neuronal messages are relayed to the brain. In the brain, all relevant stimuli are processed and sorted out to determine the best course of action. There is not one part of the brain, but several, that deal with pain. These areas are called “ignition nodes.”

The response that can occur from the brain can affect multiple body systems in order to get us out of trouble. Here are the different effects that can occur with an injury.

  • Sympathetic nervous system – Increase heart rate and vigilance, mobilize energy stores, sweat.
  • Motor system – Run away, fight, protect damaged area.
  • Endocrine system – Mobilize energy stores, reduce gut and reproductive activity.
  • Pain production system – Motivate to escape and seek help, attract attention.
  • Immune system – Occurs later post-injury, but cleans up injured area, increases sensitivity, produces fever, makes one sleepy.
  • Parasympathetic system – Occurs later post-injury, but promotes healing.

The Sensitive Nervous System Chapter XV: Clinical Aspects of Neurodynamics

This is a summary of chapter XV of “The Sensitive Nervous System” by David Butler.


In this chapter we discuss many specific neurodynamic pathologies and implementing the nervous system into treatment approach.

Conservative Nervous System Decompression

Here is a general step-by-step approach to decreasing threat throughout the nervous system.

1)      Decrease tissue sensitivity by removing relevant stimuli and decreasing CNS threshold.

2)      Improve container tissue health.

3)      Improve the nerve tract’s ability to absorb traction forces.

4)      Assess and improve the nerve to container relationship.

5)      Assess/modify any adverse ergonomic or environmental factors.

Carpal Tunnel Syndrome

Tests to perform.

  • ULNT1 & reverse.
  • ULNT2 (median) & reverse.
  • Compression (can add ULNT).
  • Phalens and reverse Phalens.
  • Phalens + ULNT.


There are several options to treat carpal tunnel syndrome. Mobilizing not only the median nerve, but radial and ulnar is beneficial because the nerves are closely connected. Movement is critical because nerve inflammation and swelling does not leave the carpal tunnel easily. This problem is because there are minimal lymphatic channels in the tunnel.

Or Bengay, Bengay always works for Carpal Tunnel

Nerve Root Complex

Nerve root issues often have corresponding postural adaptations.

  • Cervical – forward head posture.
  • Lumbar – Flat lumbar spine with knees flexed, positioned toward the injured sign. In acute instance, it may be okay to let the patient rest in these antalgic postures until AIGS settle.

Other presentations indicative of nerve root complex pathology include numbness/tingling down the extremities. Other possibilities include coldness, shooting, tiredness. Pain rarely goes into the extremities.

Double Crush

Double crush is a phenomenon where two AIGS or compressive locations are present on a single nerve. Currently, the literature is mixed on its existence. However, Butler feels that the second pain that occurs with this phenomenon is likely an old problem showing itself.

More like double entendre.

The Foot & Neurodynamics

The biggest take home point here was regarding heel spurs. With these pathologies, there is evidence of concomitant peripheral neuropathic pain. The likely involved nerves include the lateral plantar nerve or medial calcaneal nerve. With these, it is important to check eversion and implement this movement into the straight leg raise.

Neurodynamics and the Thorax

A couple suggested treatments include sliders and tensioners in the slump long sit, as well as Anterior to posterior glides of the thoracic spine. Butler feels these lead to more thoracic spine movement.


Rapid changes can frequently occur with these conditions, and often this speed is due to patients altering the way they think and feel about the problems.

The Sensitive Nervous System Chapter XIV: Management Strategies: Integration of Neurodynamics

This is a summary of chapter XIV of “The Sensitive Nervous System” by David Butler.

The Big Picture Evidence Based Approach

Here is the step by step patient care process that Butler advocates.

1)      Identify red flags and manage accordingly.

2)      Educate on the whole problem to include tissue health status, the nervous system’s role, and test results.

3)      Provide prognosis and make realistic goals.

4)      Promote self-care, control, and motivation.

5)      Decrease unnecessary fear and manage catastrophization.

6)      Get patients moving as early as possible.

7)      Help patients identify success and sense of mastery of a problem.

8)      Perform a skilled exam.

9)      Acknowledge that biopsychosocial inputs combine with the nervous system to produce pain and disability.

10)   Use any measures possible to reduce pain.

11)   Minimize number of treatments and contacts with all medical personnel.

12)   Chronic pain may need a multidisciplinary approach.

13)   Manage physical function and dysfunction.

14)   Assess and assist in improving general fitness.

15)   Assess how injury affects creative outlets and assist the patient with regaining creativity and discovering new creative outlets.

Incorporating Neurodynamics

There are several ways to incorporate neurodynamics into the patient’s plan of care which will be outlined below.

  • Reassessment.
  • Explanation.
  • Passive mobilization.
  • Active mobilization.
  • Posture and ergonomics.


There are many evaluation protocols that warrant constant reassessment after applying an intervention. Be it a comparable sign or audit, neurodynamic tests can be utilized well within these systems.

A word of caution with instant reassessment, as quick changes could merely be playing with impulses in a healing environment. The real sense of improvement is through improved function.


When working with Peripheral neuropathic pain (PNP), it is important to educate patients on normal responses. Many may find it weird that neck movements can change sensations at the wrist, but patients must realize that the nervous system is a continuous structure. Providing stimulus at one point of the structure can lead to responses at other ends of the same structure.

In central sensitization, the language provided must be spoken tactfully. The following points are important to hit home:

1)      Acknowledge the specific dysfunction, but say it has had time to heal.

2)      Real processes within the central nervous system occur that magnify inputs.

3)      There are several reasons why this increased sensitivity occurs, including biopsychosocial inputs.

4)      The nervous system produces chemicals that keep it sensitive.

Regardless of how we communicate with patients, the most important thing is to not be frightened by pain. If we are frightened of pain and do not understand it, this will be carried to the patient.

Good clinicians ain’t never scared of pain.

Passive Mobs

First some ground rule concepts.

1)      Reject the notion of neural stretches and crude assessments.

2)      Passive is only a part.

3)      Your patient interaction could affect the response.

4)      Passive could educate a patient on what they are capable of.

5)      Judgments about technique efficacy should consider the evidence.

6)      Early mobilization is best after nerve injury.

7)      If there are many sensitive tests, mobilize the least sensitive first.

Here are some potential mobilization techniques.

  • Tissue mobilization with the nervous system positioned.
  • Nervous system mobilization with the tissues positioned.
  • Neurogenic massage

Here are some examples of the above.

Active Mobs

Several options can be used.

  • Movement breakdowns.
  • Change movement order.
  • Trick movements: Changing positions or using eye movements.
  • Slider/tensioner.
  • Relate to a meaningful activity.
  • Pacing – Working into painful activity with a gradual progression into further activity.

Here are some examples of sliders and tensioners

Here is an example a movement breakdown I have been using a lot.

Posture & Ergonomics

Here we present a table of potential movements that can affect sensitivity of specific nerves.

Nerve Movement/Position/Injury
Sciatic Sitting long periods or on a hard edge.
Common fibular Ankle sprains, squatting, repeated leg crossing, tight splints
Deep fibular Tight shoes, high heels, sitting on ankles.
Superficial fibular Repeat ankle sprains, tight shoes, metal capped boots.
Tibial Excessive exercise, running in shoes without arch support.
Sural Tight ankle bracelet or sustained compression.
Femoral Repeated lumbar extension and hip flexion; prolonged FABER.
Lateral femoral cutaneous Tight jeans; weight gain.
Saphenous Straddling a surfboard.
Pudendal Long bike ride.
Brachial plexus Contralateral cervical sidebend + shoulder depression (football tackle).
Ulnar at the wrist Cylcing, wrist used as hammer, prolonged video gaming.
Ulnar at the elbow Elbow flexion + compression, taxi driver, being chair-bound.
Radial at the upper arm Crutches or Saturday Night Palsy.
Radial at the elbow Repeated pronation/supination.
Radial Sensory Tight handcuffs or bracelets; repeated pronation/supination.
Median at the upper arm Saturday Night Palsy
Median Repeated wrist flexion/extension; vibration.
Musculocutaneous Heavy bicep exercise; strap heavy bag at the elbow.
Axillary Anterior-inferior shoulder dislocation; sleep with arm overhead.
Suprascapular Repeated overhead movement; volleyball/swimming.
Spinal accessory Comatose surgical patient head down with shoulder support; “Love bite.”
Long thoracic Tight bandages; forceful shoulder motion; overuse
Only at zaccupples.com do we put our tables back to back.

The Sensitive Nervous System Chapter XIII: Research and Neurodynamics: Is Neurodynamics Worthy of Scientific Merit?

This is a summary of Chapter XIII of “The Sensitive Nervous System” by David Butler.


Research has demonstrated that often evidenced-based medicine is low on the list for why clinicians choose a particular treatment. From an ethical standpoint, it is important to consider evidence. This chapter is very short so I will just provide the highlights that I got from it.

Appraising a New Theory or Approach

There are six criteria that a new theory should be evaluated by:

1)      Support from anatomical and physiological evidence.

2)      Designed for a specific population.

3)      Studies from peer-reviewed journals.

4)      Include a well-designed randomized controlled trial or single experiment.

5)      Present potential side effects.

6)      Proponents discuss and are open to limitations.


Here are some definitions of different ways research measures agreement.

–          Cohen’s Kappa: Measures nominal data reliability.

  • >0.75 is excellent agreement.
  • 0.40-0.75 is fair to good.
  • <0.40 is poor.

–          Pearson product movement correlation: Measures interval/ratio data.

–          ICC: Measures continuous data.

  • The closer to 1, the better.


There are also many different validity types defined throughout this chapter. The first two are proven through logic and have the least evidence support.

–          Construct Validity: Valid relative to a theoretical foundation.

–          Content Validity: Can I use this measure to make an inference?

The next two are higher up on the evidence support hierarchy.

–          Convergent Validity: The test shows a correlation between two variables.

–          Discriminant Validity: The test shows a low correlation between two variables.

Lastly, these are criterion-based tests that infer similar results compared to an established test.

–          Concurrent Validity: the compared tests are performed at the same time.

–          Predictive Validity: The tests are compared at different dates.

If only EBP were as exciting as evidence-based law.

The Sensitive Nervous System Chapter XII: Upper Limb Neurodynamic Tests

This is a summary of Chapter XII of “The Sensitive Nervous System” by David Butler.


Today we will take a look at assessing upper limb neurodynamic tests (ULNT). These assessments used to be called tension tests, but that terminology is now a defunct mechanical description. We now describe these as neurodynamic tests to better appreciate the neurophysiologic aspects of mechanosensitivity and upper limb homunculi stability.

Neural tension is so passé
Neural tension is so passé

These tests are numbered based on the movement sensitizer, which are as follows:

1 – Shoulder abduction.

2 – Shoulder depression.

3 – Elbow flexion.

ULNT1: Median Nerve

Here is the quick test first.

Here is how to do the manual test.

A quick heads up regarding head motions.

  • Sidebending away increases symptoms in 90% of people.
  • Sidebending toward decreases symptoms in 70% of people.

ULNT2: Median Nerve

Here is the manual test

ULNT2: Radial Nerve

Here is the active test.

And the manual test.

ULNT3: Ulnar Nerve

Here is the active test

And the manual test.

Musculocutaneous Nerve

Here is the active test

And the passive test.

Axillary Nerve

Here is the passive test.

Suprascapular Nerve

Here is the test.

Final Words

Have some fun with these tests, and be mindful that you are not too aggressive.

Thanks to Scott and Sarah for your videotaping help. You guys rock.


Course Notes: Graded Motor Imagery

I recently attended another great course through the NOI Group called “Graded Motor Imagery” (GMI) taught by Bob Johnson. These guys are the industry leaders in all things pain so please check them out. It was great connecting with Bob and learning what I think will be an excellent adjunct to what I am currently doing. So here is the run down on GMI.


GMI is a three-pronged sequential process of establishing early, nonpainful motor programming. Johnson calls this synaptic exercise to limit negative peripheral pain expression. GMI is a 3 step process:

1)      Laterality reconstruction (Implicit Motor Imagery).

2)      Motor imagery (Explicit Motor Imagery).

3)      Mirror Therapy.

The Neuromatrix Paradigm & Pain States

Before delving into the neuromatrix, we first must define pain. Pain is a multiple system output or expression by an individual-specific pain neuromatrix that activates when the brain concludes that body tissues are in danger and action is required.

The neuromatrix, like I talk about in this post here, is the nervous system’s coding space and network. It is first and foremost affected by genetics, sculpted by experience, and constantly evolving. It is the entity that makes us who we are—the self.

The neurosignature, or neurotag, is an output’s representation in the brain. For example, regions in the brain will activate in response to produce the pain output. This sequence is the neurosignature. Some common activated areas when pain is expressed include both primary and secondary somatosensory cortices, insula cortex, anterior cingulgate cortex, thalamus, basal ganglia, and the cerebellum. However, areas activated differ among individuals.

A way to akin the neurotag is that of several movies occurring throughout the brain that represent past, present, and future. The United Airlines map is another example.

Just looking at this is starting to induce my pain neurotag.

Neurotags have an activation threshold which can be modified by various ways. Some examples are the context of injury, beliefs, perceptions, feelings, and sensory input. Previous injury can also activate this neurotag and increase nervous system sensitivity.

If pain persists because the brain perceives the body as threatened, the pain neurotag becomes sensitized and disinhibited. These changes result in smaller inputs creating painful outputs and pain locations spreading.

There are several of these representations in the brain—motor, endocrine, immune, limbic, etc—but most famous is the somatosensory homunculus.

There are several key features of this homunculus

  • Somatotopically organized – meaning different body parts are represented next to one another.
  • Areas that require more sensation are larger, such as the hands
  • These representations are dynamic throughout the day.
  • They can be fooled.

What can be problematic is that in certain pain states smudging can occur, in which the representation is not seen as well in the brain. This change occurs in both acute and chronic pain states, though the brain activity is different. Areas can also become smudged depending on which parts a person may use more. The hand representation of a musician will likely be larger than a non-musician. It can also take on nonorganic parts, such as a wedding ring or a watch.

Graded Exposure & the Pain Neurotag

Graded exposure is a way to expose the brain to painful activity without activating the pain systems. This tactic can be performed by breaking down movements or changing the movement context.

To begin graded exposure, the patient’s baseline for each task must be found first. The baseline is the amount of activity that one can do without flaring up. A flare-up is when a certain amount of activity is performed that maintains the pain neurotag sensitization with the corresponding activity. This is a line we would ideally like to avoid, but is not something to freak out about if we hit.

TT = Tissue tolerance PBP: Protect by pain barrier FUL: Flare up line BL: Baseline
TT = Tissue tolerance
PBP: Protect by pain barrier
FUL: Flare up line
BL: Baseline

There are three strategies in which people approach graded exposure.

  • Fear-Aviodance (bad): Do less and less and not move toward the baseline.
  • Boom-bust (bad): Ignore flare line and push through the pain barrier.
  • Graded Exposure (good): Knock on the door where pain resides and slowly push farther and farther. Do not do too much or too little.

In order to perform graded exposure, the first step is to identify both physical and contextual fear-related challenges based on the painful movements. Physical challenges include performing the activity through a larger range of motion or for a longer duration. The activity can also be broken down into parts. Contextually, the activity can be changed several different ways.

  • Threat and threatening equipment.
  • Changing vision.
  • Changing emotion.
  • Changing meaning (kicking a ball instead of a straight leg raise).
  • Non-contaminated representations.
  • Expectation.
  • Place.
  • Distracting.
  • Gravity.
  • Change neighboring tissues.
  • Time
  • Metaphors.

But what if you try all of these ways and still get a pain response? Use your imagination…Literally. This is where GMI comes in, as it has the ability to fly under the radar of the pain neurotag yet still activate motor receptors.


If utilizing GMI, the above order must be performed, as research has shown that if you perform mirror therapy after laterality retraining there are negative benefits.

Implicit Motor Imagery (IMI)

IMI, or laterality retraining, is the ability to determine whether a presented image is left or right. Performing IMI disengages the primary motor cortex while simultaneously activating premotor cells. This activity may lead to decreased pain neurotag activity while still activating motor areas.

Left/right discrimination appears to be delayed in acute, expected, and chronic pain states. Some of the below conditions are affected per research.

  • Complex regional pain syndrome (CRPS).
  • Spatial neglect.
  • Amputation.
  • Back pain.
  • Neck pain.
  • Knee pain.
  • Carpal tunnel syndrome.
  • Cervical dystonia.
  • Focal dystonia.
  • Congenitally absent hand.

Here are some normative values for IMI, though Bob suggested that normal will be very much patient-specific.

  • Accuracy of 80% or above.
  • Speed of 1.6 ± 0.5 s for necks and back. 2 ± 0.5 s for hands and feet.
  • Accuracy and response time should be fairly symmetrical.
  • Patient results should be stable for at least one week; should not fade out with stress.
  • Personal relevance of responses should take precedence.

Other rules of thumb, typically reaction time increases with age, males are faster than females, and left handed people are faster than right handed (score).

Add to the list of things lefties are superior in.

Here are some potential indicators that would indicate a possible trial of using IMI.

  • Ongoing pain.
  • Some less obvious pain states.
  • Variable diagnoses.
  • Cold sensitivity.
  • Tender away from injured site.
  • Bilateral pain.
  • Unpredictable treatment responses.
  • Chasing pain.
  • Everything hurts.
  • Immune imbalances.
  • Disembodiment metaphors.
  • Cyclical.
  • Two-point discrimination changes.

There are several ways to train IMI. The use of flashcards in various positions, finding body parts in magazines, digital cameras, basically any activity which challenges left and right discrimination is useful. The challenge of the pictures can also be increased depending on orientation.

Easy---little challenging---that was tough---OMG
Easy—little challenging—that was tough—OMG

You can also change the context of the pictures to further increase difficulty.

  • Speed.
  • Image number
  • Image context (hand on plain background versus hand in patterned background).
  • Different/abstract body parts (Painted or animal hand).
  • With distraction.

If performing laterality retraining of the affected body region is painful, then adjacent or distal areas

The most important thing when training IMI is that accuracy is emphasized before speed and that the activity is relatively pain-free.

Explicit Motor Imagery (EMI)

EMI is imagining moving your own body without actually moving it. This activity leads to movement neurotags, namely the preparatory and initiating ones, to activate.

Intention → preparation→ carrying out→ evaluating

Observed, imagined, and performed movements activate many of the same brain regions albeit to varying degrees. Working from observation all the way to performance is essentially graded exposure from a top-down approach.

Research has actually demonstrated that imagining movement has been shown to increase pain and swelling in patients with CRPS type I. Therefore, sometimes this activity can be too much for patients. If you activate the pain neurotag, you may have to take a step back. Even if IMI is too much, then watching someone move is likely the most ideal.

To perform EMI, it is very important to imagine all movements in the first person. Imagining in first person makes the activity more kinesthetic than visual. It is very important to make the task individualized to facilitate best outcomes. Here are some ways to make EMI more effective.

  • Have the eyes open/closed
  • Imagine the affected body part in the starting position.
  • Describe the environment.
  • Demonstrate the movement.
  • Use words to describe the process.
  • Use cues from the 5 senses.
  • Recall memories.
  • Prior relaxation techniques.
  • The activity should be imagined as long as it takes to do in reality.

Typically, here is the EMI progression that can be utilized.

Watch the activity –> Hold affected body part in static position –> dynamic imagery –> manipulate an object.

Terrible pun but I am still going to use it.

Mirror Therapy

Mirror therapy is a novel way to trick the brain into thinking the moving limb is the hidden limb. When the limb is viewed in a mirror, the motor cortices in both brain areas are activated. This activation is more than in EMI, but less than actual movement. Mirror therapy is another step in graded exposure.

Sometimes with mirror therapy dysynchiria may occur, which is when the person feels pain or pins and needles in their hidden limb. This phenomenon most often occurs in patients with CRPS. If this does occur, it is important to advocate to the patient that nothing is being damaged because the hand is not even moving.

Here are some general guidelines to utilizing mirror therapy.

  • No jewelry or cover tattoos on the affected side.
  • The more severe the problem, the less movement amplitude and increased frequency may be needed.
  • The patient cannot see the other side.
  • Feel comfortable with the movement before progressing to a more challenging movement.
  • Once you feel comfortable with a movement, change the context.

Here is a way to progress/regress mirror therapy.

Threat value Hand inside box Hand outside box
Less threatening Hand resting. Hand resting. Just observe.
Hand resting. Rotate the hand.
Hand resting. Finger opposition.
Hand resting with a slight bend in the fingers. Slow fists.
More threatening Bend the wrist up/down within pain limits. Bend the wrist up/down through full mobility.
Finger opposition gently touching together. Forceful finger opposition.
Make a fist into some discomfort in time with outside hand. Fist for repetitions.
Full mobility. Copy hand in box.
Most threatening Tool manipulation. Copy hand in box.

The Clinical Reality

Before GMI is implemented, the patient must first be educated on pain. Educating patients on pain physiology has been shown to have many benefits including decreased pain thresholds, improved pain beliefs and attitudes, and improving outcomes of therapeutic approaches.

The big keys that must be advocated include that the brain changes undergone with pain experiences do not equal brain damage. The nervous system is just unhealthy. These effects are reversible and take time. It is similar to learning to play a musical instrument. Jimmy Page didn’t become a great guitarist practicing two times a week for 4 weeks.

Hyooge hand representation.

Many times patients may get the feeling that you are suggesting the pain is in the head which is not the case. However, the brain decides whether or not you will experience pain. A good example is an ankle sprain. Say you sprain your ankle on the street when all the sudden you notice a bus coming your way. Does the ankle sprain hurt at that moment? Not likely because your brain is going to be focused on you moving out of the bus’ way.  Changing the patient’s mindset is key to having the most successful outcome.

Great Bob Johnson Quotes

  • “The goal is pain freedom. Even if it hurts, I am less threatened.”
  • “Ask with every patient how the nervous system is involved.”
  • “If you say the neurodynamic tests involves only the median nerve you are lost.”
  • “50% of people have joint noises. It is just the way your body protects you.”
  • “The [nervous] system will do what it needs to survive.”
  • “Get the patient to think they can get better and they will get better.”
  • “One cannot have pain with just physical damage.”
  • “Pain holds on because the patient is misunderstood, not broken.”
  • “Just because the police are at the scene doesn’t mean they committed the crime.”
  • “The motor homunculus doesn’t think muscles, it thinks movements.”
  • “Glia are immune cells for the CNS. They are gates that turn the system on and off.
  • “Movement is an antigen.”
  • “Ask patients how stressed they were when they hurt themselves.”
  • “Our goal is to get the patient moving without turning on the system.”
  • “The two biggest factors for chronic pain development are work and home satisfaction.”
  • “Two point discrimination treatment changes brain sensitivity and cortical reorganization.”
  • “Emotion is lotion.”
  • “I don’t take medical histories; I need to find out who the patient is.”
  • “Imagining impossible movements are possible with phantom limbs.”
  • “25% of premotor neurons are mirror neurons” This is why watching movement works.

Final Verdict

Overall, I thought this was a fantastic course, and put more skills into my clinical skillset. It may take some time for me to implement GMI into my practice (I need to make a lot of laterality cards), but I bet this will be very useful.

I also wonder if there are potential for using this modality in a performance aspect. Imagery has been used with great outcomes in athletes, but laterality retraining and mirror boxes have not. Could this be another way to increase performance? Only time will tell.

To sign up for more NOI courses, check out www.noigroup.com