75 is the number of continuing education classes, conferences, home studies, etc that I’ve completed since physical therapy school.
Though the courses are many, it was probably too much in a short period of time. When quantity is pursued, quality suffers. Sadly, I didn’t figure out how to get the most out of each class until the latter end of my career.
Yes, the content was great, but these classes stood out for a different reason. You see, instead of just doing a little bit of prep work, I kicked it up a notch. I extensively reviewed supportive material, took impeccable notes, and hit all the other essentials needed to effectively learn.
I was prepared, and because I was prepared I got so much more out of these classes than my typical fair. The lessons learned in those courses stick with me to this day.
For the stuff you really want to learn, I’ll encourage you to do the same. Here is the way to get the most out of your continuing education. By the time you are done reading this post, you’ll understand why I now recommend a more focused learning approach and fewer courses.
It’s that time of the year that we get to look back and reflect and what posts killed it (and which bombed).
It seems as though my fine fans be on a pain science kick this year, and rightfully so. It’s some of the best stuff on the PT market right now. It’s definitely a topic I hope to write about more in the coming year, and one I will be speaking on at this year’s PRC conference.
But without further ado, here are the top 10 posts of 2014.
Going through the treatment process as a patient has really upped my game in terms of knowing when to integrate with my patients. It has also been a life-changing experience for my health and well-being. Learn how they did it for me.
So much fine tuning occured the second time around. I love how Jen acknowledged the primitive reflex origin of the patterns, as well as fine tuning both lift tests. She’s an excellent instructor (and fun to party with)!
One of the most powerful and humbling courses I have ever been to. Ron goes all out on this course, as it is his baby. What dental integration can do to a system under threat is a concept that I hope is further explored in medicine. We can’t do it alone folks.
This post marked a shift in my thought process and a realization of the possibilities that an integrated health system can accomplish. I have high hopes for our profession, and feel excited that an original post had so many views.
Couple the best manual therapy explanation I have come across and a gentle technique and you get a rock solid course. The only downside is that now Diane has tarnished any other manual therapy course for me, as I can’t rationalize any other explanatory model given.
I finally had the opportunity to meet my personal Jesus, David Butler, and learn the way that he explains the pain experience to patients.
It was an interesting weekend to say the least. The course started off with a smash…literally.
We had the unfortunate experience of someone breaking into our car to start the trip off. Then once we arrived to the course, we were informed that Dave was going to be 2 hours late. He was staying in Philly (where I also experienced flight troubles last week) and a snowstorm with a name no one cares about stopped his flight.
So Dave drives all the way from Philadelphia, “tilting his head back to rest” for 1 hour, and then what happens?
He, along with the other instructors, drive to the wrong campus.
So after all these crazy things happen, Dave finally makes it to the course, sets up his presentation, plays a little Bob Marley, and………………
I mean, absolutely kills it.
To see Dave present this topic under the above circumstances and be on the entire time is a testament to the type of speaker and professional he is.
David Butler is one of, if not the best speaker I have ever heard.
So I’d like to thank you, Dave, for making an otherwise stressful weekend memorable and exciting. I look forward to applying what I have learned.
If you haven’t taken a course from the NOI Group, please do so yesterday!
So what did me and my friends blossums learn this past weekend? Read on brothers and sisters, read on.
A Paradigm Shift
Conceptually understanding what pain is can be quite powerful. And pain science itself has grown by leaps and bounds.
The number needed to treat (NNT) values of explaining pain to patients is about three. That means that it takes explaining pain to 3 patients before 1 will have a successful outcome (pain relief after 12 months).
To put this value in perspective, most pain medications have a NNT over 10. Taking aspirin in hopes of preventing a heart attack is 50. Knowledge is powerful stuff.
We know lots of powerful things to tell patients regarding pain states. Take the following points as an example:
Pain is a critical protective device.
Pain depends on how much danger your brain thinks you are in, not how much you are really in.
Tissue damage and pain often do not relate.
As pain persists, the nervous system becomes better at producing pain.
Great educational pieces that patients ought to know. The problem arises in dispelling this knowledge.
Think about who educates patients on their complaints. How many people do we know are given the death sentence of a bulging disc? How many people say “look at my x-ray!!?” How many people say “There’s nothing I can do. It’s bone on bone?”
There is an obvious disconnect between what is known about pain and what healthcare practitioners educate patients on. It is a constant battle, so how do we combat this problem? As Dave so eloquently put it:
“You have to meet the patient at their story.”
Let’s face it, changing the way one perceives pain is changing a thought process and belief system; something very challenging regarding any belief.
Changing one’s pain beliefs involves first reconceptualizing pain, then translating this message to the audience, and finally altering the narrative to address misconceptions. But the quote above reigns supreme. If you start by barraging someone with pain science when they are so far away from that paradigm, you run the risk of losing them.
You must build a bridge in order to cross a chasm.
If you have not been living under a rock for the past 5 years or so, there are currently two combating models in the medical realm.
Biomedical (BM…not bowel movement)
The BM model is still the overwhelming favorite and where most of the world thinks. It combines knowing anatomy, biomechanics, and tissue pathology in order to treat conditions.
One key thing regarding this model is that it is still useful. If I have someone who is having complaints that resemble cancer, I want to utilize this model to determine if that is indeed the case.
The BPS model encompasses the above and much more. Here we take into account the neuromatrix, pain mechanisms, the onion skin model, fears, threats, and challenges, and evolutionary biology.
The important thing to realize is that the biomedical aspects are still present in this model, and can play a role in one’s pain experience. So please, do not forget them.
The BPS model’s goal is to enrich patient’s knowledge and create a conceptual change along with addressing potential problems.
However, each patient we interact with may possess many different misconceptions that we may have to address. The range goes from missing pieces of understanding all the way to lacking the requisite mental framework for understanding pain science.
We can see how sometimes teaching someone pain science can be incredibly challenging. If a patient cannot think in the way you are educating, you may not be able to alter their perceptions on the pain experience. They may lack the neurosignature necessary to understand what you are saying.
To understand pain, one must realize it is an emergent process. Many people conceptualize pain as a linear process – I pinch myself, and I feel pain. But as we know, pain is complex and results from the interaction of many variables. This process is like baking a cake. Small ingredients combine to form an end product that bears no resemblance to the individual parts.
Let’s Build Us a Nervous System, or even Better, a Neuroimmune System
While the periphery is extremely important, more emphasis ought to be put on the neuroimmune system and how it works, especially in pain states. As suggested by Butler, the nervous system works by being:
Complex – The hardware and wetware
I won’t go into great detail into these points, as I have talked about them ad nauseum here , but here are some interesting factoids regarding your nervous system:
The anatomy and chemistry of the brain do not match.
Over 80% of the brain are glial cells with an immune function and have a bidirectional relationship with neurons.
25% of the brain’s neurons are mirror neurons.
The entire brain is replaced every few weeks.
Ion channels, your body’s sensors, change every two days and reflect the individual’s needs.
Now if we want to look at the brain itself, the big kahuna, there are some key points Dave discussed with us regarding this magnificent organ:
Although pain experiences are distributed and can vary among people, common areas do activate.
The neurotag composes the areas that activate together in a particular experience. Hence, those active during pain would be the pain neurotag.
Brain representations do not indicate specific tissues, but more so areas.
Emotional and physical pain look similar. Moreover, pain and pleasure have similar neurotags.
Brain representations can be modified by cognition.
Smudging of key areas can occur.
If no problems whatsoever exist in your body tissues, nerves, or immune system, you may still feel pain if the brain thinks you are in danger.
Taking into account the above, the therapeutic goal is to alter representations, deactivate painful neurotags, and reduce the perception of threat.
Nociception is basically a danger message that comes in from the periphery. This “danger” signal is not the same as a “pain” signal, as pain is a brain output. These fibers send quantitative data as opposed to qualitative. So when you hear someone saying pain feels achy, gnawing, tearing, ripping; know that these descriptors are CNS outputs.
Nociception is neither necessary nor sufficient for a pain experience.
There are two basic nociceptive processes:
Ischemia: occurs at the end of day and when little movement is applied; address by education and movement.
Inflammation: neurogenic and non-neurogenic.
Lets break down inflammation further. The non-neurogenic side contains chemicals from cells of damaged tissues, specialized inflammatory cells, and plasma. We also see the immune system releasing pro inflammatory cytokines to help with the response.
Understanding the neurogenic side requires understanding C fibers. C fibers, peripheral nerve components, are able to send information both towards the brain (orthodromic) and periphery (antidromic). The orthodromic impulses are the danger signals sent to the brain, whereas the antidromic impulses create inflammation via peptides such as substance P. This release leads to immune activity, capillary leakage, and increased enzymatic responses.
Aside from the above mechanisms, the periphery also has the ability to become hypersensitive by increasing the ease at which nociceptive fibers fire. This increase can occur in transient receptor protein channels as well as ion channels.
All of the aforementioned changes are a normal protective mechanism that the body uses to keep us safe. Inflammation helps you heal, and ischemia prevents further tissue damage from occurring. What becomes problematic is when these processes, either by central regulation or potential re-injury, perpetuate.
Nervous tissue, like all other tissue, can become injured or unhealthy. However, nerves do not necessarily have to hurt. In fact, cadaveric studies demonstrate that 50% of people who never complained of symptoms undergo connective tissue and nerve fiber changes at vulnerable places. Moreover, 20-30% of the population has abnormally compressed nerve roots.
Like nociception, nerve sensitivity is neither necessary nor sufficient for a pain experience.
When a peripheral nerve is injured, changes occur at the injury site and centrally. Ion channels begin flooding the injured area, creating an Abnormal Impulse Generating Site (AIGS). These sites do not fire right away, but oftentimes after 3 to 21 days…quite a long time indeed.
The immune system also plays a critical role in neural sensitivity. A peripheral nerve injury turns on local immune cells and encourages further cell recruitment toward the injured site.
What is crazy about these immune cells is that they can stay active for 25 years. So recurrent pains may not be re-injury, but a helpful survival tool. It’s the body testing the fire alarm.
So how does one treat these problems? The overarching goal is reduce threat by whatever the nervous system requires. This could include unloading structures, movement, education, drug therapies, etc.
With the CNS as the overall governor of our experience, it will create responses depending on the value of received inputs. A fixed response does not occur.
In central sensitization, we see an abnormal responses to the nociceptive system by altered sensory responses to inputs and increased pain sensitivity. This state is most often present when pain occurs past normal healing duration.
There are three states in which the nervous system responds to information:
Input = output
Input > output (think injured athlete finishing a game)
Output > Input (folks with chronic pain)
The last option is the one we will deal with the most. Many changes occur to include decreased central inhibitory control, ion channel flooding by the immune system, C-fiber uncoupling and A-beta fibers (light touch) becoming nociceptive, inhibitory neuron cell death, and nociceptive fibers turning on more easily.
Dave gave us some key points on this condition to think about:
No diagnostic test can visualize these changes.
Deeper tissues injured lead to greater up-regulation.
Contributing factors (e.g. coping strategies) are strongly linked.
Sensitivity changes affect all outputs.
These changes are more reversible than previously thought.
Can occur instantaneously.
Tissues can heal though still be unhealthy.
Can see changes in 2-point discrimination.
Mirror pains may occur, which is an immune response.
Ya Other Systems
We have predominately been discussing the neuroimmune system, but realize multiple systems are involved in and respond to a pain experience. Our ultimate goal is to provide expressive freedom to these systems which creates better brain construction of all our experiences.
Think motor freedom, pain freedom, output freedom.
Here are some different responses that various systems produce:
Emotions – Anxiety and fear to increase attention, vigilance, and pain intensity.
Thoughts – Nerve impulses that could elicit a threat response.
Sympathetic nervous system – Response system to get us out of trouble by affecting many systems; it is connected to almost every body tissue after all. It can increase inflammation, cause AIGS to fire, initiate an immune response, create nociception via vasoconstriction, and potentially be compromised at the thorax.
Endocrine system – Working along with the sympathetic nervous system, the endocrine system produces ACTH via the hypothalamus in response to threats. This hormone stimulates the adrenal cortex to produce cortisol, which powers ups defensive systems necessary for survival and turns off unnecessary systems.
Parasympathetic Nervous System: Not much is known about this system, but it is thought to help with recharging and calming. With the heart as an exception however, the parasympathetic and sympathetic systems have discreet actions.
The vagus nerve is a major player here, and along with the hypoglossal nerve is linked to the immune system. These nerves accept immune compounds in the blood because they don’t have to deal with the blood brain barrier; allowing for easy access to the CNS.
Motor System: Chronic pain states are usually accompanied with unhealthy, unfit muscles that may be a nociceptive source. We can also see protective changes to include altered vocalization, muscle imbalances, spasms, and impaired recruitment.
The Immune System: The show of the course. Three components make up this system:
Innate: We are born with it (molded by it); kills microbes and stops infection
Adaptive – learns, recognizes, and remembers how to ward of disease and illness (immunizations).
Immune-like – Immune cells in the nervous system.
In relation to the nervous system, microglia in particular are capable of stripping synaptic connections and may play a role in learning. These compounds are able to move up to 3/4 of an inch to areas in need.
The immune system is also composed of pro inflammatory and anti-inflammatory components; the cytokines and chemokines. These cells are capable of increasing local inflammation, sensitizing AIGS, and decreasing opioid responsiveness. They also play a huge role in CNS plasticity, hence being a major component to learned behavior.
Therapeutic Knowledge Bombs for Patients
So with all the immense knowledge garnered previously, the challenge becomes teaching this information in a patient-friendly manner.
Rarely do patients truly change their thought process when pain is explained. Dave mentioned that only 8% of patients will undergo a true conceptual change when learning pain science. So it is of utmost importance to tailor your educational style in a manner that the patient will understand and relate to.
The process begins right at the subjective. Let the patient talk and capture their story. This part will help you understand what the patient’s pain perception is like, and give you insight to where your education must focus.
The therapeutic process via both the patient and clinician is often communicated through metaphor. This method is oftentimes the only way patients are able to enrich our understanding of their experience. Knowing which metaphors a patient will use can provide options for educational strategies:
Example: “My knee is a rusty hinge.”
The Response: Don’t respond with a metaphor.
Example: “Pins and needles” “Pelvic floor”
The Response: Have them flesh out the descriptors more. Or strengthen what they say. Instead of pelvic floor (something unchanging), call it a pelvic diaphragm (something always changing).
Example: “It hurts like hell” “Pain is a killer”
The Response: these metaphors give abstract pain some structure. Help by telling stories and helping with goal setting (a better structure).
Example: “The pain goes around” “My back has gone out.”
The Response: These are examples of disembodiment, so the goal is to get them to re-embody. Humor can be used here. Ask them “where did your back go?”
Example: “There’s a knife in my back.”
The Response: An immunological response. Often there is a representation in the brain of a knife for example. Tell a story which lets them know these thoughts are unhealthy.
Example: “I’m riddled with arthritis.” “I’m ready for the scrap heap.”
The Response: These create a permanence to the condition. Let them know nothing is permanent in biology.
The Response: GMI to re-embody the individual. Also eliminate the good part/bad part dichotomy, as well as using “we’re” going to do xyz. These can reinforce the disembodiment.
example: “Motion is lotion”
How-to: make sure to add stories to give the metaphors context. Humor is also good because it provides an immune boost.
A Great Story Teller
There are many way to explain pain to patients, but stories are often the most common. Here were some of my favorites with one common rule:
If you can give one example, give two.
Dermatomal pain: Show the dermatome map.
Mirror pains: It is an immune response to protect you.
Night pains: Blood pressure drops, so blood has a hard time entering capillaries.
Phantom pains: The brain has a template of the affected area.
Smudging: Think use it or lose it. The brain will change to look after you and help you do what you need to do.
Imaging issues: The kisses of time. We grow like trees, so branches don’t always grow straight.
And to finish this blog, I will show you in video format, two of my favorite explanatory stories:
Neurodynamic findings – The theratube trick works wonders
And one of my personal favorites, David’s drug cabinet.
Read with Dave
“Meet the patient at their story.”
“What is the person trying to protect with chronic pain? What are they escaping from?”
“Humans are inhibitory animals.”
“Humans are not bilateral animals.”
“Pain treatment, not pain management.”
“Take away the threat value of a defense.”
“All pain descriptors are metaphors.”
“Treating acute pain shouldn’t be different than chronic pain. What changes is the story.”
Sayings for patients
“Well done, that’s a great inflammatory response.”
“You little self-healer you.”
“Well done, what a great defense.”
“Well done, you’ve gotten the best protective response.”
“Nerves take up only 1/3 of space in the intervertebral foramen.”
On Therapy and movement
“Therapy is re-inhibition.”
“It’s easier to change brains than rotten shoulders.”
“Distraction disassembles the pain neurotag.”
“Anytime you can do a movement and look at it is analgesic.”
“Knowledge is the richest context you can offer movement.”
“Total-knee arthroplasty is only limited by nociception and swelling. You don’t need to jump on knees because you have full ROM after surgery.”
“Faulty movement can be caused by faulty knowledge.”
“Give a license to move.”
“Forward head posture is an avoiding posture.”
“Repetitive movements lift your body’s serotonin”
“You are immunotherapists.”
On the brain and body
“Your brain will change to look after you.”
“When we’re in trouble, our brains weigh the world and judge whether pain is appropriate.”
“Your body tells your brain about danger, not about pain.”
“The immune system knows who you are from experience and genetics. It will react when you are not you.”
“Performance is an output of the brain.”
“Alright duckies, grab this”
“Neuroimmune. Doesn’t that make your loins tingle?”
“Lorimer Moseley. He’s a smart little shit.”
“You’ve got the same number of neurons as Albert Einstein…You might want to tell patients that.”
[On a sprained ankle] “I had one of those. Worse than childbirth.”
“I’d rather a shark bite my ass off than a paper cut.”
“The only cure for pain is decapitation.”
“Trigger points are clearly cultural because you have way more than we do.”
[On trigger points, which are AIGS] “Get the needles out of it.”
And if you see my course schedule this year, the plan is indeed horrifying.
I wanted to write a post today to somewhat compose my thoughts and plans for this year, as well as what I am hoping to achieve from the below listed courses.
Because of the course load and some of my goals for the year, I am not sure what my blogging frequency will look like. I have begun to pick up some extra work so I am able to attend as much con ed as I do.
The Amazon affiliate links that I don’t get money for because I live in Illinois simply cannot pay for classes :). I am just putting these links up here because I want to encourage you to read these books on your own. Use my site as a guide through them.
My biggest goal for this year is to successfully become Postural Restoration Certified (PRC), and my course schedule below supports this goal.
The amount that I use this material and the successes that have come along with it simply compel me to become a PRI Jedi. I see the PRC as a means to achieving this goal.
The application thus far has been quite time-consuming. There are a total of 3 case studies, 5 journal article reviews, and tons of other writing that has to be done. Couple that with studying the material, and I have had a very busy year.
I also hope this year to start offering some online training at some point. I do some personal training on my own in my free time (ha), and would like to extend my services to people who are not near me. This would come complete with a full skype evaluation and unlimited access to me via email for all your questions, comments, concerns, and complaints. If anyone is interested, please contact me at email@example.com
Without further ado, here is the course list.
Course List 2015 aka “The Year of the Nervous System”
I have dedicated this year to maximizing my understanding of the most powerful way to get into my patients, here is the lowdown
January 17th-18th – PRI Pelvis Restoration, St. Louis, MO
Been so looking forward to this class. Here I hope to learn about decreasing extensor tone in those people who use it as their protective pattern. Extension is what gives us power in response to defend from threat, this course will help you turn it off when you need to.
February 8th-9th – PRI Cervical-Cranio-Mandibular Restoration, Pitman, NJ
There are several patients that I just seem to have a harder time with. People with neck pain are one of them. Moreover, there are some patients who I just can’t seem to get fully neutral from a PRI perspective. I am hoping to learn to what extent I can affect the neck and above to help my patients achieve better function.
February 15th-16th – Explain Pain, Atlanta, GA
I have already taken this course once, but the man, myth, and legend David Butler is teaching this version. EP is his baby, his muse. If I won’t ever be able to see Led Zeppelin live, interacting with Butler would be the next best thing.
March 1st-2nd – Therapeutic Neuroscience Education: Educating Patients About Pain, Naperville, IL
I have been fortunate enough to chat with Adriaan on multiple occasions, and have the pleasure of hosting him where I work. It will be nice to get his perspective towards pain education. Adriaan was who I took Explain Pain with, and I will be curious to see how his thought process has changed since a couple years ago.
March 29th-30th – PRI Postural Respiration, New York, NY
Another re-take course for me. But this time, I have much more experience with the system. I hope my understanding will be so much more enriched. Plus, I get to learn it from Ron. Anytime you can learn from this man please do.
April 26th-27th – PRI Vision, Grayslake, IL
The motor system is not the only thing that can put up defense mechanisms in response to threat. The visual system changes as well, and in many cases can drive one’s protective postures. I need to know why and how.
May 2nd-4th – Dermoneuromodulation, Chicago, IL
The skin is such a sensory-rich organ that I need to learn more about it. And who better to learn it from then the master-ectodermalist Diane Jacobs. I have yet to take a true hands-on course, and if I can learn a pain-free way into the nervous system, then sign me up.
Hopefully I can teach her some therapeutic Microsoft paint techniques in return 🙂
June 7th-8th – PRI Integration for the Home, Lincoln, NE
Sometimes the PRI movements can be very challenging for those who are older. I want to know how my man James Anderson gets this population to perform at the high level he does. I want the baked goods!
Also during this week I plan on netting some observation time at the Hruska clinic. Details to follow.
August 9th-10th – PRI Myokinematic Restoration, Indianapolis, IN
I took this class last year, and want to be as prepped as possible for the PRC. Besides, Indy is my Mecca. I have so manygoodfriends there that I cannot pass up a chance to hang at IFAST.
October 18th-19th – Neurodynamics and the Neuromatrix, Buffalo, NY
With two rounds of Explain Pain and Mobilisation of the Nervous System under my belt, what better way to put the classes together? Plus I am hoping to get my man Erson Religioso to come so we can hang out (hint hint).
November 1st-2nd – NOI Clinical Applications: Lower Limb and Lumbar Spine, Chicago, IL
I am going to this one mainly to cleanup my techniques and though process, as well as learn a little more about the less talked about nerve tracts (that darn saphenous nerve).
November 21st-22nd – PRI Integration for Baseball, Clearwater, FL
Florida in November…no brainer 🙂
But seriously, getting little snippets throughout my previous classes about what they will be teaching here has me intrigued.
Most of PRI deals with gait, which if we talk DNS is a contralateral pattern. Here my understanding is how PRI will approach the ipsilateral patterns. They will also introduce a test for the thorax, hopefully giving me a nice adjunct to the Hruska Adduction lift test.
December 4th-9th – Advanced Integration and PRC testing, Lincoln, NE
AI was such a game changer for me this year that I cannot wait to take it again. There are so many nuances I want reinforced and so many questions answered.
Moreover, the PRC test is going to happen, and learning in close proximity with Ron, James, and Mike is an opportunity I simply cannot pass up.
So there’s the plan for this year. What thoughts do you have? What’s on your con ed radar for the year? Comment below.
It seems like I took this course forever ago, but reviewing this post reminded me why I love the NOI group so much. I feel as though their message is one you cannot get enough of.
As for GMI itself, I find that it is great for people who most every movement hurts, as well as an educational piece. From a PRI perspective, it is also useful. I have had patients imagine contracting their glute max and go neutral. Crazy stuff.
Such a great class. Here we see updates to the science behind “The Sensitive Nervous System”, as well as some neat tweaks to our neurodynamic testing. My favorite pieces were on the immune system and genetics.
It seems the more and more that I read the more and more and read the more and more addicted I become to appreciating the nervous system and all its glory. To satisfy this addiction, I took Mobilisation of the Nervous System with my good friend Bob Johnson of the NOI Group.
This was the second time I have taken this course in a year’s span and got so much more value this time around. I think the reason for this enrichment has been the fact that I have taken many of their courses prior and that I prepared by reading all the NOI Group’s books. A course is meant to clarify and expand on what you have already read. So if you are not reading the coursework prior, you are not maximizing your learning experience.
What made this course so much more meaningful was being surrounded by a group of like-minded and intelligent individuals. As many of you know, I learned much of my training through Bill Hartman. Myself, Bill, the brilliant Eric Oetter and Matt Nickerson, my good friend Scott, and my current intern Stephanie, all attended. When you surround yourself with folks smarter than you, the course understanding becomes much greater. This course was so much more with the above individuals, so thank you. Try to attend courses with like-minded folks. Here are the highlights of what I learned. If you would like a more in-depth explanation of these concepts, check out my blogs on “The Sensitive Nervous System.”
Neurodynamics, Clinical Reasoning, and Neuroscience
When discussing clinical reasoning and neuroscience, we have to discuss processing. The pain processes are what we end up treating in rehabilitation, so we have to know where our patient’s problem occurs along the process:
Input – Issues in the tissues; typical therapeutic approaches.
Processessing – How the brain interprets inputs.
Output – The experiences and emotions we feel.
Processes, as opposed to structures, are what we really treat. We can define processes as changes in the physiology. These changes can include degeneration, ischemia, stiffness, inflammation, etc.
In terms of inputs, the two types of input processes that may lead to a pain mechanism include nociception (the firing of A delta and C fibers from tissues) and peripheral neuropathic (involving the neural tissues outside the dorsal horn). The above mechanisms have predictable stimulation responses.
Understand that all injuries to structures are the same, but the context and environment affect processing and output. We have all experienced this phenomenon. A paper cut can hurt like hell, but a cut from a branch while hiking in the forest may not even be noticed. Context makes all the difference.
The pain mechanism related to processing occurs in the central nervous system. With processing problems, the stimulation-response relationship is unpredictable. Thoughts, feelings, past experiences, knowledge, and other states can affect responses here. These components are designed to help us survive our environment.
Lastly, there are several outputs related to pain mechanisms. These outputs involve all our body systems, with the central nervous system acting as the driver.
All these pain mechanisms–input, processing, and output—are involved in some way during a pain state or sensory alteration. One can be more dominant than the others, but all areas are active. It is similar to energy systems. The aerobic, lactic, and alactic energy systems are always active with one often as the primary driver. So too are the involved pain mechanisms.
Often, genetics is the biggest contributing factor to chronic pain development. It is strongly hereditary, like having blue eyes. Here were some values given in the course as to what percentage of pain is genetic:
50% of migraines.
55% of menstrual pain.
35-68% of lower back or neck pain.
50% of shoulder and elbow pain.
40% of pain with carpal tunnel syndrome.
The Nervous System is a Continuum
The nervous system is one of three continuous systems, the other being vascular and fascial. If you move the nervous system at any one place, the entire system moves. It is like moving a tree branch and creating motion throughout the whole tree. Continuum concepts cannot be enhanced by tissue dominant approaches.
There are four ways in which the nervous system is continuous:
Discussing nerves often puts people at unease. However, this feeling should not be the case. Nerves are like any other tissue. Therefore, they live under the same rules as all other tissues. They can bend, twist, and slide transversely. Nerves can also take on increased pressure by loading.
This interconnected quality often confounds traditional segmental-based testing such as myotomes and dermatomes. The nervous system ought to be thought of instead as a continuous piece with multiple reference points.
Moreover, everyone has a different nervous system. Therefore, each person may require a different sequence when performing neurodynamic tests.
Ion channels are the molecular targets for manual therapy. These channels go where no myelin is present:
Dorsal root ganglion
Nodes of Ranvier
There are six points to describe these ion channels:
1) They are proteins with holes in the middle.
2) They have holes that open or close.
3) Some stay open for longer.
4) There are different kinds of channels.
5) They have a half-life of 2-7 days.
6) They represent needs and perceived needs.
I will not go over all the neurodynamic tests in this post, but there were some different variations that I liked in this course compared to what I was doing. The biggest thing when performing these tests is to have a consistent starting position every time. And if you are doing a straight leg raise, pay attention to potential responses on the contralateral leg.
Here is a radial neurodynamic test…proximal to distal style.
The biggest thing that I got out of the nociception section involved inflammation. First off there are two types of inflammation:
1) Non-neurogenic – occurs with tissue damage; creating bleeding and fluid buildup. NSAIDs work well on non-neurogenic inflammation.
2) Neurogenic – Created via C-fibers, which is driven by changes in peripheral tissues and threat perception. It can occur even if the nervous system was not fully involved in the injury. Pregabalin,Gabapentin, Cymbalta, and other similar drugs work well with these.
Peripheral Neuropathic Highlights
Injury to peripheral nerves involves blood flow, axoplasmic flow, and development of abnormal impulse generating sites (AIGS) along the nerve. There are also three different issues that can occur in the nervous system:
Physiologic conduction blocks – local circulatory changes
Neuropraxia – Local conduction block where axon is okay and conduction returns in weeks to months.
Axonotmesis – Axon continuity loss with intact endoneurial tubes; Wallerian degeneration occurs.
Central Sensitivity Highlights
It is important to understand with central sensitization is that it occurs with all injuries. The difference between those with and without chronic pain is that the sensitivity stays turned on.
The CNS utilizes opiate components to combat nociception. There are three major endogenous opioids produced in the central nervous system to create an anti-nociceptive response:
Endorphins – produced in the periaqueductal gray matter
Enkephalins – Produced in the Nucleus raphe magnus
Dynorphins – produced in the spinal cord.
There are also exogenous opioids, which include epidurals, TENS units, and counter-irritants. However, if the endogenous piece is not present first, these opioids will not work.
Arguably the most important part of the entire course was Bob’s talk on the immune system and glia. Research is starting to show that glia runs the central nervous system. They are the gate and clean up synapses. Inflammation can activate glial activity via the vagus nerve, and when glia activates are opioid systems become much less effective. Nitric oxide is also released, which can sensitize receptive fields in the periphery.
A Side Note
One area that I struggle with in pain education is patients who either dislike pain or have huge functional changes but still have some pain. Bob suggested with these folks that this problem deals with the patient’s beliefs. The best thing to do is to talk around the beliefs or find methods to get them to detach from the pain. This could involve meditation or other similar outlets.
Great Bob Johnson Quotes
“Pain is your brain loving you too much!”
“Spreading pain is connecting the dots in the nervous system.”
“We are good at gathering data, but we are not good at determining what is relevant. Gather the data and make it tell a story.”
“Ask the patient what they think the issue is.”
“Showing the patient how they are better is a central component.”
“All we do is move people.”
“We want pain freedom, not pain control.”
“If I save a patient a day, I did something good.”
“When you treat the container, you treat the nervous system.”
“Sensitivity is plastic.”
“A 30-35 degree SLR is needed for normal gait.”
“We rarely see true nerve root compression.”
“Sliders are like grade I & II mobilizations.”
“Nerves love space, movement, and bloodflow.”
“Cardiovascular health has everything to do with nervous system health.”
“The better cardiovascular fitness, the less pain people with chronic pain have.”
“Most patients have a spinal component to a peripheral piece.”
“Beliefs are a big deal.”
“A biochemical memory is left in the tissues…An immune marker.”
“Movement is Wolff’s law for the nervous system.”
“The pattern of central sensitivity is no pattern.”
The most important thing you can understand is that no one has the answer for all pains. Pain is entirely individualistic, hence requiring different answers. There are several strategies which one can undertake to triumph over pain.
Tool 1: Education
Knowing how pain works is one of the most important components to overcoming pain. Instead of no pain, no gain, the authors like to use “know pain, or no gain.” Understanding pain is essential for squashing fear of pain, which leads best toward the road to recovery.
Here are some important concepts to be known about explaining pain.
Anyone can understand pain physiology.
Learning about pain physiology reduces pain’s threat value.
Combining pain education with movement approaches will increase physical capacity, reduce pain, and improve quality of life.
Tool 2: Hurt ≠ Harm
It is important to understand that when someone feels pain it does not equate with damage. The same can be said with recurring pains. These pain types are often ways to prevent you from making the same mistake twice. If your brain sees similar cues that were present with a previous injury, the brain may make you experience pain as a way to check on you and make sure you are okay.
Just because hurt does not mean harm does not mean you can get crazy though. Because the nervous system is trying to protect you, it will take drastic measure to prevent re-injury. Therefore, the best option is to gradually increase activity levels without pressing past the nervous system’s threshold.
Tool 3: Pacing & Graded Exposure
All the body tissues are designed for movement, therefore this is how we will increase activity. Here are the steps to pacing and graded exposure.
Select an activity you want to do more of.
Find your baseline – The amount of activity you can do that you know will not cause a flare-up. A flare-up is an increase in pain that leaves you debilitated for hours to days.
Plan your progressions.
Don’t flare up, but don’t freak out if you do.
It is a lifestyle change, requiring a little bit more planning.
Take walking for example. Suppose you know you could walk for 5 minutes, but if you did 7 you would pay for it over the next couple days. You might walk for 5 the first day, then 5:15. Eventually, you would work up to past 7 minutes, then so on and so forth.
Access the Virtual Body
Just like the body, the virtual body can be exercised as well. Ways to work on the virtual body are as follows:
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.
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.
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.
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.
LAFT injuries usually do not cause instant pain. Pain usually occurs 8-12 hours later.
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.
LAFTs never slip.
LAFTs heal slowly, but they will always be a bit tatty around the edges. This attribute makes it hard to distinguish aging from injury.
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.
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.
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.
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.
Here are the common symptoms associated with peripheral nerve pain.
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.
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.
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.
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.
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.
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.
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 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.
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.