Comments

This is not meant to be a discussion board but we’ve got lots of interested and interesting people leaving comments for us so we set this up.

Comments are in chronological order with new comments are at the end.

After a while we do go through and delete comments as we get so many although we may leave up some of the interesting or useful discussion threads.

Comments

  1. John Barbis says:

    Dear Lorimer and David,

    I have been working with several CRPS in a unilateral upper extremity with quite severe and easily exasperated symptoms. I have had to limit the number of images seen at each session. In trying discern what was provoking their increase, two of the patients stated that as they moved their eyes to focus on the image, their pain increased. With each of these patients I then tested unidirectional repetitive eye motions. Eye motions, without head movement, toward the side of pain would rapidly provoke the symptoms within a few reps. other motions did not provoke the symptoms and the same movement with eyes closed did not provoke the symptoms. I have started patients on non symptom productive movements and symptom provoking directions with eyes closed. I also used palpation of the side of the face below symptoms. I have seen improvements in thier tolerance of eye movement in the past 10 days and some tolerance for other activities. Do you have any insight ( no pun) on what may be going on here?

    [Reply]

    Lorimer Reply:

    Great work John. I am particularly interested in symptoms in CRPS that seem to be related to space. what i mean by this is we know that people with chronic CRPS seem to neglect the space in which their limb normally resides [see our recent Brain paper: space-based but not arm-based shift...]. I don’t know why this happens. It seems feasible to me that, for some patients, that whole side of space becomes ‘dangerous’. If so, it would seem sensible to prevent oneself from having anything to do with it. The best way to do this would seem to be to make it painful. That is, perhaps even looking in that direction is regarded as dangerous by the brain and hence increases brain.

    I love your clinical response to this. I would love to be kept in the loop of how it goes and I encourage you to take good notes.

    [Reply]

  2. Diane Williams says:

    I’ve just been introduced to Painful Yarns through my husband attending intensive rehabilitation for his back at Salisbury Hospital, Wiltshire, UK. Whilst pondering the tales in the book in relation to my husband’s experience of pain (not necessarily easy as an interested bystander – perhaps that’s another book for you), I wondered if you thought that the same might be true of people who experience emotional pain. In that, historical experience/tangible examples of a lot of emotional pain would result in someone lacing situations with a greater amount of emotional content and therefore reacting in a more extreme manner than others might. And so, rather than learned behaviour and mimicing others, the brain’s evaluation of ‘emotional danger’ delivers an emotional wound which then leads the individual to display more extreme emotions than a situation warrants.
    Just a thought….

    [Reply]

    Lorimer Reply:

    Hi Diane. Nice thoughts. Your wondering seems sensible to me – there is no doubt that our brain remembers anything that is important to our survival. That said, I dont make a distinction between physical and emotional pain. I reckon that if it hurts somewhere in the body then it is pain. If it doesn’t, then it is not. I am very comfortable with the idea of, for example, an aching heart, but if one doesn’t feel the ache then it is probably most accurately called something else, for exmaple anguish, grief, despair etc etc. this sounds simply semantic but I think it is important if we are to accept that pain is produced by the brain and doesn’t need input from the body even though it feels exactly like there is. Anyway, that is a Cab Sav conversation, which is a conversation best had while sharing a bottle of south Australian, preferably Coonawarra, Cabernet Sauvignon. I am not sure if you can get them in Wiltshire.

    [Reply]

  3. Sabina Walker says:

    The 2009 non pain study by Mizuguchi et al (Influence of touching an object on corticospinal excitability during motor imagery) showed that the excitability of the corticospinal pathway can be increased during ‘ball squeezing imagery’ if real touch of the ball is also involved during this imagery exercise. Furthermore, this increased excitement occurred along the corticospinal pathway (including the primary motor cortex), and not along the afferent pathway to the primary somatosensory cortex.

    This raises a possibility that graded motor imagery (GMI) and actual touch of the imagined object (‘combination GMI and touch therapy’) may be an alternative for CRPS treatment, instead of GMI treatment alone?

    Studies may be warranted to determine whether ‘combination GMI and touch therapy’ results in increased activity along the efferent corticospinal pathway. If yes, this may result in increased benefits for some CRPS patients, and may even benefit CRPS patients that may not respond to GMI therapy alone.

    Neuroimaging may be useful to confirm any increased activity along the efferent motor pathway in CRPS patients.

    [Reply]

  4. Tim Vaughan says:

    Lorimer:

    Big fan of you & David Butler. I have read many of your articles, etc. but my favorite?? …..“Painful Yarns ”… what a hoot! Anyway, I’ve had CRPS type symptoms for 15 years or so. My PT and myself are going to engage on graded motor imagery path, using NOI Groups cards, etc… I have a question:

    …. I have never seen a visual image in my “mind’s eye” in my life. I just cannot visualize. Do you have any recommendations concerning how to try to kinesthetically imagine movements without actually engaging the neuromuscular system?……….

    [Reply]

    Lorimer Reply:

    Gday Tim – thanks a million for posting, and for your encouragement – much appreciated indeed! I am not sure of the answer to your question – however, the good news is that the idea of graded motor imagery is, after the initial phase of left/right recognition, to NOT imagine what it looks like but just imagine doing it. Does that make sense? That is, you don’t visualise the movement, you just imagine doing it. I will have an ask around and if i find something will let you know.
    thanks again Tim, Lorimer

    [Reply]

  5. Paul Lagerman says:

    Hi Lorimer
    I have been doing a lot of catch up reading into pain research, which is an absolutely fascinating topic!! I am a mere beginner but am enthused by it! I was speaking to a colleague of mine who is a pain specialist and we were discussing central sensitisation. As I understand it there is a genetic change in the cell nucleus which causes an increase in the embedding of NMDA receptors in the cell synapse, oh that’s already complicated writing that?? This is permanent, so if it is a permanent change and not reversible then how is it possible that this can be modulated and information that is coming from that synapse to the brain will not set off the pain signals?? Is it down to reconceptualisation of the information coming to the brain from the synapse, as in are we training the patient that although they may be getting an increased stimulus we have trained the brain to reconceptualise the information as in the brain has final say??
    Phew, that was hard but actually after having read that again that kinda makes sense if the brain has final say??
    Feedback would be good

    Paul

    [Reply]

    Lorimer Reply:

    Hi Paul –
    Great contribution. I would argue that it is not permanent. If it is a genetic switch on, we do not know that it can’t switch off. Regardless of whether it is permanent or not, we must remember that it is in the nociceptive system, not pain. Having profound spinal cord changes does not necessarily mean one has pain. Keep pursuing this stuff because it only gets better……

    [Reply]

  6. Hi Lorimer
    I have recently been introduced to your work and that of NOI. I have a patient I am ‘experimenting’ with using some of the concepts. He is an upper limb amputee, amputated at the shoulder. He has been experiencing significant amounts of PLP which can include cramping of the fingers and thumb and burning through the limb. At times he can move his fingers but his thumb consistently feels as if it is blocked by an object which stops him extending it. His elbow is also fixed although he doesn’t get pain from it. Acupuncture provides instant relieve to the fingers for about 20 min and they feel as if they are floating, but the thumb and elbow remain fixed. The OTs started him with mirror therapy, but he found this increased his pain. I have got him registered on ‘recognise online’ and I thought we could attempt to reproduce the approach used in the RCT – so 2/52 of laterality then moving towards mental imagery and if required introducing mirror therapy after this. Do you have any tips or suggestions with regard to us using this approach especially with respect to whether we should focus on getting the thumb and elbow moving or is it better to go with what moves more easily first (ie fingers) and hope that the elbow and thumb start to free up in time?

    Many thanks for you help.

    [Reply]

  7. Great question. Right. I would see how it goes with Recognise. As we learn more about graded motor imagery, our gut feelings that practice practice practice is important are being confirmed – so get him to do it as often as possible without doing it for too long each time. I would have him do the context pictures as well as the vanilla ones. I would also get him to watch footage of fingers and arms moving in a pain-free manner – piano playing, guitar playing, cards, cooking shows perhaps – watching the hands. This might seem odd to him but you could explain that the idea is to just watch and, this is the tricky bit – really attend – to the hands and arms. You could progress this to imagined movements and you could make these functional too. I would do sensory discrimination training on the stump – particularly if acupuncture gives such an excellent response. I would explain explain explain that, even when an arm is ripped off and there is a bucket load of obvious noxious input from the tissues of the body, it is still the brain that makes the final call and the GREAT thing about the brain is that it is the best learner we’ve got. Still, we have to practice practice practice. I hope this helps – keep us informed on this one?

    [Reply]

  8. Hi,
    I am working with young children with CRPS. Do you think there is a lower age limit for children to benefit from the Laterality retraining. At what age is laterality clearly established?

    [Reply]

    BiM Reply:

    THIS IS A great question, to which we don’t know the answer. YET. We are starting to find out by first assessing left right judgments in kids – see our OMIT study, link here
    Any personal experience re minimum age you would care to share?

    [Reply]

  9. After recently discovering that George Bush launched the “Decade of the Brain” with a somewhat infamous proclamation 20 years ago it seems only fair to acknowledge that the evolution in this field has been monumental -with or without George’s contribution. A recent rewiew of the ” Decade after the Decade” here http://www.sharpbrains.com/blog/2010/02/23/brain-neuroplasticity-implications/
    is a useful read. Enjoy.

    David

    [Reply]

  10. Julia Hush says:

    Hi there fantastic BiM team and friends!

    You have probably already picked this up, but just in case… check out: “Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome” published in PLoS One (link to pdf below). They show that even when patients know they are receiving placebo, it can still improve symptoms. Hmmm, might have to re-think the interpretation of those active V placebo trials….

    http://www.ihfglobal.com/education_documents/Placebo%20IBS%202010.pdf

    Julia Hush

    [Reply]

    Heidi Reply:

    Nice Spot Julia, thanks for taking the time to share it – I’m sending the link to the BiM team!

    Heidi

    [Reply]

    Neil O'Connell Reply:

    Quite a neat (but unflinching) deconstruction of this study can be found here:http://www.sciencebasedmedicine.org/?p=9339

    If you sell folk the idea of powerful minbd-body effects then they get a placebo response. Of course if you told people that estimates of placebo effects size are generally marginal (see Cochrane review) then you might not get the same effect.

    [Reply]

  11. pete roach says:

    Hi and help!
    Apologies if this is not the right forum (I’ve subscribed but not contributed to bodyinmind before) but I would like your help. Have I missd out on Upper limb tension tests and slump and neurodynamics and things for all these years? I’ve probably been not very competent in the past ( well 15 years or so ago) when I last tried them, but I never found them very reliable, so I gave up. Ok I use an SLR as more of an ‘expected’ and standard, ‘traditional’ test when What are we testing when we do an ob I’m thinking nerve rooty thnigs, but would not necessarily rely on it alone. I always thought if some part of the body / system is indicating ‘pain’ then a test lik that would be posive anyway – does it tell us what we alrady know. That and there are alot false positives (an article i read recently said there are false positves even in asymptomatic test subjects) anyway and it could vary, day to day mood to mood. Is it a bit like ‘Waddell’s inorganic signs’ and tells us that the person is in distress somehow and not much elseor have I really been missing out? What are testing when we do an objective assessment anyway eg for a medial collateral knee ligament strain if it isn’t particualrly lax but the patient reports pain. How ‘subjective’ are our ‘objective’ tests? When I was having this discussion in our journal club, I stated that I didn’t find ULTT etc very helpful, but I got lost whe i tried to explain why. Do I need to eat humble pie? Many thanks Pete

    [Reply]

    Michel Coppieters Reply:

    There is a lot of stuff in this post… Let me comment on a couple of things:

    1) Like any other clinical test, neurodynamic tests have their strengths and weaknesses. I believe they have merit if applied in the right circumstances. A recent Delphi study (by Keith Smart, published in Manual Therapy (2010)) revealed that expert physiotherapists and pain consultants consider movement tests, such as SLR and upper limb neurodynamic tests, the most significant clinical indicator for peripheral neuropathic mechanisms of musculoskeletal pain. Obviously, the response of a neurodynamic test (like any other test) has to be considered in terms of the pathobiological processes in operation. Neurodynamic tests, like many other clinical tests, may appear false positive if there is widespread sensitivity due to central sensitisation. Hence the importance of the patient interview…
    2) False positive tests deserve further consideration… it depends obviously to a large degree on the criteria that are used… In my view, reproduction of symptoms and a change in these symptoms with structural differentiation remain the key criteria (despite some other suggestions). If these criteria are applied, it is impossible to have false positive tests in asymptomatic people… Per definitions, asymptomatic people have no symptoms let alone that a test could reproduce them. Obviously, neurodynamic tests will elicit sensory responses in most healthy people, but that does not compromise the test’s validity (note the differences between ‘symptoms’ and ‘sensory responses’ – many people, including researchers, often confuse them). On a personal note (this is a blog after all), I believe neurodynamic tests are probably useful to assist to determinate whether there is a contribution of the peripheral nervous system to the pain state, but the tests are probably not of so much value to determine where along the course of the nerve the problem might be. Let’s bear in mind though that we don’t have a single clinical test or technical investigation that has a good enough validity so that it can be used in isolation to diagnose a peripheral neuropathic pain state. Hence the need to combine the results of neurodynamic tests, with the findings of other tests, patient interview, technical investigations, etc…
    3) Regarding reliability of the tests, there is increasing evidence (check out PubMed) that commonly used outcome measures of the test can be reliability measured – not just in experimental conditions, but also in clinic. These are relatively difficult tests though – to paraphrase David Butler: ‘Handle well, or don’t bother – try another branch of physiotherapy’. Sounds somewhat rude, but poor handling will indeed compromise the usefulness of the test…
    4) Of course things can vary with mood – use it to your advantage rather than as a limitation – Isn’t it a great teaching tool to show your patients the multifaceted nature of their pain experience! And again… consider the pain mechanism before conducting and interpreting clinical tests…

    Hope this makes sense – Hope you will have that journal club again; regardless of what the final conclusion might be…
    Cheers, Michel Coppieters

    [Reply]

  12. pete roach says:

    Sorry for the misspells I was in a rush, Pete

    [Reply]

    David Fitzgerald Reply:

    Hi Pete

    I suspect that this may not be the right location for detailed discussion on this topic but I think it’s appropriate to at least make some suggestions.

    “Upper limb tension tests, slump and neurodynamics – but I never found them very reliable!.

    I can’t speak with any authority on the normative data which has been collected for these tests other than to point you to David Butler’s book “The sensitive nervous system” which was the sequel to his classic “Mobilization of the nervous system”

    However, from a clinical perspective I would certainly suggest that these types of treatment approaches have direct relevance and appear to be effective (at least by test-re-test within session, sequential re-evaluation over time and correlation of objective signs with subjective improvement).

    I would qualify this with the acknowledgment that my almost evangelical enthusiasm for these techniques 25 years ago has been somewhat tempered over time – but more on the basis of patient selection rather than any criticism of technique.

    This then raises the necessary discussion of selecting appropriate patients for this type of intervention. There is some discussion on this here

    http://www.physiodigest.com/621/nerve-sensitivity-altered-neurodynamics/

    “I always thought if some part of the body / system is indicating ‘pain’ then a test like that would be positive anyway – does it tell us what we already know”

    Trying to ascertain pain mechanisms and selecting appropriate interventions based on this is the big clinical challenge facing physiotherapy, I think. An overview of this type of approach can be found here.

    http://www.physiodigest.com/371/pain-pattern-recognition-in-primary-care-%E2%80%93-mechanism-driven-management-strategies-in-physiotherapy/

    “Ok I use an SLR as more of an ‘expected’ and standard, ‘traditional’ test when What are we testing when we do a test – I’m thinking nerve rooty things, but would not necessarily rely on it alone”

    I would concur that frequently clinical testing confirms what we are ready know (or at least what we think we know) and rather than shedding any miraculous new insights simply fits into the category you describe. However, it’s no harm to have our clinical hypothesis confirmed by tests or to use these clinical signs as markers in assessing response to treatment (for better or worse).

    “there are alot of false positives (an article I read recently said there are false positives even in asymptomatic test subjects) anyway and it could vary, day to day mood to mood.”

    Maybe so, But I doubt very much if that is unique to neurodynamic testing.

    It’s probably in the category of “un-modifiable variables” that we can’t influence.

    How ‘subjective’ are our ‘objective’ tests?

    We’ll Pete I draw the line on that one but I’m sure there are others in this forum better positioned to comment on this issue.

    PS I’m sure you’re aware of David Butler’s faculty website at

    http://www.noigroup.com/en/Home

    The history of Neurodynamic ‘s is a prime example of the evolution of integrating contemporary pain sciences to explain mechanisms of effect (allbeit speculative, but at least contemporary). Some readers here will be old enough to remember the original terminology for Nero dynamics which was “ANT -adverse neural tension” – shocking and all as it may seem now.

    David

    [Reply]

  13. pete roach says:

    Many thanks for your thoughts and ideas! I did read, many years ago David Butler’s ‘ ‘Mobilisation of the Nervous System’, but I haven’t read ‘The Sensitive Nervous System’ as I gave up on ‘ANT’ as it was then, probably because I wasn’t veyry good with it and to me it just didn’t make ‘sense’. I wasn’t too worried though because along came Louis Gifford’s ‘mature organism model’ and Max Zusman’s ‘Fear Avoidance’ work and from then on…
    I think it was louis who said or wrote somewhere about not worrying if a technique doesn’t work or feel right for you and do things that you are comfortable with as any treatment (technique or exercise) in its mechanisms is multi-dimensional, genetic through physiological through neurological, emotional, psychosocial etc etc. That’s my excuse for not pursuing neurodynamics – it’s his fault! Maybe I gave up too soon!?
    I think louis’ ideas chimes in with Neil and Benedicts’ thoughts in thier recent article ‘Chronic non-specific low back pain – sub-groups or single mechanism’ (www.biomedcentral.com/1471-2474/9/11 – reviewed with Frederic Wellens’ piece ‘The mechanistic paradigm in the teaching and practice of manual therapy; time for a reality check.’ http://www.physioaxis.ca/realitycheck.pdf, in the recent PPA Journal). It seems to me that one of their points is that for all the diversity of techniques and concepts, from acupuncture, through core stability (it stills gives me nightmares…) and then CBT, their success (limited in LBP) may be because they work through similar neuro-physiological pathways /mechanisms. So if I’m going to change my ways I need to know do neurodynamic techniques (ULTT etc) stand out as being particularly useful / valid? and why? May be they are for a particular patient (and a particular ‘therapeutic relationship’) but for the general population? I don’t just need to read the book, go on the course, I need to know the results.

    I’m wary, because like most of us in the past I guess I have liked the theory, but the results / evidence / research (usually a decade or two later!) of how it works in practice has often been disappointing or made more complex to analyse. Examples – electrotherapy (we are down to 2 U/s machines now in our department), the biomechanical (roll and glide) of joint mobilisations, muscle (im)balance, acupuncture and so on. We’ve all been there!

    Granted it will be very different in a private setting (lots of non-specific effects for one) but in the cruel, harsh world of the NHS where evidence – based – medicine is becoming synonymous with ‘cost effectiveness’, where extended treatment time in departments means an extra cost (and then possibly a pressure on jobs), how would ‘neurodynamics’ be rated / recommended? What does it add to an assessment or treatment? For example what does an ULTT tell us when it can be positive in an asymptomatic subject, likely to be positive with an acute impinged shoulder or someone with trigger points? Is it not similar to what Wellens reminds us of a specificity issue where we can find (biomechanical) dysfunctions (with or without neurodynamic signs?) even in asympomatic populations?
    As you can see, I can’t help but be sceptical, but hopefully willing to change, if the evidence is there in terms of not just good theory, but one tried and tested and seasoned in practice, which might just be one definition of evidence- based – practice.

    [Reply]

  14. http://www.bbc.co.uk/iplayer/episode/b00ybvz6/Horizon_20102011_The_Secret_World_of_Pain/

    You can also download the episode on you tube.

    Excellent 1 hour on Pain and the updates research on pain. I am blown away.
    Alice

    [Reply]

  15. Hello,

    I am Spiros – reflexologist from Athens, Greece.
    I have been enjoying and sharing information from your blog on my blog for a while now.

    I read this in the news and thought you might find it interesting.

    Colorado Doctor Finds Foot In Newborn’s Brain
    Infant Recovering After Surgery

    http://www.thedenverchannel.com/health/18297954/detail.html

    Spiros

    [Reply]

    David Fitzgerald Reply:

    Thanks Spiros
    certainly will make me think of the Homonculus in a different way from now on!

    David

    [Reply]

  16. Jason Dicola says:

    Hi Guys, great site and great info, so thanks for all that. Quick question for Lorimer…I recently listened to your ABC classic radio interview and in the first section you discuss the experiment with the violinist and how their string fingers have a lower pain threshold compared to the fingers on their bow hand. You then state that your interpretation for this difference is a psychological one based on fear/anxiety relating to the ability to successfully continue playing the violin. While I obviously have no doubt of the role psychological factors play in the pain experience, how confident can you be that this is the case in this instance? How likely is it that these research subjects actually felt that much fear in a controlled laboratory setting? Maybe this is mentioned in the actual paper, but is it possible that the lower pain threshold is more of a property of injuring highly represented sensory maps? Have you done or are there any comparative studies on pain thresholds on highly represented maps (but not of a skilled/”important” finger like a violinist, but more so of just a very frequently stimulated finger doing a mundane task) and then compare pain threshold to normally represented maps of the other hand. I imagine this would negate much of the psychological factors that could confound any differences.

    So I guess basically, does the size of the representation correlate with pain threshold? It would seem to make sense that if something is highly represented then the default assumption of the brain is “this is important, protect it from danger”. And then the reason why it’s important (I need this finger to be a successful musician) is more of an after the fact rationalization, and can potentially increase pain, but is not necessary to account for any difference in pain threshold. Just curious what you think. Thanks for all the great work and look forward to a reply.

    Best regards,
    Jason

    [Reply]

  17. Hi,
    A couple of your researchers presented at an osteopathic conference I was on on the weekend. I spoke to one afterwards, who suggested that I post on this site. I seem to be able to treat CRPS-type conditions with some degree of success. I’d be interested in participating in a research project using these sorts of techniques (as the clinician, not as the researcher), if anyone is interested.
    The types of things I would normally look at for one of these patients are:
    1) Manual lymphatic drainage. The lymph is often locally congested, and some of the pain seems to relate to over-stretched lymphatic vessels. One of the good things about treating the lympathic system is that you start working proximally to the site of pain, and can reduce the swelling and inflammation without making direct contact with a painful site. This in term lets you gradually work from proximal to distal, until it is possible to introduce some normal manual stimulus to the site of pain, and often to do further manual work to decrease pain locally once it is possible to touch the area.
    2) Find and manually releasing sites of nerve entrapment and irritation proximally to the site of pain. Again, this allows you to make a change without having to directly contact a sensitive area.
    3) Ensuring adequate rib excursion. (The proposed model is that this facilitates good blood flow to, and therefore normal functioning of, the sympathetic chain, through the effect of rib excursion on the azygos system.)
    4) Seeking other potential sites of noxious stimulation that may be keeping the nervous system in a state of heightened arousal without quite registering as conscious pain. One classic site for this is a gall bladder which is painful to light touch, but is otherwise not registering on the person’s conscious awareness.
    5) Testing for an unidentified thyroid dysfunction. Thyroid dysfunction seems to increase the level of musculo-skeletal pain, and to increase congestion in the lymphatic system. The chemical pathways between thyroxine and the mitochondria do not seem to be well understood by the medical profession, which means that may people with a dysfunctional thyroid mechanism seem to be told they are normal just because their TSH and T4 are normal.
    6) Providing an increase in normal stimulation (such as massage) to non-painful areas, to increase the level of parasympathetic stimulation and to provide more normalised input to the CNS.
    I hope this is helpful. Please let me know if you are interested in discussing any of these issues further.

    [Reply]

    Flavia Reply:

    Hello John,

    I remember speaking to you at the Conference and I really appreciate your feedback. I’m glad you’ve posted on our site; we aim to maintain a forum for researchers and clinicians to stay on top of what the other lot is getting up to!

    At the minute, we are not running any clinical treatment trials in CRPS and as such aren’t in a spot to embark on any formal collaborations. But your ideas are nonetheless informative for us to see and other clinicians to comment on and add to.

    It’s interesting that several of the techniques you mention may in fact be used by other clinicians from across different disciplines; only sometimes people may have varying rationales behind why they chose that particular method, or what may be the underlying cause of the problem.

    All things worth debating! Thanks again for you input
    Kind regards
    Flavia

    [Reply]

  18. David Hanscom says:

    Your website was pointed out to me by a member of what is called the workfitnessdisability roundtable. I have somewhat inadvertantly been doing mind body work for the last 10 years with the last two years being much more consitent. I have probably a couple of hundred patient that have gone to pain free. I would offer you the use of my website, http://www.doccproject.com. I have purposefully made it non-proprietary as I think this is such a huge problem. If you have any interest in discussing any of this with me please feel free to contact me via my email. I am looking foward to exploring your site. David Hanscom

    [Reply]

  19. Hi, I was recommended to read Explain Pain by my physical therapist and I am picking up the book from them tomorrow. My question is I have been reading Dr Sarno’s mind body books and wondering what you think of them? He is from New York and has been working on this for over 30 years…in fact still working and he is 90!

    I just listened to Lorimer on youtube talking about Pain is it all in your mind. It sounds very interesting to me and I just wondered if what you believe is complementary to what I have been reading or a whole different way of looking at it. I just don’t want to get confused by believe this way or that!!

    Thanks. Marla

    [Reply]

  20. Hi Maria
    Thanks for your comment. We just look at some of the research on this site and don’t give treatment advice. Your nearest pain clinic or doctor may be able to help you perhaps. Other than that, sites like patientslikeme.com may also be useful (please note that we don’t endorse any particular site or treatment though!). Good luck
    Heidi

    [Reply]

  21. stuart miller says:

    Hi, I have started practicing and studying yoga this year to try to gain insight on helping a patient with complex pain that I have been working with for the last few months who is now reconsidering yoga now that she is ambulatory (8 months post injury). I went to a workshop with a yogi/nurse/lecturer, Jnani Chapman who works with cancer survivors and found the day was helpful – I still have trouble reconciling the NB of stillness with the need for movement – the patient is engaged with meaningful activity in the day and is managing her pain but not at night. thoughts/ options?

    [Reply]

  22. Hello Lorimer,
    The work you are doing offers the best hope for the future treatment of the most debilitating and devastating chronic pain conditions. Viewing chronic pain as a condition in the brain and affecting the whole body, not just where the pain is perceived. Many fruitless and invasive treatments could be avoided, ones that do nothing to address the origin of pain. Some patients end up more distressed and in more pain, than had they been left alone.

    I read the article in The Australian with a smile; as I understood it all too well (I have also had a consultation with Milton Cohen before!). I live with CRPS (upper limb) now for over a decade; through the worst times to some of my best achievements. I have been very fortunate to have learned this view of pain-in-the-brain back in those early and difficult years. Had I not, I would be living a much different and more disabled life.

    I too, have left/right perception problems and have worked with mirrors (I also have a mirror box!). It really is a memorable moment,seeing a “normal” hand in a place that was completely blank. Movement and mobility are my goals. Though the pain remains constant, I live quite well with it (most of the time!). I will never again, suffer as much as I once did back in those early years. Knowledge is everything!

    With regards to visualisation/imagination, though I realise it was some time ago. What I have found helpful is to pay attention to other peoples’ hands. How they move them; how they manipulate their hands around objects; if they are left- or right-handed. I am also very interested in pianists and artists, those hands are the hands I want! I played piano as a child, so it’s a memory I can use from the years I had normal hands. What it felt like right at that moment (because I can’t remember not having the pain). I’m not really imaginative either, so I use my memories to put myself into the “mood”. I am rather visual anyway… and I observed a lot! But it could just as simply be a memory of signing your name, or running down the beach. A time when your body was free of pain.

    It always sounds so incomprehensible! You have helped me to not only understand the process better, but to explain it more effectively to others. Pain causes so much needless suffering; suffering that can be alleviated, even if the pain itself cannot be. I try to live with my pain as though it is not there. I think it is essential to the “retraining” of my brain away from the constant warning bells; even when there is no danger. Particularly in CRPS, a condition that strikes fear in the eyes of most doctors/therapists, many of them admitting that they don’t really know what to offer me.

    It was a relief to finally open up to people. I started to blog so that I had a place to talk about what I live with. To give my long suffering family respite! Writing has proved to be a very important step in reconciling the person in pain, with the person I really am. To accept this “quirk of my brain” in a positive manner, because it has made me find strength in myself I didn’t know I had. Changing pain from a negative experience, also changes also how I perceive the pain so that it can be an annoyance, rather than ruling my life. It’s the only thing I have control of really. Mastering my own brain.

    Once again, thank you! I enjoyed the article and TEDx talk very much! I hope that it raises awareness and that more pain patients are able to access the support/treatment networks that could very well, save their lives and families from much needless and uncecessary suffering.

    [Reply]

  23. ian stevens says:

    Not sure if this is the place to post this but this exhibition at the Wellcome trust in London looks really interesting………..The essay available to download on the exhibition is good too…

    http://www.wellcomecollection.org/whats-on/exhibitions/brains.aspx

    Guardian review here…..

    http://www.guardian.co.uk/culture/2012/apr/13/mind-as-matter-brains-wellcome?newsfeed=true

    [Reply]

  24. Trena Youngblutt says:

    I am hoping someone can direct me to where i can obtain ‘Explain Pain’ or persistent pain information sheets for clients who speak languages other than English.

    [Reply]

    BiM Reply:

    Hi Trena
    You might want to try the publishers (noigroup.com) to see if they are able to help you.
    Heidi

    [Reply]

  25. Hi all

    a very low-brow query…….any way of getting a Ride4Pain cycle jersey if unable to actually be there for the ride………?

    Thinking about promoting the cause (and activity for life, hurt not equating to harm etc..) when out on the bike but here in the UK.

    cheers

    [Reply]

  26. Austin Gallaher says:

    I greatly appreciate the BodyInMind web site. Even though I am not a neuroscientist I find much of the material interesting. Good luck with your cafe film series. Think about including Suddenly Last Summer. It’s very dramatic (Tennessee Williams) but a lot of fun to watch.

    EMPATHY Survey. I urge everyone in the community of neuroscientists to consider finding another word to use. In my opinion this word (concept) is causing a great deal of confusion on several fronts. The arguments about the function of mirror neurons is partially the result of misusing this concept. In my opinion “empathy” is learned from experience. You don’t know what it means to be hungry until you have experienced hunger. Empathy is the result of a learning experience. The attributes you are asking about in the survey are not measures of empathy. You are asking about what used to be called beside manners. A good clinical physician does need to do most of things you ask about but they must also remain objective in their assessment of the options open to the patient. I patient may be very afraid of dying from a minor illness. The physician needs to be sensitive to the patient’s fear without feeling the fear themselves. I think the community of pain researchers and neuroscientists should consider finding a better way to talk about this subject. From the standpoint of developing useful, accurate models of the brain and its activities there needs to be more precision in the use of this word.

    [Reply]

  27. Sharlene Harrison-Hinds says:

    First, compliments on your book — Explain Pain. I am a recuperating patient currently in physio and I borrowed the book. Just wanted to give you a heads up about an error in the book. See your page 16. The correct name is Couvade Syndrome (see http://en.wikipedia.org/wiki/Couvade_syndrome). I only know this because I was a sociology/anthropology major. You might want to correct this in the next edition. Thanks ever so for the wonderful insight on pain.

    [Reply]

  28. Hanneke van der Weijden says:

    Dear BiM,

    thank you for making research available to all on your website. I really like the posters. I saw that you sell flashcards for hand recognition on your webside. Have you considered making a smartphone app for this? I really think that clinicians will start using this more in their practice and even patients can practice at home aswell.

    [Reply]

  29. Tom Van Loon says:

    I am a recent leg (trans tibial) amputee with accompanying “phantom pains”. Working on managing pain using stump massage, TENS machine and now GMI having just purchased the GMI Handbook and the Recognise iPad App.
    The GMIHandbook covers the theory but its focus is more on hands than legs and the iPad App is only for hands.
    The website refers to course notes but these are password protected.
    How do we obtain access to these and are they relevant to my case?

    [Reply]

  30. Thanks for contacting us Tom. I help moderate the site here. The objective of Body in Mind is to promote research and discussion about research in the area of the brain and mind in chronic pain and as such we are not in a position to offer clinical advice or treatment recommendations. The course notes are for clinicians who are attending one of our training courses and probably not that useful in your case.

    However, with regard to phatom pain you might find the book Explain Pain to be useful for your situation, or perhaps the book Painful Yarns – you can find more about them in our resources section here: http://www.bodyinmind.org/resources/books/

    NoiGroup have developed the iPad app, and you could contact them with your suggestion to increase the scope of the app here: info@noigroup.com.

    Hope that helps a little

    Heidi

    [Reply]

  31. Ruth White says:

    There’s a nice little video animation on neuroplasticity that might be worth a look on YouTube
    http://www.youtube.com/watch?v=ELpfYCZa87g

    cheers, ruth

    [Reply]

  32. Leonie Rogers says:

    Hi all,
    I’m a physio in rural NSW, and I’ve been working with a lady with very nasty CRPS. She has had a number of confounding issues along the way, including diagnosis of Hypereosinophilic Syndrome and Systemic Mastocytosis.

    Yesterday, her nine year old daughter was diagnosed with CRPS as well (quite independent of the assessing specialist knowing about the parental CRPS) – consequently I’m on the hunt for information regarding familial CRPS. I have found some research which mostly appears to be coming from Dutch sources, and it does suggest there may well be some genetic contribution.

    Any direction pointing towards resources would be greatly appreciated. (This is posted with full agreement from my client).

    Thanks,
    Leonie

    [Reply]

    Lorimer Reply:

    Hi Leonie
    The Dutch are at the front of the game here so what you have found (de mos etc) is what there is
    It is interesting but difficult to know what it means – nature nurture etc
    All the best with it – get to the kid fast and results are often also fast
    Best
    L

    [Reply]

  33. Leonie Rogers says:

    Thanks, Lorimer. I will continue to pursue the Dutch info, and hopefully things will improve for the little girl.

    [Reply]

  34. Brain / Illusion /CBT strategies to address cervical dystonia.

    I hope this is not an inappropriate place to comment but I’m wondering of there are any resources /clinicians frequenting BiM with experience in this type of caseload. I want to expand my repetoire of management options for this type of case load and am struggling to apply visualisation or illusionary techniques in these patients.
    Any help greatly appreciated.
    David

    [Reply]

  35. I’m a psychologist working in Oregon and I’m wondering how I can apply these principles to the treatment of persistent pelvic pain.
    I have a patient who wants to re-train her brain, so that it stops interpreting stress as pelvic pain, but we are having trouble using the graded motor imagery handbook. Have you done any case studies with imagery for pelvic pain? Any tips or treatments that are effective?
    Kindest regards,
    Sue

    [Reply]

    BiM Reply:

    Calling Sandy Hilton! Are you able to respond to this?

    [Reply]

    Sandy Hilton Reply:

    Hi Sue,
    This is a great question. I hope this isn’t too long of an answer. I’m a PT in Chicago who’s been working with this for a bit and love these conversations.

    As far as I know there are no case studies on imagery and pelvic pain (yet). I’ve been trying things clinically for a while and have found some adaptations that appear to be helpful.
    We can make an assumption that pain is pain, if it is in the shoulder or the pelvis, even in the inside bits. It is certainly more challenging to apply the GMI techniques to internal pelvic pain since the person experiencing the pain can’t see the part that hurts and it is socially unacceptable to touch it, or show it to others. These are things we typically do with parts that hurt: Look, touch, compare.

    What I’ve done is adapt the GMI ideas to what is probably best called Graded Exposure rather than GMI. Laterality may have little to do with vaginal or rectal pains. I don’t think anyone knows yet. What appears to be helpful in the clinic is introducing pain education and imagery (used here as imagining a pleasant sensation or movements in the painful bits and moving on to non-threatening movement) with a careful and graded approach (imagined movements, watching others, and then graded exposure to the activity). Applying the principles of GMI and Graded Exposure have made working with persistent pelvic pain exciting and very hopeful.

    I would be very happy to take this conversation offline or however is most beneficial. I’ve chattered on about this in a couple opinion papers that can be found here:
    http://entropy-physio.com/resources/
    in 2 parts, evaluation and then treatment ideas.

    Sandy

    [Reply]

  36. Dennis Nesheim says:

    Dear Professor Lorimer Moseley and BiM Team,
    If knowledge is power you must be god and the BiM team are angels! Okay, no hyperbole; you are all Rock Stars!
    Thank you for the BiM website, your blogs, and the links you provide to your own research and the research of others investigating chronic pain. Whoever funds your work should know that you have created a valuable resource. In fact, your research and website have helped me find new directions for my own chronic pain and I am sharing your website with other people who have chronic pain.
    To give you some context: I am a retired teacher. While working in a factory to pay for college, a crush amputation took the ends of three fingers on one hand. For years I experienced phantom pain, which is mostly gone now. As an art educator I was interested in visual perception, memory, and learning. In short, brain plasticity. In the late 1990s I earned a masters degree (MA) in special education and went to work with students who had “moderate” learning disabilities, including Traumatic Brain Injury. I learned a bit about neuroplasticity over the years; in the context of education.
    In 2009, after treatment for back pain and the end of my 30 mile (50km) bike rides and high mountain hikes, MRI imaging showed a tumor at the base of my spinal cord. The solid tumor (size 1.5 x 1.3 x 2.0 cm) was benign and removed in a successful seven hour neurosurgery. I was still introduced to pervasive chronic pain. I heard the pain was caused by nerve damage and nerve tissue is slow to regenerate. During the two year post-op appointment I heard, [sic] “…it is as good as it will get,” plus “you worry too much, be happy it’s not worse.” I am generally a persistent and optimistic person but after two more years of attempts to relieve the pain, I resigned myself to incurable 24/7, worsening chronic pain in my back, abdomen, and the entire bottom half of my body. In December 2013, I did my annual search for more relevant research through the U.S. National Institutes of Health, and I hit the motherlode!
    I saw a link to your BiM website, started reading your blog, and followed your links to other resources. You inspired me to connect my experience in education to the context of pain. Your talks on YouTube are really helpful, and I tell others to, “…watch the video Getting a Grip on Pain and the Brain, Lorimer is a Hoot, and he really knows his stuff!” I also send them the link to Tasha Stanton’s excellent video from the Seminar on Successful Aging. You at BiM have inspired me to look differently at chronic pain. I am now using my training and experience, what I know about brain plasticity, and information from current research to affect my own chronic pain. Thank you for inspiring me.
    Your research, blog, and links provide better information about the neurological processes of chronic pain. You have certainly made a difference for me. Thank you all so much, for your research, blog-website, care for people with chronic pain, and your assistance to people around the world.
    This is a longer message than I intended but I chose to give you anecdotal information that, hopefully, makes my praise a little more meaningful. You are indeed, Rock Stars!
    Dennis Nesheim
    Lakewood, Colorado, U.S.A.

    [Reply]

  37. Hi Dennis – glad you found us. Thanks for your very kind comments!

    [Reply]

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