10 Things I learnt From 10 Days With Diane Jacobs

Across the end of March and the start of April I spent 10 days straight with Canadian physiotherapist Diane Jacobs, who was in Australia to teach her DermoNeuroModulating (DNM) workshop, which I attended.

Twice.

The first event was held in Noosa, Queensland. It was hosted by Robin Kerr at her recently sold practice, Alchemy in Motion.

The second event was held in Melbourne, Victoria. It was hosted by me at the lovely Parkville hotel The Larwill Studio.

Each event started with a 3 hour lecture by Diane, which covered the theoretical foundation of her work, and was then followed by 3 full days of teaching the manual techniques and clinical reasoning outlined in her book.

I also spent a few days before and after the Melbourne workshop hosting Diane – we went to the zoo, some local pubs and restaurants as well as the Shrine of Rememberance and the National Gallery of Victoria. She even got to have lunch with my mum!

I thought the course was fantastic, overall one of the best courses I have attended, and definitely the best manual therapy course I have attended.

50 Years Is A Long Time

Diane is the same age as my mum. I won’t say what that is exactly (not that I think she’d mind), but she has been in practice for almost 50 years.

Her first years were spent in a hospital setting, which almost turned her off the profession. In fact, she did leave for a short while, but she found her groove, and has never looked back (mostly).

I think anyone who has lived a life, worked thoughtfully and experienced many interactions with people is worth listening to and learning from, and Diane proved me right.

Not David Letterman

In 2013, I took a visceral manipulation course. It was interesting, but implausible. I’d say that Diane’s explanations make more conceptual sense.

One of the benefits of the course was the location – it was in New York City, and while I was there I went to a recording of The Late Show With David Letterman.

His Top 10 lists were great.

I’m not sure I’m of that calibre, but here goes.

NEW YORK – APRIL 24: Dave reads the “Top Ten List” on the Late Show with David Letterman, Friday April 24, 2015 on the CBS Television Network. (Photo by Jeffrey R. Staab/CBS via Getty Images)

On Life

Life mostly works itself out over time. We worry about things we can’t control very much (like outcomes in manual therapy) and cause ourselves a lot of bother, but it mostly works itself out.

On Work

Being a manual therapist is a peaceful way to make a living.

On Not Knowing

It’s okay to not know something, and it’s okay to have a story that may be somewhat, or even entirely inaccurate, as long as you acknowledge it.

The first principle is that you must not fool yourself – and you are the easiest person to fool.


Richard Phillips Feynman 

On Listening

At the Noosa workshop, Diane asked the group if anyone had neck pain, as she was about to demonstrate techniques targeting the occipital nerves.

A man in his sixties volunteered, and she asked him about his pain.

What followed was a 40 minute implicit demonstration of how to listen to someone (not just a patient). Diane seemingly made him feel as they were the only 2 people in the room with her facial expressions, body language and most importantly, her quiet attention.

I really think we need to start considering listening as an intervention itself

Alison Sim

On Manual Therapy

It’s non-specific and n=1 and that’s completely okay.

Additionally, manual therapy can be optimal when it is used for certain presentations (and not very good at all when used for others).

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“For the treatment of pain, manual therapy is always OPTIONAL, but it can be OPTIMAL” – Diane Jacobs ~ So when is manual therapy likely to be optimal? According to Diane, when pain is: ~ ▪ Localised/discrete ▪ Changes with movement/position (ie mechanical) ▪ Changes with distraction ~ Manual therapy is not likely to help (resolve the condition) when: ▪ There are multiple sites of pain that are likely to be the result of central sensitisation ▪ Conditions like fibromyalgia and hyperpathia (basically anything which is highly centralised) ▪ Most (but not all) neuropathic pain ~ I think there is a dearth of research looking at indications and dosage for manual therapy, and as a result (and due to the non specific nature of manual therapy), a lot of research into effectiveness is poor and doesnt help clinical practice. ~ What are your indications for manual therapy? (if you don’t use it, don’t comment, as I know the arguments against, I’m interested in arguments for) ~ #integrativeosteopathy #osteopathy #physiotherapy #massage #manualtherapy #myotherapy #chiropractic #clinicalreasoning

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On Interoception

Often Diane would ask someone if they had pain in the region she was about to demonstrate techniques for.

One thing that really stood out was how she always wanted to get people aware and thinking about how their body felt, rather than the labels and diagnoses they’d been given.

“Does anyone have a sore back”

“I do”

“Tell me about your sore back”

“I had a disc injury”

“How does that feel?

On Beer

Dark beers are her favourite, but The Damned Pilsener by HopNation in Footscray was pretty nice as well.

On Lifespan

It’s mostly genetic.

People try all kinds of things to live longer, but it’s mostly down to genes, and maybe stress.

On Asymmetry

Asymmetrical structure is normal, common and completely okay.

Habitual asymmetrical use of our body is possibly a predisposing factor for mechanical pain.

  • Sleeping on the same side every night
  • Curling up in the same position on the couch all the time
  • Crossing arms/legs the same way all the time
  • Standing with your weight on one leg
  • Carrying bags/children on one side

Her rationale is that such sustained postures/positions/movements relatively tension and shorten the same neural tissues in the same way over time, impacting their fluid dynamics.

Better awareness leads to better use of our body, which leads to feeling better in our body.

On Diagnostic Errors

Everything is a type 1 error (when it comes to musculoskeletal pain diagnoses).

Most of the pain problems we see in clinical practice have been given structural or biomechanical labels.

Yet, often neither changes when the pain resolves.

Or on the other hand, many people walk around with these structural or biomechanical changes and experience no pain.

She is very comfortable with simply calling something “pain”, treating it conservatively and if it improves, not pursuing it further (she will refer for investigations if it doesn’t and she suspects pathology).

DNM: Just Another Acronym?

Manual therapy is full of acronyms and techniques.

Does DNM bring anything different to the table?

Yes.

DNM isn’t about the techniques, which are lovely, but often just rebadged osteopathic techniques.

DNM is about the clinical reasoning process in manual therapy.

It is about considering the role of the nervous system in pain.

It is about understanding what we can affect with manual therapy (nerves, the most excitable tissue in the body), and what we can’t (muscles, fascia and joints – at least not directly).

DNM was the first approach to manual therapy I came across that not only considered the skin (the only thing we can touch), but the physiology and potential therapeutic effects of treating the skin.

There are no rules for DNM techniques – it’s jazz, not classical music.

It’s not copyrighted.

It’s not a business.

It’s simply one woman’s interpretation of the literature on pain, physiology and manual therapy.

Pain Is A Mystery, But How Do You Solve It?

Puzzle

It is easy to think of pain as a simple puzzle. Find the missing pieces, put it all together in the right order and then voila, you feel better.

Unfortunately, as much as we’d like things to be this simple, it’s not the case, and pain is more like a mystery.

Allow me to let Malcolm Gladwell explain (1):

The national-security expert Gregory Treverton has famously made a distinction between puzzles and mysteries. Osama bin Laden’s whereabouts are a puzzle. We can’t find him because we don’t have enough information. The key to the puzzle will probably come from someone close to bin Laden, and until we can find that source bin Laden will remain at large.

The problem of what would happen in Iraq after the toppling of Saddam Hussein was, by contrast, a mystery. It wasn’t a question that had a simple, factual answer. Mysteries require judgments and the assessment of uncertainty, and the hard part is not that we have too little information but that we have too much. – Malcolm Gladwell

Although it seems like there a new discoveries about pain being published almost monthly. So much about is still unknown.

And, because pain is invisible and has many unconscious components, we simply cannot know why you, or any individual is experiencing pain at a particular moment.

The Case Against Diagnostic Imaging

You would think that being able to visualise the structure of the body would be helpful to clinicians treating pain.

It turns out that this isn’t quite the case.

Firstly, there is a large, and growing, body of research that shows there is very poor correlation between the structure of our bodies and symptoms of pain.

From disc injuries (2) to degeneration (3)  and even partial or full thickness tendon tears (4), most of us are walking around with structural “damage” that would show up on diagnostic imaging (X-ray, CT, MRI etc).

Secondly, and most interesting to me, is due to the fact that the interpretation and reporting on diagnostic imaging varies wildly.

In a recent study on MRI reporting and interpretation (5), a woman with low back pain and neurological referral was sent for an MRI at 10 different locations. The results reported 49 total findings, with not one interpretive finding consistent across all 10, and only 1 finding consistent across 9 of the 10 reports.

This means:

  1. MRIs require skill to interpret, and not all radiologists are equally skilled, thus, it matters where you get an MRI done.
  2. Radiologists working in isolation from the patient, are assessing an image, not a person, and have to make a lot of assumptions, even with a comprehensive history.

What About Physical Assessments?

Physical assessments are a necessity for clinicians, but which assessments are valuable, and which just add confusion?

We can break physical assessment into 3 components:

  1. Vital signs like pulse, blood pressure and breathing
  2. Neuro-orthopaedic examinations that are designed to rule in or rule out specific pathology or conditions
  3. Functional assessment designed to determine an individual’s movement competency and capacity

It is the third area which is the most “grey”.

This is because human movement, being an emergent property, is not an easy thing to classify (6).

We can define good and poor movement, but again the definitions are somewhat arbitrary, and their are many exceptions who fall outside those defined ranges who do not have an consequences (injury, pain etc).

This isn’t to say their isn’t such thing as good movement, bad movement or better movement, but only that it is person specific.

So if we use a movement assessment to gain insight to a person’s movement at that moment in time, in those conditions (in the clinic for example)then we can look for a movements that can be better.

If we identify movement that could be better, we can challenge to brain to improve movement, with a variety of techniques.

Even Histories Can Be Misleading

A good clinician will help someone in pain by creating the right context, or environment for them to heal.

To do this, a good clinician will know what they need to know, and more importantly, what they don’t.

By focusing only on the important, relevant, information, a good clinician minimises the chance of nocebo, and maximises the chances for recovery.

What exactly then does a good clinician need to know?

Is this pain dangerous?

When consulting with a patient, first, we want to rule out risk – some musculoskeletal pain can be caused by serious pathological conditions that need medical intervention. We have to rule these out first, and when in doubt, err on the side of conservative.

As a caveat to the above section on imaging, an “unnecessary” X-ray is a small price to pay if the alternative is missing an early cancer diagnosis. This does not mean imaging should be routine!

Is this pain affected by movement or position?

Mechanical pain is characterised by changes related to movement or position. If the answer to this question is yes, this rules in mechanical pain as a diagnosis. This does not yet rule out other origins of pain.

We can follow this up with more exploratory questions around which movement or positions feel good and which don’t.

Combined with the assessment findings, this will give us some more insight into how to proceed with treatment.

What is your current autonomic state?

Your autonomic state says a lot about you.

If you are wound up tightly – in a sympathetic or stressed state, characterised by elevated heart rate and blood pressure, shallow breathing and decreased blood flow to the periphery of the body (including the skin) – then it will be hard to resolve your pain until you enter a more balanced autonomic tone.

What are the barriers to recovery?

These are often implied, and a good clinician will be able to identify these as much from what a patient doesn’t say, as what they do.

Factors that can affect recovery include:

  • Age
  • Disease
  • Nutrition
  • Thoughts
  • Comorbid conditions – anxiety, depression, high blood pressure etc
  • Medications
  • Family and friends
  • Employment, or lack thereof

As always, it’s not simple, and it’s definitely not linear.

We are, after all, dealing with people – you know, those confusing, irrational beings who like to “go out”, but not for too long, because then they have to “go home” (Seinfeld reference, video below).

The Downside of Irrationality

Human beings are irrational. This is a fact.

Being irrational has positives, the most obvious being love.

Love is a fantastic human emotion that is completely irrational. If we were completely rational beings, then we wouldn’t spend so many of our resources chasing love, or any feeling for that matter.

But, this is exactly why too much information does not help us treat pain.

Too much information can lead us to make false assumptions and draw erroneous conclusions.

This doesn’t help patients seeking help for pain at all.

Pain has very tenuous links to tissue damage, body structure, posture, strength, symmetry and stability. (8,9)

Investigating these to a high level, and then describing pain as a result of these findings is not only inaccurate, but also harmful. (9, 10)

Every time someone is told their pain is the result of the above findings, a link is made in their brain. This is called a neurotag. Think of it like a storage file in the brain. (11, 12)

If a clinician, family member or friend tells someone with low back pain they lack “core stability”, then this is added to the low back pain neurotag.

Then, because of the way our brains function, when we have existing knowledge, we look for examples to confirm this knowledge – this is called confirmation bias.

So the person with low back pain, who has been told their pain is caused by a lack of core stability, finds “evidence” to support this.

If their back hurts when they lift something, they blame their lack of core stability. If their back hurts after activity, it’s core stability’s fault.

They forget to focus on the times that they lifted something without pain, or that activity didn’t hurt.

This is just one simple example. There are many others like it.

Conclusions

Mysteries are interesting to us as humans – as long as we get closure and the mystery is solved in the end. This is the basis of the “open loop”*  TV shows, movies and books use to keep their audiences engaged.

Unfortunately life is not like a movie. We don’t always get a neat and tidy closure.**

The challenge facing any clinician, when we treat people in pain, is to focus only the important and relevant information, and to educate patients on why this is so.

The even bigger challenge, is helping patients face the reality that the mystery of pain can’t always be solved, no matter how much (or little) information you have.

 

*An open loop is used by writers whereby earlier in the story they introduce something, but don’t address it immediately, in order to keep your attention, because you want to find out what happens next.

**Except not all movies or TV shows have closure. One of the greatest TV shows of all time, The Sopranos, has a famous ending that didn’t give it’s audience the closer they were hoping for.

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

 

References

(1) Enron’s Open Secrets

(2) MRI findings of lumbar spine in people without back pain

(3) Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation

(4) MRI findings in throwing shoulders: abnormalities in professional handball players

(5) Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period

(6) Metastability and emergent performance of dynamic interceptive actions

(7) The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain

(8) Different contexts, different pains, different experiences

(9) Nocebo hyperalgesia and the startle response

(10) Context as a drug: some consequences of placebo research for primary care

(11) Pain really is in the mind, but not in the way you think

(12) Reinstatement of pain-related brain activation during the recognition of neutral images previously paired with nociceptive stimuli

Chronic Pain Is Rooted In Fear

fear painChronic pain is rooted in fear.

Chronic pain is defined as pain persisting more than 3-6 months, this is the time it typically takes for injured tissue to heal.

However, both acute and chronic pain have a tenuous association with injury (tissue damage).

People can exhibit the signs and symptoms of chronic pain earlier than 3 months.

This is influenced by factors associated with developing chronic pain, including, but not limited to, a history of anxiety and/or depression, low education level, lower income and age.

In general, most treatment of chronic pain is unsuccessful.

This is related to poor expectations of patients (after many failures, who can blame them) (1), and treatments that are overly focused on the biomedical (tissue) factors of pain, that often don’t match up with patients’ goals (2).

There have been promising results achieved by combining physical therapies with cognitive based therapies to treat chronic pain. (3)

Why Do We Experience Pain?

Professor of neuroscience and world leading expert on pain, Lorimer Moseley, has previously described pain as:

…a conscious correlate of the implicit perception that tissue is in danger

For most, the perception of danger evokes feelings of fear, heightened sensory awareness and decreased cognition.

When we assess danger, there are two main forms:

  1. Actual danger – situations where our life or safety is at risk.
  2. Perceived danger – situations where we perceive our life or safety to be at risk, but it really isn’t.

Both actual and perceived danger activate the same neuro-networks in the brain and the same physiological responses in the body. (4)

Our perceptions of danger are shaped by numerous factors, including:

  • Our age
  • Our gender
  • Our social
  • Our cultural upbringing
  • Our experiences
  • Our current capabilities.

If pain is related to a perception of danger, and our perception is shaped by all those factors, it is fair to say that pain is shaped by those factors too.

Pain science has moved forward, and beyond simply being a perception of danger, pain is beginning to be defined as a “need to protect”. (5)

The perception of danger, or threat, is in part based on predictive processing. (6)

Predictive processing is what our brains do to make sense of the world we experience and take shortcuts to achieving a conclusion.

An optical illusion based on predictive processing.

An optical illusion based on predictive processing.

Because of predictive processing, and other neural processes, we tend to not see an objective reality, but rather a subjective reality.

This is especially true when it comes to pain.

When we are experiencing pain, our brain makes predictions about whether something is going to be “dangerous”, and produces pain preemptively, in order to protect us.

Pain is not the only time that our brains use predictive processing.

Take a look at the brick wall, and see if you can spot what is not quite right.

The Neurobiology of Pain

The big problem with pain, is that pain is perception that we perceive as a sensation.

It tricks us into thinking that it is coming from our body, when in actual fact, pain is always produced by the brain and localised to the body. (7)

It is complex, and emergent, not linear.

So just because you feel a certain way after doing something, or not doing something, does not mean that your actions, or lack thereof, caused that feeling.

In the diagram below, I’ve simplified the neurobiology of pain with injury (remember, pain can occur without injury, and injury without pain as well).

neurobiology-of-pain-injury

Injury here is used loosely to describe the inciting physical event that damages the body tissue – it could be physical trauma, it could be an immune response from an infection or an auto-immune condition, like rheumatoid arthritis.

This leads to nociception – “danger” signals that convey a change to the status of the cellular environment.

That could mean a change to the mechanical load, a change to the chemical environment or a change to the temperature (the three primary types of nociceptors).

Inflammation is an immune response, and we know the brain and nervous system has a large role to play in the immune response (these days, doctors are calling it the neuro-endocrine-immune system). (8, 9)

Inflammation can lead to increased nociception, and if nociception increases, then this is a mechanism for increased inflammation. (10)

This can lead to peripheral sensitisation – where the sensory nerves in the affected body region become more sensitive due to physiological changes that take place.

All of this takes place locally, but we do not experience pain as a result of this just yet.

The Brain Modulates Everything

Modulation is a process whereby signals (nociception) reaching either the brain or spinal cord are amplified or inhibited. (11, 12)

Modulation can be affected by our thoughts – conscious or unconscious.

Here is where it gets interesting: we often think that our thoughts are ours, but there is compelling evidence that this may not be the case, and that our culture and environment shapes our thoughts, feelings and actions more than many of us would care to admit. (13, 14)

“You can do what you decide to do — but you cannot decide what you will decide to do.”
― Sam HarrisFree Will

Using this line of thought – when it comes to pain, our ideas and understanding, especially at an unconscious level are already implanted by the culture we live in.

Currently our culture around pain is:

  • Pain is bad.
  • Pain is caused by damage, or degeneration (the dreaded “wear and tear”) or misalignment.
  • “I’m just getting old.”
  • Pain needs to be “fixed” – and can be done so by the right practitioner.
  • We need to find the cause of pain, and this can be done by physical assessment and diagnostic tests (MRIs, X-rays etc).
  • The weather causes pain to flare up.

If you live in Australia, or any other Western nation with a similar culture, all of these memes, plus many others, have been implanted into your thoughts.

You don’t even question them most of the time, because you don’t know you have them, until you experience pain.

Our thoughts shape our emotions, our emotions shape our actions and our actions reinforce both.

This is especially evident when we experience pain.

Changing The Unchangeable?

We discussed earlier that pain is a protective response, which is based on the perception of threat.

There is a greater evidence of danger to ourselves, than there is of safety for ourselves. (15)

Going back to the premise of this post: chronic pain is rooted in fear.

Fear changes our perceptions.

Fear makes us think or feel that we are in danger moreso than we actually are.

Fear makes us want to find safety.

But if fear is influenced by a host of factors, many that we don’t know, and most that are unconscious, can we change it, and as a result, change pain?

I say yes.

Cognitive Based Therapy

CBT

When we can identify our fears around pain, then we take away some, if not all of its power.

Yes, pain will still hurt, that’s the nature of pain, but our suffering is different.

We stop catostrophising.

We stop worrying.

We start focusing on what we can do.

We start focusing on who we are.

The challenge of identifying and treating unconscious fears is obvious.

Fortunately, over the years, psychologists have developed many ways to explore our unconscious.

One of which, is cognitive behavioural therapy.

Cognitive based therapy is based on the premise that each thought is related to a certain emotion and behaviour, and vice versa.

By exploring each aspect around our beliefs and understanding of pain, we can change what we think, feel and do, to decrease our pain and suffering and eventually, change our unconscious thoughts.

Cognitive behavioural therapy is not only effective for treating pain, but also something that can be performed by suitably trained manual and physical therapists*.

A Way Into The Neuromatrix

The most up to date, and most widely accepted model of pain, is the neuromatrix model, proposed by Melzack and Wall (pictured).neuromatrix

What you can see in this diagram, is that there are multiple inputs (on the left) to the “body-self neuromatrix” (the representation of ourselves, within our brain) from both the body and brain, which influence what our body does, how it feels and how it functions (outputs, on the right)

These include:

  • Cognitive related brain areas
  • Sensory signalling systems
  • Emotion related brain areas.

But, that’s not all, each of these inputs can affect each other, as can each output.

Everything affects everything when it comes to pain.

What any good clinician is trying to do when treating someone in pain, is provide enough context for the outputs of the neuromatrix to change.

We do this by influencing the inputs in a way that promotes increased descending inhibition (as discussed earlier).

In addition to CBT, we can use other interventions like touch (manual therapy from intelligent, responsive hands) and movement.

Basically, we are trying to tell your brain that it’s okay, things are safe and you don’t have to be on edge.

When your brain is no longer in “fear mode”, it can resume normal modulation duties and you start to feel better.

Conclusions

Most chronic pain occurs in post surgical patients. (16)

There is an obvious physical trauma that takes place.

Many others develop chronic pain conditions after intense and/or prolonged psychological and/or emotional distress.

Something occurs to shift the brain into “fear mode”, in which it wants to do nothing more than protect itself (and you), which it does by producing pain.

We know that pain is complex and multi-factorial, but too often we think we are the exception.

It can feel like we just need to “release” that tight muscle or “crack” that stiff joint.

It can feel like there is “wear and tear” or “damage”.

But at least 40% of people with widespread arthritis don’t experience pain.

Amputees with no limbs do experience pain, in the absent limb!

You have to be fully engaged in the process, and willing to confront a lot of home truths about what you think, feel and believe if you want to treat your chronic pain successfully.

Even when you do that, sometimes you’ll still be in pain.

But, if you don’t, you’ll definitely still be in pain.

 

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

 

*If your condition was too complex for the therapist alone, we would refer you to a psychologist. In Australia, there is a mental health plan, under which your GP can refer you for up to 10 consultations with a psychologist, partly subsidised by medicare.

References

(1) Expectations and chronic pain outcomes

(2) Patient goals and measuring treatment outcomes

(3) Cognitive functional therapy for low back pain 

(4) Activation of threat-reward neural networks

(5) What is pain?

(6) Predictive processing simplified

(7) Pain

(8) Nervous and immune system interactions

(9) Structure and function of nervous system lymphatic vessels

(10) Mechanisms of inflammatory pain

(11) Descending control of pain

(12) Continuous descending modulation revealed by FRMI

(13) Free Will

(14) Myth of free will

(15) DIM-SIMS

(16) Chronic pain and surgery

Osteopathy For Carpal Tunnel Syndrome

Image credit: By DoPhotoShop - http://dophotoshop.com/carpal-tunnel-exercises.php, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=14614865

Image credit: By DoPhotoShop – http://dophotoshop.com/carpal-tunnel-exercises.php, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=14614865

Carpal tunnel syndrome is a common presentation, but is often poorly managed. Osteopathy can provide a conservative option to treat carpal tunnel syndrome.

Carpal tunnel syndrome is a fairly common condition that affects women slightly more than men, with numbers ranging from 1-7% of the population affected. (1)

It is described as “a painful disorder of the hand caused by pressure on nerves that run through the wrist. Symptoms include numbness, pins and needles, and pain (particularly at night).” (2)

It usually presents with the following symptoms (3):

  • paresthesia, dull, aching pain, or discomfort in the hand associated with weakness or clumsiness;
  • fluctuating level of symptoms with exacerbation at night (nocturnal numbness), worsened by strenuous hand use or activities with maintained posture (driving);
  • and partial relief of symptoms by changing hand posture or shaking the hand.

Diagnosis or description?

Generally speaking, any condition that has the word “syndrome” in its name is not a diagnosis, but rather a collection of clinical findings.

In the case of carpal tunnel syndrome, it is considered a clinical diagnosis, but, whilst the symptoms can be similar from person to person, the clinical findings (and thus underlying causes) can be quite different, based on a variety of different factors.

Some of these factors include:

  • Individual anatomical differences (wrist space, nerve length, a cervical rib etc)
  • Lifestyle and occupational activities (assembly line workers tend to have a higher incidence of carpal tunnel syndrome than other occupations – NINDS)
  • Pregnancy – pregnant women have a higher incidence
  • Health status – diabetes, hypothyroidism and obesity are known risk factors (Frontiers)

To diagnose carpal tunnel syndrome a clinical examination is sufficient, though in more severe cases, nerve conduction tests are recommended.

When you consider that any combination of factors can be present, an individualised approach to management becomes critical.

General Recommendations

The general medical recommendations (1, 4, 5) to treat carpal tunnel are (in order):

  • Rest. Rest is important, but it is often futile if there are other issues involved, because as soon as you stop resting, symptoms flare up again.
  • Splinting, particularly at night. Splinting can be useful, but again, it isn’t because of a “lack of splinting” that you develop the condition in the first place. This means, that without addressing the other factors, splinting is just another form of rest, and symptoms will likely return once splinting has stopped.
  • Physiotherapy. Hand, wrist and arm exercises can be useful in helping reduce symptoms and address causative factors. Exercises targeted at mobilising the nervous tissue, can be particularly helpful here. Whilst different professions, osteopaths can do most of what physiotherapists can do and vice versa, and what matters most is that the professional in question is up to date in their knowledge and provides an individualised treatment approach.
  • Diuretics to reduce fluid. Diuretics can provide a short term reduction in fluid, but again, we need to work out why the fluid was accumulating in the first place. If, for example, there is lymphatic congestion, the diuretics will only have a short term effect, often with the risk of side effects. Another common cause of congestion is hypothyroidism, which needs to be medicated properly, so identifying the cause of the congestion is as important as reducing the fluid with diuretics.
  • Cortisone. Cortisone can reduce inflammation locally, with the potential risk of nerve injury resulting in worse pain. The benefits do not outweigh the risks, in my opinion, considering the alternatives available. If you do decide to have a cortisone injection, it’s best to have it performed by a surgeon who performs it often, as their skills will be higher, reducing the risk of adverse effects.
  • Surgery. Surgery is indicated in severe cases, but is not always successful (like any treatment). It has the risk of nerve and/or artery damage, with the benefit of increasing the space under the transverse carpal ligament, which is often a cause of symptoms. The success rate of surgery for carpal tunnel is generally higher at 12 months than conservative approaches, when considering nerve conduction studies, but due to the risks involved, the recommendation is to initially treat conservatively, and only explore surgery if there is not the desired improvement.

(My) Osteopathic Approach

To understand my osteopathic approach to treating carpal tunnel syndrome (and any condition really), you have to have a grasp of complex systems and emergent properties.

Put as simply as possible:

This means that something like pain, or symptoms arising from the nervous system are not predictable based on statistical or experiential averages, and any linear causality we deduce, is false logic.

So, when it comes to treatment, we have to have an understanding of normal physiology, then use our clinical skills to find the “abnormal” or “dysfunctional” or “disturbances to normal”.

We can then apply an intervention that results in a change (remember, this change is unpredictable), monitor the change (see if the abnormal has become normal) and then reevaluate the approach.

In essence, it is a trial and error approach, but an educated one.

Measure Twice, Don’t Cut

It’s important to measure the effects of treatments somehow, but, this can be hard, because clinical findings vary for the same condition, and the same clinical findings will not always result in symptoms, even in the same patient.

Because of this difficulty in measuring clinical findings and symptoms, I try to use objective outcome measures. These are simple, validated (by research) questionnaires, like the Boston Carpal Tunnel Syndrome Questionnaire, which provide a measure of the disability associated with a certain condition; and they can be very helpful to use at the beginning, mid-point and end of treatment process to gauge efficacy.

As mentioned earlier, nerve conduction tests are valuable in certain cases, but are invasive and costly from an economic point of view, so they are not always practical.

Treat The Whole, Not The Cause

As I described in Osteopathy For Low Back Pain, there are general, or systemic effects from osteopathic treatment, as well as local.

When treating a person with carpal tunnel syndrome, as opposed to treating carpal tunnel syndrome as a condition, these general effects can be important in improving overall sense of wellbeing as well as positively affecting the body’s physiological functioning.

Sense of wellbeing is often overlooked in outcomes based medicine, but, with outcomes being equal, the process that produces a more pleasant/less unpleasant experience for the patient is superior.

nerves_of_the_left_upper_extremityIn addition to the general aspects of an osteopathic manual treatment, with carpal tunnel syndrome, a focus on the structures related to the median nerve starting from it’s origin in the brachial plexus as it arises from the C5-T1 nerve roots, all the way to it’s end point in the hand.

It is surprising how many people I see who have consulted with their GP and perhaps a rehabilitation professional (occupational therapist, physiotherapist, hand therapist) who have only had interventions directed at the wrist and hand.

Simple anatomy suggests that this will not be adequate.

Given the nature of nerves, symptoms will appear distal to (below) any site of adverse tension/compression. Considering the hand is the site of carpal tunnel syndrome symptoms, my preference is to work up from the hand and wrist towards the neck and thorax.

Common areas of dysfunction include:

  • Transverse carpal ligament (this is what surgeons cut)
  • Carpal (wrist) bones
  • Radius and ulna (forearm bones and their joints)
  • Interosseus membrane of forearm (connection between radius and ulna)
  • Elbow flexor muscles and associated connective tissues
  • Pectoralis minor
  • Upper ribs (especially the 1st rib) and clavicle
  • Scalenes (and other neck muscles)
  • Cervical spine (neck) and thoracic spine and rib cage

Unless all these areas are considered and any dysfunction addressed, I wouldn’t consider the examination process thorough enough.

Neurodynamics must be considered

One of the issues with traditional approach to carpal tunnel syndrome, is that the median nerve itself is not considered as a primary cause of the symptoms, but rather a secondary “victim” to other changes.

Neurodynamics considers 3 aspects (Shacklock):

  1. The mechanical interface of the nerve and body tissue (joint, ligament, muscle etc)
  2. The neural tissue itself
  3. The innervated tissues

Abnormal changes at any of these aspects can alter neurodynamics (the function of nerves), leading to symptoms.

Techniques Are Secondary

Lot’s of people want to know what technique will work best, whether it is a manual technique delivered by an osteopath, or an exercise to self manage. The technique doesn’t matter as much as the reasoning behind the technique and how the technique is executed.

So if someone reasons that muscular tension in the neck muscles is affecting the median nerve, a range of techniques to reduce said tension will be helpful. These can be active or passive and are guided by patient and practitioner experience and preference, as well as a risk to benefit analysis (when known).

This technique needs to be delivered or performed in a mindful manner, with attention being paid to the experience of the technique, as well as the response, by all parties involved (patient and practitioner).

By engaging patients in the process, the treatment automatically becomes more “active”, which we know produces superior results to passive treatments in the long term (BMP).

Conclusions: Putting It Altogether

 

Carpal tunnel syndrome has two components – the symptoms experienced (pain, numbness and tingling etc) and the reduced nerve conduction, which is not always perceptible.

Osteopaths have a role to play in reducing the symptoms (6), and research performed on other manual therapies supports this (7).

However, it must be considered that there is no set formula for a condition like carpal tunnel syndrome, and that each person will have their own “physical story” explaining their condition, and it is this story that a practitioner must somehow read, understand and interact with.

So when you are seeking treatment for carpal tunnel syndrome, you want to find a practitioner who considers everything, not just what is happening at the wrist, not just what is happening “in your body”, but everything.

It sounds cliche, but that is what a truly holistic approach entails.

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

References

(1) Primary Care Management of Carpal Tunnel Syndrome

(2) Better Health Channel – Carpal Tunnel Syndrome

(3) Carpal Tunnel Syndrome – Primary Care and Occupational Factors

(4) Conservative Interventions for Carpal Tunnel Syndrome

(5) Is surgical intervention more effective than non-surgical treatment for carpal tunnel syndrome: a systematic review

(6) Effectiveness of Osteopathic Manipulative Treatment for Carpal Tunnel Syndrome: A Pilot Project

(7) A Pilot Study Comparing Two Manual Therapy Interventions for Carpal Tunnel Syndrome

(8) Median Nerve Image

Brain Training That Works

Brain Training

Brain training has become popular in the last few years, but does it live up to the hype?

No. (1)

Unfortunately, playing games on your phone doesn’t do much for your brain, aside from make you better at playing those games. (2)

Does that mean you are doomed to suffer from declining cognitive function as you age?

Not necessarily.

There are activities which have demonstrated positive effects on both brain structure and function.

Despite what advertisers tell you, these are not found in your app store.

So what can you do to “train your brain” and make it (and the rest of you) healthier?

Learn A Language

Learning a language is one of the best things you can do for your brain, and your life.

Learning a language opens up your world, from business to social and travel opportunities.

The added bonus is that it reshapes your brain, improving both the structure and function, and potentially helping stave off Alzheimer’s. (3, 4)

In this case, apps can be helpful, but nothing beats engaging in conversations – you are challenged to think in a different language, which is fantastic for cognitive function.

What’s great is that whilst becoming fluent is great for the brain (and your life), the act of learning a language, even if you struggle, still yields improvements.

Learn an Instrument

Learning an instrument has similar effects on the brain to learning a language.

Both the structure of the brain as well as the function are affected positively.

It seems that in the case of musical instruments, the longer you have played them, the better. (5, 6, 7) This doesn’t mean you shouldn’t bother if you are “older”, it simply means, once you start, keep it up, the benefits are well worth the effort!

One of the more interesting findings made by researchers, is that playing an instrument can help mitigate hearing decline due to ageing as well!

This occurs because we “hear” with our brain. Our ears translate vibrations of the air to electrical impulses that our brains decipher as sounds, and it is thought that playing an instrument helps enhance “meaning” associated with sound, allowing better function when hearing.

Exercise

Exercise is probably the best brain training activity of them all, because it offers so many benefits not only to your brain, but body and soul as well.

It makes sense that moving is so good for our brain, given how much real estate in our heads is allocated to performing and controlling movement.

The list of studied effects of exercise on brain training includes:

  • Structural growth via increased signalling of various growth factors.
  • Improved memory and cognitive function.
  • Delayed onset of neuro-degenerative diseases.

So what’s the best exercise for your brain?

There is research on cardio exercise (running, cycling, walking etc) and strength training, but not much on complex functional movements.

I would hypothesise, that the best form of exercise for your brain is a circuit style workout that challenges you to move in 3 dimensions, pushing, pulling and carrying different loads over different levels – from the ground to standing.

Crossing midline (imagine a line vertically through your body, cutting it into two halves) movements are super charged brain boosting exercises (they use low level versions of these movements in neuro-rehab).

Examples of movements that cross midline:

  • Crawling
  • Skipping
  • Juggling (8)
  • Alternate single leg/arm movements
  • Rolling
  • Rotational movements

Of course, if this sounds too much, just get some vigorous walking in, the research is still positive – move it or lose it (brain function that is).

Meditate

Meditation has been getting a lot of attention from scientists lately.

Research is showing positive changes to brain areas involved in stress and pain, along with global improvements to brain structure and function.

A while back I wrote an article on mindfulness for pain management – the principles described in it are relevant to brain health too.

Whether you do focused meditation, pray or simply spend time quietly contemplating, it is a fair assumption to say that inward focused practices can all have a positive affect on your brain.

Drink Coffee

Not everyone responds to coffee positively, but if you respond well, enjoy it or are addicted to it (not the greatest thing mind you), then there is some positive news.

Drinking u coffee a day can be neuroprotective (9).

I’m not sure it makes your brain better, but it can help stave off neurodegenerative diseases, which I guess, makes your brain better simply by virtue of not getting worse.

Of course, coffee has adverse effects that are more pronounced in some people, so exercise good judgement when deciding whether coffee “works” for you.

Conclusions

Brain training apps don’t work to make you smarter or improve the structure and function of your brain.

In fact, not much can make you more intelligent, as psychologists have been trying for almost 100 years to do, with very little success.

There are many things you can do to improve your brain health and potentially protect yourself against neurodegenerative diseases.

Like all biological cells, the brain responds to stimuli, and if you use your brain for challenging stimuli, it responds positively, growing new neural connections, increasing in density and improving in function.

Ideally, you will have a coffee before you exercise with your trainer who speaks to you in a new language, followed by an evening meditation before you play your instrument of choice.

 

Nick Efthimiou OsteopathThis blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

Integrative Osteopathy is an osteopathic practice located in the heart of Fitzroy North, within the reputable Healthy Fit gym. With a focus on education, manual therapy, and active rehabilitation, Integrative Osteopathy offers individual solutions to various painful problems.

If you liked this article, and would like to learn more about maintaining brain and body health throughout your life, call 0448 052 754 to have a chat with Nick, or, to make an appointment online, click here.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 



 

 

 

References

(1) Consensus on Brain Training

(2) Putting Brain Training to the Test

(3) Language Learning Makes the Brain Grow

(4) Growth of Brain Areas After Foreign Language Learning

(5) Effects of Music Lessons on Aging Brain

(6) Brain Structures Differ Between Musicians and Non-musicians

(7) Effects of Musical Training on Structural Brain Development

(8) Juggling Enhances Connections in the Brain

(9) Neuroprotective and Anti-inflammatory Properties of Coffee