Tom Jesson is a physiotherapist with a passion for lumbar radicular pain. Last month he recorded a conversation with David Butler talking all things nerve root pain. You can listen to the podcast here. Tom has recently posted a transcript of the conversation, you can read the whole thing here, with some excerpts below.
Tom Jesson: And you said in that book [The Sensitive Nervous System] , a line that stuck with me because I think it’s one of the reasons I’m particularly interested in radicular pain is that they’re particularly frightening thing for the therapists to being encountered with.
David Butler: Yeah, that’s a really, that’s a, that’s a really important thing. And that probably also leads into a lot of my more recent work, which, if I can express it like this, you can talk or provide a context for a patient that takes some of the sensitivity out of the system. So whereas in the old days I might have gone in, and let’s wriggle this, let’s move this, let’s pull this, [now] I’ll sit down and see what other things are going on that we can… Take the sensitivity out of the system and you know, and with our knowledge of how quickly that can happen, whether that’s neuro chemistry changes or even ion channel changes. Perhaps the education paths become important…
TJ: Yeah, I’ve recently been working in a persistent pain service and found that a lot of people with nerve root pain can have been through many years of that pain and seen many clinicians without ever kind of establishing an understanding of what’s going on in their body. It’s a very weird kind of pain to have and it’s not very intuitive at all for a lay person.
DB: That’s correct. Yeah, I’m right with you there, the the assessment of it and it and even without going into the fancy scans and stuff and all of their false errors and the like you know the top quality of high quality neurological assessment has to be done. I think a high quality physical assessment you got to be you know, take backs back into extension and see what sort of pinch or see what sort of shift back the root’s got. High quality neurodynamic evaluation as well too. And also very high quality subjective assessment. To be aware of the huge variety of symptoms…
TJ: I think the temptation with nerve pain sometimes and I’ve definitely fallen into it is to feel like it’s more… I don’t know, I think we’re used to kind of drawing in all the various systems of the body and all the various psychosocial factors to understand chronic low back pain, but often the temptation with nerve pain is to feel like they don’t apply somehow?
DB: Yeah, I think… ‘it’s in the root, it’s away from the brain, it’s something distinct’. And that’s a critical point. I mean, you know, you would find plenty of evidence that the moment you have some sort of change, compromise, or whatever the dorsal horn sort of representation will just flare. And of course, you know, the body’s an organ, it goes right through the system. And those stories that you tell there, they’ve always been out there but I reckon a lot of people haven’t told us that because it’s too weird for them or therapists haven’t really delved in and encouraged them to tell those stories that we now know are absolutely explainable and understandable. And, you know, that’s treatable as well too. Highly treatable.
Even in that state there’s still the for me a place for what I call ‘mechanical permissibility’: providing, where we can, optimal mechanical permissibility of the nerve root and nerve complex and around it, in simple language, to to give any production of stress chemicals less chance to act upon an area, if that make sense? So in that, I’m still I’m still gonna have a lot of talking, education, movement, graded stuff. And of course, the nervous system lends itself to graded movement beautifully. But I’m still there. It’s a simple thing, I remember as an undergraduate about 100 years ago, an old neurosurgeon coming in to talk to us at physio school and he was talking about nerves and he looked at the group and he said, “somehow you lot have to let a bit of air in there, into those nerves; give it a bit of oxygen.” Whether it’s moving change posture regularly… And I’ve always taken that.
TJ: The quote from Romberg, the neurosurgeon [sic – he was a neurologist], that “Pain is the prayer of a nerve for healthy blood.”
DB: Yeah, exactly. That’s a lovely one, isn’t it? And yeah, and of course I think that the nervous system takes 25, 30% of every bit of oxygen and every heartbeat so yeah give back that permissibility. And then of course we’ve got the immune system. I thought Tom I knew everything and then I thought “Oh, shit, we’ve got to learn about the immune system!” And in retrospect how could we have forgotten? How could we have forgotten that? That it is so important. What is it, a trillion cells in our nervous system and the majority are immune, immune reactive cells. But of course that that’s allowed us to talk to people about why it might flare up when you are anxious, or, you know, the latency that the immune system allows, why you might do something and then it sort of buzzes two weeks or even sort of a year or so later. And the other thing I tell is, this is going back to the mechanical thinking you can mechanically actually mobilize the immune cells within the nervous system. So you know, here we are on the edge of science here, but of course, you know, Schwann cells. We haven’t got any Schwann cells in the roots, but but in nerves and elsewhere, you know, they need to be actually moved. Complexes of glial cells become stiff too so they… it’s all movement you know, and of course the nerve root gets half its nutrition from CSF so whole body movement comes into play comes into play really nicely. I’m not sounding too wah-wah am I, for you Tom?
TJ: I did I think I would [sic] people would be upset if we didn’t touch on it because I watched your I want to say “Le Pub Scientifique?” Which was good by the way. Although, you kept you kept your clothes on for *this* chat so I don’t get what’s missing here! In it you mentioned it a little bit and I wonder if you could just tell me or you know, tell the listeners if anyone’s listening to this what’s next for Explain Pain.
DB: The Explain Pain world is moving really quickly here. Just briefly, it’s moving in a couple of directions. Just to mention two of them probably the major shift that’s happening in our writing, thinking and research is what we call the integration of the Learn to Learn strategies. So that’s sort of based on the notion, or not the notion, the knowledge that we know that most people including university students have never been taught how to learn. So who are we to teach somebody about pain when our own learning systems are probably flawed? So we went back and now integrate learning strategies, subtly, but sometimes overtly into Explain Pain, research and now into the clinic. So that’s the first thing.
The other thing is Explain Pain thinking, linked to DIMs and SIMs and whatever, now moving into other areas, areas of breathlessness of post traumatic stress disorder, fatigue, and other areas because these states are really not much different to pain they’re all productions, are perturbations, of homeostatic systems, of the nervous system, in response to injury, need, threat, curiosity, whenever. We – and I say we, that’s the noi group, that’s my colleague, Lorimer Moseley and others – were quite slow in doing this. And, for example, we’re moving into some pretty sort of much deeper explanation with knee osteoarthritis. What we like to do is, we like to get a PhD student along at the same time, they’re researching, we’re making sure it’s really valid before we unleash these concepts on the unsuspecting world. But you know to me, Tom, I’ve always said, increasingly, I’m an educationalist. Now I’m loving storytelling. I’ve always believed, as I’ve said, knowledge is the greatest energy resource we have on earth. And we certainly need that now, we certainly need to teach people to, to think critically. And I think we can do that in health, which has an effect on on the whole world as well..
Thanks to Tom and David for a great conversation