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  • Preventing opioid-induced nausea and vomiting: Rest your head and close your eyes?

    Nausea during remifentanil administration was triggered by movement and avoided by rest in all subjects independently of visual input. This suggests that vision is not the major cause for an inter-sensory mismatch with semicircular canal input during head motion.

    Remifentanil reversibly affects vestibulo-ocular reflex function, as measured by the VOR gain of the horizontal semicircular canals [9,10]. This altered information could clash with neck proprioception or other vestibular sensory information. An intra-vestibular mismatch between reduced horizontal semicircular canals [9] and not accordingly altered otolith signals seems likely. Such an intra-vestibular mismatch is acknowledged as a causative factor for seasickness (for review, see Bertolini&Straumann, 2016 [16]) and also seems to provoke space sickness where altered otolith signals in weightlessness clash with regular semicircular canal input.
    Last edited by Jo Bowyer; Yesterday, 05:25 PM.
    Jo Bowyer
    Chartered Physiotherapist Registered Osteopath.
    "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi


    • Is the headache in patients with vestibular migraine attenuated by vestibular rehabilitation?

      Background: Vestibular rehabilitation is the most effective treatment for dizziness due to vestibular dysfunction. Given the biological relationship between vestibular symptoms and headache, headache in patients with vestibular migraine (VM) could be improved by vestibular rehabilitation that leads to the improvement of dizziness. This study aimed to compare the effects of vestibular rehabilitation on headache and other outcomes relating to dizziness, and the psychological factors in patients with VM patients, patients with dizziness and tension-type headache, and patients without headache.
      Methods: Our participants included 251 patients with dizziness comprising 28 patients with VM, 79 patients with tension-type headache, and 144 patients without headache. Participants were hospitalized for 5 days and taught to conduct a vestibular rehabilitation program. They were assessed using the Dizziness Handicap Inventory (DHI), Headache Impact Test (HIT-6), Hospital Anxiety and Depression Scale (HADS), and Somatosensory Catastrophizing Scale (SCSS), and underwent center of gravity fluctuation measurement as an objective dizziness severity index before, 1 month after, and 4 months after their hospitalization.
      Results: The VM and tension-type headache groups demonstrated a significant improvement in the HIT-6 score with improvement of the DHI, HADS, SCSS, and a part of the objective dizziness index that also shown in patients without headache following vestibular rehabilitation. The change in HIT-6 during rehabilitation in the VM group was positively correlated with changes in the DHI and anxiety in the HADS. Changes in the HIT-6 in tension-type headache group positively correlated with changes in anxiety and SCSS.
      Conclusions: Vestibular rehabilitation contributed to improvement of headache both in patients with VM and patients with dizziness and tension-type headache, in addition to improvement of dizziness and psychological factors. Improvement in dizziness following vestibular rehabilitation could be associated with the improvement of headache more prominently in VM compared with comorbid tension-type headache.
      Keywords: Vestibular Diseases, Migraine Disorders, Rehabilitation, Treatment, vestibular rehablitation, headache impact, dizziness handicap

      I find this interesting in that I have rarely been able to affect the nature of migraine pain although patients have found reduction in vestibular symptoms and frequency of migraine episodes helpful.
      Jo Bowyer
      Chartered Physiotherapist Registered Osteopath.
      "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi


      • Dynamic Shaping of the Defensive Peripersonal Space through Predictive Motor Mechanisms: When the “Near” Becomes “Far”


        The hand blink reflex is a subcortical defensive response, known to dramatically increase when the stimulated hand is statically positioned inside the defensive peripersonal space (DPPS) of the face. Here, we tested in a group of healthy human subjects the hand blink reflex in dynamic conditions, investigating whether the direction of the hand movements (up-to/down-from the face) could modulate it. We found that, on equal hand position, the response enhancement was present only when the hand approached to (and not receded from) the DPPS of the face. This means that, when the hand is close to the face but the subject is planning to move the hand down, the predictive motor system can anticipate the consequence of the movement: the “near” becomes “far.” We found similar results both in passive movement condition, when only afferent (visual and proprioceptive) information can be used to estimate the final state of the system, and in motor imagery task, when only efferent (intentional) information is available to predict the consequences of the movement. All these findings provide evidence that the DPPS is dynamically shaped by predictive mechanisms run by the motor system and based on the integration of feedforward and sensory feedback signals.

        SIGNIFICANCE STATEMENT The defensive peripersonal space (DPPS) has a crucial role for survival, and its modulation is fundamental when we interact with the environment, as when we move our arms. Here, we focused on a defensive response, the hand blink reflex, known to increase when a static hand is stimulated inside the DPPS of the face. We tested the hand blink reflex in dynamic conditions (voluntary, passive, and imagined movements) and we found that, on equal hand position, the response enhancement was present only when the hand approached to (and not receded from) the DPPS of the face. This suggests that, through the integration of efferent and afferent signals, the safety boundary around the body is continuously shaped by the predictive motor system.
        via @neuroconscience
        Jo Bowyer
        Chartered Physiotherapist Registered Osteopath.
        "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi


        • Stories from neuroanatomy: ascending thoracic nerve roots

          Jo Bowyer
          Chartered Physiotherapist Registered Osteopath.
          "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi


          • Posts awaiting moderation.............................

            won't stop me reading

            Update 24.03.17

            It has happened in the past that a user name, rather than posts from certain journals has triggered automatic moderation. I have had nothing back via the Contact Us button. Having lost a few posts which makes it difficult to curate subject threads, I won't be posting again until I know more.


            A fortnight down the line Contact Us has not contacted me, but some of you have been in contact asking if I have been "blocked". The answer is that I can't be sure, but I don't think so.

            I haven't made any new posts as these seemed to trigger automatic moderation especially if I posted a paper.

            During the last couple of days, I have had no trouble editing my existing posts and experimentally posting relevant papers into them and I plan to continue this over the few months it will take to read the threads, to which I haven't yet got around .

            There is no Plan B.

            Twitter doesn't appeal, and I have no current plans for a blog. I hope to do a bit more on iCSP once they have done the upgrade.

            I am very touched that this thread has had over 2,700 views in the last two weeks and that my other threads continue to be read and used for CPD. I have made friends here and had the enormous pleasure of meeting some of you.

            I doubt that I will find a better user interface anywhere and would encourage lurkers to give it a go, just for the pleasure of finding out what you can do with it.

            There may be one near you.

            On 22 April the London March for Science will go forward from the Science Museum to Parliament Square. Scientists and science supporters will march in solidarity with colleagues in the US and over 420 locations around the world as a massive, diverse, non-partisan, and celebratory demonstration of public support for science that highlights challenges facing the scientific community and will act as a catalyst for ongoing public action around specific issues.
            ALL ARE WELCOME!
            On eve of science march, planners look ahead

            As the 22 April March for Science in Washington, D.C., and some 400 sister marches around the world approach, march organizers are already looking toward next steps. For almost 3 months, a team of volunteer coordinators, most of whom have yet to meet in person, have been working around the clock to inspire supporters, negotiate partnerships with dozens of science groups, and raise enough money to pull off their upcoming event. March organizers admit they don't know what they'll find at the end of their exhausting sprint. They are uncertain of how many marchers will appear, and how the demonstrations will be received. But they see march day as a beginning, not an end, as March for Science tries to pivot from being an event organizer to becoming a lasting force for science advocacy.

            Marchers around the world tell us why they're taking to the streets for science


            Update 13/04/2017


            Dr Francisco Diego
            Astronomer and science educator at University College London
            “Science shows that humanity had a single origin in central Africa not that long ago, that genetically, we all are almost identical.
            Science shows that our environment is a cosmic miracle, possibly unique.
            Science discoveries unify humanity and empower us to manage and preserve our fragile environmental paradise.
            I am marching because we must work hard to make science a main topic at all levels of education and a major component of modern global culture, for a brigher future, for a better world for all.”
            Update 19/04/2017

            Just got back from the 12,000 strong London march which was good natured and diverse, lots of Americans and Europeans and a gratifyingly high turnout of children and teens. Peter Capaldi (Dr Who) turned up.

            I didn't meet any physios. Several of the scientists I spoke to had come straight from all nighters in their labs, It made me feel lucky that it's decades since I had to be up all night seeing to patients on three sites and then put in a full day afterwards.

            I am the one with grey hair and matching fishing vest.

            Update 22/04/2017

            Some post #MarchforScience thoughts.......APRIL 23, 2017 NEUROCONSCIENCE


            Update 23/04/2017

            ‘Boffins and their VERY academic chants’: How the media covered the March for Science


            “What do we want? Evidence-based policy. When do we want it? After peer review.” That slogan, heard in many cities on Saturday, was a source of amusement for the U.K. tabloid The Daily Mail. “Boffins’ VERY academic chant as Doctor Who joins thousands protesting against Brexit during global March for Science,” the paper headlined its story about the march.

            But U.K. march organizers had little reason to complain: The Daily Mail, not known for its interest in science, reported extensively on the marchers’ motivations and interspersed its 1500-word story with 27 big photos. It helpfully explained the sign “No Taxation Without Taxonomy” to its readers: “Taxonomy is the science of classifying animals, plants and other organisms.”

            Largely unknown until a few weeks ago, the March for Science suddenly became a global news story the past weekend. Coverage was most extensive in the United States, which also had the most marchers. Major news outlets including ABC, CNN, The New York Times (NYT), and The Washington Post covered marches in Washington, D.C., and other cities with an abundance of op-eds and news pieces throughout the weekend.

            Scientists protest in Parliament Square, central London, during the March for Science. After speeches, the rally ended with a rendition of Monty Python's Galaxy Song

            Update 26/04/2017


            Hurrah! I seem to have shaken off the ModBot

            Hello Jo Bowyer it appears that you have not posted on our forums in several weeks, why not take a few moments to ask a question, help provide a solution or just engage in a conversation with another member in any one of our forums?
            Hello ModBot,

            How kind of you to get in touch, thankyou for the above notice.

            If you would care to peruse the top of this post, it may become clear to you why I appear not to have posted on your forums over the last few weeks.

            I have several posts on machine learning you might like, at least one of which has been added as an edit within the last month

            As for asking questions, neither you or Contact Us appear to be able to provide answers. I hope that the many papers and the few bits of script I have added might help to provide solutions for those who want them and I have been engaging in conversations with other members (and guests), but not on the forums.

            If ever you are in London, we should meet up for a plate of data and some sewing machine oil.

            Machine learning is important, but some AIs just want to have fun


            Set to the pulsing, ethereal sounds of Steve Reich’s minimalist score Music for 18 Musicians (1974-6), this video by the French computer programmer Damien Henry is a clever visual demonstration of machine learning – a term coined by the US computer scientist Arthur Samuel (1901-1990) to describe an algorithm that gives computers the ‘ability to learn without being explicitly programmed’.

            Using several videos recorded from windows during train rides, Henry trained an algorithm to predict what the next frame of a train ride should look like. Then, starting with a single frame chosen by Henry, the algorithm generated, to the best of its ability, scenes from an hour-long train ride, improving itself roughly every 20 seconds. The resulting video demonstrates machine learning in action through a dreamy, impressionistic take on the experience of observing flowing, fleeting landscapes passing by. Though machine-learning algorithms are used more practically in applications where adaptability is greatly advantageous, such as anti-virus software and driverless cars, there’s an undeniable charm to seeing a computer engage in a version of one of our more ephemeral but corporeal experiences – the train ride.
            For you, dear ModBot, an hour long train journey generated by one of your friends and set to music by Steve Reich. It's fab! If you are still sitting on the papers I posted, how about putting them up?, and by the way what is your bias against BMC Musculoskeletal Disorders? It's one of my favourite journals.

            Update 06/06/2017


            Hoping ( but not holding my breath!), that this new paper from The Crick will put a further nail in the coffin of "North American Ectodermalism" and the suppression of debate on this site engendered thereby. I did not become a member of this congregation four years ago in order to sit in a pew.

            A Gene Regulatory Network Balances Neural and Mesoderm Specification during Vertebrate Trunk Development


            •Single-cell RNA-seq reveals a signature of neuromesodermal progenitors
            •In vitro NMPs resemble and differentiate similar to their in vivo counterparts
            •Dual role for retinoic acid signaling in NMP induction and neural differentiation
            •A transcriptional network regulates neural versus mesodermal allocation

            Transcriptional networks, regulated by extracellular signals, control cell fate decisions and determine the size and composition of developing tissues. One example is the network controlling bipotent neuromesodermal progenitors (NMPs) that fuel embryo elongation by generating spinal cord and trunk mesoderm tissue. Here, we use single-cell transcriptomics to identify the molecular signature of NMPs and reverse engineer the mechanism that regulates their differentiation. Together with genetic perturbations, this reveals a transcriptional network that integrates opposing retinoic acid (RA) and Wnt signals to determine the rate at which cells enter and exit the NMP state. RA, produced by newly generated mesodermal cells, provides feedback that initiates NMP generation and induces neural differentiation, thereby coordinating the production of neural and mesodermal tissue. Together, the data define a regulatory network architecture that balances the generation of different cell types from bipotential progenitors in order to facilitate orderly axis elongation.

            Cell fate decisions in developing tissues are made by gene regulatory networks comprising transcription factors and intercellular signals. These networks determine the rate of self-renewal and differentiation to ensure the balanced generation of different cell types and the production of well-proportioned tissues (Stern et al., 2006, Davidson, 2010). The formation of the vertebrate trunk, which extends progressively during embryogenesis, is one example. Successively more posterior neural and paraxial presomitic mesodermal (PSM) cells of the trunk are generated from a bipotential population of cells (Tzouanacou et al., 2009), termed neuromesodermal progenitors (NMPs) at the posterior end of the embryo. Proliferation of NMPs fuels the elongation of axial tissues (Cambray and Wilson, 2002, Cambray and Wilson, 2007, Wilson et al., 2009, Henrique et al., 2015, Neijts et al., 2014, Kimelman, 2016). Hence, the rate at which NMPs are generated, self-renew, and differentiate must be carefully regulated in order to balance the production of different trunk tissues and to prevent the premature or delayed depletion of NMPs that will affect the length of the embryo.

            my bold

            Gene expression rules OK!


            Crossing the Chasm with Dr. Jason Silvernail


            I thoroughly recommend this, it doesn't conflict with his original crossing of the chasm, but shows his evolution between then and 2015. He illustrates this with a slide of a chasm that could be traversed by means of a simple bridge, followed by one with undergrowth, trees and jagged rock faces, which better depicts the navigational skills that might be required by someone standing on the edge preparing to cross.

            His updated version, is in my opinion, less likely to encourage susceptible readers to become enmired in memes and unthinking discipleship.

            He advocates ongoing science based study, lots of it, along with the ability to cite references from memory when defending our practice during discussion.


            Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews



            Clinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules (CDR] for the identification of the most common patho-anatomical disorders in the lumbar spine; i.e. intervertebral discs, sacroiliac joints, facet joints, bone, muscles, nerve roots, muscles, peripheral nerve tissue, and central nervous system sensitization.

            A sensitive electronic search strategy using MEDLINE, EMBASE and CINAHL databases was combined with hand searching and citation tracking to identify eligible studies. Criteria for inclusion were: persons with low back pain with or without related leg symptoms, history or physical examination findings suitable for use in primary care, comparison with acceptable reference standards, and statistical reporting permitting calculation of diagnostic value. Quality assessments were made independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies tool. Clinical examination findings that were investigated by at least two studies were included and results that met our predefined threshold of positive likelihood ratio???2 or negative likelihood ratio???0.5 were considered for the CDR.

            Sixty-four studies satisfied our eligible criteria. We were able to construct promising CDRs for symptomatic intervertebral disc, sacroiliac joint, spondylolisthesis, disc herniation with nerve root involvement, and spinal stenosis. Single clinical test appear not to be as useful as clusters of tests that are more closely in line with clinical decision making.

            This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.


            Diagnostic accuracy Sensitivity and specificity Clinical examination Low back pain classification Clinical decision making

            Identifying diagnostic, prognostic and treatment orientated subgroups of patients with low back pain (LBP] has been on the research agenda for many years [1, 2]. Diagnostic reasoning with a structural/pathoanatomical focus is common among clinicians [3], and it is regarded as an essential component of the biopsychosocial model [4, 5, 6]. Within this model, emphasis has been on the role of psychosocial considerations and how these factors can interfere with recovery. Indeed, there is good quality evidence for the predictive value of a set of psychosocial factors for poorer outcome in patients with LBP [7, 8]. These factors are multifactorial, interrelated, and only weakly associated to the development and prognosis of LBP [9], which might be one of the explanations why effects of treatments targeting those risk factors has been reported to be small, mostly short term, and there was little evidence that psychosocial treatments were superior to other active treatments [7, 10].

            Maybe it is time to swing the pendulum towards the “bio” in the biopsychosocial model. There are many examples in medicine where the pathology has been identified prior to any effective treatments being developed making it an ongoing challenge to generate new diagnostic knowledge on which to base more effective treatment strategies in the future. Alongside clinicians, many researchers within the field of LBP feel that choosing the most effective treatment for the individual patient is not possible without better understanding of the biological component of the biopsychosocial model [4].

            Good grief!!

            The last six papers I tried to post from this journal into new posts were intercepted by the ModBot and subsequently lost. Posting into existing posts works .

            How can latent trajectories of back pain be translated into defined subgroups?



            Similar types of trajectory patterns have been identified by Latent Class Analyses (LCA) across multiple low back pain (LBP) cohorts, but these patterns are impractical to apply to new cohorts or individual patients. It would be useful to be able to identify trajectory subgroups from descriptive definitions, as a way to apply the same definitions of mutually exclusive subgroups across populations. In this study, we investigated if the course trajectories of two LBP cohorts fitted with previously suggested trajectory subgroup definitions, how distinctly different these subgroups were, and if the subgroup definitions matched with LCA-derived patterns.

            Weekly measures of LBP intensity and frequency during 1 year were available from two clinical cohorts. We applied definitions of 16 possible trajectory subgroups to these observations and calculated the prevalence of the subgroups. The probability of belonging to each of eight LCA-derived patterns was determined within each subgroup. LBP intensity and frequency were described within subgroups and the subgroups of ‘fluctuating’ and ‘episodic’ LBP were compared on clinical characteristics.

            All of 1077 observed trajectories fitted with the defined subgroups. ‘Severe episodic LBP’ was the most frequent pattern in both cohorts and ‘ongoing LBP’ was almost non-existing. There was a clear relationship between the defined trajectory subgroups and LCA-derived trajectory patterns, as in most subgroups, all patients had high probabilities of belonging to only one or two of the LCA patterns. The characteristics of the six defined subgroups with minor LBP were very similar. ‘Fluctuating LBP’ subgroups were significantly more distressed, had more intense leg pain, higher levels of activity limitation, and more negative expectations about future LBP than ‘episodic LBP’ subgroups.

            Previously suggested definitions of LBP trajectory subgroups could be readily applied to patients’ observed data resulting in subgroups that matched well with LCA-derived trajectory patterns. We suggest that the number of trajectory subgroups can be reduced by merging some subgroups with minor LBP. Stable levels of LBP were almost not observed and we suggest that minor fluctuations in pain intensity might be conceptualised as ‘ongoing LBP’. Lastly, we found clear support for distinguishing between fluctuating and episodic LBP.

            Classification Low back pain Subgroups Trajectory

            Update 04/07/2017

            How clinicians analyze movement quality in patients with non-specific low back pain: a cross-sectional survey study with Dutch allied health care professionals



            Observation of movement quality (MQ) is an indelible element in the process of clinical reasoning for patients with non-specific low back pain (NS-LBP). However, the observation and evaluation of MQ in common daily activities are not standardized within allied health care. This study aims to describe how Dutch allied health care professionals (AHCPs) observe and assess MQ in patients with NS-LBP and whether AHCPs feel the need to have a specific outcome measure for assessing MQ in patients with NS-LBP.

            In this cross-sectional digital survey study, Dutch primary care AHCPs (n = 114) answered one open and three closed questions about MQ in NS-LBP management. Qualitative and quantitative analyses were applied.

            Qualitative analyses of the answers to the open questions revealed four main themes: 1) movement pattern features, 2) motor control features, 3) environmental influences and 4) non-verbal expressions of pain and exertion. Quantitative analyses clearly indicated that AHCPs observe MQ in the diagnostic (92%), therapeutic (91%) and evaluation phases (86%), that they do not apply any objective measurement of MQ and that 63% of the AHCPs consider it important to have a specific outcome measure to assess MQ. The AHCPs expressed added benefits and critical notes regarding clinical reasoning and quality of care.

            AHCPs recognize the importance of observing MQ in the assessment and management of LBP in a standardized way. However, there is no consensus amongst AHCPs how MQ should be standardized. Prior to standardization, it will be important to develop a theoretical framework to determine which observable and measurable dimensions of MQ are most valid and relevant for patients with NS-LBP to include in the assessment.

            Assessment Allied health care professionals Low back pain Movement quality

            Update 05/07/2017


            London Moonwalk

            I caught the finishing stages of the Moonwalk as I drove into London early this morning. It is a power walk over marathon distance, or half for those who wish, which starts and finishes on Clapham Common and is in aid of breast cancer charities. There have always been men volunteering and stewarding, but this year there seemed to be a lot more walking.

            I know very few men who haven't tried on a bra and it seems logical that some would jump at the chance to walk 26.2 miles wearing one, especially if they have friends and family who have been affected by breast cancer.

            Breast cancer in men is rare, but it happens. So far, during a forty year (and counting) career, I have had three male patients who gave a history of breast cancer, one of whom I treated for post op sequelae.

            It's tough, not least because those who see a chap sitting in the waiting area of a breast clinic, assume that he is there for a female family member and not for himself.

            Signs and symptoms of breast cancer in men


            Solution to the Grandfather Paradox


            Update 19/05/2017


            Manchester Arena

            Some of us have and others have yet to deal with the aftermath of acts of atrocity . It is unbearably sad, especially when children and young people are involved. Ariana Grande who gave the performance is still in her early twenties.

            Our threat level in the UK is now critical.

            Who is afraid of ISIS? ISIS anxiety and its correlates



            Islamic State of Iraq and the Levant (ISIS) is a relatively small organization, yet it wields its terror and media campaigns efficiently. Its presence has altered security measures in many western counties. In the current study, I assess anxiety of the ISIS threat and its correlates in a convenience sample of 1,007 adult Israelis (mean age = 29.61, SD = 7.16). Findings show that being female, a lower socioeconomic status, and having elevated post-traumatic stress disorder (PTSD) symptom levels were all associated with ISIS anxiety. Likewise, exposure to ISIS media, as well as having low resilience, was also correlated with ISIS anxiety. The correlations between ISIS anxiety on the one hand and ISIS media exposure, PTSD symptoms, and resilience on the other hand remained significant even after controlling for general anxiety symptoms. Finally, the PTSD- ISIS anxiety relationship was especially pronounced when resources (resilience/optimism) were low. This critical interaction also remained significant after controlling for general anxiety. Theoretical and practical ramifications of ISIS anxiety are discussed. Both resources for addressing current tasks (resilience), as well as those aimed at future outcomes (optimism), may be required for addressing ISIS anxiety, especially when PTSD symptoms are high.
            I am noticing very little ISIS anxiety in comparison to the extreme fear felt by some in London during the Irish "troubles".

            Update 10/07/2017


            Mancunians are special, they are a close knit community and they have pulled together in dealing with what is happening as well as offering numerous random acts of kindness to victims, families and the emergency services.

            I'm not saying that Londoners don't step up in similar situations, but there is more rush and bustle and possibly more who walk by on the other side rather than getting involved.


            Our threat level is now severe, which means that attack is highly likely rather than immanent, this is due to the fact that eleven people are now in custody. I know some who prefer to avoid events, crowds and use of public transport, but most prefer to go about their daily business with a heightened sense of awareness.

            Can terrorists be deradicalized?


            Investigators are still piecing together exactly what drove Salman Abedi, the suspected assailant in the recent concert bombing in Manchester, U.K., to kill 22 people and wound dozens more, but early indications suggest he had become a radicalized jihadist. How formerly harmless members of society go on to embrace violent extremist ideologies is a looming question in the world of counterterrorism, yet increasingly so is the problem of “deradicalization,” or convincing people to abandon an extremist mindset.

            Worldwide, hundreds of deradicalization programs have sprung up. They typically consist of trained counselors either convincing the extremists their religious views aren’t founded in proper theology, treating the subject’s extremism as a mental health issue, or trying to nudge the extremist’s value system away from violence.

            Despite their ubiquity, there’s been precious little effort spent evaluating whether these programs actually work,

            Strongly held beliefs are wired into neural networks. I keep my treatment sessions short in order to focus fully on the patient's verbal and physical response to whatever is said and done during the encounter. I pay particular attention to autonomic signs.

            Update 29/05/2017

            Ariana Grande is returning to Manchester for her One Love Manchester Benefit Concert.

            Read more:

            Giving practical help and taking the edge off money worries makes a huge difference.

            Update 31/05/2017


            End-times for humanity


            What contemporary post-apocalyptic culture fears isn’t the end of ‘the world’ so much as the end of ‘a world’ – the rich, white, leisured, affluent one. Western lifestyles are reliant on what the French philosopher Bruno Latour has referred to as a ‘slowly built set of irreversibilities’, requiring the rest of the world to live in conditions that ‘humanity’ regards as unliveable. And nothing could be more precarious than a species that contracts itself to a small portion of the Earth, draws its resources from elsewhere, transfers its waste and violence, and then declares that its mode of existence is humanity as such.

            To define humanity as such by this specific form of humanity is to see the end of that humanity as the end of the world. If everything that defines ‘us’ relies upon such a complex, exploitative and appropriative mode of existence, then of course any diminution of this hyper-humanity is deemed to be an apocalyptic event. ‘We’ have lost our world of security, we seem to be telling ourselves, and will soon be living like all those peoples on whom we have relied to bear the true cost of what it means for ‘us’ to be ‘human’.


            Chronic pain may be due to receptors that hide within nerve cells


            New York, NY (May 31, 2017) -- A study led by Columbia University Medical Center (CUMC) has shown that chronic pain may occur when pain receptors migrate from the nerve cell's surface to the cell's inner chambers, out of the reach of current pain medications. The discovery, in rodents, may lead to the development of a new class of medications for chronic pain that is more potent and less prone to side effects than currently available pain treatments.

            The study was published online today in the journal Science Translational Medicine.

            An estimated 20 percent of people have chronic pain at some point. Currently available therapies for chronic pain include opioids and nonsteroidal anti-inflammatory drugs (NSAIDs). Both have drawbacks: opioids are addictive and can cause constipation and respiratory distress, while frequent use of NSAIDs can cause stomach ulcers and kidney damage.

            "Opioids and NSAIDs do not work for everyone and have unacceptable side effects, particularly when used over a long period of time," said Nigel Bunnett, PhD, professor of surgery and pharmacology at CUMC. "However, previous efforts to develop more effective analgesics have been stalled by our limited understanding of the mechanisms that allow nerves to sense and transmit pain signals."

            Some pain medications work by targeting G protein-coupled receptors (GPCRs) on the cell surface. GPCRs are implicated in nearly all biological processes, including our brain's ability to sense and transmit pain signals. Activation of opioid receptors--one type of GPCR--blocks pain.

            Another type, the neurokinin 1 receptor (NK1R), causes pain and inflammation when activated. However, most clinical trials of compounds targeting NK1R have been unsuccessful.

            In the current series of experiments, Dr. Bunnett and colleagues discovered that NK1R, when stimulated by pain, quickly moves from the cell surface to endosomes--intracellular compartments--within nerve cells. Once inside the endosomal network, NK1R continues to function for a prolonged period, causing pain and inflammation.

            Additional experiments revealed that attaching a lipid (fat molecule) that can cross the cell membrane to compounds that block NK1R provided potent, durable pain relief in rodents.

            "From these experiments, we have demonstrated that designing NK1R inhibitors that are capable of reaching the endosomal network within nerve cells may provide much longer-lasting pain relief than currently available analgesics," said Dr. Bunnett. "More than a third of all currently available drugs act on GPCRs in some way. We think that modification of many existing compounds, as we did with NK1R inhibitors, may have the potential to enhance the effectiveness of many different classes of medications."


            London Bridge and Borough Market.

            7 dead, 48 injured and 3 assailants shot dead. This was a low tech attack with similarities to the Westminster incident and therefore much more difficult to predict. The police and emergency services did an excellent job as did members of the public who assisted the injured. We have a general election coming up within days, but today politicians from most parties are singing from the same hymn sheet. London is subdued today, no one I have seen in clinic so far today has mentioned it.......they don't need to. Currently, I am hearing police sirens and there are more helicopters than usual.

            BBC...London attack: 12 arrested in Barking after van and knife incidents


            Are health professionals parasites?


            Generous health insurance plans encourage overtreatment, but may not improve health


            Offering comprehensive health insurance plans with low deductibles and co-pay in exchange for higher annual premiums seems like a good value for the risk averse, and a profitable product for insurance companies. But according to a study, such plans can encourage individuals with chronic conditions to turn to needlessly expensive treatments that have little impact on their health outcomes.
            I see very few insurance patients, but have noticed a tendency in some of those I do see to expect me to provide the number of sessions allowed by the claims manager. I am not prepared to go along with this, it smacks of entertainment.

            Update 06/06/2017

            Blue Brain Team Discovers a Multi-Dimensional Universe in Brain Networks


            For most people, it is a stretch of the imagination to understand the world in four dimensions but a new study has discovered structures in the brain with up to eleven dimensions – ground-breaking work that is beginning to reveal the brain’s deepest architectural secrets.

            Using algebraic topology in a way that it has never been used before in neuroscience, a team from the Blue Brain Project has uncovered a universe of multi-dimensional geometrical structures and spaces within the networks of the brain.

            The research, published today in Frontiers in Computational Neuroscience, shows that these structures arise when a group of neurons forms a clique: each neuron connects to every other neuron in the group in a very specific way that generates a precise geometric object. The more neurons there are in a clique, the higher the dimension of the geometric object.
            If 4D worlds stretch our imagination, worlds with 5, 6 or more dimensions are too complex for most of us to comprehend. This is where algebraic topology comes in: a branch of mathematics that can describe systems with any number of dimensions. The mathematicians who brought algebraic topology to the study of brain networks in the Blue Brain Project were Kathryn Hess from EPFL and Ran Levi from Aberdeen University.

            “Algebraic topology is like a telescope and microscope at the same time. It can zoom into networks to find hidden structures – the trees in the forest – and see the empty spaces – the clearings – all at the same time,” explains Hess.

            In 2015, Blue Brain published the first digital copy of a piece of the neocortex – the most evolved part of the brain and the seat of our sensations, actions, and consciousness. In this latest research, using algebraic topology, multiple tests were performed on the virtual brain tissue to show that the multi-dimensional brain structures discovered could never be produced by chance. Experiments were then performed on real brain tissue in the Blue Brain’s wet lab in Lausanne confirming that the earlier discoveries in the virtual tissue are biologically relevant and also suggesting that the brain constantly rewires during development to build a network with as many high-dimensional structures as possible.

            When the researchers presented the virtual brain tissue with a stimulus, cliques of progressively higher dimensions assembled momentarily to enclose high-dimensional holes, that the researchers refer to as cavities. “The appearance of high-dimensional cavities when the brain is processing information means that the neurons in the network react to stimuli in an extremely organized manner,” says Levi. “It is as if the brain reacts to a stimulus by building then razing a tower of multi-dimensional blocks, starting with rods (1D), then planks (2D), then cubes (3D), and then more complex geometries with 4D, 5D, etc. The progression of activity through the brain resembles a multi-dimensional sandcastle that materializes out of the sand and then disintegrates.”

            The big question these researchers are asking now is whether the intricacy of tasks we can perform depends on the complexity of the multi-dimensional “sandcastles” the brain can build. Neuroscience has also been struggling to find where the brain stores its memories. “They may be ‘hiding’ in high-dimensional cavities,” Markram speculates.
            O...M...G :clap1:

            On the other hand......

            Weird Animal Brain: Sea Squirt


            Update 13/06/2017


            Medical disrespect

            Bullying doctors are not just unpleasant, they are dangerous. Can we change the culture of intimidation in our hospitals?

            I have been on the receiving end and I have dished it out, on the basis that the patient is at the centre of everything we do. 25 or so years ago I decided that it was best to be self employed after a threat of disciplinary proceedures directed at me, for explaining to a member of the admin staff (in graphic detail) the clinical effects on a real person.....of her repeated errors and failure to follow up. She saw what she did as shifting bits of information around. My line manager was more afraid of flack from Human Resources, than possible malpractice. It was clear to me that my place was not within large, or even medium sized organisations.

            The buck stops here. I am always on call so to speak, but I no longer have duodenal ulcers.

            A surprisingly simple explanation for the shape of bird eggs



            Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence



            Background & aims

            Musculoskeletal pain, the most common cause of disability globally, is most frequently managed in primary care. People with musculoskeletal pain in different body regions share similar characteristics, prognosis, and may respond to similar treatments. This overview aims to summarise current best evidence on currently available treatment options for the five most common musculoskeletal pain presentations (back, neck, shoulder, knee and multi-site pain) in primary care.


            A systematic search was conducted. Initial searches identified clinical guidelines, clinical pathways and systematic reviews. Additional searches found recently published trials and those addressing gaps in the evidence base. Data on study populations, interventions, and outcomes of intervention on pain and function were extracted. Quality of systematic reviews was assessed using AMSTAR, and strength of evidence rated using a modified GRADE approach.


            Moderate to strong evidence suggests that exercise therapy and psychosocial interventions are effective for relieving pain and improving function for musculoskeletal pain. NSAIDs and opioids reduce pain in the short-term, but the effect size is modest and the potential for adverse effects need careful consideration. Corticosteroid injections were found to be beneficial for short-term pain relief among patients with knee and shoulder pain. However, current evidence remains equivocal on optimal dose, intensity and frequency, or mode of application for most treatment options.


            This review presents a comprehensive summary and critical assessment of current evidence for the treatment of pain presentations in primary care. The evidence synthesis of interventions for common musculoskeletal pain presentations shows moderate-strong evidence for exercise therapy and psychosocial interventions, with short-term benefits only from pharmacological treatments. Future research into optimal dose and application of the most promising treatments is needed.
            One of my local clinical commissioning groups has PROMs which show that allowing patients a choice of intervention is the way forward.

            A classic film on communication finds renewed meaning in the age of memes and emojis


            From personal email and texts to Facebook, Twitter and the like, the last several decades have seen an unprecedented influx of new means of human-to-human communication. So it’s a testament to the work of the US mathematician and ‘father of information theory’ Claude Shannon (1916-2001) that his model of communication, laid out in his landmark book A Mathematical Theory of Communication (1949), is still so broadly applicable.

            Working from Shannon’s book, in 1953 the iconic husband-and-wife design team Ray and Charles Eames created the short film A Communications Primer for IBM, intending to ‘interpret and present current ideas on communications theory to architects and planners in an understandable way, and encourage their use as tools in planning and design’. Released at the dawn of the personal computer age, the film’s exploration of symbols, signals and ‘noise’ remains thoroughly – almost stunningly – relevant when viewed some 64 years later.

            I can science better than you…
            By timcocks


            Update 27/06/2017

            How To Practice Placebo-Based Physiotherapy......Chris Worsfold June 29, 2017


            This starts with an account of how Chris dealt with an issue involving one of his children, then segues into an argument for making the most of the placebo effect during our work with patients. On reading it, I reacted as if I had discovered a large clump of coriander in my sandwich

            I'd like to think that there is nothing I do or say that could be construed as placebo.

            But......I am a walking talking placebo, I wear an old fashioned tunic, I have grey hair and look at people over the top of my glasses, I speak with conviction. Many of them can't remember the advice I gave or the movement and loading I prescribed, only the fact that they they feel better for the encounter.

            Update 29/06/2017

            Short-Term Effects of Thoracic Spine Manipulation on the Biomechanical Organisation of Gait Initiation: A Randomized Pilot Study


            Speed performance during gait initiation is known to be dependent on the capacity of the central nervous system to generate efficient anticipatory postural adjustments (APA). According to the posturo-kinetic capacity (PKC) concept, any factor enhancing postural chain mobility and especially spine mobility, may facilitate the development of APA and thus speed performance. “Spinal Manipulative Therapy High-Velocity, Low-Amplitude” (SMT-HVLA) is a healing technique applied to the spine which is routinely used by healthcare practitioners to improve spine mobility. As such, it may have a positive effect on the PKC and therefore facilitate gait initiation. The present study aimed to investigate the short-term effect of thoracic SMT-HVLA on spine mobility, APA and speed performance during gait initiation. Healthy young adults (n = 22) performed a series of gait initiation trials on a force plate before (“pre-manipulation” condition) and after (“post-manipulation” condition) a sham manipulation or an HVLA manipulation applied to the ninth thoracic vertebrae (T9). Participants were randomly assigned to the sham (n = 11) or the HVLA group (n = 11).The spine range of motion (ROM) was assessed in each participant immediately after the sham or HVLA manipulations using inclinometers. The results showed that the maximal thoracic flexion increased in the HVLA group after the manipulation, which was not the case in the sham group. In the HVLA group, results further showed that each of the following gait initiation variables reached a significantly lower mean value in the post-manipulation condition as compared to the pre-manipulation condition: APA duration, peak of anticipatory backward center of pressure displacement, center of gravity velocity at foot-off, mechanical efficiency of APA, peak of center of gravity velocity and step length. In contrast, for the sham group, results showed that none of the gait initiation variables significantly differed between the pre- and post-manipulation conditions. It is concluded that HVLA manipulation applied to T9 has an immediate beneficial effect on spine mobility but a detrimental effect on APA development and speed performance during gait initiation. We suggest that a neural effect induced by SMT-HVLA, possibly mediated by a transient alteration in the early sensory-motor integration, might have masked the potential mechanical benefits associated with increased spine mobility.
            Interesting arguments, along with a reference to my old teacher John Wernham who had fixed ideas with regards to osteopathic biomechanics. Osteopathy spread widely through Europe in the 1980s and claims were made for the efficacy of the approach, which were inevitably met with "Where's your research evidence?". It's good to see that some are prepared to attempt to meet this challenge.

            Update 03/07/2017

            Cardiopulmonary resuscitation – 30:2 or just keep going?


            If it happens while out and about just keep going


            Calling out the bullshit, horseshit… all the shits


            Boyd Cordner has sought treatment from an inner Sydney energy healer – recommended by NSW legend Wayne Pearce – in a desperate bid to prove his fitness for the State of Origin decider.

            Cordner used the session to complement his around-the-clock care from Roosters medical staff, who have worked overtime to help their co-captain be fit for the Suncorp Stadium showdown.

            The straight-laced 25-year-old resorting to alternative healing techniques shows the measures he is prepared to go to in a bid to lead NSW in next Wednesday’s Origin decider, billed as the biggest interstate clash in recent memory

            On Farrow, Cordner said: “He’s just an energy healer and he doesn’t really work on you, but he did some work on Wayne and it helped him. It’s hard to explain. It sounds weird explaining it, but sometimes they touch points and other times they’ll just put their hands above [the affected area].
            Some of my complex patients go to healers. Once they have sufficient understanding of their own amazing neuroendocrineimmune system, they don't feel the need to go off piste, or to see me. Mostly, they keep in touch via email.

            Update 06/07/2017

            Embodied Pain: negotiating action


            We determine our world through the actions we take. Whether from the inside or out, our bodies provide us with the means to actively investigate our environment. This investigation is vital to survival. Active investigation enables us to reduce the uncertainty of the world, accommodate the unexpected, and better predict the consequences of our actions. The significance here is that the traditional boundaries between action and perception are blurred. These ‘embodied’ approaches to experience place the body at the centre of investigation.

            At first glance this may seem intuitive, an unnecessary qualification of experience, particularly when we extend the embodied agenda to investigate the experience of pain, an experience that is fundamentally to do with the body. Yet, as we recently asserted under the Embodied Pain Framework (Tabor et al, 2017), simply recognising the body as ‘real and substantial’ (Hohwy, 2013) does not go far enough in promoting the role of the body in experience.

            Modern, neuroscientific approaches to perceptual experience have turned traditional conceptions quite literally on their head. Rather than experience being determined by the passive receipt of information, experience is now widely considered primarily in terms of prediction (Friston, 2010): a fundamentally active pursuit undertaken by the organism in an attempt to work out the most likely consequence of an interaction. In essence, we have shifted from a sensory impingement model, that stated experience was driven by bottom-up information, to a predictive model (Friston, 2010; Hohwy, 2013), that proffers a top-down approach, with the brain predicting the state of the environment in which we exist.

            Such a position has looked to dismiss remnants of a Cartesian love-in, replacing it with a platform that unifies the mind, body and brain. In reality, we are at risk of remaining in the same boat (albeit a bigger and shinier model), having replaced one dualism for another. The self-declared neurocentric contingent of this predictive approach (Friston, 2010; Hohwy, 2016), propose that experience is necessarily represented in, and isolated to, the brain. In so doing, relegating the role of the body to that of an experiential messenger, passively relaying information toward or away from the organ of import. So, although neuroscientific developments have potentially provided a powerful means to unify our understanding of experience, including pain, it seems to have done so by sidelining the body (Burr and Jones, 2016)

            Whether experiencing pain, itch, fatigue, or indeed any bodily experience, we propose that the role of the body, not separate from brain nor world, is 3-fold: it reduces uncertainty (through active inference), it functions within evolutionarily determined limits (liminality) and it takes necessary action (defence). From here, we are best placed to describe experience, not as an isolated representation in the brain, but as adaptive behaviour that extends beyond the brain to incorporate the “context of the body”, the structure of the organism’s environment and the continuous exchange of signals between the nervous system, the body and the environment (Clark, 2017).
            This needs to flagged up to the remnant persisting in defence of ectodermalism.

            In my opinion it should also be gently conveyed to those of our patients who perceive that they are sitting in a command module behind the eyes.

            Many of my younger patients are gamers who identify more with the avatars they create than they do with their own casing and the care and attention required to ensure that they rather than the tech they use to run their lives, has agency. The nervous system will run for a while with neuroendocrine compromise, poor nutrition and deconditioned cardiovascular/respiratory systems, but there comes a time when the chickens come home to roost.

            I also have a difficult elder contingent who live with limited mobilty and multiple co morbidities who skate over the need to address lifestyle issues. There is nothing sadder than trying to support someone who says "Well what do we do now?" when the options have run out.

            Chew On This: Reduced Mastication Impairs Memory and Learning Function


            Update 11/07/2017

            I attend, therefore I am


            Daniel Dennett proposed that the self is simply a ‘centre of narrative gravity’ – just as the centre of gravity in a physical object is not a part of that object, but a useful concept we use to understand the relationship between that object and its environment, the centre of narrative gravity in us is not a part of our bodies, a soul inside of us, but a useful concept we use to make sense of the relationship between our bodies, complete with their own goals and intentions, and our environment. So, you, you, are a construct, albeit a useful one. Or so goes Dennett’s thinking on the self.

            And it isn’t just Dennett. The idea that there is a substantive self is passé. When cognitive scientists aim to provide an empirical account of the self, it is simply an account of our sense of self – why it is that we think we have a self. What we don’t find is an account of a self with independent powers, responsible for directing attention and resolving conflicts of will.

            There are many reasons for this. One is that many scientists think that the evidence counts in favour of our experience in general being epiphenomenal – something that does not influence our brain, but is influenced by it. In this view, when you experience making a tough decision, for instance, that decision was already made by your brain, and your experience is mere shadow of that decision. So for the very situations in which we might think the self is most active – in resolving difficult decisions – everything is in fact already achieved by the brain.

            In support of this view, it is common to cite Benjamin Libet’s brain experiments of the 1980s, or Daniel Wegner’s book The Illusion of Conscious Will (2002). Yet, these findings don’t come close to showing that our experience is epiphenomenal.
            Most agree that the predictive power of science reveals a Universe that can be captured by laws. When we make an error in prediction, it is because we have not yet discovered the right law. The old-fashioned worldview is that these laws should privilege the microphysical domain, such that all happenings at the macro level – the level at which we experience the world – are ideally described by happenings at the micro level. In this view, even if we cannot provide an account of our conscious experience in terms of electrons, our experience comes down to the movement of electrons.

            What’s more, activity at the micro level is ultimately deterministic: the movement of electrons that account for our conscious experience right now comes down to the movement of electrons a moment before, and the movement of electrons a moment before comes down to … the movement of electrons at the very beginning of the Universe. There is no accounting for true indeterminism in this view, nor for effects of scale. There is no room for autonomy or free will (or, at least, one way of thinking about free will), since all microphysical events have already been accounted for by prior microphysical events.

            Yet, another worldview is now emerging that emphasises nonlinear dynamics and complex systems. Importantly, this worldview sets aside the assumptions of reductionism and micro-level determinism. In this vein, neuroscientists have begun to argue that the brain’s causal power cannot be reduced to small-scale brain activity. This provides room for a substantive self, with its own powers and properties, distinct from those of individual neurons or mere collections of neurons.
            This understanding of the self can account for the process of attention. As mentioned above, attention is informed both by your current task and by new stimuli that might appear. ‘Top-down attention’ refers to your ability to direct and maintain focus according to your current goals and interests, whereas ‘bottom-up’ attention directs your focus to new and different stimuli. Your top-down attention might help you to focus on this article, while your bottom-up attention might urge you to focus on a conversation nearby. In the cognitive sciences, these are treated as separable, interacting processes. So what accounts for your ability to balance these forces? How are you able to stay on task and resist the pull of new and interesting stimuli, such as the conversation nearby? In my view, the determination of whether and when to stay focused on a current task versus switching focus to a new stimulus is best explained as directed by a substantive self. This is because the substantive self is more than the current task, incorporating the organism’s full set of interests. So the substantive self will be best able to balance the current task with other potential interests.
            This view of the substantive self need not fall prey to the ‘homunculus fallacy’, in which we explain a phenomenon by introducing a homunculus, which then must also be explained by introducing a new homunculus, and so on. Instead, my understanding of a substantive self is as a physically realised emergent phenomenon – it is made up of parts but it has a property that goes beyond the sum of its parts, in that it has some degree of power or control over its parts. This power might be simply to increase the influence of some parts (eg, goals or interests) at the expense of others, in keeping with the needs and capacities of the whole.
            I came to this view – that attention comes about due to the interaction between our interests and the resources shared by those interests as a whole – by thinking about flocking behaviour. That is, our interests, goals, desires and needs interact with one another much like birds interact in a flock. Yet, birds also interact with the shared environment of that flock (eg, gusts of wind), which provides special constraints to the flock as a whole. The interactions of the flock with its environment can create beautiful patterns, known to bird watchers as ‘murmurations’. Similarly, the interactions of our interests and the resources shared by those interests can result in real, observable patterns. These patterns reflect the enhancement of some interests at the cost of others. That is, our interests, as a group, lead to changes in our interests, as members of that group.

            How might this work in the brain? One possibility is that it relies on a phenomenon much like the synchronisation of metronomes. If you place several metronomes on a table, and start them at different places, they will eventually synchronise. This is because the metronomes share the table, in which the various oscillations cumulate (ie, forces in opposing directions cancel out, unlike forces in the same direction), leading to an overall push in a specific direction at a specific time. For neurons, it might be a shared electromagnetic field, bound by the meninges and skull, rather than a shared table, that allows for synchronisation. In this case, the electromagnetic field would be a resource shared by the neurons, and patterns of synchronisation within that field would reflect the division of this resource based on the whole set of neurons.

            This is a mere ‘how is it possible’ account of the substantive self, and over time it might be shown to be inconsistent with either reason or empirical evidence. Yet, at this time, no reason or evidence exists that I know of that would counsel against this account. Further, a substantive self, as described here, would help to make sense of certain features of attention, discussed above. Thus, I see no reason to reject the existence of a substantive self.

            But note that, in my picture, the self is only as strong as its powers of attention.
            Nota bene "non dualists"!........... Woo based explanation is superfluous.

            Update 11/07/2017

            The economy is more a messy, fractal living thing than a machine


            Discovery of brain-like activity in immune system promises better disease treatments





            I have often wondered why Physios, Physio educators and Physio managers align our profession with the categorisation of illness and disability. Thomas Sydenham started the diagnostic ball rolling in his ‘Observationes Medicae’ in 1676, his ‘carving nature at its joints’ was thought to be a methodically sound and scientific approach that matched the ideas of the biological sciences of the day in the classification of plants and animals. Thus, the idea of difference in medicine began. Diagnoses were separated from each other and over time became culturally sanctioned and eventually embedded in the International Statistical Classification of Diseases and Related Health Problems (ICD) now in its 10th revision. This has given us a technical and categorical way of applying treatment, from which ‘pathways’ and ‘protocols’ are born, outcomes and cost measured.

            I can’t help feeling we are missing the point.

            The very structure of the system ignores the lived experience for the patient. Ironic for a profession whose main aim is to help people function how they want to function, which is an entirely lived experience. In Andy Clark’s ‘Surfing Uncertainty’ he describes a model in which cognitive short cuts serve to limit processing demands, making efficiency its goal whilst sacrificing, sometimes vital, information. Cognitive short cuts based on previous experience, probability and prediction could be responsible for some well-known illusions such as the McGurk effect (if you’ve never seen it, look it up on utube, its really cool!) It occurs to me that segregating patients into broad categories like respiratory or neurology, or filling in an assessment form that demands a diagnosis and a ICD10 code, might be a consequence of the way this predictive model works. Are we the product of a combination of cultural and computational brain-washing? Are we missing vital information by succumbing to a diagnostic illusion? I can’t think of a patient in the last 25 years who fitted neatly into any category. Why am I doing it then?

            It’s a question that challenges many facets of Physiotherapy, from the structure of our degree courses, to the structure of our departments and how we interact with our patients at a personal level.

            Segregation and specialisation of services seems a convenient and relatively straight forward way of dealing with substantial numbers of patients. Similarly, using diagnostic codes to cost outcomes provides a ‘bottom line’ for those in charge of Physiotherapy purse-strings, but if it’s not reflected in clinical reality for us, or life reality for our patients, we need to glue nature’s joints back together, put a gentle hand over the mouth of medical history, loosen the grip of categorisation, de-code and re-think.
            As a generalist I can't help but agree, but when something is outside scope of practice, in my case, complex post surgical hand patients and those with continence issues, it is useful to have the categories in place in order to find a suitable specialist.

            Update 14/07/2017

            Diseases of the Will: Neuroscience Founding Father Santiago Ramón y Cajal on the Six Psychological Flaws That Keep the Talented from Achieving Greatness


            Update 16/07/2017

            Pain leads to empathy and self-preservation: should we make robots ‘feel’ it?


            The right way to kiss: directionality bias in head-turning during kissing


            Humans have a bias for turning to the right in a number of settings. Here we document a bias in head-turning to the right in adult humans, as tested in the act of kissing. We investigated head-turning bias in both kiss initiators and kiss recipients for lip kissing, and took into consideration differences due to sex and handedness, in 48 Bangladeshi heterosexual married couples. We report a significant male bias in the initiation of kissing and a significant bias in head-turning to the right in both kiss initiators and kiss recipients, with a tendency among kiss recipients to match their partners’ head-turning direction. These interesting outcomes are explained by the influences of societal learning or cultural norms and the potential neurophysiological underpinnings which together offer novel insights about the mechanisms underlying behavioral laterality in humans.
            Update 17/07/2017

            Will technology make physiotherapy obsolete?

            18th July 2017 by Dave Nicholls

            Many traditional jobs – like journalism – are falling by the wayside, and there are some predictions that up to half of the work of lawyers, doctors, bankers, market gardeners, librarians, and shopkeepers will be handed over to digital technologies in the next few years.

            There is almost no debate about these things in physiotherapy. It is possible that some aspects of our practice will be retained – perhaps the things that we think require the most human-to-human engagement. So the question is what aspects of physiotherapy do we think we will lose in the not-too-distant future, and should we not, therefore, be preparing now for the change that is to come?
            It is likely that we will still be needed for complex interactions with patients who present with pain, vestibular conditions, and for those who require rehab following trauma, or acute management of multiple co morbidities, once they are medically stable. It has been said by several that the coming generation of physiotherapists will require breadth as much as depth in expertise.

            My thanks go to colleagues who continue to check for updates in my subject threads, it gives me hope for the future prospects of "the generalist" in physiotherapy and osteopathy.

            Researchers have successfully tested face cooling to prevent steep drops in blood pressure during simulated blood loss, a prehospital intervention that EMTs and battlefield medics could one day use to save lives.


            University at Buffalo researchers found that placing a plastic baggy filled with an ice water slurry over a person's forehead, eyes and cheeks for 15 minutes prevents a drop in blood pressure during a simulation of blood loss.
            Face cooling works because it constricts the blood vessels, which sends blood back to the heart, increasing blood output from the heart. The result is increased blood pressure.
            Update 18/07/2017

            Reflections of a quantitative researcher on the CPN Salon


            The day after WCPT Congress, I attended the CPN Salon in a beautiful venue in Cape Town. I had become a member of CPN about 6 months ago, mostly out of curiosity. I didn’t feel like I belonged or that I shared similar philosophies but I was intrigued by the group. After chairing the scientific program of WCPT, I thought it would be refreshing to spend a day at the CPN Salon listening to intellectual discussion among individuals that thought quite differently than I did. I had the intention of being a passive listener as I didn’t feel that I could contribute much. I was slightly intimidated by the topics on the agenda, as they were not part of my daily discourse.
            As often is the case in life, expectations and reality did not match and the day was greatly enlightening and highly relevant to my world. I would like to share with you four reflections on the day.
            The CPN Salon took me outside my comfort zone. Comfort kills productivity and pushing our boundaries can not only increase efficiency, but also maximize creativity and make it easier to push boundaries in the future. I felt outside my comfort zone for most of the day and came away invigorated.
            By no fault of its own, the CPN speaks to the converted. Despite the fact that anyone can join CPN, members of CPN are mostly qualitative researchers or clinicians who are not happy with some aspects of practice. They are like-minded individuals who think in a similar way and mostly agree with each other. Although I appreciate the need for a group that supports this common thinking, more could be accomplished to improve physical therapy care by expanding the network beyond those individuals.
            Critical doesn’t mean judgmental. Critical means “challenging physiotherapy practice and thinking and critically reflecting on the profession’s past, present and future”. However, at times, I felt that critical could slip into being judgmental, making it counterproductive. It is true that the ideas of critical physiotherapy are not main stream and need to gain more momentum. However, we must pay attention to language and tone to make sure we don’t create alienation in the profession. For example, I can agree with many sensible comments about the limits of randomized controlled trials. However, I will become defensive and even argumentative when disrespectful or snide comments are made about this research design.
            “Let’s build bridges not walls”. A wall stops us from connecting with one another and creates distance. Instead, let’s create means to meet even when our ideas are drastically different, making it possible to create solutions and new knowledge. Building bridges will help empower physiotherapists to engage in thinking and practice that will move physiotherapy profession forward. In addition to a CPN Salon, let’s bring the ideas of CPN into the more indoctrinated areas of physical therapy. For example, I could benefit from the ideas of CPN when designing an international randomized controlled trial of balance training in COPD. Maybe PEDro could benefit from some of the ideas in CPN and so could many of the special interest groups in the profession.
            After the CPN Salon, I no longer feel the “us”, quantitive researchers involved in generating conventional scientific evidence, and “them”, critical thinkers who challenge conventional research and practice. Instead, I have come to appreciate how important it is that these two worlds collide and interact regularly. Let’s break the walls and create bridges!

            I am fascinated by both quantitative and qualitative research. I don't have the training to lead it, but have learned a great deal by participating. If ever you get the chance to participate, I recommend it. I have yet to meet a researcher who hasn't found time to have a chat and answer questions.

            This can be incredibly valuable to us "coal face" practitioners and the researchers tell me that they gain something too.

            Update 20/07/2017

            Foam Rolling: What Actually Is It And What Are The Benefits?


            The simple (and painfully satisfying) movement of rolling to and fro on the muscle is said to improve circulation and help soothe tight areas known as “trigger points”.

            We spoke to Roger Kerry, physiotherapist and associate professor in Physiotherapy and Rehabilitation Sciences at the University of Nottingham to find out the research-backed benefits of foam rolling.

            "Invisibility is the enemy of rehabilitation”


            "There’s no area of medicine where physiotherapy isn’t involved.”

            While acute rehab within hospitals is recognised and “pretty good”, the CSP is concerned about what happens when the patient goes home. “TV presenter, Andrew Marr told us that the inpatient treatment for his stroke was fantastic but that life after discharge was like falling off a cliff – and he’s one of the fortunate ones who can pay for ongoing treatment.”
            Update 21/07/2017

            What Is the Molecular Signature of Mind–Body Interventions? A Systematic Review of Gene Expression Changes Induced by Meditation and Related Practices


            There is considerable evidence for the effectiveness of mind–body interventions (MBIs) in improving mental and physical health, but the molecular mechanisms of these benefits remain poorly understood. One hypothesis is that MBIs reverse expression of genes involved in inflammatory reactions that are induced by stress. This systematic review was conducted to examine changes in gene expression that occur after MBIs and to explore how these molecular changes are related to health. We searched PubMed throughout September 2016 to look for studies that have used gene expression analysis in MBIs (i.e., mindfulness, yoga, Tai Chi, Qigong, relaxation response, and breath regulation). Due to the limited quantity of studies, we included both clinical and non-clinical samples with any type of research design. Eighteen relevant studies were retrieved and analyzed. Overall, the studies indicate that these practices are associated with a downregulation of nuclear factor kappa B pathway; this is the opposite of the effects of chronic stress on gene expression and suggests that MBI practices may lead to a reduced risk of inflammation-related diseases. However, it is unclear how the effects of MBIs compare to other healthy interventions such as exercise or nutrition due to the small number of available studies. More research is required to be able to understand the effects of MBIs at the molecular level.
            So much out there to little time. There is really no need to make stuff up when we can be science based and evidence informed. Practice is an art, which is why the effects are non specific and almost impossible to replicate. I see no dichotomy. It's all about getting people back to work.

            The Seven Ages of Man by William Shakespeare.

            All the world's a stage,
            And all the men and women merely players,
            They have their exits and entrances,
            And one man in his time plays many parts,
            His acts being seven ages. At first the infant,
            Mewling and puking in the nurse's arms.
            Then, the whining schoolboy with his satchel
            And shining morning face, creeping like snail
            Unwillingly to school. And then the lover,
            Sighing like furnace, with a woeful ballad
            Made to his mistress' eyebrow. Then a soldier,
            Full of strange oaths, and bearded like the pard,
            Jealous in honour, sudden, and quick in quarrel,
            Seeking the bubble reputation
            Even in the cannon's mouth. And then the justice
            In fair round belly, with good capon lin'd,
            With eyes severe, and beard of formal cut,
            Full of wise saws, and modern instances,
            And so he plays his part. The sixth age shifts
            Into the lean and slipper'd pantaloon,
            With spectacles on nose, and pouch on side,
            His youthful hose well sav'd, a world too wide,
            For his shrunk shank, and his big manly voice,
            Turning again towards childish treble, pipes
            And whistles in his sound. Last scene of all,
            That ends this strange eventful history,
            Is second childishness and mere oblivion,
            Sans teeth, sans eyes, sans taste, sans everything.
            Update 22/07/2017
            Last edited by Jo Bowyer; Yesterday, 07:34 AM. Reason: update
            Jo Bowyer
            Chartered Physiotherapist Registered Osteopath.
            "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi