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365 days of noijam

By Timothy Cocks Education for all 24 Dec 2014

It’s been a big year on noijam; our readership has more than doubled, we’ve published over 100 posts, and we’ve reached more people via social media than ever before. We’ve had a few surprises, and bit of controversy, but the support for our little blog has steadily grown and we think that we have achieved what we set out to do.

Because it’s that time of year for self-indulgent, nostalgic reviews here’s the top 5 posts of 2014:

5. Knee replacements in the brain – the patient’s side

At number 5 is a collaborative piece from David Butler and his good mate John Barbis; “an aging Philadelphian PT”. In John’s own words:

“The new knees were all mine as soon as I woke up and I was glad to say  goodbye to the old ones. I wanted to be in total control. I didn’t want anyone pushing on my knees.  There is no reason why someone else should have to push on someone’s knee to get range of motion”.

“I knew there would be nociception, I knew there would be neural flares but I knew they could be made safe. I avoided the total knee education class offered – it was scary”

“Overall,  I worked on my brain more than working on my knees”

4. What is the difference between cancer and whiplash?

At 4, an emotive post in the midst of some difficult times. Along with some typical tongue-in-cheek invention of an acronym, there was deep personal reflection and a challenge to the physical therapy professions:

“Whiplash, which is really just “Sprained Neck at Speed with frequent Neural Irritation” (SNSNI) – is it really more difficult than a cancer to treat? Chekov looms – so many remedies offered by so many groups for the problem. Perhaps some of the problem starts when we whack the useless and danger enhancing metaphor “whiplash” onto it.

I guess this blog is all about asking people to reflect on where you want to be and where your moral compass lies; and to create a greater awareness of how the patient is the sandwich in the middle. In cancer there is no room for bullshit. Why should whiplash be any different?

Further reflections most welcome.”

3. Explain Brain

The third highest read post was a classic, longer neuroscience narrative on brain smudging and neuroplasticity.

“At NOI, we have trialled, played with, and guessed at ways to tell people about their brain and pain. Like many clinicians out there, we have had some great wins –“Yes. I understand it now, of course that makes sense, thanks“… and some spectacular failures – “bloody physio thinks it’s all in my head”. Over time I think we are getting better and better at this complex intervention – future clinical studies will let us know. But for now, there is research from educational psychology and science that we can and should apply – there are ‘guidelines’ from evidence based multimedia to power up and improve our ‘made in the brain’ narratives. (We have written about these before.)”

2. Time for motor freedom

At number 2, another reflective piece taking a look at the findings of a major study using the ‘motor control’ paradigm for chronic whiplash. The post was one of our most commented-on pieces for the year; possibly because it spoke to a topic at the core of what many clincians have been taught, and questioned a paradigm that has dominated physical therapies for decades. A bit overlooked however, was a section on the ‘bastardisation of education’:

“Nothing so detailed for training in the education group – this was 30 minutes which included reading the handout, answering questions and access to two explanation sessions. We have no information on the core educational competencies of the therapists, or whether they were even aware of and trained to answer the most common questions. Education is belittled – it is as though it is an accepted intervention which we are all competent and equal at!

We need to get serious about how we define education and how we research it. If the education group in the study considered educational competencies and modern pain biology educational interventions known to work, I hypothesise that the outcomes would be better than that of the 20×1 hour group work. Education based on motor freedom principles may be better and a realisation that that includes immune, linguistic, emotional, cognitive, creative, autonomic and endocrine freedom as well.

Explore the second last line in the Lancet paper – “Last, how to successfully deliver simple advice needs to be established”. Advice is never simple. A Steve Job’s quote comes to mind “Simple can be harder than complex. You have to work hard to get your thinking clean to make it simple. But it’s worth it in the end because once you get there, you can move mountains”. A start would be to use the word ‘curriculum’, something rarely used in our clinics. If you are educating seriously you would have considered the notion of curriculum, both one-on-one or in a group. The word should instantly bring up content, delivery, timing and measurement. Perhaps educational psychology may be a new and better path to follow rather than health psychology.”

1. Shin splints, taking out the tension

The most read post of 2014 took us by complete surprise. Perhaps it was the typo in the original posting, perhaps it was the clinically relevant video with the post, or maybe the topic itself, but this noinote on shin splints had an overwhelming response with tens of thousands of views and many thousands of shares across social media. But there was also some cause for consternation about the popularity of the post – “Will clinicians watch this and just treat all shin pain as if it was the same – one (neurodynamic) size fits all?” “Will therapists use this as a ‘script’ and leave out the thinking and clinical reasoning parts?” Hopefully there was enough of the thinking behind the technique to encourage clinicians to work hard to get their thinking “clean and simple”

“My Thinking 

There was just some basic clinical reasoning powered up by a modern, neuroimmune understanding of how pain works – or at least the best understanding available to us right now.

“The kind of pattern reported above is common and will usually ease with the simple principles showed in the video. If I had to have a go at the pathology, I would suggest some tibial nerve irritation, perhaps even a minor compartment syndrome in the posterior compartment which houses the tibial nerve. How simple it would be to suggest that the nerve and its connective tissue sheath were sticky, perhaps with limited oxygenation, some local immune inspired inflammation perhaps also related to slightly altered anatomy post fracture. But more than that – I suggest that the person’s perception of the problem has also added to the sensitivity both locally and in neuroimmune territory representing the meaning and the function of the leg.”


So there it is; knees, brains, necks, cancer and shins – an eclectic mix for the top 5 in 2014.

Because it’s also that other time of year, we’re running a little competition and giving you the chance to win an eBook version of Explain Pain 2nd Ed, The graded Motor Imagery Handbook or The Sensitive Nervous System. In the comments below, simply let us know what your favourite post from 2014 is and why, and mention which eBook you’d like a chance to win (if you have all three already, you can still nominate a book as a gift for another person). An independent judge will pick the three best comments and we’ll let you know the results. Entries will be open until 14 January 2015.


-Tim Cocks


  1. Time for motor freedom – Im a big believer in education and think open mind is essential for changing thinking about treatment of pain.
    (The Sensitive Nervous System)

  2. betsancorkhill

    My vote is for No 3 on your list ‘Explain Brain’ because although the theory of ‘explain pain’ and the power of knowledge/education is getting through to clinicians many are still not getting the story telling right. I think many find it hard to convert their knowledge into a story a particular patient will understand and take on board. The same stories and metaphors are used rather than being made specific the the patient and their individual story. A great example of this – A patient was telling me about her experience with another physio. It was a version of ‘Bloody physio told me it was in my head!’. This time it was ‘Physio came out with this weird story about some strange man walking through a jungle wearing a sarong….A SARONG! And he got bitten by a snake….well what does he bloody expect walking through the jungle in a sarong…. AND ANYWAY what the F**** does that have to do with my back pain?’
    I had to smile and you ought to have seen her face when I said ‘ Ah! I know that man!’ 🙂

    I’d like a copy of the sensitive nervous system please.

  3. My favourite post in 2014 is the one about GMI, because it is amazing to see what the mind can do to help rehabilitation, and the video was really gorgeous.
    The book I’d like to receive is explain Pain 2nd Ed

  4. Definitely explain brain! As someone who has (had) crps and central sensitisation understanding what’s happening has had the biggest impact on me getting passed the pain and getting on with life. Not sure where I’d have been without my physios explanations and the research I’ve done (from places like this).
    Thank you for all the work you do. My life is that much better for it.

  5. this-is-a-story-about-peaches-and-burnt-tar would be my favourite it reminds me that whilst knowledge is absolutely important in working with pain it also reminds me that how the individual uses the knowledge to normalise the experience, to help recovery and to do this gently is important too. I would like Explain Pain 2nd Ed if I’m the lucky one

  6. I really like “The professional rollercoaster and burnout”. I admire David’s braveness that he really challenged “guru” mindset thru social media and has been having the enthusiasm in encouraging physiotherapists to to put modern pain neuroscience into their tool box. I left Oz land this January and currently have my own clinic in Taiwan. I do feel the resistance of knowing pain science here. I really hope based on Davis’ work and Noigroup’s great contribution in “explain pain”, it won’t take long to instill the “pain” concept to Taiwanese physios. If I am lucky enough to be picked up, Explain Pain, 2nd would be the one.

  7. The Time for motor freedom blog particularly struck a chord with me.
    “Education is belittled – it is as though it is an accepted intervention which we are all competent and equal at!”

    Therapists competency in delivering education interventions is as varied as the ways in which we deliver any therapeutic intervention. Competency is not automatic. We don’t know what we don’t know.
    To educate requires at minimum a basic understanding of adult education theory and at the very least being able to work out how our “individual” clients learn. Hence not one size fits all. A primarily visual and or kinaesthetic learner is less likely to get the message from a spoken story than the learner who learns best through auditory means. Delivery of the education intervention must therefore be tailored, in some case requiring one or more of stories, pictures, activity and for the reader/writers amongst out clients the ability to take away and old fashioned leaflet/article to read and absorb at leisure. It took me six months to get to grips with adult education theory and practice and integrate it into my practice . It takes time to build up a tool box of resources that can be utilized for clients. One of the things that I did learn is that before the adult education course I taught the way I learnt best. Not the way my patients did. Now its all about them.
    Explain Pain 2nd edition would be a fantastic additions to my toolbox thank you.

  8. My favorite was Shin splints, taking out the tension. Simply because it was a brand new way of reasoning about shin splints. I had recently discussed the subject of shin splints with some fellow students when I read it. I therefore shared the post on our physio-page on Facebook which many of the other students appreciated.
    I would love a copy of The Sensitive nervous system!

  9. Thanks to all who have taken the time to comment and tell us about your favourite post of 2014. We’ve had an independent judge poring over all comments and she has selected her top three.

    And the winners are….

    Cathrine Rubach
    Mary Murdoch
    Dominic Gage

    We’ll be in touch with the winners by email to arrange electronic delivery of your selected eBook.

    Thanks again to everyone.


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