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Clinical mileage

By Noigroup HQ NOI Notes Archive 18 Aug 2017

About 25 years ago I was teaching a week long Dynamic Nervous System course in Nevill Hall Hospital, Abergavenny, Wales with Louis Gifford. It was our early and admittedly crude attempt to introduce pain treatments via exposure and education. At the end of day three, as we were leaving the hospital, we noticed three young women still in the classroom – they were visibly upset and one was crying. We went to them and one asked, “Well what now, what will we do in the clinic, is all that stuff I have done before just rubbish?”

I have never forgotten this moment. Clearly, at that stage of the course, we had brutally deconstructed deep frameworks and beliefs of many members of the class, but we were not able to adequately reconstruct new ones at the same time. I wonder if any of these three are still working. I would love to hear from them or anyone who was on that course.


Clinical baggage

Looking back now I can recognise that we had torn down their clinical mileage. By clinical mileage, I mean all the processes, techniques, thoughts, principles, reasoning, and interventions -successful and unsuccessful- that a clinician has brought with them to this point. We all have clinical mileage that we should reassess from time to time. I believe that to achieve better treatment outcomes, where for example, pain recovery rather than pain management is the expectation, many of us need to shed some of our clinical mileage. And at the same time, perhaps realise we also carry around a lot of useless clinical baggage, picked up along the way. This is not about a skill fade or decay, but the recognition that deep in your heart (brain!) you realise that some of your thoughts and beliefs may not be accurate, that you could have helped more people, some of what you did may have been based on dodgy science , or perhaps your reasons for why someone got better or worse were not correct.

And I’d just mastered the cervical lateral flexion manipulation…

I remember, about 15 years into my career, the moment of realising my clinical mileage was not quite right, and it hurt – and I had just got the C2/3 lateral flexion manipulation down pat! I know some get elated by the shift, the revelation, the freshness of new ideas, but for many I reckon it hurts. In my case I was completely unsure of direction for a couple of years and I rejected and disliked some of those purveying new material. The shift I am talking about here is taking the biopsychosocial mental framework deeply “into the marrow of our bones”.

In Kuhnian talk – a clinical mileage shift comes from a crisis in your thinking, which leads to a realisation that you weren’t quite right, then a search for and adoption of other paradigms.

So shift, educate, re-educate, reallocate resources, refresh.

It’s good for your brain and the brains of others.

What are your experiences of clinical mileage shifts? Were they painful or pleasant? Your stories welcome in the comments below.

-David Butler

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  1. Anita Erens

    Hi David. I wasn’t one of those 3 from Wales but one from Cape Town in 1997 when you and Louis ran a course here. And I had the same response but for me it was a watershed moment, when I realised just how much bigger my scope of learning and practice could be. And I’ve never looked back. Still think that of all the courses I’ve done (and there’ve been many in 33 years of practice) it was the most influential one. Thank you! Anita Erens

    1. davidbutler0noi

      Thanks Anita,

      I remember that course well. It was a bit uncomfortable for us too as we were going though “the shift” at the time.

      Lovely to hear from you


  2. Chris Watson

    I had my whole McKenzie Zealot identity deconstructed by Louis Gifford at a similar time to when you are talking about. It was thoroughly liberating to be honest.

    1. davidbutler0noi

      Hi Chris,

      As David Bolton noted in a post below, you still have that material archived. it can offer useful contrasts, a balance and some really good bits. And of course it can be very liberating to not DO McKenzie, Maitland, Feldenkrais ,whoever, but something created out of reasoned and justified clinical and research mileage.



  3. David,

    “…to be honest.” jumped out at me in the previous post, I think that science, evidence and detection were replaced by technique and method. Many therapists can’t argue for or adequately defend what they’ve done. No wonder they cry. The truth hurts.


    1. davidbutler0noi

      Hi Barrett,

      Although there is a troubling trend where some resort to fake news to defend!



  4. Daniel Martin


    It’s wonderful to think that you could be reading this right now! I’ve felt the existential burn of my clinical mileage somewhat recently – there’s nothing quite so simultaneously depressing but, as Chris put it, liberating. It seems that the more I learn, the less I understand…but perhaps that’s the secret to it. Without the ability to ask new questions, we could certainly never find new answers.

    Dan, OT.

    1. davidbutler0noi

      I am with you Dan! There is a balance between the liberated and sometimes euphoric feeling and the existential anguish that comes from many sources –
      am I letting the profession down, am I true to best science, memories of past clinical inadequacies, letting down the gurus who once were such a source of help, etc….
      I am realising that towards the end of my career, that I can be satisfied with the knowledge of biology increasing far faster than I can take in. I still have many questions but they are now far broader than they once were.

      Best wishes


  5. Hi David,
    Personally I’m not so sure that your approach, at that time was in anyway rubbishing that which we brought with us from our previous learnings, both academic and experiential. I remember Geoff Maitland, in his teachings, was very gentle how he presented his paradigm shift, back in the 80s encouraging us not to change anything on our first Monday back into the clinic. “Let it soak in” and mould into your present approaches. If it fits then some “Old Knowledge” might need to be archived but, never lost ! I have experienced the same with youself, at the outset of your teachings. You were gentle with, yet confident of the knowledge you shared with us. I don’t think you can take responsibility for the emotional response of others to their own knowledge base ……

    1. davidbutler0noi

      Thanks David,

      Perhaps my feelings relate to the existential anxiety which Dan has just brought up?



  6. Mel Macoun

    Thanks David, and the other readers.

    I really appreciate this topic. I think that most practitioners have experienced the feeling of coming away from a training course with a new skill set that suddenly all your patients can’t possibly go without! The feeling of – “I wish I knew THIS before…think of all the people I could have treated better if I knew this EARLIER”.

    Louise Gifford gave me that feeling when I did his Graded Exposure course some 18 or so years ago. That certainly was the first step on my journey of pain science, and I’ve covered a lot of mileage since then!

    I’ve never got the message from you guys that what we’d done so far in our clinical mileage (ie until our path crossed yours) had been a waste of time. The real message I heard, was that when I had helped people to get better, they might have improved for different reasons than what I had intended. And if they hadn’t got better, I now had different tools in my tool box for next time. I couldn’t undo the past, but I could do a lot more good in the future. That’s just like learning ANYTHING new. And, armed with the power of pain science in particular, we can all be more effective, more of the time! And now we can even make people better with WORDS. What’s not to love about that?

    I hope that the Pain Revolution keeps up the momentum. Lots of change still needs to happen to help practitioners see that there’s more that can be done for people in pain.

    Thanks for the journey so far.


    1. davidbutler0noi

      Thanks Mel,
      That’s helpful – people improve (or worsen) for reasons that are different to our initial beliefs. I think that if we could all take that on, and realise that pain sciences continually offers new reasons for change , we will really be cruising!

      Its been quite an exhilarating journey so far!



  7. I had a different experience when I attended a long lecture given by Lorimer at a CPD event aimed mainly at physiotherapists in London a few years ago. An Australian colleague who was both a physio and a Feldenkrais teacher had recommended the lecture, and I did not quite know what to expect. It was really exciting to discover that so many of the Functional Integration and Awareness Through Movement strategies I was using were so thoroughly backed up by current research. I do believe that we have an overall advantage because we identify ourselves as teachers rather than therapists, as people come to us with more flexible expectations – but I also suspect that many of my colleagues would not agree with me! It certainly makes what we have to offer hard to fit into a clear niche, promotion-wise…

  8. Margaret Coles

    Hi David,

    I met you at our CSP conference in Liverpool some years back. You signed my book! I’m now in what they call the new ‘middle years’ of being in your seventies. I’m still on the go and completed an MSc in Public Health last year. I’m making my mind and body work for a living, much as you recommended at our conference.

    I’ve experienced a number of mileage shifts as you can imagine. One of which lately is a dawning understanding of the role of ion channels in all parts of our bodies and that our bodies run mainly on electricity. This is right up our street and I’m finding it fascinating as I have a genetic kink in some of my ion channels.

    At times my muscles become flaccid and at others they go into overdrive and lock down. It feels as if I’ve pulled every muscle in my body and can go on for days. Extremely painful and debilitating. Then it suddenly releases till the next morning. Hopefully I’ll be finding out which channels are faulty and given appropriate treatment, including that given by neurophysiotherapists.

    Mention is made of a faulty Nav1.7 sodium ion channel which stays open and active and so sends signals to the brain which register as pain. Do you have any mileage on this? I asked you once whether you knew of any way to relieve Tardive Dyskinesia. Perhaps this is linked to ion channels.

    Wishing you well in keeping our knowledge channels open and active!
    Margaret Coles

  9. Hello,

    Though i have not attended any of yours working ethos, i read and learning from books and e-materials. Recently relocated to Africa for spreading awareness about stroke and way forward. Clinical mileage that something novel i have learnt after reading this and i am surely keep in mind if sharing or teaching upcoming principle to others that i should not ill respect their past. Looking forward to have workshop in africa.

  10. What you describe – it’s definitely a strong form of resistance to new experiences. It’s one of the big reasons people don’t risk learning anything new. Threatening, that state where you don’t know enough of the new capacity to make it fly and get its benefits…but your old way of doing things has just been blown out of the water.
    We need more ways to provide a “safety line” of a fall-back position. But that’s so tricky when it is the “Doors of Perception” that are being opened. Maybe more ways to convince yourself that you could gain significant benefits… Otherwise, why risk learning, even if it could be a totally revolutionary improvement in your life?
    I think the convention of authors who merely trash and criticize shouldn’t continue. Authors should be compelled to offer creative and practical solutions for the significant complaints and needs they outline….spending a significant portion of their content on these answers instead of on the complaints.

  11. What you describe – it’s definitely a strong form of resistance to new experiences. It’s one of the big reasons people don’t risk learning anything new. Threatening, that state where you don’t know enough of the new capacity to make it fly and get its benefits…but your old way of doing things has just been blown out of the water.
    We need more ways to provide a “safety line” of a fall-back position. But that’s so tricky when it is the “Doors of Perception” that are being opened. Maybe more ways to convince yourself that you could gain significant benefits… Otherwise, why risk learning, even if it could be a totally revolutionary improvement in your life?

  12. Yashaswi Agarwal

    Clinical Mileage, as I understand, is not only what we learned or acquired knowledge about, it also includes the understanding we gained with our clinical experience and self-reasoning we do at our clinics. So , I believe, anything I learned in the past was not waste, it was just incomplete. And i get this feeling every time I learn some new tool, technique or concept. It’s like, “Oh! this was also happening there with the treatment i was giving, I never thought it that way.”
    Also, out of my experience, I have realized that none of the particular technique or concept is absolute that solve all our clinical cases, but each new concept we learn gives us a new insight to think and work over , also we bag a new tool in our kit to reason/answer our clinical challenges. Richer the tool kit is, greater number of problems we can solve easily.

  13. Anny Luty

    Hi David and everyone at NOI – I just got round to reading the ‘clinical mileage’ from August.
    I was on your first Swiss conference and course in 1989 and 1991. Young inexperienced physio- to me your course opened up a new world. The biopsychosocial model later helped me greatly as I used to be frustrated thinking the only reason my patients got better is because I am a nice person and make them laugh- I was considered a good physio by patients and colleagues whereas I knew/thought I was really a sham- just have the gift of the gab and good people skills. You made me realise that these skills are just as valuable as my manual skills.
    I treat a lot of chronic pain patients now and I still use my my manual skills especially in assessment -it’s a way of validating the patient’s symptoms, to gain their trust and motivate them to be receptive to the non-manual part of treatment 🙂
    Thanks for your work and sharing your insights!

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