All posts by richmondstace

27Aug/16
Busy

Busy

BusyEveryone is busy. We are busy doing all sorts of things: working, cleaning, gardening, studying, exercising, reading, watching TV, listening to music. In fact, when we are occupied, we are busy doing whatever is occupying us, even if this is lying on the sofa; ‘I am busy lying on the sofa’. So it is a given that we are all busy, even if someone else deems us to be doing nothing, because I am still busy; busy doing nothing. When I am asked if I am busy, I always think about how to answer because in essence it is like being asked whether you are breathing. We are always breathing, we are always occupied with something.

Naturally, some occupations require more energy that others. The exertion of exercise or the concentration upon a piece of work would be deemed effortful, utilising our finite energy resource that is built from our intake of nutrients and rest, including sleep. Good sleep is fundamental for health so it seems — we know what it feels like the day after a bad night’s sleep. Building up our energy reservoir is important for engaging effectively with life: moving, thinking, focus, performance, communication. What fills our consciousness is impacted upon by how much energy we have in that moment. Tiredness tends to cause our attentions to drift towards the negative. How do children react when they are tired? Adults are not necessarily very different!

Sleeping well does not come easily to many people. Crafting a good sleep habit takes time and perseverance, and not just on the way to bed, through the day. With so many people suffering the effects of stress, which switches their biology to survive instead of thrive, night time continues to be a period of alertness, on the lookout for danger. Of course there is no danger, except thoughts that pass through the embodied mind as past is re-lived and future anticipated. Being present is the antidote, and there are simple practices to achieve this (next blog: simple skills).

Sleeping at night is not the only time we need to refresh and renew. We also benefit from regular bouts of relaxation during the day that allow us to recharge. Recharging underpins performance, as to perform optimally we must engage and focus, which we can only maximise if we have energy. Every 90 minutes, taking a break and refreshing with simple practices is a good start point, diarising if necessary. Additionally, each day a period of 10-20 minutes of deeper relaxation is important. Some people will have a longer bout of rest between 12pm and 3pm — the siesta is a great idea. You may be thinking that you don’t have time for all this rest, however, the gains in energy allow you to perform with greater efficiency. Multi-tasking is a red herring; it simply means we are doing several things without our full focus. In summary, without refreshing and renewing, energy levels dwindle and performance fades so in fact we cannot afford not to factor this into our day.

Athletes periodise their training. This is a habit we can adopt day to day to optimise performance as individuals: e.g./ work, relationships, activities, communication. It is easy creating a new habit. It just needs practice. So, be busy, but make sure you have enough energy.

Pain Coach Programme to overcome pain problems and to optimise performance | t. 07518 445493

27Aug/16
If pain

If pain

If painIf pain was understood, there would be less suffering.

If pain was understood, the right messages would be given from a young age, sculpting behaviours based on what needs to be done.

If pain was understood, there would be no fear about it.

If pain was understood, we would focus on what we can do to feel better.

If pain was understood, it would be known that listening deeply is the first step to help someone transform their pain.

If pain was understood, it would be known that understanding pain changes pain.

If pain was understood, there would be an enormous amount of money available for a better society.

If pain was understood, it would sit in the realm of public health and not medicine.

If pain was understood, there would not be the reliance on medication.

If pain was understood, what would the world be like?

— this is the mission of UP | understand pain; to globally change the understanding of pain, because put simply, the world would be a better place if pain were understood.

www.understandpain.com

23Aug/16

Inequalities in pain relief

A brief article in yesterday’s Guardian highlighted one of the inequalities in pain relief. The author, Grace Rahman, focused on the question why black patients are given less pain relief in the light of recent research. With pain being the most common cause of Emergency Room visits, there is plenty of data to analyse. This is likely to be the same in the UK, pain being the primary vehicle that takes people to seek help. As a significant aside, it astounds me that pain is so low on the public health agenda in terms of funding for research as well as overall recognition.

Depression and chronic pain take the first two positions in global health burdens — they cost us the most. Yet where are the campaigns? Where is the TV coverage? They do not exists despite the fact that pain is a universal experience, except in an unlucky few with a rare genetic disorder, which is normal and necessary for survival but so deeply troubling when it persists. Therein lies a major issue contributing to the question penned by the journalist: why are black patients given less pain relief?

Previously, young babies may not have been given pain relief and older people may still not receive adequate pain relief, especially those who are cognitively impaired. The aggression seen in someone suffering dementia may well be due to pain that a simple analgesic would relieve. The misunderstanding of pain underpins all of these contexts, resulting in poor treatment that is based on the wrong thinking. The lack of pain education is incredible when you consider it in this light.

A study quoted by the author highlighted the knowledge gaps of white medical students who rated pain levels to be lower in black people when looking at case studies. Why would this be the case? It was thought to be due to ‘entrenched ideas’ about how people differ biologically and about how they behave in relation to using medication.

Each person is unique with their own personal experiences and narratives of their life to date. This makes an individual’s pain unique, and at any given moment our lived experience that could include pain, is also unique. I have never had this moment before and never will again. So even in the individual, the pain is never the same. We are always changing as we build up prior experiences with every passing moment in time. Understanding this is important and also delivers hope, because when combined with a working knowledge of pain and what we can do to actively steer a desired course within realistic parameters, we actualise change.

Therefore, as clinicians and as a society we must appreciate that each person’s experience of pain is unique and just as they person says it is — listening deeply is vital to gain an understanding with the required compassion. Just spending those moments with the person, allowing them the time and space to describe their experience allows a calming. We must certainly appreciate culture, gender and beliefs as we impart the truth behind someone’s pain, giving them knowledge and skills to overcome their pain and what fuels the sensations. This is the same for every person — whatever the colour of your skin, age or sex. Deep listening, compassionate speech and a focus on what action to take in this moment.

Much suffering comes from how we think about our pain, which is why we feel better when we understand pain and the fear dissolves. When the fear and worry decrease, so the pain eases and we can focus on what we need to do to get better. Fear, worry and depression are based on the contents of our thinking from the past or the future, neither of which exist except in our embodied minds. The only real moment is this one, now. Practicing being present and seeing what is actually in front of you by using the breath for example, allows the person to let go and concentrate on this moment. This is the foundation for moving onward in a chosen direction.

Medication is part of overcoming pain. It can be useful when used wisely within a plan that includes how and when the drugs will be reduced. Of course this is individualised to the person, their condition and their needs. Many people choose not to use pain relief, and certainly the opiate based drugs. Everyone wants relief and this should be a primary aim of any treatment programme, however, the person needs to understand how they themselves via their own thinking, perceptions and actions can change their pain. This is the main bulk of the work for that person as they need to be able to coach themselves at any given moment, each day. The strategies and exercises become healthy habits formed through practice that interweaves into the day. Continuing with normal activities in tolerable chunks maintains a sense of living a life and I often say to people that they can only get only get back to living by getting back to living — doing the things you want to and starting doing the things you have not been doing, bit by bit; thinking ‘can’ instead of ‘cannot’. It is just that you need some ways and means to do so as you build up tolerance by following a programme. A simple analogy is all the background work that an athlete would do in order to perform their sport. The programme is the background work.

Bearing this in mind, there is only one way and this is to consider and treat the unique person as much as the condition. In doing so we learn about their suffering and guide them forwards with treatment that gives the person working knowledge of their pain and skills so that they can coach or mentor themselves forward by thinking and acting in such a way as to take them forwards.

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Pain Coach Programme for persistent and chronic pain | t. 07518 445493

 

22Aug/16

Learn from the Olympics

Whilst we have witnessed some magnificent feats of athleticism, there is always an opportunity for humanity to learn from the Olympics. The humble winners stand out but of course behind each victorious performance is dedication, focus and pure hard work. Nothing is achieved without effort and practice regardless of talent. Let us practice and encourage effort.

There is often a desire to believe in natural talent, and although an individual requires a certain aptitude, without effort there will be limited success. We must work for all that is worthwhile and encourage this attitude. Telling a youngster that they are brilliant or gifted will not necessarily encourage the right attitude. Let us encourage the right attitude.

In particular, watching sports that do not receive the coverage of others is a pleasure. The Olympics was an opportunity to see athletes at the top of their game, performing on the biggest stage. They took their opportunity by mustering every cell in their body, fuelled by a passion and a desire to achieve their dream. The dream is always a medal, but there is a huge chunk of pride that must be taken from being there and taking part. This is also something to consider, being part of something that by and large is positive and inspiring. Let us encourage participation.

This last point is important on a number of levels including the health of society. Witnessing the Olympians will hopefully inspire people from all backgrounds to participate in activities far and wide. There are many so sports to choose from, suiting different individual strengths. Society and policy makers can take note and create opportunities, regarding the benefits of more and more people engaging in meaningful activities. We have land, water and many facilities. Making best use on the back of what has been in Rio over the last few weeks and with what is to come with the Paralympics.

Let us use the examples we have seen and will see soon to inspire us to work hard, to be humble, to support each other and create a better society for all.

 

18Aug/16
Trauma

Trauma

TraumaAll injuries have a degree of trauma, but some more than others. The moment of injury is just that, a moment. Part of the experience is an urge to do something in a way of protecting the self both in thought (what shall I do here?) and action taken. The thoughts and actions, unified into a lived experience of action-perception, are based on prior knowledge and situations as we try to make some sense of what is happening now. As humans, we have a tendency to flavour the present moment with thoughts of the past or future, neither existing beyond the thought itself. The problem lies in the fact that the thought is embodied, resulting to a greater or lesser degree from the current body state, which we then fully experience with sensations in the body, feelings and emotions; embodied. For example, purposefully thinking about a prior happy occasion usually fills you with the same feelings of joy and pleasure as if you were there again. The same is true for thoughts of an unhappy situation in the past. However, this body state is continually updating and hence we are in a position to steer our change in a desired direction by thinking-acting in a way that aligns with our values and vision of how we want to be. We purposely put ourselves into situations to get better.

Understanding the state of the individual before the trauma and at the time of the trauma provides important insight into the subsequent unfolding of events. A person experiencing persistent pain continues to suffer despite the tissues (body) healing, which they do to the best of the body’s ability, because the systems designed to protect us continue to be vigilant to potential dangers. These potential dangers soon become normal day to day situations, now regarded as posing a threat to the individual’s survival, hence the pain to motivate defensive thoughts and behaviours. The longer these habits persist, the more suffering. But, this is not set in stone and indeed the practice of new, healthy habits steers a new course. We are designed to change and we can decide on the direction, using new habits to get there. Not always a smooth route, it is the one that takes you towards a meaningful life as you overcome the challenges with new understanding of pain and the best course of action. Maintaining this course also relies upon recognising distractions (unhelpful thoughts that affect mood and motivation — old habits) and re-orientating to the desired route.

Healing is not simply about the muscles, bones and other tissues repairing. It is about the person resuming their sense of self — ‘I feel like me’. This is a process of understanding, adapting, gaining insight into the causes of suffering, the practice of new habits and gradually engaging once more in normal activities including socialising. I think about this as getting back to living, by getting back to living instead of waiting for pain to subside before re-engaging. The re-engaging itself has a role in getting better and pain easing. This comprehensive approach, or whole-person approach, is key to success.

A pure focus on tissues means that the person living the experience is neither acknowledge nor addressed. There is the pain, the injury (the two are not well related) and the person’s appraisal of both, which if not validated and considered, means that a huge source of suffering is neglected. This does not mean in-depth psychological assessment, instead recognising that there is an individual with a story that needs guidance towards getting better. We are more than an injured leg or back. Insightful and compassionate clinicians will work in an egoless way as they focus on the person getting better by helping them to understand how they create the conditions for their health — environment, surrounding and influential people, their programme. We often use the phrase ‘I want to go back to how I was’, but of course this is impossible as we cannot go back in time. What we can do is adapt and focus on getting fit and healthy, and in so doing the body, the self, predicts less and less need to protect and hence the pain changes as we get better.

On first seeing a person who has experienced a trauma and on-going suffering from their persistent pain, we must consider prior health, pain experiences and beliefs about how we overcome problems. It is common to have had or to have other sensitivities, sometimes for many years, which exemplify a pre-existing state (or pain vulnerability) that has been primed by painful episodes over the years. This means that a new injury or situation deemed in need of protection will arouse a more vigorous and potentially prolonged set of protective responses, vigilant and fear-based behaviours. Knowing this from the outset means that the new issue can be addressed fully. Examples of common prior conditions include irritable bowel syndrome, migraines, jaw problems, persistent aches and pains (e.g. back pain), pelvic pain or period pain. These sensitivities can have arisen as part of an overall protect state following early traumas in life that have triggered the protect state, which has continued to emerge in many circumstances including normal ones. We learn to avoid and look out for trouble and can see it in the face of day to day activities, resulting in persisting pain and anxiety. However, with change occurring every new moment, we are able to transform this suffering by seeing things for what they are as opposed to being lost in thoughts about the past or future that arouse unpleasant sensations and emotions (in the body — we are embodied).

In discussing emotions and thoughts, this does not mean that we only focus on these dimensions. As stated earlier, we must focus on the person and their unified experience that is constructed by their brain, mind, person, body etc. On shifting a thought purposefully, inferring something different, we immediately feel differently about that situation. ‘How are you choosing to think about this?’, you could ask yourself. ‘Is there another way I can look at this?’. Recall the experience of where you feel emotions. It can only be in the body as thoughts are embodied. They are not ‘out there somewhere’, they are here, in me. My body state determines my thinking as much as my thinking determines my body state. Sit up for a while and notice how your thinking and feeling changes. You can gain insight into how someone is feeling by observing their posturing and manner. Imagine going into a business meeting to find the person you are about to discuss a deal with, sprawled across his chair with his feet up on the table. He has not said anything yet you gain insight into his approach, character and manner. Will you do business with him? Further, force a smile by gripping a pencil longways between your teeth, look in the mirror and notice how your feelings and emotional state change.

We are complex, predicting what needs to be experienced in any given context based on what we know. There are a huge number of variables that we cannot account for as we are only aware of a very thin slice of what is going on in any given moment — what we are conscious of, making many assumptions from prior learning. In terms of persistent pain, the intensity, the impacting nature of the experience usually far outweighs any signs of ‘damage’ or injury. Often there is evidence of natural degeneration that slowly evolves, quietly informing body systems which predict the meaning of the information, eventually reaching a point of conscious protection when it hurts. This is a slow burner with a point in time when pain is noted. 

In trauma, there is an obvious incident, which is embossed upon the person at that moment in time. The reverberating effects from there on depend upon that person: what they have experienced before, how their body systems predict the causes of the sensory barrage, urges manifesting as behaviours and actions taken, thoughts about the situation (meaning, attribution of causes etc.), emotions that emerge and the onward unfolding of these experiences unified as the story. Naturally the time frames vary according to the conscious awareness of the person, wherein a head injury would impact on memory of the event. In an emergency situation, clearly there are priorities for the medical team to protect the person and maximise the chances of survival and sets the scene for recovery and healing.

From the earliest possible time point, the right messages about what has happened and what needs to be addressed should be purported. The person needs to understand their pain and problems so that they can focus on the right action to get better. This is day to day, moment to moment as the advice and education are taken, internalised and become second nature as new healthy habits are practiced. The notion of the Pain Coach emerged from this thinking, blended with a strengths-based approach. Strengths-based coaching focuses upon developing a person’s existing strengths and managing their weaknesses. On the basis that we are seeking to focus and perform to the best of our ability, the strengths coaching method offers an effective modus operandi stretching across recovery from injury to sports and business performance. Strengths are many, and can include perseverance, attention to detail and compassion. People often realise that they use these strengths in other areas of their life but not in relation to getting well again.

Experiencing trauma in life presents the person with a challenge in many different ways. It also presents a challenge to those around them including family and friends as we are not in isolation to others or the environment in which we reside. There may be a region of the body that has been injured or affected, however, it is always the person who has to deal with the situation and recover. This is a key point that can often be missed, particularly when the injury is complex and multiple parties are involved in the treatment planning. Whilst we discuss the incident, the injuries, the symptoms and the impact upon that person’s life, they are living that life and only they know what that experience is like. This is the reason why deep listening is so important from the outset. It is the person who heals and recovers. It is the person who gets better, and hence it is the person we must know and treat as much, if not more, than the condition because each of us will experience our life events in our own unique way.

The Pain Coach Programme to overcome persistent and complex pain | t. 07518 445493 

15Aug/16
get the most out of your exercises

Get the most out of your exercises

get the most out of your exercisesIt is highly likely that when you visit a physiotherapist you will be given exercises and hence here is a brief guide to how you can get the most out of your exercises. The training is important, setting the scene for a desired change, but in order to be successful, we need to think about how we will be doing the exercises. In the Pain Coach Programme, we look at this in the necessary detail so that the individual can achieve the best outcome. Usually the exercises themselves are very straightforward, with the most complicated piece of equipment being the person, followed by a mirror. That’s it. We need to set the scene, focus, attend to what is happening now, practice, put in maximum effort, perform and learn. Sounds easy!

1. Create the right environment

Where do you do your exercises? How does that environment affect you? Are you doing some of the exercises at home, at work or outside. Notice where you can concentrate with ease and where makes you feel good about what you are doing. We are not separate from the environment in which we find ourselves and hence it can work for us well in creating the conditions to get better. It should be light, spaceous enough to move freely and as calming as possoble without stimuli that trigger survive responses. This includes phones, computers etc that can grab your attention and make you think about something else.

2. Take a moment to be present

To truly concentrate you must be present and aware of what you are feeling, thinking and doing. From there you are able to learn by gathering insights into what you are doing versus what you want to do, making corrections to movements for example. Mindful presence means you are present and aware, rather than being lost in thoughts about the past or the future that are embodied. In other words, our thinking is affected by our body state and vice versa as there is no separation. As an experiment recall a happy time: where you were, who you were with and what you were doing. This is a thought, but how do you feel in your body? So, how to be present? Simply take a breath and notice the in-breath and then notice your out-breath. We can only breathe now so gently concentrating on the breath is a simple way of being both mindful and present. Anytime you notice your attention drifting away, kindly bring it back by noticing your breath.

3. Connecting it all together

We must be fully aware of our mind and our body as a unified experience. How can you learn about your body and how it moves if you are thinking about a meeting yesterday or dinner tonight? You can bring your attention to your breath, saying to yourself ‘I am breathing in’ as you breathe in and ‘I am breathing out’ as I breathe out. Notice how you become aware of this moment, which is the creation of the right conditions for recovery and for learning. You can then expand your attention out to your whole body, thereby connecting it all together in a nourishing way. This only takes a few moments, but without the right attention, the exercise will have a limited effect as you will not realise what you have done.

4. Write a learning diary

‘What we focus upon we have more of’, is a useful way of being. When we notice our positive emotions, which can be subtle, and purposefully attend to them, our thinking broadens. There has been a good amount of research looking at this effect. Keeping a diary is a way of documenting the way we feel and what we have achieved so that when we look back and read what we wrote, we have an accurate view of what was happening at that time. Our memory of what happens is poor, but we do convince ourselves that certain things happened or we felt a particular way. Whether or not it happened like that becomes irrelevant as it is the memory we think we remember that counts. On this basis, writing down each day something that we have learned from our practices of training is a useful insight that motivates further learning as we focus on our achievements and strengths. This is encouraged by positive psychologists as well as featuring in mindfulness practices and strengths based coaching, and for good reason — focus on your strengths and manage your weaknesses, but you have to know what they are first!

5. Accepting where you are now as a stepping stone towards a desired outcome

To accept that I am here in this moment allows you to focus on what needs to be done right now that is in alignment with your desired outcome. Being really great at all the things that you need to do now will naturally allow you to move to the next step as you continue to transform. We are changing all the time and hence need to ensure that our change is in a desired direction. For this we need a vision of where we are going; a vision of a successful outcome that we visit often to ask the question to ourselves: ‘is this taking me towards my desired outcome or am I being distracted by thoughts of the past or future?’. Acceptance does not mean giving up, instead just saying ‘here I am right now’ and ‘this is what I need to think and do to keep myslf going in the right direction’.

The Pain Coach Programme to overcome chronic pain and injury | t. 07518 445493

09Aug/16
sea

Refresh and renew

seaRefresh and renew is one of the most important strategies that I teach individuals who have been suffering persistent pain. Within the refresh and renew there are a range of techniques that can be used dependent upon place, time and context, all of which are important ingredients making a whole. We are in no way separate from where we are, what we are thinking, what we are doing and what we are feeling. These are merely the conscious elements and of course there are the vast subconscious elements including our biology in the dark.

Being in pain is exhausting, usually added to by feelings of anxiety and concern. There can often be a cycle of pain and sleep disruption, one begetting the other as time moves on. It seems more and more probable that sleep is fundamental for our health, which is why creating the conditions for a consistent daily rhythm of activity and rest is vital. Most people know what it is like to ‘survive’ after a bad night’s sleep, but imagine the effect when this is on-going.

Refresh and renew is needed throughout the day by everyone. Every 90 minutes we may feel an urge to do something: move, take a few breaths (4-5 is good), have a healthy snack or a glass of water. This is certainly the case when one’s health is below par as we need to create the conditions for our biology in the dark to switch into health mode rather than survive mode. The person suffering persistent pain spends much of their time in survive mode as they are both consciously and subconsciously protecting themselves from perceived threats. Consider the person with back pain who walks into a room to survey for the closet chair, whether it is likely to be comfortable or if they will be able to have a conversation because their pain maybe too distracting. The thought processes, predictions, anticipations and expectations that are embodied, will prime the coming experiences. The good news is that creating new habits can change this routine for the better, beginning with being aware that this is what you are doing.

All the extra monitoring and thinking is tiring as you use your resources, along with imprecise and guarded movements that require more energy than normal. Too much muscle activity for example, has a huge energy consequence, which is why refresh and renew is so important through the day. Setting reminders and alarms can be effective in the beginning, but as the new habits take hold and the internal messages become second nature, you increasingly make the choices that orientate you to getting better; your desired outcome.

Pain Coach Programme to overcome persistent pain | t. 07518 445493

05Aug/16
Facial pain

Facial pain

Facial painYesterday I spent the day in Leicester and Northampton seeing several people suffering facial pain with a colleague who has been working in the field. All pains are unique to the person, however, I feel that there are some particular features of facial pain, which are similar to those of facial dystonia. Identifying these shared characteristics has guided treatment and training techniques that aim to improve sensorimotor function as part of adapting and restoring a sense of self.

The loss of the sense of self is a significant part of suffering in my view. People describe how the pain or dystonia impacts upon their lived experiences and their choices, narrowing both. This means that they are not doing what they wish to and hence do not feel themselves as they feel they should. A shift has occurred, part of which is constructed via the ‘physical’ sense of the body. Of course we have a unified experience of ‘me’ including the sense of the body, a sense of a past, a projected future and the inner dialogue that strings it together.

We literally face the world with our face and hence anything that affects our perception of how we are doing this will impact on how I feel, think, the actions I take and perceptions I perceive. There is a spectrum: a red spot through to jaw dystonia — something visible to others that makes us second guess what they may or may not be thinking. Quite easily this can mean we avoid going out or seeing people. The isolation that ensues then gathers momentum, affecting us on many levels including genetically.

In cases of facial pain there may be no clear and consistent visible signs such as the involuntary movements of facial dystonia, however there are often habitual posture and facial expressions — tension, attempts to relax by opening the mouth, rubbing, speech impediments. When we are in pain, our body sense can be different, the perception of the environment can be different, the way we plan changes and our emotional state is one of protection, as is that of our underlying biology. Whilst this is vital for survival when there is an actual threat (an injury or pathology), in most cases of persistent facial pain and other pains, there is no significant injury. The pain is a habitual response to perceived threats that increase in number with time via learned responses and expectations. Things that would not normally pose as a threat now do, including the way we think about ourselves and the world. With a sensory system detecting changes internally and externally, in survive mode we can be jumpy and very responsive.

Facing the world with a painful face is challenging. Understanding pain is the first step to steering change in a desirable direction — how do you want to be? When the person understands that pain can and does change, and that they are the drivers of that change, then new habits can be formed — new habits of thought and action that are practiced over and over to create the right conditions. Likewise in dystonia, the practice of new habits to change the way in which the sensorimotor system is working but integrated with training that addresses the influences upon this system — e.g./ the environment, thinking, emotion. Learning to recognise and let go of unhelpful and distracting inner dialogue, focusing on what you can do, noticing positive emotions and how you evoke them, re-training sensorimotor function, gradually doing more normal and desired activities are all part of a comprehensive programme based upon the neuroscience of pain and using your strengths to be successful.

26Jul/16
Back pain

Back pain

Back painIn today’s Daily Mail Good Health section an article boldly claims that an ingenious new approach to back pain could transform your life. This is indeed a big statement to make about one of the largest ‘public health’ issues — chronic pain and depression are the top 2 global health burdens.

The authors describe the biopsychosocial model for pain (BPS) that incorporates factors relating to the biology, psychology and sociology of pain. This is the model claimed for most modern pain services, although whether all are fully addressed in an integrated manner is a separate point. It is good for the BPS model to gain some air time as it is certainly a step forward in the right direction compared to the dominant biomedical model that would suggest we need to look for a structural or pathological reason for pain. For anyone with even a basic knowledge of pain, the biomedical model will be deemed outdated and lacks any use for understanding persistent pain. This is simply because pain cannot be explained by a structure or pathology.

For the first time, perhaps ever (in my memory), I was delighted to read about danger signals rather than pain signals in the public press. This is a vital piece of information as we do not have pain signals or pain centres, instead we have a biological system that detects salient events and orientates our attention — termed the salience network by Giandomenico Iannetti and colleagues. Conjoining this model with current models of consciousness, AI and brain (e.g. predictive processing) and you are getting somewhere near a very, very good way of thinking about pain. Of course we have some way to go yet and need to be careful about how we frame the current knowledge in terms of existing data.

There are many biological and behavioural changes that occur when we have back pain and other on-going pains. We change with every moment as every moment is unique. We feel that we are the authors of our own inner dialogue and this often means drifting into the past or future, becoming embroiled with what has been (as far as we can recall) and what may be, but of course neither actually exist despite the embodied sense we have in that moment. Keeping a close eye on what is in front of us, also known as being present, helps us to see what is really happening versus a story that we construct. By regularly thinking about a painful event in the past, we can easily ‘prime’ or sensitise this moment. Equally by anticipating pain or projecting ourselves forward by imagining that a movement will hurt, we change our way of moving and the sense of our body as anxiety and tension emerge. This is one of the reasons why awareness of one’s own breathing helps.

An important aside: It is important to clarify here that although we talk about the mind, thinking and emotions in relation to pain, the actual experience of pain emerges in the person and is felt in the body or the space in which the body should reside (for many biological reasons). The notion that pain is in the brain or in the head is nonsense. And, we are more than a brain.

Turning one’s attention to breathing means that you are being aware of this moment, now. There are other important ways of cultivating this skill, which allows you to think clearly about what action you can take to create a new experience, a better experience that takes you towards your desired outcome. Additionally, on the out-breath we naturally relax as the parasympathetic nervous system increases its activity. This is opposite to the sympathetic that is involved with protection in the face of perceived threat. And this is really what pain is all about.

In the face of a predicted perceived threat, we can feel pain as part of a whole person defence strategy. There is no pain system. Instead systems that have a role in protection: musculoskeletal system, sensorimotor system, immune system, endocrine system, autonomic system. Then consider how systems support each other as they are all integrated: the gastrointestinal system’s role in providing nutrients to energise the other systems — consider how many people with persisting back pain also have digestion issues as their resources are diverted away from digestion and towards protect. So, more threat to ‘me’ (the self — that’s a huge area to discuss alongside consciousness), more pain. Less threat to me, less pain. How often will a person report an increase in pain when they perceive to be in a threatening situation. The beauty of this is ‘perception’, because we can change it. So in changing our perception of threat we can change our pain. We are designed to change so we can use this biological advantage and with practice become good at it. Remember, pain and injury have a poor or absent relationship — consider phantom limb pain. There is no body part yet there is most certainly pain.

Our understanding of pain has moved on enormously over the past ten years. We are in a very exciting time now as we draw upon many areas of science and philosophy to advance this knowledge, asking new questions and gathering new data. The biomedical model is not sufficient and the BPS model has been a useful step forward but now we need to think about pain in terms of a public health issue. People need practical ways of overcoming their pain moment to moment, coaching themselves so that increasingly they generate their own better and better experiences driven by internal messages as they motivate themselves to a healthier life. This is the reason for my term ‘Pain Coach’ as the individual becomes their own coach using continuously updated thinking and actions to get better, overcome pain and resume a meaningful life.

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18Jun/16
Pain now

Biology of pelvic pain

Pain nowMost of the biology of pelvic pain does not exist in the pelvis. The same is true for any pain — back pain, knee pain, neck pain etc. Much like the screen turning blank in the cinema, the problem itself is not the screen but instead the projector or the power source. In other words, to think about pain requires us to go well beyond the place where it is experienced.

Pain is of course lived and whilst it must have a location, the relationship between pain and injury is unreliable. With a huge number of factors influencing the chances of feeling pain in any given circumstance, there is a requirement for a perception of threat that is salient and exceeds other predictions in terms of a hierarchy. Once felt, pain compels action much like thirst and hunger. Again, like thirst and hunger, context and meaning we give to the sensations influence that very experience, which clarifies to a greater extent the difference between on-going (chronic) pain and that of labour.

To feel pain we need a concept of the body, which itself is constructed elsewhere as the sensory information flowing from the body systems is predicted to mean something based upon what is already known and has been experienced, we need a nervous system, an immune system, a sensorimotor system, a sense of self and consciousness to name but a few. Where in the pelvis do these reside?

This is not to ignore where we may feel pain as this is an ‘access’ to the pain experience that should be used in terms of movement and touch. However, it is the person who is in pain and not the body part. My pelvis is not in pain, I am. My pelvis does not go and seek help, I do. My pelvis does not ease its pain, I do. So when ‘treating’ a person, we must go beyond the place where the pain is felt to be successful. And it is vital that the person is considered a whole; there is no separation of mind-body. The notion of physiological, body, psychological division etc. etc., just does not fit with the lived experience; I think, and I do so with my whole person — embodied cognition.

Locally one will usually find evidence of protection and guarding, which themselves manifest as the tightness, spasm, painful responses to touch and movement. This is all manifest of an overall state of protection, co-ordinated largely unconsciously accompanied by a range of behaviours and thinking that quickly become habitual — they are certainly learned from priors, our reference point. This is simply why delving gently into the story is important, as we can identify vulnerabilities to persisting pain such as previous experiences of pain, functional pain syndromes, stressful episodes in life; all those things that put us on alert when the range of cues and triggers gradually expand so now I am vigilant and responding to all sorts of normal situations with fear.

The start point is always developing the person’s working knowledge of their pain, which also validates their story. So many people still report that they feel that they have not been believed, which I find incredible. How can someone work in healthCARE and not believe what a person says? Baffling. Once the working knowledge is being utilised and is generating a new backstory, new reference points emerge. We create opportunities for good experiences over and over, moment to moment, day after day, in line with their desired outcome, the healthy ‘me’ that is envisioned from word go. This strong foundation that opens choices once more then permits exploration of normal and desired activities supported by sensorimotor training and other nourishing movements, alongside techniques in focus, relisience and motivation. Realising and actualising change in a desired direction must be acknowledged as the person lives this change knowing that they can.

Pain can and does change when you understand it, know where you want to go and how to get there, quickly getting back to wise, healthy action when distracted (i.e./ flare ups, mood variance, loss of focus etc). The biology of the pain is one aspect, hidden in the dark within us, and the lived experience is another. The two are drawn together to give meaning and to develop an understanding of the thinking and action that sculpt a new perception of self and pain, resuming the sense of who I am, as only known and lived by that person.