All posts by richmondstace

09Jul/17
Andy Murray's hip

Pain and injury at Wimbledon

Why is there so much pain and injury at Wimbledon this year?

Pain and injury at Wimbledon

Seven retirements and a very painful injury on-court yesterday at Wimbledon have given the tournament a different feel. Pain and injury are part of sport, but many people have been surprised by the turn of events. Federer has called for a review of the system and several players have complained about the state of the courts. All are factors of course. The game is simply made up of the synergy of players, court and tournament. When all are ticking, we see great tennis.

The very painful moment

Bethanie Mattek-Sands was screaming out in pain this week after her knee appeared to give way. One report suggested that she could have sustained a knee cap dislocation. This can be extremely painful until relocated. Seeing the dislocation can add to the trauma. When our body does not appear as we expect, the sight can trigger feelings of aversion.

Why so much pain?

Pain is a part of the way we protect ourselves. There are many other things going on when we are in state of protect: change in movement, change in sense, altered thinking and emotion, change in perception. In other words, the world looks different and feels different as we take action in the name of survival. This is a normal shift of state in the face of a perceived threat. Pain is a lived experience when there is a perceived threat. Pain is not well related to injury. This is the common misunderstanding. Just because it hurts a lot, it does not mean that the injury is more severe. We have known this for a long time ~ see here: pain in sport, 3 key points.

When thinking about the reasons for the pain response, the context is key. In other words the situation plays a significant part in the pain experience. As well as potential tissue injury, where that possible injury occurs and what is happening is highly relevant — it always has to happen somewhere! The full picture perceived creates a learning opportunity. If this is possibly dangerous, I need to remember what happened and where so that next time I can react differently.

All of this information is processed together with sensory information from the body, based upon what is already known about injury and the situation. In essence we make a best guess about the possible causes of the sensory information on a background of our previous experiences. In effect, we weigh up the evidence: new information vs what we know, which then suggests a scenario. If this is a potentially dangerous situation, pain can then form part of the experience. The more danger perceived, the more intense the pain.

How much danger did Bethanie perceive when her knee gave way at the biggest tennis championship in the world, in front of a big crowd, when each game is career shaping?

Whatever the outcome for Bethanie, I wish her well.

Messi’s knee

In 2012 Lionel Messi was running into the box when he brushed the keeper as he came out to meet him at speed. Messi managed to get a shot away (he missed) before he hit the ground clutching his knee. He was quoted as saying that he thought his career was over because of the pain.

How dangerous was the situation to Messi? Consider: the perceived injury (he did not know about the extent of the damage at that point), the game, the crowd silent, the body part involved, how knee injuries are thought of in the culture of football, the immediate thoughts about injury and what it means and much more.

Messi was taken off the field on a cart and whisked to hospital where he was scanned. What was the injury? A bruise.

Pain and injury are not the same. The terms are often used synonymously, but this is not correct usage. A further example is phantom limb pain. The person suffers pain in a limb that no longer exists.

Pain and injury

Why have there been so many injuries?

We have seen multiple retirements during games at Wimbledon this year. Whilst some people have been frustrated, we must also consider that these players have to make choices. These are based on the culture of the sport, the system, their career, their income and their understanding of pain.

There will be a weighing up of the pros and cons, and each individual will consider different factors before deciding. We do not know what those factors are in each case, so we cannot make any specific assumptions or criticise. In life, how many assumptions are made when someone is being critical of another without knowing the full picture?

“aches and pains are part of sport

In sport, the day to day aches and pains are a well known part of the deal. Simple measures are taken to address theses responses so that the athlete can continue to perform: e.g./ physiotherapy treatment, massage, ice baths, stretching, periodisation. However, despite the level of fitness, each body needs to adapt to the demands of the training and play. Without this time, there can be a tipping of the ‘build-breakdown’ balance towards the breakdown (inflammation). A state of chronic inflammation is likely to explain a range of common problems that can become significant.

When an acute injury occurs in sport, there is pressure to resume play as soon as possible. Do players return too soon? Are they fully ready? Being ready means that the body tissue are robust to withstand the stresses and strains, movement patterns are normalised (and not guarded), body sense is acute and thought patterns focus on the game and not on the body.

“the clues are in the story

We do not know all the factors involved with each player at Wimbledon who had to retire, but the points described above are relevant and need consideration. When clinicians are assessing an injury, this is especially so. Each injury or pain moment (the two are different) occurs in a context as we have established. Nothing happens in isolation, we are on a timeline, and hence we must consider how the person may be primed by prior learning. What are the influences upon this current moment? Some will be obvious and some more hidden. This is why allowing the person to tell their story is vital. The clues lie within their narrative, so we must listen actively and be open.

This is a brief look at some of the key issues. Pain and injury are always going to feature in sport. We need to draw upon the pinnacle of our knowledge of pain and bring this into the athletic world. In other words, we need a shift in the thinking away from the biomedical model, instead looking at the wider picture: a true biopsychosocial, or sociopsychobio model. Here is a reminder of the key points:

The key points:
  • pain and injury are poorly related
  • pain is suffered by the (whole) person not a body part (e.g. tendon pain ~ the primary focus remains on the tendon rather than the person)
  • pain does change when it is understood by the person and they actively create new patterns

04Jul/17
Pain and injury

Andy Murray fit for Wimbledon ~ pain in sport: 3 key points

Andy Murray fit for Wimbledon ~ pain in sport: 3 key points

Andy Murray fit for Wimbledon ~ pain in sport: 3 key points, but first…

What does Andy Murray have in store for fans this year?

Undoubtedly Andy Murray is resilient. He declared himself fit for Wimbledon 2017 and he has just beaten Alexander Bublik to take a step closer to the final: one game down, six to go.

There were concerns in the media about Murray suffering left hip pain during the build up to Wimbledon. Apparently this is a problem he has had for many years, however he is not going to let this stop him from giving his best. We have become used to his determined attitude, one that he has had to develop towards pain and injury in particular.

Clearly performing at the elite level has an impact upon the body, which is why the conditioning must be right to check the physical stresses. But, we are more than a physical shell. We are a ‘whole person’ and hence being resilient to life’s challenges is a key skill. This is an exciting time for Andy Murray as he embarks on his defence of the title whilst expecting a second child with wife Kim. Being able to put aside the hip pain, he could even be using this wonderful news as an inspiration.

In 2013 I wrote a blog about Andy Murray, back surgery and microdiscectomy. It still gets a fair few hits, particularly at this time of year when people are reading about him and Wimbledon. I stated that the rehabilitation “is not just about exercising. It is about understanding, learning, motivating, creating the right context for movement with confidence and many more factors that can lead to optimised outcomes”. Since then Murray has had a remarkable time, currently holding 45 titles.

“rehabilitation is not just about exercising

Murray fans now hope to enjoy (is that the right word?) the next two weeks. The pinnacle would be next Sunday watching a closely fought final with a Murray victory. Who knows? Sport these days chucks out surprises that ultimately keep us all riveted. Look at the Lions last Saturday!

Now, my blogs would not be my blogs if I didn’t somehow turn the thinking to pain. One of my favourite areas of discussion is pain in sport, in particular chronic pain in sport. Yes it exists! (Some people seem to think it may not….). Many times I have given my lecture and talks on the topic, encouraging modern thinking about pain to emerge in the sporting realm. There are some simple principles to begin with, and we can use Andy Murray to illustrate the points.

3 key points

Pain and injury are neither the same nor well related

We have known this for many years. The famous lecture and paper was in 1979! So when you see Murray in pain on the TV, this does not tell you much about the state of his hip. It does tell you that his body systems are in protect mode, compelling a range of behaviours and actions that can be seen. Pain on the other hand, cannot be seen. Pain is a lived experience. Can you see funny? Can you see hunger? All these experiences are whole person, which is my second key point.

“pain has only a weak connection to injury but a strong connection to the body state

Pat Wall (1979)

Andy Murray fit for Wimbledon ~ pain in sport: 3 key points

Pain is whole person

This means when we are treating pain and overcoming pain we have to think about the whole and not reduce it to a body part or some physiology. If my knee hurts, it is ‘I’ who feel pain and not my knee. Much like thirst. It compels action by me, the agent. Think for a moment: where do you feel thirst? Some may say in my mouth or throat. Think again. That is a dry mouth, which you may interpret as a sign suggesting that you need a drink. Pain always exists in a context. The context is the person, the environment, the action, the perception, and prior experience. Of course this changes all the time, as are we, the dynamic and ‘updating’ humans that we are. This gives great hope because when we tap into our incredible ability and resource, we realise that we can chnage pain and transform our experience. And that is my third point.

Pain can and does change, beginning with truly understanding pain

This has become so important to me over the years that I have set up a social enterprise in that name: understand pain or UP. Understanding pain gives you the foundation that you need to be able to take the actions that get results. Build upon a model of success and using the tools of coaching, in particular strengths based coaching, you set out your vision. What do you want? Then you orientate your thinking and attitude towards this picture of success and do your utter best. This is the route that Andy Murray has taken and continues to pursue, just like any elite athlete or person who has achieved.

These 3 key points are fundamental and continue to feature in my talks and writings. They do so because they are vital ingredients in the clinic. There are many others, but to start with these orientates the person in the right direction. As clinicians we may think ‘treatment’ but we offer so much more. We do treat and this is important. We also coach: we coach people to coach themselves in their world and to immerse themselves in the practices that result in living as best they can. Together we create the understanding and conditions for the person to flourish and feel themselves. They live fulfilling lives with all the joys and pleasures that exist whilst developing the resilience and skills to face challenges and learn. We can do this at any age, and we should be teaching kids these skills right now in schools ~ that’s for another time.

So, good luck Andy Murray and all the others chasing the Championship! We will enjoy watching you all over the next two weeks.

RS


Pain Coach Programme ~ treatment, training and coaching to overcome pain and live life 07518 445493

 

 

22Jun/17
CRPS UK

Delighted to be a trustee for CRPS UK

delighted to be a trustee for CRPS UK

CRPS UK ~ a charity supporting people suffering Complex Regional Pain Syndrome (CRPS) and their carers

I am delighted to be a trustee for CRPS UK. In recent years I have spoken at the conferences and this year was invited to run the 2017 London Marathon for the charity.

CRPS is an example of a condition that can be excruciatingly painful. The Budapest Criteria lays out the necessary signs and symptoms, which is important in terms of a diagnosis and for research.

There are several issues that need urgent addressing and I will help CRPS with their endeavours.

As with other painful conditions, the first problem lies with the misunderstanding of pain. The predominant model remains biomedical, however this approach does not offer answers for persistent or chronic pain. The biomedical model relies on finding a pathology or structural basis to explain the pain. Pain is poorly related to tissue state because it is part of the way that the body protects itself. We have known this for many years, the famous lecture and paper being published in 1979.

“society does not understand pain despite it being the largest global health burden

Early diagnosis is important for CRPS as it guides treatment and prevents unnecessary suffering. This means that CRPS needs to be recognised by healthcare professionals. A common scenario is an incident resulting in the development of the condition, which is not recognised, thereby treated inefficiently, the symptoms worsen and so the cycle goes on. An important note is that poor treatment outcomes and low expectations affect the outcomes. However, the third point is that pain can and does change.

The predominant messages in society (and healthcare) are negative and suggest that the person has to merely cope or manage their pain. With the bar set so low and teeing up the person’s expectations at such a meagre height, no wonder there is minimal improvement. Why would you bother? This is all wrong and certainly not in line with what we really know about pain and people.

We have remarkable potential and need to know how to tap into it. What is getting in the way of recovery and getting better? What are the barriers to living? In exploring these by using our own amazing resources, we can achieve success and change. We are designed to change; you cannot not change! It is a matter of choosing a direction.

“what do you want in life? How does it look?

My Pain Coach Programme stemmed from understanding and believing in people’s ability to change, their resourcefulness (that they may not know they have because of negative messages to self and from others) and the latest pain sciences.

delighted to be a trustee for CRPS UK

Richmond Stace

Who am I?

For those who don’t know me and who are wondering why I have been asked to be a trustee for CRPS UK, here is a brief background. I am a physiotherapist with a background in pain neuroscience, rehabilitation and nursing. For many years I have worked with people suffering chronic and complex pain, giving them the understanding of pain that they can use to get better. In 2015 together with Georgie Standage, who came to see me with CRPS, we created UP | understand pain. Starting as an awareness campaign, UP was launched with a huge singing event.

delighted to be a trustee for CRPS UK

UP is now focusing on delivering the right messages about pain via the new website due to be available as a resource this year, and workshops for people who need to understand pain: sufferers, their families, clinicians, policymakers, patient representative group and other stakeholders.

I am very excited to be working with the team at CRPS UK, driving forward to change the way that the condition is recognised and treated. At the outset, people need to understand pain and know their role in getting better and their potential. Setting the scene from the beginning is vital and then using the right approaches so that the person can overcome their pain and live a meaningful life.

RS

 

 

13Jun/17

Steps forward at SIP 2017

Positive work done at SIP 2017

There were some important steps forward at SIP 2017 last week when stakeholders got together to discuss the societal issue of pain and agree ways forward. Positive work was done by the collective, consisting of patient representative groups, policy makers, clinicians, scientists and others.

It is rare that all the stakeholders meet, making this a very special conference. Here is an initial summary.

Societal Impact of Pain

Steps forwards at SIP 2017

The problems

The title of the interest group itself, ‘Societal Impact of Pain’ or SIP, drew me to the 2017 conference. I firmly believe pain to be a societal issue that has enormous consequences for individuals and the world in which we live. Whilst there are many meetings dedicated to pain, most focus on a scientific programme. This is only part of a much bigger picture that includes socioeconomic factors, culture, beliefs, gender, access to healthcare, understanding of pain and lifestyle, to name but a few. SIP, as far as addressing pain as it needs to be addressed is ‘on the money’. And speaking of money….

Chronic pain is a huge economic burden. The cost of pain to the EU each year is up to €441 bn — today that is £387 bn.

Wake up policy makers, yes that is £387 billion.

Back pain alone costs €12 bn per year in Europe although the most staggering figure is the €441 bn think about all the other conditions that hurt) and the source of immeasurable suffering for millions. It is estimated that 100 million people suffer in Europe.

“Pain causes a problem for individuals as well as a challenge for healthcare systems, economies and society (SIP 2017)

Clearly, what we are doing at the moment does not work. There are reasons for this, including the fact that pain is misunderstood in society: healthcare professionals and people (patients). This results in the wrong messages being purported, low expectations and poor outcomes. This must change and the SIP 2017 meeting was a perfect breeding ground for positive work in the right direction. There were some significant steps forward, emerging from the synergy of different groups gathered together.

What was my purpose?

Representing UP | understand pain, I was attending SIP 2017 to gain insight into the current thinking about pain from a societal perspective. In particular I was interested in the language being used, the messages being given about pain, and the plans for positive work to drive change. Listening to the talks, being at the meetings and talking to different stakeholders, I was inspired. My passion has been strengthened by what I heard. I know that UP is absolutely on track and my aim now is to contribute to the on-going work, primarily by changing the way society thinks about pain — see workshops here.

The message that I deliver, and that of UP, is that pain can and does change when it is understood thereby empowering, enabling and inspiring the individual to realise his or her potential. The individual is part of society and hence with so many people suffering, this means society is suffering. Drawing together the necessary people to create the conditions for change was the purpose of SIP 2017. From the outcomes (see below), this is what has been achieved.

See the SIP 2017 Impressions here: videos and photos

Who was there?

One of the features of the meeting was the range of people in attendance. For fruitful discussion and action it is essential that stakeholders from the different sectors get together. This is exactly what SIP 2017 created. In no particular order, there were clinicians, academics, scientists, policy makers, MEPs, patient groups and organisations, patient representatives and others who have an interest in the advancement of how society thinks about and addresses pain.

Understand pain to change pain

The right language

The focus was upon the person and their individual experiences of pain within the context of modern society. We all need to understand pain for different reasons, although we are all potential patients!

  • People suffering need to understand pain so that they can realise their potential for change and live a purposeful life
  • Clinicians need to understand pain so that they can deliver the treatments and coaching to people in need
  • Policy makers need to understand pain so that they can create platforms that enable best care

I was pleased to hear and see recommendations for coaching, although the term was not defined. Having used a coaching model for some years, I have seen this bring results, as it is always a means to getting the very best out of the individual ~ see The Pain Coach Programme.

Within the biomedical model, which does not work for persistent pain, the person is reliant upon the clinician providing treatment. We know that this approach is ineffective and in turn, ineffective treatments result in greater costs as the loop of suffering continues. Giving the person the skills, knowledge and know-how enables and inspires people to make the decision to commit to the practices that free them from this loop. People do not need to be dependent upon healthcare to get better. With a clear vision of success and a way to go about it, people can get results and live a meaningful life. This is the philosophy of UP and I was delighted to hear these messages at the meeting.

An issue raised by many was the measurement of pain. The way that pain improvements are captured and the desired outcomes differed between people (patients) and policy makers. The Numerical Rating Score (NRS) is often used, but what does this tell us about the lived experience of the person? Pain is not a score and a person is not a number. If I rate my pain 6/10 right now, that is a mere snapshot. It could be different 10 minutes later and was probably different 10 minutes before. The chosen number tells the clinician nothing about the suffering or the impact. It is when the impact lessens, when suffering eases does the person acknowledge change. No-one would naturally be telling themselves that they have a score for pain unless they have been told to keep a tally. We need to understand what is meaningful for the person, for example, going to work, playing with the kids, going to the shop.

Understand pain to change pain

Valletta panorama, Malta

Steps forward

SIP have issued this press release following the symposium:

‘MARTIN SEYCHELL, DEPUTY DIRECTOR GENERAL DG SANTE, FORMALLY ANNOUNCES LAUNCH OF PAIN EXPERT AND STAKEHOLDER GROUP ON THE EU HEALTH POLICY PLATFORM AT THE SOCIETAL IMPACT OF PAIN SYMPOSIUM’

Mr Seychell gave an excellent talk, absolutely nailing down the key issues and a way forward. This has been followed by with positive action. The SIP statement reads:

‘The European Commission is following SIP’s lead and has launched the EU Health Policy Platform to build a bridge between health systems and policy makers. Among other health policy areas, the societal impact of pain is included as well and will have a dedicated expert group.’

From the workshops the following recommendations emerged:

  1. Establish an EU platform on the societal impact of pain
  2. Develop instruments to assess the societal impact of pain
  3. Initiate policies addressing the impact of pain on employment
  4. Prioritise pain within education for health care professionals, patients and the general public
  5. Increase investment in research on the Societal Impact of Pain

A further success has been the classification of pain

Building momentum

Following this inspiring meeting where so much positive work was done, we now need to take action individually and collectively to get results. I see no reason why we cannot achieve the aims by continuing to drive the right messages about pain. This is a very exciting time from the perspective of EU policy but also in terms of our understanding of pain. The pinnacle of that knowledge must filter down through society, which is the purpose of UP.

To do this we (UP) are very open to creating partnerships with stakeholders who share our desire for change. UP provides the knowledge and the know-how that is needed for results, because without understanding pain, there can be no success. Conversely, understanding pain means that we can create a vision of a healthier society that we enable with simple practices available for all. Society can work together to ease the enormous suffering that currently exists. We all have a stake in that and a responsibility to drive change in that direction.

~ A huge thanks to the organisers and Norbert van Rooij


Please do get in touch if you would like to organise a meeting or a workshop: +447518445493 or email [email protected]

 

12Jun/17

What is pain?

What is pain?

Thoughts from the SIP 2017 Conference

Societal Impact of Pain

“Society needs to understand pain ~ what is pain?

Last week I attended the SIP 2017 Conference in Malta where a meeting of stakeholders deeply considered the issue of pain in society. Pain is a societal problem and the way forward will emerge from considering pain in this light. Significant and exciting steps were taken, which will be covered in a forthcoming article on this site and the UP | understand pain site.

Chronic pain is the number one global health burden. The approaches used for pain are not working. We are seeing the figures increasing over the years as more and more people suffer ~ 100 million people in Europe. Why? The main reason is the misunderstanding of pain that results in unnecessary investigations, treatments that don’t work and low expectations. The predominant thinking remains ‘biomedical’ both in terms of healthcare delivered and society’s expectations. Pain is not a medical problem. It is a public health, or societal issue. We are in it together, all of us. Even clinicians are patients!

Where do we start?

The UP enterprise has a purpose, and that is to change the way that society thinks about pain, hence Understand Pain. From the point of understanding comes new belief and commitment to reach one’s potential. The vision is a world where people understand pain so that the focus is upon the practices that foster a healthy, meaningful existence within the context of the person’s unique life. This emerges from co-operation between the person and the care-giver, working together to achieve results. This is the essence of Pain Coach, grounded in pain sciences, modern philosophy and strengths based coaching, delivering results based on what works.

Pain Coach not only gives individuals unique knowledge and skills according to their needs, but also the all-important know how. I may have the best drill in the world, but without the know-how I will still make big holes in the wall as I try to hang a picture. The Pain Coach coaches the person to coach themselves to overcome pain. Conversely, interventions and medicines are ways to circumnavigate the problem. This is not to say that they do not have a role, however, the person learns nothing about facing it and transforming the experience and therefore will continue the loop of suffering. Only by learning about one’s existing patterns and creating new patterns in line with a vision of success, can the person overcome their pain.

“What do you focus on?

What do you focus on? What language do you use to yourself over and over? What story do you tell yourself? You can make the decision to change your story. What can you control? Your attitudes, your thoughts, your day to day decisions are all yours. What do you do consistently? What do you think and embody consistently? That becomes the story of you. You can choose another script. That is the role of a coach, to help you realise and actualise your choices. To help you make decisions but ultimately you make them and commit to doing positive work to move in a desired direction. You decide the direction.

What is pain?

Pain is part of the whole person state of protect. Pain is poorly related to any stage of injury, tissue damage or indeed tissue state. This is the common misunderstanding, that somehow pain and injury are the same or related. This is not the case and indeed Pat Wall, the father of pain science and medicine, stated this in his 1979 paper. Why then, is this not practiced as mainstream? This is one of the key messages for all.

What are we protecting against? Initially there may be some kind of actual threat such as an injury or disease state, which is rightly interpreted by body systems as dangerous or potentially dangerous.  That’s the whole point of pain in a sense, to be so unpleasant that it compels us to take action. It is a vital survival mechanism without which we have no way to detect actual or potential danger. But, the pain itself remains part of a protect state in light of a perceived threat.

“Pain is a feature of a state of protection

When pain persists, aka chronic pain (not everyone likes this term or wishes to be labelled as such), it means that a state of protect is persistently emerging as the prediction of threat frequents each day. The range of cues or patterns interpreted as potentially dangerous seems to widen and widen so that normally innocuous situations are deemed to be dangerous. This does not mean it has always to be at a conscious level as most of our biology operates in the dark, ie/ there are hidden causes. However, expectation does play a role in as much as when we expect something to hurt it does and often more as we prime, raise the threat level, predict to ourselves that it will hurt and guess what?

Pain is not a constant state. There is no constant state, instead we are continuously ‘updating’, dynamically exploring the environment with the aim of meeting our predicted needs. When a person suffers chronic pain, they will experience a number of episodes in a given day, with a more challenging day featuring more frequent or longer episodes, and a better day featuring less or shorter episodes.

We are changing by design. No moment is the same. Like a foot placed in a river, it is never the same water that passes by. So change is not the question, rather which direction will you go? Which direction will you choose? To coach yourself towards a vision of success? To decide to commit to the practices of well-being? When people realise that they do have a choice it is empowering, inspiring and enabling.  We can decide to reach our potential.

Who suffers chronic pain?

Work is being done to discover more about who would be vulnerable to a chronic state of protect. Players include genetics, past experience (e.g. prior pain, early life events) and gender. One way to think about this is that we are on a timeline, so nothing happens in isolation. When I stub my toe, my existing health and sense of well-being will influence how I react both ‘myself’ and my biology. In other words, if I am very tired and stressed, my experience will be very different to if I were relaxed and happy. Getting the person’s story is key to understanding the context.

You can think of life’s events as priming. From day dot we are shaping ourselves and being shaped, right up until this moment. Every experience and everything learned sculpts us, our body manifest of the sum of all the things we have done and felt. The body systems that protect us evolve and become highly efficient, predicting that the causes of the sensory information mean that danger exists. Actively changing the sensory information with new practices, new habits and patterns of thought and action take us on different path. A path onward in a chosen direction. Our attitude to change and belief in our own abilities are both key factors — and both can change in themselves!

“Pain is whole person — it’s not my back in pain, I am in pain. Me

The perception or experience of pain is coloured by many factors in that person’s life, including past experience, beliefs, context, environment, actions (current and predicted), emotional state, attentional bias (what I am focusing upon), other people and more. Pain undoubtedly emerges in the person. In other words, it is the person who suffers pain, not the body region where it is felt. Much like it is the person who is thirsty, not their mouth.

In summary

  • It is the whole person who feels pain
  • Pain is part of the way we protect ourselves in the light of a perceived threat
  • Pain can and does change
  • Understand pain to change pain
04Jun/17

Headache

Headache is a leading cause of suffering

Headache and migraine are in the top 12 of the Global Health Burden of Disease Study (2011)

 

Headaches

If you watched Doctor in the House on BBC recently, you would have gained an insight into the terrible suffering caused by cluster headache. This is one of the many conditions characterised by chronic pain. In this case, there was significant improvement as the family made some important changes. More on this shortly.

Chronic pain is the number one global health burden, costing more that cancer, heart disease and diabetes put together. There are millions of people across the globe enduring chronic pain states. They have little or no understanding of why they continue to suffer and no knowledge of how to overcome their pain. This can and must change, and to do so means that society needs to understand pain ~ this is the reason for UP | understand pain. Pain is a public health problem of huge significance.

The programme hosted by Dr Rangan Chatterjee highlighted the impact not only upon the brave lady Gemma, but also upon the family. It was their shift in thinking that resulted in new habits, which create the right conditions to get better. That was a choice made based upon new understanding. Realising that we have a choice is a key first step. We can make the decision to commit to doing the things that will change our health, our relationships, our performance and our pain.

Pain always occurs in a context and involves life’s habits. On realising the range of influences upon pain, the person can instigate changes that make a huge difference. In the family setting, this involves all members, including children. There are huge numbers of children who suffer pain (1 in 5) and huge numbers who support a parent. This is a vast problem in itself.

A brief look at pain ~ what is it?

Pain is a whole person state of protect based on the existing and prior evidence that there is a threat or possible threat to the person. Much of the processing is subconscious, our biology in the dark (e.g./ you don’t know what your liver is doing right now), emerging as a lived experience or perception. Anything that poses a possible threat can result in pain. It is important to consider that something only becomes a threat when we think it so, and hence the meaning we choose to give a situation makes it what is it.

It is not only when we are thinking that something is a threat to us of course. Our biological systems interpret sensory information and predict that it indicates possible or actual danger. Working on a just in case basis means that we can get it wring. When we are sensitive,m this can happen more often than not, which is why pain can become so dominant. The range of contexts and situations widen and we notice the pain moments over and over. This does not have to continue. We can actively infer something else with new understanding, new actions, new habits and new patterns — that’s the programme.

Pain and injury are words often used synonymously, but they are simply not the same. Pain is part of a protect state, very similar to that of stress, and injury is something you can see. The former uniquely subjective and a perception constructed by the whole person

What can we do about pain?

The short answer: a lot!

The first step with any change is to make the decision to commit to practicing new habits that lead towards your desired outcome. This decision comes off the back of understanding pain because then you realise that there is plenty you can do to change and overcome your pain.

This always starts with developing a working knowledge of your pain so that you can coach yourself: the right thinking and the right actions to get the best outcome. Initially you are likely to need advice, treatment and coaching to ensure you remain on track.

When you understand pain, you do not fear it or try to avoid it, instead you face your pain, learn about your pain and overcome your pain. This is different to taking a pill or having an injection, which circumnavigate the issue. Only by facing the challenge can we transform the experience of pain. Many messages in modern society encourage us to avoid the difficult things in life but they are unavoidable. We are not typically taught skills to face the challenges that will come up, and so when we do have something to deal with, we suffer. This does not need to be the case, certainly when it comes to pain.

This is not to say that pain is not unpleasant. Of course it is, but we can learn how to minimise the impact and work to create a happy and meaningful life, by living and practicing the skills of well-being. By living I mean that you try to do the things that you want to as much as you can. More dated thinking about pain suggests that you have to get better in order to resume living, however I have turned this on its head and said that you get back to living by getting back to living. Getting back to living IS the way to get better.

In a sense there is a template of how your life and you should be, and there is no real separation between the two. When the template of what is actually happening is different to the expected one, this mismatch creates a drive to bring them together. Pain is one of those drivers. So, if we try to live as best we can, we are in fact bringing these two templates together. Of course there will be a certain tolerance, even perhaps a few moments in some cases, but this is the start point or the baseline. Working from your baseline, you can get ‘fitter’ and healthier with the practices you commit to, and thereby point yourself in a desired direction.

“what is your vision of success?

A treatment programme is therefore weaved into your life. You are in the driving seat. This is an important concept as healthcare often puts you in the passenger seat, or as one patient told me, ‘in the boot’. This is not right and will certainly not help the person to get better. The modern understanding of pain tells us a very different story, which is exciting, but must be told as far and as wide as is possible, which is the reason for UP | understand pain.

If you are suffering headaches, you should consult with your healthcare practitioner as a first port of call. You will want to know the possible reasons why you have headaches, but then you will want to know what you can do, what they will do to support you and roughly how long this will take. With an understanding and a direction, with a decision to commit to practices of well-being and determination, it can be transformative.

RS

 

 

 

 

24May/17
Are you ready for clinic?

How do you get ready for clinic?

Prepare for a successful performance

Are you ready for clinic?

 

Remember the excitement of those first clinics? The anticipation of that first patient, the challenge of working out their story and coming up with a solution. The opportunity to practice those skills. The fascination with the narrative blending with the body language and phraseology used by the patient. The feeling of pride wearing the uniform. And so on. All great feelings!

How do you feel now? Are you aware of how you feel now before clinic? Do you make time to notice or do you walk in on autopilot and crack on without any awareness?

When we fall in love, we will do anything for that other person. Take the bins out — yes please! Clear the dishwasher — anything for you!! Six years later…. take the bins out — you gotta be kidding! I’m not your servant! Wash up — no chance, why can’t you do it….. How about acting like the first few months, always? How about acting like those first years of clinic, always?

“have you warmed up?

You go to watch your favourite team. The excitement builds, the crowd are singing, you can’t wait for the whistle to start the game. Then you see the players wandering in aimlessly, not paying attention, just moments before the kick off. Have they prepared before the game? Have they warmed up? Got their thinking in the right space? Attuned to the situation? Players prepare. Musicians prepare. Actors prepare. Should we prepare? Of course!

Let’s create a routine of warming up for our performance today. Let’s get our thinking aligned with our values; what’s important right now? Let’s get focused. Let’s be the best we can be and notice when we are distracted and come back to the focus. In clinic, we are performing. This is our centre court, our pitch, our stage where we work with a person to present them with the opportunity to commit to change to improve their life.

“what’s your kindset?

What were the reasons you went into this job? Why did you choose this career? What is your ‘WHY’? Think about this each day to refresh and renew and drive yourself to be the best you can be. It’s a choice. Feel motivated, feel great about it!

It’s a mindset that you choose. It’s a ‘kindset’ for the people coming to see you — what a privilege that people come to see you. That is an opportunity to practice gratitude as well. What is a kindset? It’s a mindset driven by kindness!

RS

1:1 Pain Coach Mentoring for Healthcare Practitioners and Clinicians: practice the very skills that you present to patients to improve your life, improve your relationships, improve your performance. Feel inspired because you CAN! See more here
05May/17

Exams, stress and pain tips

Exams, stress and pain tips
Exams, stress and pain tips

Exam exhaustion | Felix Neumann

Exams, stress and pain tips ~ It is that time of year again when kids are preparing for their exams. With the emphasis on high grades reflecting success, the pressure on youth has increased. There is the sense that if they do not achieve all those ‘A’ grades, then somehow they are a failure. What a terribly damaging way to go about it, and indeed one of the major influences upon kids health. Levels of pain, anxiety and depression are on the rise. Social media also has a part to play, not the channels themselves per se but the way in which it is used and relied upon as a source of temporary reward ~ ‘likes’ etc. We can and must change this as a society.

One of the most respected and successful sports coaches of all time, John Wooden, made the key point that each person should be focusing upon what they can control and to do their very best. If your attentions are on doing your very best, you will be successful, for you. If you thinking drifts towards the grade ‘you must’ achieve, then your focus is not on doing your best, it is on the grade. Re-focus on doing your very best: maximum effort. Besides, if you are focusing on and doing your best, there is no worry or anxiety because you are doing. Those feelings only appear when we are thinking about being somewhere else, whilst embodying the feelings and hence suffering. That somewhere else is the past or future, and neither exist.

We can realise that this is not necessary as we learn to make other choices. Ask yourself: How am I choosing to feel? Could you choose to think about the situation in another way and feel better or good? Yes you can. Try it and see!

Read hereJohn Wooden ~ Wooden: A Lifetime of Observations and Reflections On and Off the Court
Choice

You could choose to think about something in life you face as a problem, that it is difficult, perhaps impossible or that your efforts are doomed to failure. How are you likely to feel? Or, you could choose to view the situation as a challenge, an opportunity to learn something and seek to find and practice ways to overcome the challenge. How would this feel? Very different. We feel better when we have understanding and a plan that we action because we are actually doing, and this includes writing a new inner dialogue or script. How are you pre-empting or expecting things to go? How often do they actually turn out that way? Well if so, why not water the seeds of positivity rather than anticipate the worst outcome or a miserable outcome? Re-frame your thinking that is always embodied, i.e. we experience our thoughts with our whole self including our bodies — where do you feel the feelings that you label as anxiety? They are remarkably similar to the feelings of excitement but which label are you choosing? Choose another and see what happens.

Here are some exercises from Mike Pegg on Positive Scripting: click here
The inner dialogue

What are you telling yourself? Are you listening? The two are different. You cannot stop thoughts popping in but you can choose what you do with them. The practice of mindfulness is a way of achieving this as you are aware and open to the different thoughts, feelings and emotions as they pass through rather than become embroiled.

Self-confidence relies upon the inner dialogue. No matter what you have achieved before, what you are telling yourself and listening to now is what determines your confidence. Create a positive script about what you can do and what you can control: my own thoughts, my own actions, where I focus, doing my best.

Developing insight into your own mind creates the opportunity to choose your direction. We are always changing, but which way do you want to go?

Some great reading on how to communicate with yourself and others: Thich Nhat Hanh
Movement and posturing

Movement and exercise are healthy. During periods of revision we need to move to nourish the body but also our thinking — the two are NOT separate but parts of you. Changing position, using some exercises, walking, jogging and other activities punctuated through the day help to keep the focus. Some exercise in the morning before starting, changing posture and position every 30 minutes or so and having a good break every 45-60 minutes can help to keep a certain freshness and concentration.

This is about performance and to perform we need to focus in the present moment. Refresh and renew then, are key ingredients.

Recharging and sleep

You need good sleep patterns for healthy functioning. Make sure you have a routine that you stick to through the exam period. Many important healthy activities occur during sleep, including a kind of physiological cleaning in the brain. When this does not happen we can feel groggy and moody the next day.

If you are tired, focus on mantras such as ‘I need energy’ rather than ‘I am tired’. We notice what is on our agenda and therefore by telling yourself that you need energy, you’ll be orientated towards this as a goal: regular healthy snacks, fresh air, movement, mindful practice, periods of relaxation.

Through the day we need to plug in. Refreshing yourself allows you to focus well for bursts of time.

Pain and stress are body (whole person) states due to a perceived threat

People come to see me because thus far they have not been able to recover from their pain problem. This is inherently stressful, which adds to the biological and behavioural mix resulting in on-going states of protect.

~ pain and injury are poorly related and are definitely not the same

Pain is about protection and not a precise guide for tissue health or state. This is the common misunderstanding that leads to ineffective treatments. Pain and injury are not well related and they are definitely not the same. Pain is a unique perception emerging in the person and belonging to the person. This is one of many we experience but it is a dominant feeling, as it should be, to motivate action in line with getting better.

Persistent pain involves many adaptations that include those in the brain (emotional, reward and emotional centres in particular), the way we perceive the world and ourselves, the way we make decisions, behave and the way we act. The world appears to be far more dangerous than it really is and the rating of threat is applied in normal circumstances, just in case. For example, sitting is not dangerous yet it is often associated with back pain. The body systems in weighing up the evidence and based on prior experience, deem sitting in a chair to be actually or potentially dangerous. It is the result of the weight of this evidence that manifests as pain in the area of the body deemed to need protection and awareness.

Overcoming pain is about changing this weighting of evidence by taking new actions (habits) based upon new thinking (understand your pain), beliefs and expectations.

During exam times there is usually a change in routine. More sitting, less exercise, and potentially more stress depending upon how the individual views the situation. For optimising performance, this must be addressed whether there is pre-existing pain or not.

It is common for pain to increase during times of stress and pressure. This is not because the tissue state changes greatly but instead the perception of threat is raised and hence protection more likely. We can also tend to anticipate certain relationships. For example: ‘sitting will hurt’, which can become a predominant thought pattern unless we work to create a new way forward. We are always changing, it is a matter of which way you choose to go.

Simple practices during exam times can make a significant difference. Starting with understanding your pain, you can choose to use the strategies mentioned previously that include regular movement, appropriate exercise, practicing a positive script, refreshing & renewing, together with mindful practices (that actually enable many of the others), deep relaxation, imagery and visualisation. Making a plan of which to use and when through the revision and exam timetable can make all the difference.

Pain Coach and Wellness Coach ~ to overcome life’s challenges, live well and perform

For appointments or enquires about Pain Coach Mentoring and speaking events, call Jo on 07518 445493
02May/17

Dystonia and the stretch

Dystonia and the stretch

One Day Closer
https://flic.kr/p/dH5H6h

You may think that I am talking about stretching as in stretching a muscle as this is often given as an exercise in dystonia. In fact, I am referring to the point in time when there is an opportunity to stretch oneself and go a little longer without botulinum toxin injections.

Injections are often given at 3 monthly intervals. The effects often begin to be felt at 10-12 days and then there is a period of better control (less spasm, torsion etc) before the pulls and tremors start to appear again. This last phase, and they are not distinct, instead on a time continuum like every other moment, is when the person starts to feel something. They then focus in upon the sensation, toying with the meaning by thinking about it, looking at it, becoming increasingly aware until finally the next injection date arrives and the circle begins again. Although it is not really a circle because each day, each moment is utterly unique.

A modern approach that we take is to use the period of relative quiescence to be proactive by following a training programme. The programme involves actively creating a new way forward with sensorimotor exercises and other practices that addresses the non-motor factors that hugely influence how we move. These include attentional bias, emotional state, environment, context and past experience. There are many more. Without comprehensively addressing the person, their life, the condition and how these interface as a lived experience, it is likely that the 12 week cycle will continue. We can do better.

When we move we are fulfilling a prediction that has already been made, mainly by the brain, based on what we know and what has happened before. From this you can probably see how the pattern continues until you start making new predictions. That is the programme: new thinking, new understanding, new expectations, new exercises, new practices, all of which create the conditions for a change in a desired direction. We are always changing, but which way do you want to go? You have a choice.

~ how am I choosing to feel right now?

We always have a choice in how we think about things ultimately. Initially we may have the habitual thought, but with practice we can write a new script. And that script influences how we move.

Movement is part of who we are and what we do. We need movement to survive. Losing the precision and awareness of body sense are key observable features of dystonia and we can practice exercises to improve both. By investing time and effort, and doing your absolute best, you can forge a better experience when you can concentrate on living, being healthy and happy, and when you face one of life’s challenges, you do so with resilience, clear thinking and determination.

The stretch comes when those first feelings begin. You continue to use your practices, keeping a focus on your desired outcome and being inspired by successes you have noted down along with way. You stretch yourself so that you go just a bit further, gapping out the time between injections. Not so much that you suffer greatly, instead feeling a sense of achievement and that you are heading in the right direction.

This is an approach not just for dystonia but also for pain and other challenges in life. We seem to have a tendency to try to avoid unpleasant feelings and situations, which makes sense. The problem is that we cannot avoid them and so developing a way to see an opportunity to learn and grow makes it a challenge to be overcome, an experience to transform.

You can when you think you can.

Pain Coach & Dystonia Coach Programmes to overcome challenges: call us to start your programme 07518 445493 or email [email protected]

 

01May/17

High Performance Sport Knowledge Exchange 2017

High Performance Sport Knowledge Exchange 2017

~ some comments following a really engaging day when I was delighted to be asked to speak at the High Performance Sport Knowledge Exchange 2017 held at the Sport Ireland Institute last week.

I was fortunate to share the speaking platform with Dr Brian Cunniffe, Performance Lead from The English Institute of Sport, and Jason Cowman, Strength & Conditioning Coach of the Irish Rugby Football Union.

It was a great day of discussion amongst people involved with optimising performance, both their own and athletes ~ S&C coaches, elite performance coaches, physiotherapists, support staff, doctors, military personnel and more. I say ‘their own’ because the success of an athlete or sportsperson is intimately related to the way in which the coaching and support staff operate. We are all seeking to do our very best, every day.

Here is a brief summary of some of the points that were raised and talked about in relation to my talk and Q&A. Some great questions were asked.

~ Make each day a masterpiece ~ John Wooden

Despite the talks appearing to be very different, there were in fact some common themes. The emphasis was upon how the team can best function to deliver results, considering communication, facing challenges, developing relationships and trust, and creating a team that delivers. At the heart of this of course, are people with differing backgrounds, views, beliefs, experiences, knowledge, cultures and professions. Everyone has strengths and something to bring to the table, which is where the potency arises once these are clarified.

** As you read and take note, consider that these skills of performing and well-being are as relevant to the coach, physio, doctor, support staff as to the athlete.

Language & the inner dialogue

Language is powerful ~ the language we choose to use with others as well as the language we use to ourselves, the inner dialogue or script. Certainly in my talk and in the Pain Coach day on Tuesday I put an emphasis on developing skilful use of our inner dialogue. So much of what we experience and how we experience it comes from what we are telling ourselves. Realising this and harnessing the potential from running a positive script is hugely empowering. This is a skill that a performance coach, a strength and conditioning coach and a physiotherapist (anyone actually!) can foster and nurture in themselves and those they work with, the athletes and colleagues. Here are a couple of great questions to self that allow you to calibrate and make a new choice:

How am I choosing to feel? How am I choosing to think?

What you are telling yourself right now impacts upon your emotional state and quality of life. Which seeds are you watering? The ones that foster positivity, understanding, compassion, openness and patience or the ones that harness anger, frustration, impatience, and resistance? Developing one’s awareness of the workings of the mind and how thoughts are embodied creates a great opportunity to live increasingly well. This includes the ability to focus and hence perform. There is only this moment in which to focus and perform, whereas the inner dialogue can tend to take us off into the past or future. Of course this will happen but there is a difference between the drift away from the now with awareness and on autopilot. We do not have to be slaves to the wanderings of the mind. Simple attentional training and mindful practices help to develop this skill. We know that a wandering mind is an unhappy mind, so this kind of training is a key skill.

Super-teams

Super-teams can be created to nurture the abilities of the athletes. One of the problems of chronic pain is that people can fall in the cracks between different disciplines. This need not happen with a super team in place that has a clear vision of success that has been clarified and stated. This is known by all team members who have identified their strengths, their reason and purpose and their individual roles. Communication is effective, regular and uninhibited. Strengths are developed and areas of improvement identified and worked upon with a complete focus upon growth together. Naturally this includes the athlete ~ there is no separation between team and athlete, athlete and team. Regular meeting and clarification maintains momentum. The team is steered by a leader who is prepared to truly lead and inspire action by exhibiting courage, authenticity and compassion. This takes time but is of course worth the effort in terms of outcomes.

The problem of pain & pain in sport

Pain is a huge global health burden. Pain costs society because of investigations and treatments, many of which are unnecessary or ineffective, and loss of productivity. The suffering for individuals is immeasurable and of course those close by also suffer the consequences.

The existence of such a significant problem in society means that this is a public health concern of major proportions. Without new thinking this will likely worsen. Arguably we are seeing this in the younger generation as they grow in a world that validates materialism, unhealthy communication (e.g. social media), thinking that the individual supersedes everything (i.e. selfishness), success based on ‘A’ grades or income and pressures to conform to practices that do not nourish self-compassion. 1 in 5 children suffer chronic pain and the statistics on mental health are horrific. I do not use that word by mistake.

I do not believe that the term mental health does justice to the reality that the ‘mental’ condition is embodied, which is why in most cases chronic pain and depression or mood changes come hand in hand. Thoughts are embodied, which is why practices that develop healthy use of the inner dialogue are vital. 

This problem reaching across society means that it does exist in sport. One of the challenges is to differentiate between the pain of being an athlete, the pain of a new injury (expected and understood) and the persistent pain that is due to a range of biological and behavioural factors. This will need athletes and coaches to learn about pain and communicate together with the athlete to establish what is happening and what needs to be done. The super-team vision will include these scenarios in the planning.

~ pain and injury are poorly related

There is no single clinician or therapist for pain. This is a problem and indeed perhaps part of the wider problem (the misunderstanding of pain in society), as the person suffering receives many different ideas about the possible causes and suggested solutions. This is the reason for Pain Coach, which is a blend of the latest understanding of pain together with known coaching methods that work to maximise learning and potential. The over-arching aim of the Pain Coach Programme is to change the way society thinks about and hence addresses pain. And there are exciting times ahead on the basis that we need to be talking about and enacting overcoming pain, not just managing and coping.

#upandrun

In relation to sportspeople, we can focus upon an understanding of pain that works for performance coaches, S&C coaches, clinicians as well as the athlete himself/herself. Working together to understand will be key and there is no reason why workshops cannot be run with the super-team that includes all these people. In fact, everyone needs to understand pain ~ the reason for UP | understand pain.

Chronic pain in sport is a blight upon the careers of many. Open discussion and an open forum for athletes to talk and express their fears is important as this provides an opportunity to face the problem, or rather the challenge, learn and overcome. Only by facing our challenges can we truly surmount them and move on. Distracting, avoiding and circumnavigating do no good in the long-term. I acknowledge that there is a place for a ‘patch up’ before an event if need be, but thereafter the challenge must be addressed. Again, the super-team creates the environment and context for this to happen.

Communicating

Language and the content of the inner dialogue has been mentioned but what about delivery: Who? When? How? And there’s the vital part, active or deep listening. Only through listening deeply can we truly hear what is being said. Paying the fullest attention (there’s the practice of paying attention again!) to this moment and what the other person is saying creates a trusting bond and an opportunity to gain insight. This insight delivers all you need to know right now. Sometimes just listening is all that is needed right now. The gifts of ‘you’ and time are two of the most valuable in life. This is easily practiced both at work and at home and soon enough you find yourself to be proficient and increasingly effective.

Some good questions for self:

~ after a training session, who speaks first? Who does the most talking? Who has the key information? 

Summary

There was much more discussed through the day and in the Pain Coach day on the Wednesday before. Hopefully this has provoked some new thinking and realisation. The beginner’s mind is open to possibility and opportunity. We are designed to change and grow as each moment passes. It is a matter of choosing which direction, which begins with realising that we have a choice. The awareness of choice is empowering and exciting but comes with responsibility.

All of us in the room have great jobs that we are passionate about and feel inspired to perform each day. We have meaning and purpose. This drives us to be successful because we always strive to be the best that we can be. That is exciting and fulfilling.

Choose to feel excited.

RS

For further information about Pain Coach training and mentoring, please do get in touch: [email protected]

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