22May/16
Physiotherapist's hands

The physiotherapist’s hands

Physiotherapist's handsSynonymous with physiotherapy are exercises and hands-on treatments. And rightly so, because these are our basic interventions that we are expert in delivering. However, it is not just the manual therapy and massage that we use our hands for in the clinic. No, no. There is much more as I will describe below as we consider the diverse role of the physiotherapist’s hands.

The hand shake

In many cases, we shake hands with the patient at the start and end of their session. A hand shake is important and must be right — don’t crush the other person’s hand but equally there needs to be some firmness to communicate confidence and sincerity. The hand shake is accompanied by an appropriate greeting, definitely a smile and followed by an invitation to enter the room or sit down. Think about how you would invite someone into your home, wanting them to feel welcome and comfortable. Not everyone receives a hand shake though, so a different gesture is used to imply the same welcome.

The welcome gesture

Hand shake or not, we indicate that the person can enter the room or sit down by gesturing towards the door or chair. A soft, smooth movement obvious enough for the person to understand your message, and soon the person will feel more relaxed, particularly if you use some words of welcome.

Gesticulation

When talking I use a great deal of gesticulation, both with patients and when lecturing. It is thought that we gesticulate to reduce the cognitive load on the brain — one of many ways that we think by using our body (embodied cognition). Moving one’s hands, we do this to make a point, to act, to demonstrate a movement, to point, to emphasise, to distract, to guide, to communicate, to sympathise….and much more. We can learn to use these movements with great skill as part of the art of communication. So much of our work as physiotherapists is about communication, whether this be helping someone understand their pain, move in a different way, create calm or guiding a mindful practice.

Washing our hands

This is a demonstration of cleanliness and the patient seeing this act is important. We can also use it as a natural break, feeling the pleasure of running water and a light massaging effect.

Writing and typing

There is always plenty to type and write. I have an online note taking system, which means that I type whilst the patient talks but I use a paper body chart to scribble notes about the symptoms. My hands are well occupied with these tasks, transmitting the patient’s words onto the screen or the chart without thought as I concentrate on the story that they tell me.

Guiding movement, reassuring touch and pointing

We may support a body area, or lightly apply pressure to guide the patient as he or she re-trains normal movement. Pointing to where the person needs to stand, signalling the direction of movement and gesturing encouragement are all important jobs for our hands.

Clapping, punching the air, slap on the back…

I love to celebrate someone’s success and will choose an appropriate action along with congratulatory words. It is important that the person knows that their efforts have resulted in successfully overcoming their pain problem. Praising the work that they have done, their courage and resilience will make them feel good about what they have achieved.

Wave

Goodbye for now.

Pain Coach 1:1 Mentoring Programme for clinicians and therapists | t. 07518 445493

22May/16
Sports injuries

Sports injuries brewing

Sports injuriesHaving seen a couple more cases of sports injuries brewing this week, it reminded me how common this issue is amongst the active population. It goes something like this…..

A minor tweak that improves somewhat, but not entirely, hanging around and occasionally reminding you that there’s something going on. Often dismissed as a pain that will get better in time if I forget about it and think about something else. It goes away for now.

Then another body part or region chimes in, sometimes replacing the first tweak, sometimes in concert. You tell someone who will listen that the pain has moved from A to B, as B now demands some attention now and again. Except now and again becomes more frequent, being more now than again, subtly creeping up on you as a more consistent pain. You may notice that your running style has changed, or that you are not concentrating so much on the activity but instead wondering if it will hurt or why it is hurting. Performance suffers.

I have described a two step story when in fact in most cases the person tells me about their pain and as we look back, there are multiple aches and pains. It is not unusual for there to be a slight change in general health, and most definitely lifestyle patterns influence the problem. This is simply because none of the issues are separate or in isolation. It is the person who lives the experience and hence they are the perceivers of their body and environment (unified) as well as the producers of that perception and the action taken.

What is happening?

Some refer to kindling, like a fire building up over time. There is an injury or inflammatory response during a time of vulnerability (e.g. perceived stress, tiredness, illness), or the person is vulnerable to experiencing an amplified protective response due to prior learning — how their protective systems have learned to interpret the possible causes of sensory input. So each time there is a protective response, the effects grow, the impact increases and all quite gradually in many cases.

How did this happen? This is frequently asked as the gradual nature means we forget about the priming or kindling events on the way to what is happening now.

This is why it is important to fully recover from injuries and illnesses so as not to carry over the effects. To do this, one must restore the normal healthy mode, re-train body sense and movement, develop confidence and technique; in essence feel yourself again, which is to say that the focus is on the performance.

Pain Coach Programme to comprehensively overcome persisting pain and sports injuries | t. 07518 445493

** Common persisting pains from sports injuries include back pain, tendon pain, knee pain, ankle pain, shoulder pain, tennis elbow, wrist pain.

19May/16
Cervical dystonia and anxiety

Cervical dystonia and anxiety

Cervical dystonia and anxietyVarying degrees of anxiety are usually described by the person who suffers cervical dystonia and there are a number of understandable reasons. Firstly, anxiety about the condition itself — what is it? What does it mean for me? Will it get better? What can I do? Can anyone help me? Secondly, the person suffering dystonia often has had a tendency to worry in life, frequently feeling anxious, over-thinking things, ruminating and over-focusing on unhelpful thoughts. These are all habits of thought but experienced as that story we tell ourselves, the inner dialogue, that can be so impacting on our reality and perception. Combining these, there is usually an attentional bias towards the feelings of dystonia, the pulls, the tension or spasm, and at these times, the symptoms are worse. Conversely, when distracted or engaged in something more interesting or meaningful, the symptoms ease. And when we are not aware, in essence it is not happening!

When we feel anxious it is because of the meaning with give to those familiar feelings in our body — tingling in the tummy, tension etc. The meaning we have attributed to the causes of those sensations is something threatening and consequently we act by preparing to deal with that threat. This is the same biology as used to face a threat in the wild: fright or flight. Part of the way the body/we deal with threat is to get ready to run away or fight, both of which need mobilisation of resources to our muscles, which is why they tense up in readiness. But, in dystonia there is already overactivity and unwanted movement, so the additional preparation as described can only add to this experience and put out attention on the sensations.

One of the issues in cervical and facial dystonia is altered body sense and sense of self. It seems that when we have an altered body sense, which means that there is a mismatch between what is happening (sensory input) versus what the brain expects (or predicts). This creates a threat and hence the biology that is responsible for detecting and acting upon this state is active in creating a fright or flight response that the person then predicts as anxiety. The same happens in persistent pain states when body sense and sense of self changes; not permanently, but it needs training. This is one of the reasons why exercise and movement reduce anxiety because we improve our body sense.

A significant part of the re-training programme for both dystonia and pain is body sense based. Body sense, ‘where I am’ and ‘what I am doing’, is really a unification of internal sense, external sense and proprioception somewhat threaded together by the narrative that I tell myself. Ironically, when we feel ourselves, we don’t really think about our body! So this is the desired outcome: not thinking too much about our body and in fact using our body to help us focus on the job in hand; e.g. when walking, we don’t normally think about how we are walking, we just walk; the body is thinking for us — aka ‘embodied cognition’. When the person says to me, ‘I feel myself again’, then I know that they are reaching or have reached their desired outcome.

Pain Coach Programme and Dystonia Coach Programme | t. 07518 445493

17May/16
image

Cervical dystonia and body sense

Cervical dystonia The main focus of cervical dystonia is usually the neck yet in my experience it is not just the neck where body sense changes. A simple balance test identifies a poor ability to remain upright in an economical fashion in most cases and there are several reasons for this feature: altered body sense and the fact that with cervical dystonia, the involuntary movements ensure that the world appears to be constantly moving and thereby the person is perpetually correcting their position relative to the environment. We are all doing this, but in dystonia when there is spasm, this is amplified and hugely troublesome for the person, often the cause of great suffering.

Many people with cervical dystonia tell me that their awareness of the movements increases when they are walking. Walking involves transferring weight from side to side, in effect re-balancing over and over as you move forwards. Without precise body sense this becomes a challenge. I use oversteer as an analogy when playing an arcade driving game, as I turn the wheel too much one way and then the other with compensation after compensation. Continue update and correction is exhausting, so no wonder people with dystonia often feel tired. Heads are heavy and with all the extra muscle activity, fatigue sets in and often hurts if not the cause of stiffness and tension alone.

This being the case, improving one’s overall body sense is an important part of improving cervical dystonia. This is done simply with balance exercises set up in such a way that the position is precise thereby creating an effective learning opportunity. What we do now impacts on the next movement or position, so practicing best quality is key. This is why when balancing, some support is important so that the person can hold best posture, feel it and see it in the mirror; i.e./ learn.

There are a couple of other important points about walking and an increase in symptoms that I will not be going into details about here, but they are part of the bigger picture. Firstly we can have an attentional bias, which means that the person will regularly focus on the feelings (pulls, twists, spasms etc.). Secondly, there can be an expectation or anticipation that this is what happens when I walk down the road, even before you do it. This primes and an association builds — i.e./ it becomes a habit. But, habits can be replaced.

Training a better body sense locally is a key part of changing dystonia and improving movement quality. We cannot move normally without experiencing a normal body sense — where I am, my position, speed of movement, when to stop, where I am in relation to the environment etc. So in cervical dystonia, learning where your head is positioned and re-training normal muscle activity when you are using your arms and hands is key, as is an overall body sense.

RS

Cervical and facial dystonia training programme | t. 07518 445493 — call us now to start your programme

15May/16

Simple guide to CRPS

CRPSMany people have not heard of complex regional pain syndrome (CRPS), and many who have heard of CRPS do not understand the nature of the condition, so here is a simple guide to CRPS.

— What is CRPS? Types of CRPS and common confusions:

  • C – complex: CRPS is a complex condition in that it involves many body systems and a range of signs and symptoms must be present for the diagnosis (Budapest Criteria — see here).
  • R – regional: CRPS emerges in a region of the body, most commonly affecting a hand or a foot.
  • P – pain: CRPS is typically very painful — things that would normally hurt really hurt, and things that don’t normally hurt now also hurt. The pain can often be excruciating and incredibly disabling.
  • S – syndrome: a syndrome is simply a collection of signs and symptoms

There are two types of CRPS, Type 1 and Type 2:

  • Type 1 – CRPS evolves from an injury such as a sprain or a fracture. Sometimes the injury is innocuous with the resulting symptoms of CRPS being an over-response, especially the pain that is out of proportion to the injury.
  • Type 2 – CRPS evolves from a nerve injury

Common confusions

The pain

The pain of CRPS is vastly out of proportion to the seen injury. Pain does not have a reliable or direct relationship with pain in any circumstance; pain is simply not an accurate indicator of tissue damage. Believing that more pain equates to more damage results in wrong thinking and wrong management. People describe the pain of CRPS in many ways.

Pain is often the main focus and reason why the person seeks help. Drugs are frequently viewed as the way to control and ease pain and indeed medication can and does have a role. However, there are many other ways to change pain, including a range of strategies and techniques that steer the person back to meaningful living.

Pain is an ultimate example of a conscious experience that grabs our attention and compels action. Pain is all about protection and is related to the level of perceived threat. In CRPS there is a high threat value associated with the region being protected, both in terms of our biology in the dark and the way we think about the pain and problem; i.e./ we raise the threat value by the way we think about our pain and the meaning we give to the pain, which is why understanding the problem and knowing you can change it is the vital start point.

Pain is complex and involves all the body systems that detect possible threat and then protect us: nervous system, immune system, endocrine system, sensorimotor system, autonomic nervous system (fright or flight). Consider the way in which CRPS presents and you will begin to see how these systems are all playing a role. There is no pain system or pain signals. Pain is about perceived threat: reduce the threat by thinking in the right way and taking healthy action, and the pain changes.

How it looks

Of course you cannot see pain but you can see when the region is inflamed — red, swollen, shiny etc. Inflammation plays a significant role in CRPS as in some people there is an over-inflammatory response to injury. Inflammation is normal but the volume is pumped up in some people, perhaps due to genetics but it can also be due to prior learning. The body systems that protect us have learned earlier in life to respond in a particular way and each time we need them to work, the do but with a bit more volume. Some call this kindling or priming. Examples of prior and existing conditions include: previous injury in the area and the sensitivity has persisted, irritable bowel syndrome, pelvic pain, migraine. A further consideration is the state of the person and the context of the injury. A traumatic injury, such as a car accident, can trigger over-responses as can a more straight forward injury occurring at a time of stress or anxiety. Understanding the person and knowing their complete story is key to gathering insight into what has happened and how it has happened.

How it feels

The affected region commonly feels different. It can feel alien, like it is not attached, not part of self, look different to how it feels. This can be strange and worrying but is characteristic of CRPS (and many other painful problems). It is due to a change in the sense of the body that is in part created by representational maps in the brain. We have many of these representations that allow us to perform tasks every day — imagining what we will have for dinner, thinking about how we will take the penalty or mow the lawn for example. However, when we have pain and move differently, i.e. we are protecting ourselves, the maps change thereby giving us a different ‘sense of self’. People don’t usually volunteer this information for fear of disbelief, however it is such an important part of identifying the problem and deciding upon the approach needed to overcome CRPS. Envisioning a normal sense of self is important before deciding on the right course of action: the aim is to feel oneself again after all.

Summary

CRPS arises within a circumstance, often an injury (but this can be minor), but the context in which the injury is embedded and prior experience determine how our biology in the dark responds. Pain is in the face of perceived threat hence the need to reduce threat to change the pain. We do this in a range of ways begining with understanding and thinking the right way before taking action (a coaching, treatment & training programme) to overcome the problem in as much as the person feels themselves and leads a meaningful life.

** If you think you have CRPS or have any concerns, you should always seek the advice of a healthcare professional who understands your condition.

Pain Coach Programme for CRPS and persisting pain | t. 07518 445493

 

14May/16
Pain distraction

Kids know about pain distraction

Pain distractionI overheard an interesting conversation this week that demonstrated kids know about pain distraction.

Driving my kids to swimming, my eldest daughter was giving us an update on her wobbly tooth and the fact that it hurt. She was concerned that it maybe too painful to go swimming. My youngest daughter, 6 years, then piped up with an insightful suggestion: don’t worry about your tooth because when you are in the cold water you will forget about it’.

To me, as a pain-head (a term sometimes used to describe someone who is obsessively interested in pain and what it is), this was fascinating. Life in action, a natural comment based on some experience that my youngest must have had at some point, or at least heard about. I would think the former is more likely as the message surely stuck with her to the extent that her model of the world in relation to safety-threat has been updated to consider distraction as a way of changing pain and reducing the threat value — pain is a lived experience, compelling action in the face of a prediction of a perceived threat based on the hypothesised causes of the sensory information in relation to prior experience.

RS

10May/16
Pat Wall Lecture 2016 | British Pain Society ASM

Pat Wall Lecture 2016

Pat Wall Lecture 2016 | British Pain Society ASM Listening to Professor Stephen Hunt give the Pat Wall lecture 2016 this morning at The Pain Society ASM evoked a number of thoughts. The meat of the talk addressed recent molecular experiments that could provide new forms of treatment; very much a mechanism-based approach to modifying peripheral and central adaptations (sensitisation) — of course the two are not exclusive, instead being part of a spectrum of changes in respect of an initial insult (usually), and in those vulnerable, a state of persistency ensues. Whilst fascinating and relevant of course, it was the references to Pat Wall that really interested me due to the insights that still hold true.

I was struck by Professor Hunt’s point that many do not consider pain to be a need state. A need state that is a conscious means of motivating action that is the thin slice atop biology in the dark that prepares and operates the healing process, most of which is unbeknownst to us — we feel pain, note swelling and the feel of swelling as it occupies space, changes in the way we move, feel and think. The notion of pain being a need state has been a big part of my thinking over the years, and to me it would seem strange not to consider pain this way. Having been educated by Dr Mick Thacker, who spent a great deal of time with Pat Wall, it is no surprise that these messages have been handed down.

Everyone has examples of the unreliable relationship between injury and pain if they stop and think for a minute. Often quoted are phantom limb pains, paper cuts and battlefield wounds to illustrate the enormous variance. The tissues themselves simply do not explain pain. So what does explain pain? The meaning, the context and ultimately the level of perception of threat (predicted top-down): more threat = more pain, which is why it usually hurts more when you don’t understand your pain and worry about it! And why pain feels better when you, the person feels better. Again it was Pat Wall who provoked this realisation.

It is always valuable to go back to the original lectures and writings as they remain so relevant. We desperately need to address pain globally, it is the reason for so much suffering. New questions to provoke new thinking and research will add to the already gathering hope, steering society towards a modern understanding of pain: what is pain? What is it’s purpose? Knowing that it changes and taking action to enact that change. The coming together of philosophy and neuroscience is really helping us to see pain in a different light, explaining it to patients so they can understand how they have got from A to B and then how to coach themselves to overcome their suffering.

09May/16
GB: Get Better

Get better

GB: Get Better

GB: Get Better

Regular readers will know that I firmly believe in getting better when it comes to pain and persisting pain. This should be our aim with each person. This thinking also needs to underpin research, policy making and clinical decision making across the board.

Recently I was asked to speak at an event that considered the question ‘how do tendons get better’, and my area of focus was the brain and pain. More on this shortly, but it was a pertinent question because for some time I have been pondering why people do get better (from persistent pain), what does getting better actually mean and who gets better?

To answer these questions experientially, I thought through many cases that I have seen to identify the common features. Not especially scientific, but a start point. People getting better meant that they would report that they felt more like themselves. A common phrase that we use, ‘I don’t feel myself today’, tells the world that all is not well, and equally saying ‘I feel myself again’ reports that what is happening in my world is what I expect to happen; a match up in other words. And who are these people who get better from a persisting pain state in the face of messages from society that chronic pain is here to stay and needs to be managed or coped with?

In short, these are people who take on board the true messages about pain and what it really is based on our modern understanding. Not only do they listen and put in into perspective within their lives, but they use the new information as working knowledge to be applied consistently, challenging previous thinking to drive new actions that are congruent with being healthy. With this working knowldge, moment by moment they are able to make clear decisions and groove new habits, pointing themselves via their perceptions and actions towards their desired outcome, as defined by themselves at the outset.

Everyone has experienced success in one or more arenas of their life, whether at home, at school, in work or playing sport. This success is achieved by focusing upon the desired outcome and then taking every opportunity to get there, even if things go wrong along the way. Distracting (unhelpful) thoughts and unforseen events are dealt with as learning experiences, and soon enough the person is back on the path towards their vision of success. Take a moment to recall a success and note how you did it. What strengths did you use? How could you bring them into this arena? The people that use their strengths and focus on their vision consistently, get better.

The tendon debate resulted in agreement that people needed to understand their problem and pain as a foundation from which different strategies could be used. The strategies chosen for the individual must reflect their needs and desired outcomes. I was asked if brain and pain could explain why a tendon gets better, and I argued that we are more than a brain, and in fact the construct of self is made up of a number of facets: my physical presence, how I experience that presence, the story I tell myself about me, the sense of the environment in which I reside in this moment, my past (perhaps unreliably retold to me by me) and my anticipation to name but a few. It is the person who gets better and not the tendon or the back or anywhere else in the body, because we are that body as much as we are the mind (the mind does not just exist in the head or brain, instead we are our mind, often using our body to think — embodied cognition). We are necessarily all of these things together: body-brain-mind-environment.

The overaching aim must be that the person gets better as defined by themselves as only they know what it is like to be better. And when the person is better, they feel themselves again, which in terms of pain emerging from me (felt in a body area), it exists less and less in the thin slice of awareness that is consciouness — most we are unaware of; externally and internally (the biology in the dark). When we are better, we don’t think so much, if at all, about our body until we have an itch or have sat too long and become uncomfortable. Then we scratch or move and resume a state of non-body awareness, just focusing on what it is that we need to in that moment.

Pain Coach Programme to get better: t. 07518 445493Get better

 

03May/16
Fear

Fear

This is a very brief treatise on fear. Fear is a unification of thoughts and feelings experienced by the individual as an attention grabber, motivating avoidance. We feel fear in our bodies in many ways, for example tension in the body, freezing on the spot, and a sharpening of visual acuity. It can pay well to experience a burst of fear as we become conscious of a threat that needs our attention in as much as we must face it or run away.

So whilst there can be an adaptive nature to short bursts of fear, prolonged or repeated fears to non-threatening or low-threat situations is a problem. Fear can in this way become hugely problematic as it grows to encompass the original ‘stimulus’ but then increasingly becomes a response to similar stimuli and then unrelated stimuli. The feelings and thoughts that are recognised and contributory to the lived experience that is fear become easily evoked and potentially destructive unless they are comprehensively addressed. And they can be by understanding what is happening — what comes together to be unified as the experience of fear — and gaining insight into the way in which one’s mind is working.

Fear is whole person — it is the person who fears. Yet it is the person who both creates the fear and experience the fear, which is why the person needs to be the focus of treatment.

RS

Here is some biology — Serotonin, Amygdala and Fear: Assembling the Puzzle:

Abstract: The fear circuitry orchestrates defense mechanisms in response to environmental threats. This circuitry is evolutionarily crucial for survival, but its dysregulation is thought to play a major role in the pathophysiology of psychiatric conditions in humans. The amygdala is a key player in the processing of fear. This brain area is prominently modulated by the neurotransmitter serotonin (5-hydroxytryptamine, 5-HT). The 5-HT input to the amygdala has drawn particular interest because genetic and pharmacological alterations of the 5-HT transporter (5-HTT) affect amygdala activation in response to emotional stimuli. Nonetheless, the impact of 5-HT on fear processing remains poorly understood.The aim of this review is to elucidate the physiological role of 5-HT in fear learning via its action on the neuronal circuits of the amygdala. Since 5-HT release increases in the basolateral amygdala (BLA) during both fear memory acquisition and expression, we examine whether and how 5-HT neurons encode aversive stimuli and aversive cues. Next, we describe pharmacological and genetic alterations of 5-HT neurotransmission that, in both rodents and humans, lead to altered fear learning. To explore the mechanisms through which 5-HT could modulate conditioned fear, we focus on the rodent BLA. We propose that a circuit-based approach taking into account the localization of specific 5-HT receptors on neurochemically-defined neurons in the BLA may be essential to decipher the role of 5-HT in emotional behavior. In keeping with a 5-HT control of fear learning, we review electrophysiological data suggesting that 5-HT regulates synaptic plasticity, spike synchrony and theta oscillations in the BLA via actions on different subcellular compartments of principal neurons and distinct GABAergic interneuron populations. Finally, we discuss how recently developed optogenetic tools combined with electrophysiological recordings and behavior could progress the knowledge of the mechanisms underlying 5-HT modulation of fear learning via action on amygdala circuits. Such advancement could pave the way for a deeper understanding of 5-HT in emotional behavior in both health and disease.

Full article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4820447/

 

26Apr/16

Why tendons get better or not…

Why tendons get betterWhy tendons get better or not… was the question posed. Six of us were lined up to look at potential answers, the areas including isometrics, movement, injections, brain and pain. I was asked to consider brain and pain. Here are my thoughts.

To feel, to think, we need a brain but we are not just a brain. We are of course much, much more. We are a whole person and hence the brain is not the answer to the question why tendons get better, or worse. My main clinical focus is upon those that have not got better, looking at why (the back story, the primers and vulnerabilities) and then what thinking and action is needed now to change course. So most people I see are those who have got worse and in fact, we need to know as much about getting better as we do getting worse. Both are complex but then I argue, we have a greater opportunity to intervene.

The emphasis in my 10-minute talk, a format that is increasingly popular, was upon the fact that it is the person who gets better and not the tendon. What is getting better? What does this mean? I asked myself this question some time ago and followed up with asking ‘who gets better?’ for a talk at a CRPS conference. It has to be the person because it is the person who is conscious and ‘rating’ themselves as being better. The tendon cannot do this — a tendon does not know if it is better or not. Semantics you may think, but important I would say on the basis that we ‘treat’ a person.

A sense of being better results in a person being able to fully engage in their lives as they wish — meaningful living. However, much of our day to day existence is unremarkable, punctuated by situations we remember unreliably. However, we tell ourselves a story about ourselves over and over, with the ‘self’ as the main part in the film. It is strongly argued that the ‘self’ is an illusion: ask yourself where your ‘self’ exists? When you have finished pondering on that small questions, consider again getting better — ‘I’ must rate myself as getting better, meaning that I am able to focus on the task at hand and not be regularly drawn to unpleasant sensations in the space where my tendon (and other tissues) lie or be thinking about the implications of the pain — I can’t do this or I can’t do that etc. So, I concluded that the person gets better when they judge it so and hence the person being more than a brain, but certainly needs a brain, then we have to think wider.

On brain, I also briefly cleared up the seeming confusion between talking about the brain and central sensitisation. Because I argue that we need to address the person (a brain, a body, a context, an environment — unified) to address pain, and that this includes the brain, this does not mean we are saying it is central sensitisation. Without a thought that I have a tendon pain, there is no tendon pain, and hence we must address the top down processing (e.g. thoughts that are underpinned by beliefs, because of what we have been told or learned) because they impact upon the prediction as to what the sensory information means in this moment; the brain’s best guess, which is what you and I are feeling right now. Changing this prediction by minimising the prediction error by taking action is most likely how we are going about getting better.

In terms of pain, this is usually the driver that takes the person to seek help. The pain is stopping the person performing and motivating or compelling action because it hurts. The pain itself is flavoured by thoughts, sensations, thoughts about sensations as a unified experience involving many body systems that have a role in protecting us. Pain is about protection yet is part of the way we protect ourselves with other adaptations including changes in sense of self via altered body sense, altered movement, altered thinking and perception of the environment. With these adaptations occurring over and over, adapting to adaptations and onward, we need a programme that matches pain as a lived experience. What do I think and do now in this moment? The person needs to become their own coach to think and act in a way that takes them towards their vision of getting better, over and over. This means creating new habits, and that is the training programme aspect.

There is much more that can be said on this area, which has many common features with other persistent pain states. We can summarise by agreeing, as we did on the night, that there is no single answer but instead we must draw upon different areas of science and philosophy to ask the right questions and create the wisest programme that addresses pain as the unified experience that it is — physical, cognitive and emotional — but in that person with their story.