18Jun/16
Pain now

Biology of pelvic pain

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

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

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

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

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

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

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

09Jun/16
Pain and injury

Pain and injury

Pain and injuryPain and injury are poorly related. Unfortunately most of society continues to believe in a stimulus-response relationship between these factors, but in reality it does not exist. This was raised by Pat Wall in his classic 1979 article entitled ‘On the relation of injury to pain’.

Since then we have learned an enormous amount about pain; what it is and the purpose it serves. Why should the relationship between pain and injury be so unreliable? The answer is because pain is contextual, motivating appropriate action for that moment depending upon a range of factors. These include the injury itself and what it means, prior experience, beliefs about pain, the environment, who is there, how one is feeling before and at the point of injury and what is going on at the time. Here are some examples:

* a carpenter hitting his thumb with a hammer — despite the fact it will hurt, this is not unexpected, an occupational hazard if you will, and soon dismissed.

* an electrician electrocuting himself — similar to the carpenter; the context is key

* spraining an ankle in a cup final — there are many reports of injuries being sustained whilst playing sport that are not painful at the time, because playing on is more important

* battle hospital reports — severe injuries but no pain initially; the same in many accident and emergency reports

* a concert violinist who cuts his left index finger the day before his most important gig — what do you think this experience could be like versus a chef?

These examples demonstrate the variability in lived experience despite the biology of healing being similar (effectiveness may vary depending upon existing and prior health) — the two lives, that of our biology and that of our lived experience. The clinician’s role is to marry the two for the person so that they understand the hows and whys before focusing on what needs to be done to get better.

When my knee hurts, or any other body area, the vast majority of the biology that is involved resides elsewhere. Pain is located to my knee, although I can’t possibly know from where exactly; where is the stimulus? Yet to feel pain in my knee I need the systems that protect me to detect certain sensory activity, predict that the causes are threatening and then translate this to a sensation that is pain; i.e./ the biology becomes ‘conscious’. Whilst there are signals from the knee to the spinal cord and onwards, this is not necessary for us to feel pain. Think about phantom limb pain.

There are many levels whereby signals and predictions are modulated until the most credible prediction emerges as a lived experience. This is why prior experience, beliefs, emotional state and our thinking play such a role in pain as all can modulate the meaning and level of perception of threat.

An analogy is watching a film at the cinema. The film is on the screen yet for this to happen and be experienced, there must be a projector, electricity into the projector, and this electricity comes from the grid. Most of the necessary elements are not where you watch the film. The same can be said of pain, when it is made up of many non-pain factors that come together to create that lived experience. The point there is that when we address these in a comprehensive treatment and training programme, we can change pain and get better. But to do this we must think beyond the structure (the cinema screen) and consider the person, their beliefs, their thinking, their lived experience, the phenomena of their life, in order to be successful, which we can.

Pain is not related well to injury, but instead to the level of predicted threat.

Pain Coach Programme for persistent pain | t. 07518 445493

 

08Jun/16
Space

Space

SpaceThere are things that we know are good for us: sleep, water and space. Of course then we need quality sleep, water and space. I’m interested in space, and not the kind that is out there, but rather the space we choose to place ourselves day to day and how this impacts upon us consciously and subconsciously. In particular I am keen to understand how we associate with certain environments and in fact how our brains predict the meaning of a given environment and the experiences that emerge.

Here are a couple of classic examples that I hear about:

1. RSI — repetitive strain injury: I am using this term for ease, although I have issue with it, but that’s for another time. I refer to pain and other symptoms that people attribute to repeated use such as typing, clicking a mouse and texting. In the vast majority of people I see with this burdensome condition, we can evoke their symptoms by just thinking about certain environments! Their desk at work for example. When we close our eyes and think about a place, we are in essence there and it feels like it. When a place or space becomes associated with a threat value because of a link that has been established, then it makes sense to feel a warning when we think about it. However, when this persists, this becomes an increasing problem due to the behavioural aspects — altered movement, restricted use and guarding, all of which perpetuate the threat value and hence the on-going pain. Thankfully, this cycle can be broken with the right understanding and training.

* This is not unique to RSI, but any pain problem is contextual and becomes associated with certain places, positions, movements, activities etc etc. A significant part of overcoming persistent pain is by creating new habits.

2. A place in nature: a pleasant image comes to mind, unified with feelings of comfort in the body to make it an overall calming and soothing experience. This is why visualisation is so effective as we can choose to shift into our resource state whenever we need: when anxious, stressed or in pain for example. This is a technique that I blend with others to create the necessary calm we need to refresh and renew, particularly if we are suffering pain or tiredness.

Placing ourselves in an environment has enormous effects upon us as we become part of that very environment. In fact, what you experience as that environment you are creating using at least your brain, your mind and your body, and importantly how they unify. Using a film analogy, you are the film maker, the script writer, the star and the audience all rolled into one. Wow! How do we explain that? Using the very same unified processes to explain themselves! So, in becoming part of threat environment, the importance of choosing the right space is vital. Each day we should absorb ourselves in a nourishing place such as a park, by a river, in a forest or at least in a space where there is plenty of exactly that, space! And if you can’t do this on a particular day, then you can use imagery and visualisation and feel the resulting great feelings.

On a moment to moment basis, where we spend a lot of time, perhaps home and office, these spaces need to be nourishing and promote the feelings we want to feel — e.g./ at work to concentrate, focus, think, write, communicate; at home to feel comfortable, warm, safe etc. This may take some thought and some re-organising but it will be worth it — see here, a professional organiser: Cory Cook. Remember that the environment you choose to put yourself in impacts upon you enormously: the way you feel, the way you think, the way you interact. Something similar could be said for the people you spend time with.

So, when you are at work, at home, choosing a new job or accommodation, think carefully about the environment in which you will be living moment to moment experiences, because they will be shaped somewhat by that very environment. Get out into a big open space and move around in it, see it, smell it, feel it, using all your senses. And if you can’t, then take a deep breath, slowly let it go, do it again, close your eyes and take yourself to a space where you will feel great.

Pain Coach Programme for persistent pain | t. 07518 445493

07Jun/16
Pain, loneliness, poverty and health

Depression and inflammation

Depression and inflammationFor some years there has been thinking about depression and inflammation being related in as much as when we are in the throes of inflammation, our mood changes. Think about when you feel unwell and how your mood drops, which is part of the well known sickness response. In some people, probably a large number, these sickness responses are the norm. In other words, they endure a level of this sickness response consistently that is underpinned to an extent by on-going inflammation.

Reports today about a study at Kings College London describe how inflammatory markers in the blood could identify a ‘type’ that would benefit from a certain antidepressant drug — read here. This would make the prescription specific for the person, so rather than trialing a drug, we would know which would be most likely to be effective for that person by identifying the blood markers.

Many people I see with persistent pain are low in mood and some have been diagnosed as being depressed. In my mind, it is entirely understandable why someone suffering on-going pain, who cannot see a way out, would be in such a state. In simple terms, the person with chronic pain may well be chronically inflamed. We know that people who perceive themselves to be under chronic stress will be inflamed as the body continues to protect itself via the immune system and other systems that have such a role. Typically and understandably, someone in a chronic pain state is stressed by their very circumstance and hence can be inflamed.

It is very common to suffer an enduring pain state and generally feel unwell; a sickness response. We all know what a sickness response feels like — we don’t feel ourselves, aches and pains, loss of appetite, irritability, emotional, sleepy, tiredness, poor concentration etc. This is underpinned by inflammation and how this drives a range of experiences and behaviours, all designed to create the conditions for recovery. In the short term this is adaptive but if prolonged, the symptoms are enormously impacting and potentially maintaining a cycle of stress and anxiety.

Like any problem, understanding its nature is the start point so that problem solving can be effective; i.e. think about it in the right way and take the right action, congruent with recovery and the desired outcome. Realising the links between health state, depression and inflammation helps to distance oneself from the lived experience, being less embroiled with that particular ‘film’, instead focusing on what needs to be done to overcome the problem.

A loss of the senses of self is often a part of a persisting condition such as chronic pain or dystonia. The overarching aim of a followed programme is for the individual to resume living their life with a sense of self worth which they can identify: I feel myself again. This self feels normal to that person, and only that person knows how that experience is lived. As best they can, I ask them to describe that experience, and this forms the desired outcome. The sense of self is at least a unification of body sense, interoception, exteroception, the inner dialogue and our past experiences. Improving body sense with exercises, some general and some specific, is a simple way of stepping towards that outcome. And of course there are all the other benefits of exercise to consider.

It will undoubtedly be very useful to identify who will benefit from which antidepressant drug, yet we must still consider each (whole) person. A comprehensive programme of treatment for pain for example, includes developing working knowledge of pain so that the person can independently make effective choices as well as eradicate fears, specific training, general activities, gradual progression of activity, and mindfulness to name but a few. However, it is not just the exercises that are important. The person also needs to be motivated, resilient and focused, all strengths that they have likely used before in other arenas but now need to employ here and now with their health — this is the strengths based coaching aspect of the Pain Coach Programme. In cases of depression, the chosen drug maybe more specific and hence more efficacious, yet there are other actions that are also important such as understanding the links as explained and consistent physical activity. Great work in the aforementioned study; it will be interesting to watch how this progresses.

Pain Coach Programme | t. 07518 445493

31May/16
Wrist injury

Wrist injury for Nadal

Wrist injuryThe wrist injury for Nadal has been heavily reported in the media. This must be immeasurably disappointing for Nadal, who has suffered with a catalogue of problems over the years, as he seeks to overcome the pain and injury.

Playing sport at this level means that your body is your business. I am going to qualify the term ‘body’ for it is important to consider the body as part of the whole and is in no way separate from the concept of mind — we are our mind; we are our body; the unification has no beginning or end, just emerging as ‘me’, the self.

As we know, to play top flight sport requires immense fitness that necessitates training that blends with that of technique. Nadal has always played an extremely physical game, which is his style, his tennis character or persona. From the first step onto court until the final stroke, physicality predominates but the notion of physicality is not only in the muscular frame, but emerging from the man himself. We can see his body move, but it is he, the man who moves and lives that experience. The point here is that a body does not move in isolation from who we are, what we think and feel emotionally. This factor starts to provide some insight into how we must approach recovery from injury, especially when there are a string of injuries that can appear to be unrelated. I would argue against this, suggesting that there is a commonality in the way we respond to injury and how this governs the recovery.

The way we respond to injury and pain (the two are unreliably related) is individual and dependent upon our beliefs and what we think according to what has happened before. If I believe that pain is related to tissue damage, still the predominant thinking, then I will act in a particular way, and if I know that pain is a normal part of a protective response related to the level of predicted and perceived threat, I will act in another. This highlights the importance of the person understanding their pain to get the best outcome.

When an athlete or a non-athlete suffers on-going injuries or repeated injuries, even in different body locations, one must consider why this is happening and why they are not fully recovering despite their apparent health. One could also ponder on the question of whether they are as healthy as they can be? Chronic stress, where the person consistently perceives threat thereby feeling anxious and tense, changes our chemistry as we operate in survive mode. This does not allow for the most effective healing process as our resources are diverted elsewhere. The athlete in a stressed mode who then sustains an injury will have a different response to the athlete who feels empowered, who is in control and has a high level of resilience at the moment of injury. This is why looking at the whole context of the injury is so vital as important influences and vulnerabilities can be overlooked. Understanding these means that the person and the team can fully address the problem.

Priming or kindling is a good way to think about persistent injuries or the string of injuries scenario. An initial sensitisation is a learning experience for the systems that protect us, meaning that it has a bearing upon the next injury or pain and so on. A string of injuries suggests that a vulnerability has arisen, often due to the prior recoveries not reaching full resolution; i.e./ there remains a perceived threat and on-going protection. In this situation, a further injury, either actual or potential, creates a context for the body systems that protect us to kick in, emerging as pain, altered body sense and movement, a story that we tell ourselves, all unifying to create a change in the sense of self, and not one that is congruent with desired performance outcomes.

The story of a player or athlete being plagued by on-going problems is common in sport as they patch up one area after another. Investigations, treatments, injections etc etc., yet not fully shifting from protect mode to health mode. This must be at the heart of a rehabilitation and recovery programme — the person must get better as a unified experience. I must feel myself again, which means that I am the performance, I am the shot I play rather than over-thinking to anticipating or focusing on another factor that interferes and distracts me from what I am doing.

In summary, completeness of recovery is key and this begins with understanding pain and its poor relationship with injury before creating the right conditions in thought and action. The programme must include threat reducing experiences including the way we think, how we attribute sensations, what we tell ourselves, redefining precise body sense (where I am in space and how I move in relation to the environment) and movements to say the least. Maintaining the desired outcome in mind, remembering that you are your mind (it is not just behind your eyes) and that some of your thinking is done with your body and its movements, both motivates and allows one to question if you are heading towards this or being distracted. Learn and take every opportunity to be on the path of change towards this desired outcome, persevere and dare to be great at what you are doing.

Pain Coach Programme to overcome pain | t. 07518 445493

26May/16
UP | Understanding Pain

Children, pain and school

UP | Understanding PainPeople are usually shocked to hear how many children suffer persisting pain, and quite naturally there is an impact upon school as much as the school environment plays a part in the pain experience. The education system needs to acknowledge this fact and institute a change of thinking that of course begins with understanding pain. Pain is a societal issue not a medical issue in isolation. Maintaining pain in the medical realm is one of the reasons that it is such a big problem. Looking at pain through but one lens means that the bigger and truer picture is missed and the natural opportunities for change are minimised when reliant upon limited options.

Children, pain and schools

Maybe 1 in 4 or 1 in 5 children suffer persistent pain. That is an awful lot of kids struggling along with their families. If there was greater understanding then the right thinking and actions could help these individuals to improve their lives by overcoming pain — not just managing or coping.

The current education systems place an enormous and continual strain upon children. Many rise early, spend all day at school and then come home to do homework. Hours and hours. Then there is the pressure, the unspoken pressure to achieve the best marks and anti thing else is failure. The greatest demands are usually placed upon oneself but this thinking emerges via the system and the culture. We should be doing the best we can and putting in effort of course but not just into schoolwork. Carrots are good for you, but would you eat them all day, every day? The internet is useful but is it healthy to be doing this every day, all day? The continued strain shifts the child into protect and survive mode so no wonder we are seeing the following list of ailments and issues: tummy pain, IBS, headaches, migraines, painful periods at the onset of this development, widespread musculoskeletal pain, anxiety, sleep disruption, low self-esteem, altered body sense and image…..just to name a few. Will we look back and ask ‘what were we thinking?’

So as we hit revision time and kids are preparing for exams, we need to make sure they are being nourished — meet the basic needs: food, drink, rest, sleep, exercise, movement, belief in themselves…you are good enough!!!! We want good marks, you may say. Of course you do. But you also want a child who believes in themselves, feels good enough and is not scared of getting things wrong. This can only be fostered within society.

Going to school is normal and healthy. School offers a context for learning how to be you — communicating, laughing, playing, problem solving, thinking clearly, changing state, how to be healthy, how to be a good citizen in a community, insight into the way I think etc etc. Wow, what a wonderful time and opportunity. So when pain is a problem (and it almost always comes hand in hand with more anxiety than is helpful — some anxiety is of course normal and a motivator to take action), missing school becomes part of the issue. The school environment can become a threat when the thought of returning to the busy corridors, the demands, sometimes unsympathetic staff, is enough to trigger pain and anxiety. However, this can be overcome with a comprehensive approach and indeed gradually building up time at school is part of the way that the child gets better. Much like an adult returning to work; this is part of getting better instead of waiting to get better to go back to work. The thinking needs to change with understanding of why it is important. It is important because we want normal; the resumption of normal ‘self’ and this self is the one who goes to school and become part of that environment.

To enact this needs understanding and communication between the child, caregivers, the school and parents. There is no reason why this cannot happen. Gradually building time whilst working on a programme that is making the child feel better and better — this includes working knowledge of pain to create a sense of safety, movement, exercises, mindfulness, relaxation, but the child becomes their own coach, knowing what they need to do at any given moment. Their confidence builds, they feel better and head towards their desired outcome.

We all know that our world is fast changing and the life that a child leads now is very different to ours when we were growing up. But there are still the same biological needs and these are being impacted upon by connectivity on social media, the devices themselves, the demands from society and their thinking that is being mounded by all of the aforementioned. In relation to the problem of pain and children and schools, we can start by helping all those to understand pain. It should be part of their education as we all feel pain at some point and our understanding of it and what it means frames how we behave and react. That would be a great start.

22May/16
Wrist injury

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
Your life and your pain

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
Space

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

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