Low back pain specialist London

Relieving low back pain — keeping it simple but effective

Low back pain - simple strategies to change pain and move on

Low back pain – simple strategies to change pain and move on

Back pain is very common and most people will experience it. Many reasons are given for back pain, usually blaming the discs (they are not discs but rather amazing structures that work with the vertebrae to allow movement and force transduction — they are also very robust), joints, muscles and posture.

The simple fact is that the pain we feel in our body is not because of a structure. It is because our brain thinks we are in danger, or the tissues in the area of pain are in danger or potential danger, a warning. Pain is an output from the brain that is detected in the body, driving and motivating protective behaviours. This can be helpful in the acute stages of pain, but as time moves forward and the tissues heal (if they have been injured), these learned strategies become part of the problem. The pain persists, the alarm bells go off during normal activities (e.g. sitting, standing, walking) and we continue to behave as if we need to protect healing tissue. This on-going guarding, change in movement and adapted activities causes many problems including pain and fear.

Breaking the habits of protection and guarding are essential. The increased and inappropriate use of muscles in the back means that they work hard, too hard. Similar to a challenging workout, there is post-exercise soreness and pain, except this is happening on a day to day basis. Re-training the way the brain is activating muscles is vital but to do this, firstly you must understand that you are safe. The movements that re-educate normal movement are simple and can be done at home, at work, in the garden, in the park, anywhere that promotes safe and varied actions. This safety comes from an individual’s understanding of pain. So, this is the first step, making sure that pain is understood in the context of the patient’s narrative.

Understanding pain plus simple movements to develop body sense, nourishment for tissues (‘motion is lotion’) on a consistent basis (again very simple moves with feedback and a sense of safety) and skills to calm systems that are on alert to protect such as mindfulness or relaxed breathing. A basic movement can be primed and used in many different ways to represent the variance we experience every day. The brain loves variety and if it feels safe, you will be able to gradually build your activities back up to recover and get back to having fun.

Here are my formulae:

Understand pain + simple movements + confidence + feedback = reduced threat

Reduced threat + gradual increase in activities + mindfulness = pain relief and resolution of normal activities

For further information about our programmes of treatment and training for low back pain and other painful problems, visit our home page here or call to book an appointment 07932 689081


Beyond the biomedical model of pain – an interview with Richmond Stace

physiospotRecently I was interviewed by Rachael from Physiopedia and Physiospot. We discussed some of the areas I feel are important in tackling the problem of pain, in particular chronic pain.

Click here for the interview

Primarily the topic focus was the psychosocial aspects of pain, an area that has provoked increasing interest. The word is often used but I find in practice that the social or societal influences upon pain are rarely included in a treatment programme. The most obvious example is the way in which a couple live and interact and how this impacts upon pain. Culture and gender both play a significant role in how pain is perceived, experienced and treated.

Of course the psychosocial elements are not in isolation to the physical and in fact I would argue that they are as biological as movement or nociception. All our experiences are constructed by the brain and involve neuronal activity driven by chemicals.

The understanding of pain sciences has moved on dramatically over the past 5-10 years but sadly the management trails behind, held back by old fashioned thinking and views based on out-dated thinking. We have an obligation to reconceptualise the way we deal with pain because the information exists and there are vast numbers of people who need to know that they can both control and change their pain.

Specialist Pain Physio Clinics in London for chronic pain, pain and injury

Mindfulness for pain, health and performance

Want to feel happier, suffer less pain & anxiety, think more clearly?

Mindfulness for pain, health and performance

Mindfulness for pain, health and performance

Mindfulness programme

The brief practice of mindfulness for just 10 minutes each day has a positive affect upon physical and psychological health.

Mindful practice forms part of our treatment and proactive training programmes for chronic pain and health problems. However, learning the practice is beneficial for anyone who wishes to reduce feelings of tension, anxiety and stress; improve sleep, concentration and clarity of thought; and overall have a healthier and happier experience of life.

Mindfulness itself is very simple and practical. Much like we train our body in the gym to be fitter and stronger, mindfulness trains our ability to be aware of what is happening in the present moment, and without judgement.

How much time do you spend on autopilot? How much time do you spend noticing what is going on right now as opposed to dwelling on the past or constructing a future in your mind? Does the past or future make you feel bad or anxious? Do you relive scenarios that make you feel unhappy? The problem is that the brain does not distinguish between what is happening in reality and what is happening in our mind. The body still responds, often by protecting itself using different systems in the body such as the nervous system, the immune system and autonomic nervous system (‘fright or flight’). Gaining insight into the mechanisms and becoming skilled at being present not only creates time, but also disarms the effects of drifting into the past or the future.

Enhancing the potency of mindfulness

Alongside the practice of mindfulness, a simple exercise habit that includes strategies at work will create the conditions for the body systems to cultivate health. A rounded programme of physical and mental training that interlaces with normal living improves performance, sleep, clarity of thought, sense of self, social interactions and immune responses. These factors are related and positively affect each other once healthy habits are learned.

Call us now to book your first mindfulness session: 07932 689081

The Specialist Pain Physio Clinics in London – expert treatment and training to tackle the problem of chronic pain and injury.


Ehlers-Danlos Syndrome (EDS) – a personal experience

Ehlers-Danlos Support UK

Huge thanks to Kayleigh (Follow Kayleigh on twitter @KsEDSchallenge) for sharing her experience of Ehlers-Danlos Syndrome (EDS). The way that clinicians and the public truly understand conditions is through the personal stories that are described first hand. The narrative is key.

I was diagnosed with EDS in late 2013 (aged 25), having displayed symptoms my whole life – more noticeably from the age of 19 when my right knee became unstable and I began to notice symptoms such as mennorhagia, recurrent urinary infections and shortness of breath. Then from the age of around 23 when seemingly overnight lots of my symptoms became pronounced, leading to an eventual diagnosis.

I have seen 3 different physiotherapists during that 4 year period, and every one of them commented on my flexibility and pointed out things such as my tight hamstrings, stiff upper back and neck muscles, which I now understand are the result of my muscles trying desperately to stabilise my joints.

It’s reassuring that the physiotherapists picked up on this hypermobility, but at this stage it would have been so helpful if they had suggested even in passing that I might want to visit my GP if I had ever had any other symptoms such as the ones I had experienced, and had visited GPs for, but which had never been linked to each other. This could have lead to EDS being diagnosed 6 years before it was, and 3 years before I suddenly worsened. I would encourage physiotherapists to suggest this where they feel it could be appropriate. I have read several statistics suggesting that anywhere from 70 – 80% of people with EDS (who do not know of any family predisposition from a young age) do not get diagnosed until they are in their mid to late 20s, by which point little can be done to reverse the damage already sustained.

Now that I have been diagnosed, my physiotherapist plays a central part in the ongoing management of my condition as I choose to manage my condition without the use of NSAIDs, muscle relaxants or analgesics as much as possible.

There are several reasons that I choose to engage more intensely in physical therapies than drug based relief. The overriding reason is the damage drugs will do to my organs. I already suffer with kidney infections, GERD, costochondritis and digestive issues. I’m quite sure none of these will be improved by long term usage.

I also feel that I cope very well with my day to day pain levels. Before I was even aware that I had EDS, necessity had forced me to develop coping strategies for day to day life. I didn’t even realise until I was diagnosed that the majority of things I do, I do in some adapted way to mitigate against pain. If I were to use painkillers for a prolonged period, and then stop, I’m sure the ‘background’ pain I don’t even notice would become debilitatingly noticeable.

An equally important reason that I choose to engage heavily in physical based therapies is prevention. We all have to accept that there is no cure for EDS. But I fully intend to work until I reach retirement age, to have an active lifestyle and to have a family. To give myself the best possible chance of enjoying all of these things, I know I must strengthen my body and learn safe habits.

I have realistic expectations of my physiotherapist and what they will be able to achieve. But physiotherapists do not always have realistic expectations of me. I am not, for example, going to perform a single leg squat.

If you ask me to perform that quad stretch where you hold your foot against your backside.. remember that you need to consider – is my straight knee hyperextended, is the ankle I am holding in my hand bent at an unusual angle, is the elbow of the arm holding that foot straight and hyperextended, am I touching the wall with my fingertips for balance and bending the joints backwards… you can probably also assume that my elbow and wrist subluxed with the weight of my foot/leg.

What may seem like a simple stretch, for me is a whole host of things that could be going wrong. My concept of ‘normal’ is non existent. You will need to point these little possible dangers out to me, or I will be going home and doing damage to myself without realising it.

By pointing those things out to me, and by obviously knowing your stuff when it comes to EDS, you will gain my trust.

I would say the key to successful physiotherapy with EDS is to work with your patient to improve proprioception. I do not receive correct messages back from my body to my brain, so if you tell me to lay with my spine perfectly aligned I will probably think that I am doing it when really one hip has rolled forward or my shoulder has rolled backward. I will often perform exercises incorrectly once at home as a result.

I am currently working with a therapist to improve my proprioception in a number of ways. One of those ways is that I am learning to write with my left hand (being right handed), this will open new neural pathways and should help with my overall balance and co-ordination. It will also serve the dual purpose of allowing me to swap between hands when taking notes and using a computer mouse at work, to relieve the stress on my right arm. These kinds of techniques are great as they show measurable progress, where often with physiotherapy exercises I wonder if I am even doing anything to my body – I can’t feel the stretch in the stretches, so I just have to take it on faith that they are doing any good!

What I really appreciate is a physiotherapist who will go the extra mile. There are several things you can do to show that you understand EDS, that you are taking us seriously, and that you care. These are three things that we have come to expect not to receive from people, which we find a source of frustration and upset. We have been labelled as clumsy, melodramatic, hypochondriacs our whole lives. You may be trying to reassure us by downplaying an issue, but we will just think you are doing the same thing  our families, friends and doctors have in the past and will become defensive and distrustful.

Little things mean a lot. EDS sufferers are ALWAYS cold – so ask if the temperature is OK for us if we are covered in goosebumps. A lot of us have PoTS so don’t ask us to ‘jump’ off the table, advise us to get up slowly and be nearby ready to catch us if we go dizzy or a knee collapses as we stand. Learn about EDS and think about what you can do to demonstrate that you are not ‘just another medical professional’ and we are not ‘just another syndrome’.

These things I hope will help to build what is the most crucial part of managing any chronic condition – a positive, trusting relationship between practitioner and patient. That is all any of us, on both sides of the table, are asking for!

If you would like to share your experience, please contact me [email protected]

Ehlers-Danlos Support UK

Protect the body with armour - the muscular system

Pain – the unseen force

Le Horla“Do we see the hundred-thousandth part of what exists? Look, here is the wind, which is the strongest force in nature, which knocks men down, destroys buildings, uproots trees, whips the sea up into mountains of water, destroys cliffs, and throws great ships onto the shoals; here is the wind that kills, whistles, groans, howls–have you ever seen it, and can you see it? Yet it exists.” Guy De Maupassant – the monk talking to the author at Mont Saint-Michel.

Pain, have you ever seen it, and can you see it? The unseen power of pain that is the cause of suffering is one of our greatest enigmas. We are understanding where pain comes from with greater precision but with every painful experience being unique, the pattern of activity in the brain is rightly different on each occasion. The widespread networks of neurons that are active when we are in pain are not specific to hurting, there is no pain centre. It is fascinating that we can see similar brain activity during a pain that results from nociceptive stimulation of the body and from social isolation. Neither pain can be seen from the outside, only the facial expression and verbalisation with the hundreds of words that can describe the feeling.

Is this the reason why people are disbelieved? Because pain cannot be seen. How can anyone truly measure the pain of another? Hurting is subjective. I know and only I know how much it hurts and how it affects me. All too often a patient describes returning to work and feeling a sense that colleagues do not believe or understand their suffering. This can only increase the threat and elucidate further protective responses that feed into the cycle of thoughts–physical responses–emotions–thoughts.

Thoughts cannot be seen but they are real as they play in the mind, each one creating a body response: “I am hungry,”, the stomach rumbles; “I don’t know my lines,” the stomach tightens and tingles; “I have pain, what does it mean?” the body tightens, the pain intensifies. None of these can be seen but they exist as much as the wind that can bend a tree.

Protect the body with armour - the muscular system

Protect the body with armour – the muscular system

Pain is embodied. We feel pain in a location in the body, even if the body part no longer exists such is the case in phantom limb pain. The brain networks ensure that we attend to the body region deemed in need of protection, creating the unpleasant experience that is pain so that action is taken to resolve the issue. In the early stages of an injury we actively protect the area by reducing movement, guarding with increased tension, warning others away with bandages and crutches. If you are travelling in London on the tube, this may even afford you a seat in rush hour. Persisting pain is not related to the extent of tissue damage, if it ever really is–for pain is not an accurate indicator of tissue damage. Chronic pain can feel like a fresh injury and drives the same behaviours: attention towards the painful area, guarding with the musculoskeletal system by tightening up the muscles–our natural armour, and avoidance. These behaviours feed back into the body systems that tell the brain something is up and the brain responds by continuing to protect. The cycle continues until there is a good reason for it to stop because a safe state has been achieved.

The challenge of tackling chronic pain means that we must look beyond the tissues. Exploring the brain, the immune system, the endocrine system, the motor system and how they interact to create our moment to moment experiences, the interface with life and how we respond at any given time. Nothing is permanent. Pain can come and pain can go. Cultivating the conditions for pain to change is the contemporary way of thinking and each person requires a unique approach based on sound scientific principles. So, much like we can harness the wind to create power, we can harness our biology to create a meaningful life.


To book an appointment or for information about our bespoke treatment and training programmes for pain and chronic pain, contact us today: 07932 689081




Bear traps and how to avoid them

My old headmaster would warn us not to fall into bear traps. By this he meant pay attention to what you are doing so that you do not make a simple mistake. He would set a few bear traps and see if we were concentrating or if we were on autopilot. It was also a way to note tomfoolery.

As clinicians we can also fall into bear traps by not attending to or challenging our own thinking and beliefs. This is especially true with pain, where we can so easily rely on our own beliefs about pain and what we should do in response to pain. We know for example, that GPs can give advice about back pain according to what they would do if they suffered back pain — rest or remain active.

Cultivating awareness of our understanding, beliefs and noticing the messages that we give to patients is a simple habit. It takes practice but allows us to ensure that we are giving the best possible advice and information, perhaps in the form of a metaphor. This includes the mode of delivery: body language, tone of voice, timing of the message and the environment in which the message is given.

Here are a few simple tips:

1. Before each patient, gently notice your breathing — in, and sense the chest rise and expand; out, and feel the body tension ease. This helps to create an awareness of what is happening now, including preconceptions and thoughts that could flavour the coming session.

2. Listen deeply — by continuing to breath, remaining present and listening to every word and noticing the patient’s body language, we can learn all that we need to intervene in the right way. The most potent way for that moment.

3. Speak with compassion — our brains are wired to thrive on kindness. We can create an effective session by both listening and communicating in a mindful way without the clarity being lost by intrusive thoughts that obstruct effective messages being passed.

The Specialist Pain Physio Clinics in London provide treatment and training programmes for pain and dystonia based upon the latest neuroscience of pain, brain and mind. The approach is comprehensive, addressing the problems and influences in a compassionate and encompassing way. If you are suffering with chronic pain, call us now to book your first appointment: 07932 689081

Specialist Pain Physio Clinics in London

20 years in healthcare — what have I learned?

Specialist Pain Physio Clinics in LondonReflecting back on over 20 years of time spent in healthcare there are a few things that stand out as being important. Much of what is learned has been pruned and will continue to be sculpted as knowledge emerges from the research.

Here are my top three:

1. Harnessed from the great writing of Oliver Sacks: it is as much about the person as it is the condition.

2. The effects of any intervention are affected by the patient’s perception and expectation, moulded by prior experiences and their belief system.

3. Communication sits at the heart of successful therapy, both verbal (this includes body language) and written.


The Specialist Pain Physio Clinics in London deliver the very latest in treatment and training for chronic pain, persisting and recurring injuries 

Call us for information or to book an appointment: 07932 689081

Massage for pain and chronic pain in London

5 reasons why I use manual therapy for cases of persisting pain

Some will argue that manual therapy — joint and/or soft tissue techniques — has no role in chronic pain. I disagree. Why?

(In no particular order)

1. Touch is normal and it is something that we do when we care.
2. Hands on treatment is expected when you visit a physiotherapist or physical therapist.
3. Stimulation in the area of the body that hurts can feel good. If it causes little or no pain, the brain is happy and interpreting the stimulus (touch, pressure, movement) as being safe. More of that please! A great way to desensitise and for the experience of pleasure in the affected area.
4. Change the brain’s output by addressing the area with therapy that feels good — that’s the output feeling good, along with reflexive reduction in protection.
5. What do you do if you bang your elbow? Rub it. In chronic pain, you may need to think about how and when to rub it, but nonetheless, rubbing it needs. Combine rubbing with visual feedback and there you have a pain relieving strategy.

Mindfulness for pain, health and performance

5 reasons why mindfulness is part of our treatment programmes

1. Mindfulness reduces suffering: pain, anxiety, tension.

2. Mindfulness promotes clarity of thought.

3. Mindfulness develops a sense of calm.

4. Mindfulness creates an ability to focus ones attention where you want to, and not in response to the wandering mind.

5. Mindfulness changes physiology, triggering restorative processes: e.g./ healing, digestion, sleep, anti-inflammatory action.

For pain, stress, anxiety, performance, concentration, call us to make an appointment: 07932 689081

Pain is a whole person experience

Where do we tackle pain?

Where does pain come from?

Where does pain come from?

When someone tells you that they have a painful knee, it makes sense to have a look at the joint to see what has gone wrong. Perhaps an x-ray or a scan would help to determine the state of the cartilage, bone and surrounding soft tissue. An assessment of the range of motion, motor control and the responses to sensory testing reveal any functional limitations and adaptations. Is this enough to truly understand where pain really sits? Is it enough to decide where to intervene? In some cases yes is the answer, but not always!

Important that this kind of evaluation maybe, we must consider the significant pile of literature that points out pain is not an accurate indicator of tissue damage, as so eloquently concluded by Lorimer Moseley. One has only to think about phantom limb pain to realise that there is no need to have an arm, or a leg, or indeed any body part, for there to be pain in that location.

Phantom limb painPhantom limb pain is the condition that illustrates the concept that pain is allocated a space. This space could be the knee as in our example above, any other body region or regions, or even outside of the body. A study by Lorimer Moseley also suggested that pain is felt in a space and not within the tissues. Subjects were asked to cross their arms, placing the affected hand into the space usually occupied by the unaffected hand. The effect? Pain relief. This is of course one study, however there was an impact that needs to be further investigated. Assuming that pain is allocated a space, this would explain why, when you position the hand in that of the non-painful side, both the pain and movement quality improve.

This is easily tested in the clinic with both hands and feet. The demonstration is a potent one for the individual as their limb experience can change. Seemingly there is an ease of the tension and guarding as well as the sensitivity. It can be profound, especially when someone has been suffering with a nasty pain such as in complex regional pain syndrome (CRPS) or neuropathic pain. The caveat is that this is not a cure, and it does not work every time, however in those that the effect is apparent, the ability to move more normally promotes healthy tissue and perception by the brain, especially if you are looking at the movement — extra sensory feedback via the visual system.

In summary, as best we know, pain is allocated a space. This can be a space that is occupied by a body region that why we feel pain in the tissues, the place where the pain emerges. The actual location of the pain is determined by the brain as it decides where we need to attend for protection. Recall that pain is a protective device involving a widespread network of neurons within the brain. There is no higher pain centre, but rather a network that monitors the sensory situation and responds as needed. On the basis that the sensory feedback suggests something dangerous is happening, the network will create an output that we experience in the body via a space that is deemed to need protection. Unfortunately, this output can occur without sensory input in some cases of persisting pain as the neuroimmune system becomes very sensitised and responsive to a range of stimuli including those that are not actually dangerous, hence why normal activities can hurt.

On this basis, when considering where to treat pain, we have to consider the space where the brain feels we need protecting. With the emergent property that is pain, the sensation is at the end of a process and it is therefore wise to target the entire biology from top to bottom and bottom to top. This means we need to address the higher centres, for example developing the individual’s understanding of their pain, reducing fears and using strategies for the brain maps of the body concurrent with using techniques within the space, i.e. the body area where the pain is felt.

For more about our comprehensive treatment and training programmes for persisting pain and injury, call us on 07932 689081 to make an appointment. Clinics in London & Surrey.