07Jan/14

Lesser known problems associated with Ehlers-Danlos Syndrome and Loeys-Dietz Syndrome

Here is a selection of reports and studies that discuss lesser known features of Ehlers-Danlos Syndrome (EDS):

Unexpected association between joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type and obsessive-compulsive personality disorder.

Rheumatol Int. 2013 Nov 23. — Pasquini M, Celletti C, Berardelli I, Roselli V, Mastroeni S, Castori M, Biondi M, Camerota F.

Joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type (JHS/EDS-HT) is a largely unrecognized, heritable connective tissue disorder, mainly characterized by joint instability complications, widespread musculoskeletal pain, and minor skin features. In a case-control study, 47 consecutive JHS/EDS-HT patients were investigated for the prevalence of psychiatric disorders and compared to 45 healthy controls in a single center. The psychiatric evaluation consisted of structured clinical interview for DSM-IV criteria by using the SCID-I and the SCID-II. Symptom severity was assessed using the Hamilton Anxiety Rating Scale (HAM-A), the Hamilton Depression Rating Scale (HAM-D), and the Brief Psychiatric Rating Scale (BPRS). The Global Assessment of Functioning Scale (GAF) was used to assess the overall severity of psychological, social, and occupational functions. JHS/EDS-HT patients had significantly higher mean scores for all questionnaires: HAM-A (6.7 vs. 3.8), HAM-D (6.4 vs. 2.7), GAF (75.0 vs. 86.1), and BPRS (27.5 vs. 25.6). The JHS/EDS-HT group had a 4.3 higher risk of being affected by any psychiatric disorder, and in particular, a 5.8 higher risk of having a personality disorder. In particular, 5 JHS/EDS-HT suffered from obsessive-compulsive personality disorder with an observed prevalence rate of 10.6 % (3.6-23.1). Psychiatric assessment of JHS/EDS-HT patients showed an extremely high prevalence of personality disorders (21 %), and of Axis-I disorders (38 %), mostly depressive. This study did not confirm the previously reported increased rate of panic disorders in JHS/EDS-HT.

++++

Ocular features in joint hypermobility syndrome/ehlers-danlos syndrome hypermobility type: a clinical and in vivo confocal microscopy study.

Am J Ophthalmol. 2012 Sep;154(3):593-600.e1. — Gharbiya M, Moramarco A, Castori M, Parisi F, Celletti C, Marenco M, Mariani I, Grammatico P, Camerota F.

To investigate ocular anomalies in joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type (JHS/EDS-HT).
DESIGN: Prospective, cross-sectional study.
METHODS: Forty-four eyes of 22 consecutive patients with an established diagnosis of JHS/EDS-HT and 44 eyes of 22 age- and gender-matched control subjects. Administration of a standardized questionnaire (Ocular Surface Disease Index) and a complete ophthalmologic examination, including assessment of best-corrected visual acuity, slit-lamp biomicroscopy, intraocular pressure measurement, indirect ophthalmoscopy, tear-film break-up time, Schirmer I testing, axial length and anterior chamber depth measurement, corneal topography, corneal pachymetry, and confocal microscopy. Main outcome measures included comparing ocular anomalies in JHS/EDS-HT and control eyes.
RESULTS: JHS/EDS-HT patients reported dry eye symptoms more commonly than controls (P < .0001). Scores of tear-film break-up time and Schirmer I test were significantly lower in JHS/EDS-HT eyes (P < .0001). Minor lens opacities were significantly more common in the JHS/EDS-HT group (13.6%; P < .05). Pathologic myopia with abnormal vitreous was found in 7 JHS/EDS-HT eyes (15.9%) and 0 controls (P = .01). Corneas were significantly steeper and the best-fit sphere index was significantly higher in JHS/EDS-HT group (P < .01). By confocal microscopy, the JHS/EDS-HT group showed lower density of cells in the superficial epithelium (P < .001) and higher density of stromal keratocytes in anterior and posterior stroma (P < .0001).
CONCLUSIONS: The most consistent association of eye anomalies in the JHS/EDS-HT group included xerophthalmia, steeper corneas, pathologic myopia, and vitreous abnormalities, as well as a higher rate of minor lens opacities. These findings indicate the need for ophthalmologic survey in the assessment and management of patients with JHS/EDS-HT.

++++

The cornea in classic type ehlers-danlos syndrome: macro- and microstructural changes.

Invest Ophthalmol Vis Sci. 2013 Dec 11;54(13):8062-8. — Villani E, Garoli E, Bassotti A, Magnani F, Tresoldi L, Nucci P, Ratiglia R.

To analyze in vivo corneal morphology and ultrastructural features in patients with classic Ehlers-Danlos syndrome (EDS).
METHODS: Fifty patients with classic EDS and 50 age- and sex-matched control subjects were studied. A clinical evaluation was made with the Ocular Surface Disease Index (OSDI) questionnaire and a complete ophthalmic examination, including assessment of the best-corrected visual acuity and refraction, slit-lamp biomicroscopy, tear break-up time, intraocular pressure, Schirmer test without topical anesthesia, and corneal diameter. Scheimpflug camera topography and in vivo confocal microscopy (IVCM) were used to investigate corneal morphology and corneal ultrastructural features respectively.
RESULTS: Classic EDS patients, compared to controls, had thinner and steeper corneas (P < 0.001 and P < 0.05, respectively; independent samples t-test). IVCM showed thinner stromas, lower keratocyte densities (P < 0.001), increased applanation-related stromal folds (P < 0.001; Mann-Whitney U test), and increased endothelial hyperreflective dots (P < 0.05) in these patients. The study group also had increased symptoms (OSDI score: P < 0.01, independent samples t-test) and signs (tear break-up time and Schirmer test: P < 0.001 and P < 0.05, respectively) of tear film dysfunction.
CONCLUSIONS: Patients with classic EDS had macro- and microstructural changes of the cornea, which is a target tissue of the disease. These findings should be considered to optimize clinical management of these patients and to evaluate the opportunity of adding ocular findings to the classic EDS diagnostic criteria.

++++

Neurologic manifestations of inherited disorders of connective tissue.

Handb Clin Neurol. 2014;119:565-76. — Debette S, Germain DP.

Inherited disorders of connective tissue are single gene disorders affecting structure or function of the connective tissue. Neurological manifestations are classic and potentially severe complications of many such disorders. The most common neurological manifestations are cerebrovascular. Ischemic stroke is a classic complication of vascular Ehlers-Danlos syndrome (type IV), homocystinuria, and arterial tortuosity syndrome, and may occasionally be seen in Marfan syndrome and pseudoxanthoma elasticum with distinct underlying mechanisms for each disease. Vascular Ehlers-Danlos syndrome can also lead to cervical artery dissection (with or without ischemic stroke), carotid-cavernous fistula, intracranial dissections and aneurysms potentially causing subarachnoid or intracerebral hemorrhage, and arterial rupture. Other neurological manifestations include nerve root compression and intracranial hypotension due to dural ectasia in Marfan and Loeys-Dietz syndrome, spinal cord compression in osteogenesis imperfecta, and mucopolysaccharidosis type I and VI, carpal tunnel syndrome in mucopolysaccharidosis type I, II, and VI. Impaired mental development can be observed in homocystinuria, mucopolysaccharidosis type II, and the severe form of mucopolysaccharidosis type I. For the neurologist, being aware of these complications and of the diagnostic criteria for inherited connective tissue disorders is important since neurological complications can be the first manifestation of the disease and because caution may be warranted for the management of these patients.

++++

Pediatr Radiol. 2011 Dec;41(12):1495-504;

Loeys-Dietz syndrome: cardiovascular, neuroradiological and musculoskeletal imaging findings.

Kalra VB, Gilbert JW, Malhotra A.

Loeys-Dietz syndrome (LDS) is an increasingly recognized autosomal-dominant connective tissue disorder with distinctive radiological manifestations, including arterial tortuosity/aneurysms, craniofacial malformations and skeletal abnormalities. LDS exhibits a more aggressive course than similar disorders, such as Marfan or the vascular subtype of Ehlers-Danlos syndrome, with morbidity and mortality typically resulting from complications of aortic/arterial dissections. Early diagnosis, short-interval follow-up imaging and prophylactic surgical intervention are essential in preventing catastrophic cardiovascular complications. This review focuses on the cardiovascular, neuroradiological and musculoskeletal imaging findings in this disorder and recommendations for follow-up imaging.

++++

J Bone Joint Surg Am. 2010 Aug 4;92(9):1876-83.

Musculoskeletal findings of Loeys-Dietz syndrome.

Erkula G, Sponseller PD, Paulsen LC, Oswald GL, Loeys BL, Dietz HC.

BACKGROUND: Loeys-Dietz syndrome is a recently recognized multisystemic disorder caused by mutations in the genes encoding the transforming growth factor-beta receptor. It is characterized by aggressive aneurysm formation and vascular tortuosity. We report the musculoskeletal demographic, clinical, and imaging findings of this syndrome to aid in its diagnosis and treatment.
METHODS: We retrospectively analyzed the demographic, clinical, and imaging data of sixty-five patients with Loeys-Dietz syndrome seen at one institution from May 2007 through December 2008.
RESULTS: The patients had a mean age of twenty-one years, and thirty-six of the sixty-five patients were less than eighteen years old. Previous diagnoses for these patients included Marfan syndrome (sixteen patients) and Ehlers-Danlos syndrome (two patients). Spinal and foot abnormalities were the most clinically important skeletal findings. Eleven patients had talipes equinovarus, and nineteen patients had cervical anomalies and instability. Thirty patients had scoliosis (mean Cobb angle [and standard deviation], 30 degrees +/- 18 degrees ). Two patients had spondylolisthesis, and twenty-two of thirty-three who had computed tomography scans had dural ectasia. Thirty-five patients had pectus excavatum, and eight had pectus carinatum. Combined thumb and wrist signs were present in approximately one-fourth of the patients. Acetabular protrusion was present in approximately one-third of the patients and was usually mild. Fourteen patients had previous orthopaedic procedures, including scoliosis surgery, cervical stabilization, clubfoot correction, and hip arthroplasty. Features of Loeys-Dietz syndrome that are important clues to aid in making this diagnosis include bifid broad uvulas, hypertelorism, substantial joint laxity, and translucent skin.
CONCLUSIONS: Patients with Loeys-Dietz syndrome commonly present to the orthopaedic surgeon with cervical malformations, spinal and foot deformities, and findings in the craniofacial and cutaneous systems.

07Jan/14
Hypermobility

Hypermobility – Ehlers Danlos Syndrome and gastrointestinal problems

Hypermobility

Hypermobility

Hypermobility is common and is certainly a feature that we often see in patients at the clinics. Some patients have been diagnosed with hypermobility but do not know what it really means and need clarification, some are suffering aches and pains that are limiting and troublesome and still others visit with chronic pain and hypermobility is seen at the assessment.

See hypermobility blogs — blog 1 — blog 2 — blog 3

I always begin with an explanation that includes pointing out that many top athletes are hypermobile and hence there can be advantages. Per se, hypermobility is not necessarily a problem and in fact many who come for advice do not have any significant issues. They may need a programme that includes spatial awareness training, balance and proprioceptive exercises, but in essence, they can continue as normal.

Those patients who suffer pain and on-going pain, often widespread, require a different approach that considers the pain source and the influences upon pain. The training will include proprioception and spatial awareness exercises, but the baseline start point will be different. Before this even, there is often a need to tackle the sensitivity in several ways, termed top-down and bottom-up. Top-down refers to how we can target the brain including education, strategies to deal with thoughts that create anxiety and adaptations to the body maps that change our body sense and experience. Bottom-up is the use of the body tissues to change sensory processing and hence pain and sensitivity. There are many ways of doing this, and altering the combinations of the top-down and bottom-up  strategies creates potent ways of tackling pain.

Frequently, those who suffer persisting musculoskeletal pain will also bare pain through other body systems, especially the gut. See this recent review:

BKW5H0_stomach-ache_342x198Functional digestive symptoms and quality of life in patients with ehlers-danlos syndromes: results of a national cohort study on 134 patients. Zeitoun JD et al.

Abstract

BACKGROUND AND OBJECTIVES:

Ehlers-Danlos syndromes (EDS) are a heterogeneous group of heritable connective tissue disorders. Gastrointestinal manifestations in EDS have been described but their frequency, nature and impact are poorly known. We aimed to assess digestive features in a national cohort of EDS patients.

METHODS:

A questionnaire has been sent to 212 EDS patients through the French patient support group, all of which had been formally diagnosed according to the Villefranche criteria. The questionnaire included questions about digestive functional symptoms, the GIQLI (Gastrointestinal Quality of Life Index), KESS scoring system and the Rome III criteria.

RESULTS:

Overall, 135 patients (64% response rate) completed the questionnaire and 134 were analyzable (123 women; 91%). Mean age and Body Mass Index were respectively 35±14.7 years and 24.3±6.1 kg/m(2). The most common EDS subtype was hypermobility form (n=108; 80.6%). GIQLI and KESS median values were respectively 63.5 (27-117) and 19 [13.5-22]. Eighty four percent of patients had functional bowel disorders (FBD) according to the Rome III criteria. An irritable bowel syndrome according to the same criteria was observed in 64 patients (48%) and 48 patients (36%) reported functional constipation. A gastro-esophageal reflux disease (GERD) was reported in 90 patients (68.7%), significantly associated with a poorer GIQLI (60.5±16.8 versus 75.9±20.3; p<0.0001). GIQLI was also negatively impacted by the presence of an irritable bowel syndrome or functional constipation (p=0.007). There was a significant correlation between FBD and GERD.

CONCLUSIONS:

Natural frequency of gastrointestinal manifestations in EDS seems higher than previously assessed. FBD and GERD are very common in our study population, the largest ever published until now. Their impact is herein shown to be important. A systematic clinical assessment of digestive features should be recommended in EDS

It is routine in our clinic to ask about other body systems as this tells us a great deal about the level and type of sensitivity, which in turn guides the comprehensive treatment and training programme.

Increasingly, patients are being referred for irritable bowel syndrome and other functional pains (e.g./ migraine, headache, chronic back pain, chronic joint pain, pelvic pain, vulvodynia). Due to the underpinning sensitivity residing within the central nervous system — this is not a disease but rather an adaptation; neuroplasticity at play — we can target these mechanisms with a range of effective strategies to re-learn or re-programme the way in which the neuroimmune system is expressing itself. These systems are fundamentally designed to change, learn and grow. They simply need the right conditions to do so, and all too often there is a belief that a situation cannot change and hence all the choices and behaviours prevent any form of forward movement. This is just not true and through our understanding of the body systems and their adaptability, we are creating increasingly effective and diverse ways of tackling pain and suffering.

If you have been diagnosed with hypermobility or are suffering with chronic pain, call us now to discover how you can change your experience and move on: 07932 689081 — Specialist Pain Physio Clinics in London: Hypermobility Clinics

05Jan/14
Basal Ganglia | Dystonia

Dystonia — facing the world

Basal Ganglia | Dystonia

Basal ganglia | Dystonia

Dystonia — the term used to describe uncontrollable and sometimes painful muscle spasms caused by incorrect signals from the brain. It is estimated to affect at least 70,000 people in the UK; Dystonia Society — has varying impact upon the individual. By this I refer to the way in which it makes the person view themselves, their sense of self, and how the world sees them.

Our physical persona, the way we represent ourselves to the world via body language, posturing and movement to an extent defines us and how we feel. This is bi-directional as we will respond physically to how we are feeling and what we are thinking as much as noticing how our body feels to then ascribe an emotion; for example, butterflies in the stomach will typically trigger thoughts that we must be anxious.

Having spoken to many people with dystonia, this significant part of the experience is rarely addressed. It must be. On a practical level, understanding that movement is affected by a number of influences such as where we are, who we are with, how we are feeling, where we are and what we have been doing, helps to cope and deal with the unwanted motion on several different levels. Further, to know that the brain is constantly predicting what actions will be required next and planning how to use the body, provides insight into how certain involuntary movements can be initiated.

In dystonia, the way in which the brain perceives the body is altered as is the way movements are planned and executed. A loss of precision means that there is unwanted and uncontrolled actions in both a sensory and motor context. This is why training must be multisensory and embrace the sensorimotor system as a whole, from a planning stage through to actual movement.

How we face the world and whether we choose to face the world will be dependent upon how we feel. Being able to cope with this will impact upon the extent to which socialisation continues or is voluntarily curtailed. Cultivating skills in dealing with the thought processes and being able to intervene independently has a positive effect, reducing and minimising the impact. This is also a key skill to use in optimising the outcome of the training programme, by changing the way that the brain is functioning in a motor sense, so that the focus and quality is of a high level. Practice is key.

Focused attention training or mindfulness should form part of a comprehensive treatment programme. It can be thought of as setting the scene, creating a brain state of calm and readiness for the actions that are required to re-train precision of movement and body sense. It is a state that can be cultivated that means troubling thoughts do not get played through the body (tension, altered movement, involuntary movement).

There are many healthy, physical and mental benefits of mindful practice, tackling the so significant non-motor factors that are barely mentioned, yet play such a huge role in the individual’s suffering. We are understanding the brain changes associated with this practice as neuroscientists study the effects upon the wiring — a crude analogy of the brain’s function — and how this translates into a positive experience of life.

Stand alone, mindfulness practice can change our interface with the world. Combined with specific sensorimotor training and the creation of new habits, the potency is magnified. On a practical note, mindfulness can be used at all stages of dystonia, acute through chronic. The sensorimotor training often requires a degree of quiescence and hence will usually begin after botox treatment. The design of any treatment and training programme will depend very much on the individual need and circumstance.

As I have argued recently in writing and speaking at several conferences (Dystonia Society DayBritish Neurotoxin Network meeting 2013) , to address dystonia — and chronic pain — we must consider the biology of the condition but also the biology of the influencing factors that are such a significant part of the narrative.

Appointments — please call us on 07932 689081

 

 

03Jan/14
The fulcrum point

Changing pain and suffering in 3 steps

The fulcrum pointLogically, anecdotally and empirically, understanding one’s pain is a foundation from where action can be taken to initiate change. Conversely, lacking insight into the cause of pain and being unaware of the contributing factors creates anxiety that forms its own cycle of problems. This is certainly true when pain persists with no obvious structural or pathological reason — a common scenario.

The initial feeling of pain could be termed the primary sensation. The location, quality and intensity are noted, motivating responses: have a look, move, perhaps touch and seek advice. From the primary feeling comes an automatic thought that is deeply grounded in a belief system about pain, injury, life, health and the landscape of our world. This automatic thought triggers a range of emotional and physical responses that are experienced as secondary effects. The secondary effects of limitation, suffering, further pain and sensitisation — an often downward spiral accompanied by despair,  a perceived loss of control — accounting for much of the impact upon quality of life.

There is a fulcrum point between the primary and the secondary that is so potent; a fulcrum point being the place where leverage can be applied to affect a process. In physical therapy — for this is my background — this could be the careful and reasoned application of a hands-on technique to effect change in the way the brain processes sensory information from the body; the basis for relief as the brain alters it’s outputs and hence the sense of physical self. Similarly, to intervene at the point of feeling pain so as to minimise or even prevent the secondary effects that are driven by the automatic thought is a practice that can be cultivated.

  • Pain -> thought — meaning? -> increase in pain, tension, suffering
  • Pain -> thought — mindfulness -> reduced pain, tension, suffering

3 steps to easing pain & suffering 

There are several steps to developing the practice. Firstly, understanding your own pain is vital. What are the biological mechanisms and sources? And what can influence this biology? The latter includes stress, fatigue, movement, thinking, beliefs and the environment. A further point to consider is always that of perception. We all have our own unique perception that is created by our mind~brain, again based on our view of ourselves and the world, moulded by years of experience that blends with our genetics. No matter what the situation, our own reality is the one we respond to, and in the case of pain and sensitivity, the responses can increasingly be triggered by non-threatening situations and environments that are perceived now to be threatening.

The second step is to develop awareness of one’s own thinking and perception at the point that pain is noted. It is by becoming aware that we can then make the necessary change and apply leverage. To be aware means that you must be present as opposed to the autopilot mode where the mind drifts into the past, replaying tapes of previous events — that can equally trigger emotional and physical responses — ruminating on what has been, or fantasising or constructing a future. Neither fundamentally exist, yet we respond and behave as if this is the case; it is our reality for that moment. In doing so, the present moment is missed and we follow the mind and it’s wanderings. All minds do this, this is normal, but if the wanderings create suffering, angst and discomfort, it does not bode well for a happy existence.

The third step is to practice. Being aware is being mindful; the way in which pain and suffering can be eased. Creating a habit of regular practice is certainly achievable with a little motivation, guidance and support. Within a few weeks, people often report a significant difference in how they feel in terms of pain but also in their ability to deal with pain, their resilience. Mindfulness practice changes how the body physically feels and there is a fortified sense of facing life. The release of tension, the removal of the sandbags from the shoulders is welcome in all cases.

Specialist Pain Physio Clinics in London for chronic pain and injury — mindfulness is part of a comprehensive treatment and training programme to reduce pain and suffering, and guide individuals back to a fulfilling life — call us on 07932 689081

01Jan/14
The patient journey

Humanising the patient journey

The patient journeyModern healthcare features innumerable methods of technical investigation such as the MRI scan, blood tests and nerve conduction tests. All provide detailed information about structures and physiology state yet none tells us about the person, the human being.

Many people will undergo tests and often this is necessary to determine whether there is a serious pathology or changes in body that require specific procedures.

No matter what the test or investigation, it must never be forgotten that it is a human being ‘tested’, not a number in a line, or a condition, but an individual with thoughts, beliefs, expectations and fears. It is by addressing these that we can make the patient journey a human one that has meaning.

The patient journey usually begins when something feels wrong: a pain, a change in the way the body works or is experienced, a sudden incident or a gradual realisation that there is an altered sense of self. This threshold and realisation prompts action. A visit to the doctor or in the alarming situation a rapid transfer to a hospital, may be the first encounter with the healthcare system.

Those first moments of the experience, the thoughts, the feelings, the interactions, the words, the fear evoked by all of these, will impact upon the trajectory of the journey and of course the immediate care for an emergency.

At each of these points, when there is an opportunity to reassure, calm, listen, just be, they should be taken. These simple yet potent interjections that can be administered with ease in amongst the hullabaloo of tests, wires, medical language, white coats, stethoscopes, needles, injections and trolleys. Let them not be lost.

As we stroll into 2014, as the science progresses, it is reassuring to see some authors drawing upon philosophical thought, in particular phenomenology, so we can keep a firm footing in the patient’s experience, for this is where the real story resides. The patient narrative is the key thread that must be given room for expression via firm description, vague terms and bodily expression. The examination that follows; who examines who? The connection, the information flow that requires sound mind, as this is the function of the mind that must interact with the examiner.

So let us in healthcare be mindful of the human being at the centre of the story. The experience that they share with us is unique and an expression of their perception build upon a set of entrenched beliefs about their life, the World and their expectations — and hopes and dreams. We are in a strong position to oil the wheels that need to turn smoothly for a patient journey to lead anywhere meaningful.

01Jan/14
Specialist Pain Physio Clinics in London for pain, complex pain and injury

Mindfulness programme

The light out of the darkMindfulness commonly forms part of a comprehensive treatment and training programme for pain, anxiety and stress. The origins of the practice stem from many years ago but in a modern sense, mindfulness is mind training that is akin to physical training used to improve fitness. A great deal of time is dedicated to physical activity for health, less so on the mental side, however the two are inextricably entwined. For one you simply need the other, and to combine the training is the most potent way of cultivating the conditions for healthy living or recovery from pain and injury.

The modern day use of mindfulness is to create health, foster clarity of thought, increase awareness of thoughts and actions for self-improvement and to reduce stress, anxiety and pain that occurs as a consequence of simple practices. Mindfulness is not steeped in religion, but is a philosophical framework to attain a more fulfilling existence.

See Vietnemese Buddhist monk Thich Nhat Hanh speaking here 

Thich Nhat HanhA programme of mindfulness activities, followed week by week over a period of 8-10 weeks is an excellent way to groove the habit. It is a learning process that increasingly develops awareness in order to make the necessary changes to promote health. Many activities and thought processes are automatic or habitual, but do not point us towards a positive, fulfilling existence. To change this situation requires practice, in essence to re-wire the way we are working via the characteristic neuroplasticity, a feature of the nervous system that underpins learning and adaptation.

Over the 8-10 weeks the practice of a variety of mindfulness activities creates a healthy habit. Several daily sessions of 12-20 minutes focused training is the goal. In addition, forming a routine of performing tasks in a mindful way is a powerful way of regularly enrich awareness; this is simply by paying attention to a normal activity such as cleaning, making a drink or walking. Attend to the sounds, the feel, the aroma and physical sensations thereby standing in the present moment rather than drifting automatically into the past or building a future.

Typically over the period of training, the practice of mindful breathing to cultivate awareness of the effects of thoughts upon the body and vice versa, the body scan to regain a sense of the physical body and how it constantly changes and responds, mindful movements that combines awareness with comfortable motions that nourish the body tissues, working with the pain and suffering and developing compassion towards oneself and others.

For further information or to book, please call us: 07932 689081

31Dec/13
Matthieu Ricard

The habits of happiness | Matthieu Ricard speaks

Matthieu RicardPreviously a scientist, Buddhist monk Matthieu Ricard, talks about happiness and the ability to train the mind to cultivate well-being, serenity and fulfilment.

How can we nurture happiness?

Ricard describes how we can do this in order to lead happier and fulfilling lives, blending the fundamentals of mind training with science.

Many people who are starting the journey towards changing their pain, begin from a start-point of unhappiness. Beginning the treatment and training programme by creating a positive mindset builds a strong foundation from where one can move forward, by both understanding pain and cultivating the practice of specific mind training techniques.

23Dec/13
lion

Thoughts can be threatening

lionA threat can arise in many forms. Years ago, it would have been a wild animal that posed a potential danger, responded to with a fight or by running away — flight. Nowadays we don’t often face the physical threat of an animal attack, more likely it being the menace of street crime or the risk of an injury whilst undertaking activity. The context of each of these scenarios is very different with distinct and personal meanings that result in varying responses.

The key point about a threat is that is must be interpreted as being dangerous in order to arouse activity in the autonomic nervous system. This system is the link between what we think, the meaning we ascribe to a circumstance and how the body responds. With connections that reach far into the body systems, in particular the cardiovascular system and the gut, the autonomic system is a major player in creating awareness that something is potentially unsafe and hence drives behaviours to approach or avoid.

Most of the time we do not face a physical threat. However, familiar feelings in the body signify anxiety most likely on a daily basis: tension, butterflies in the stomach (actually changing blood flow that triggers neural activity), increased heart and breathing rates and perhaps a sense of panic. Why? Because of our thoughts.

Thoughts can be threatening. A thought that is lived, given significance, engaged with or is considered to be self-defining, will evoke emotional and physical responses. If the thought is one that plays a tape of an unpleasant past experience, fashions an image or a story that is troubling or builds a future of uncertainty, the autonomic system will be aroused. This happening over and over ensures that the system becomes more easily switched on and vigilant to a range of cues, even normal situations that can become threatening in some cases.

Feeling anxious is normal. It warns us that we need to place our attention upon the trigger and take the necessary action. Once this has been done, there is no need to continue to feel anxious, but often the association continues. Automatically there is a response to a thought, or waves of thoughts, and without control over this, the spiral continues. How can we gain control?

Mindfulness is a very potent way of tackling stress. The bodily feelings of stress are triggered by our perception of a situation being negative, risky, dangerous and somehow threatening to our beliefs about ourselves and our world. At the point where a thought or a situation prompts an automatic thought that is negative, these emerging from our belief system that has been evolving from a very young age, this propels us into greater suffering, pain, and sensitivity with increasing impact. Mindfulness practice refines the awareness of this process, maintaining a presence that prevents the dwelling upon the past or a leap into the future. Neither of these actually exist as they are constructs of our mind. The problem is the brain’s response to past or future thinking is very similar to actually being there — a lack of discrimination means that the same autonomic actions are triggered.

In the short-term, the autonomic responses are adaptive and useful. If they persist, the chemicals released over and over become problematic as certain systems are shut down due to the perception of danger. For example, the gut and reproductive system are not needed when we are escaping the clutches of a wild animal. But, similarly, chronic stress from an on-going negative assessment of a situation, thinking, will have the same effect. This is often a feature of infertility when the reproductive system is being impacted upon time and again.

The biological reality then, is that no matter what the situation, it is the individual interpretation that is key in determining what happens next. In developing mindfulness practice and emotional intelligence at the fulcrum point that is the automatic thought popping into consciousness, suffering, pain and on-going stress responses can be subdued and dissolved as presence and awareness rules over.

For further details about our treatment and training programmes for persisting pain and stress, call now 07932 689081

19Dec/13
A scan does not show pain

Low back pain & neck pain | a very common problem

Back pain and neck pain are very common

Most of us will experience low back pain and neck pain at some point in our lives. In fact, it is unusual not to have some aches and pains around the spine. With back and neck pain being so common in the modern world, you would assume that treatment is very effective. Sadly not.

There are different scenarios with back and neck pain, often either a nasty acute type pain or a lower level nagging pain that grinds on and on. A further common situation that I see is a persisting back pain that is part of an overall picture of widespread pain. Accompanying the pain is altered movement and muscle tension that adds to the unpleasantness. This is mainly due to the effects of overactive muscles that are being told to protect the area — acids released, reduced oxygen levels; both of which can excite local nerve endings (nociceptors) that send danger signals to the brain.

When a particular movement or action triggers the pain, we assume that this is dangerous and the cause of the pain. This is not quite the case. There is a lead up to the moment of pain when the nervous system is becoming sensitised, often slowly, over a period of time. This is called priming. Then, at a given moment, when the system is close to the threshold of becoming excited, a normally innocuous movement just tips the physiology over the line with a consequential range of protective responses that include pain, spasm and altered movement.

Sometimes there are changes in the tissues or ‘damage’. Again there is often an assumption that when the pain begins, this is the point of injury. This can be the case but equally the changes in the tissues may have been evolving over a period of time. The reality is that you will never really know, even with a scan. The scan may show a disc bulge or herniation but does this describe your pain? Or tell you when the problem began? No.

Unpleasant as the body responses are, they are normal, necessary and part of the way in which the body defends itself, largely organised by the brain. The pain draws our attention to the area that the brain wants us to protect. When the pain is severe of course our attentional bias will be towards the region most of the time — hypervigilance. How we think about the pain will determine the impact, level of suffering and influences the trajectory of the problem as our thoughts and beliefs about back pain will impact upon what action is taken. In the very acute stages, there may not be a great choice when the pain and spasm is strong, thereby limiting movement vigorously. It is good to know that this phase, as horrible as it can be, does not last too long in most cases if the right action is taken based on good knowledge.

It is always advisable to seek help and guidance: know that nature of the problem, how long it can go on, what is normal and what you need to do to ensure a good recovery. Generally, understanding that pain is not an accurate indicator of tissue damage — see video here — , controlling the pain with various measures in the early stages and trying to move as best you can starts off on the right footing. It can be scary when the pain is severe, so calming strategies really help to reduce the impact — anxiety is based on thinking catastrophically about the problem, thereby triggering more body defences in pain and tension. Mindful breathing and other relaxation skills should be practiced regularly.

In summary, back pain and neck pain are very common. The primary message here is that the acute stages are unpleasant and often distressing but they do not last long in most cases if the problem is managed well with understanding to reduce concerns and to minimise the threat value, good pain control, simple movement strategies and a little treatment to ease tension and change the sensory processing in the body so that it feels more comfortable.

If you have low back pain or neck pain, especially persisting pain or widespread pain, come and see us to find out how you can change your pain and get moving again: call 07932 689081

 

17Dec/13
Brain~Body

A quick note on brain~body — body~brain

Brain~BodyThe brain is where it’s at. Or so it seems if you read the press or look at the bookshelves. The notion that brain is everything has been challenged recently and so it should — see here. We need enquiry at every point, challenging the comfort of thinking that we know.

Despite this, it seems logical to think that the brain is involved with much of our existence. The ‘hows’ and ‘whys’ need continued clarification. In a crude sense, on the end of our brain lies a body. This body is where we feel life whether that be the experience of an external stimulus such as touch or the result of a thought that always triggers a physical and emotional response once we engage with that thought.

The term ‘body-mind’ has been used countless times by both mainstream practitioners of medicine and health and alternative or complimentary therapists. Most people understand the concept although many still try to deny the links. Can a thought really change the physiology in my body? Of course it can. It happens all the time. In fact, I would argue that our body functioning is the emergent physical manifestation of all the processing going on in the mind.

The way in which we move, posture, position ourselves is dependent upon the task at hand but also the task that we may engage with at some point in the near future. The brain is the greatest predictor and will continually analyse the environment, the situation and compare this to what it knows to create the actions necessary. In cases of chronic pain or stress, the brain becomes hypervigilant and responsive to a range of cues that would not normally evoke a protective response but now does via the the autonomic nervous system (‘fright or flight’), the nervous and immune systems.

Much of the activity in our body systems we are unaware of as the brain and reflexive activity takes care so we can attend to the necessary survival tasks. Filtering out the millions of stimuli, the brain draws our attention to what is deemed to be salient for that moment.

In a state of anxiety, this is usually felt in the body — churning stomach, tension, sweaty palms etc. We use the body as a yardstick as to how we are feeling although the thoughts evoking these bodily and physiological responses are not always immediately apparent. The thoughts will eventually pop in there, or emerge, this from an unspecified network of neurons in the brain.

In essence, we can think about the body~brain or brain~body relationship as a needy one; they need each other for full function. To separate makes no sense bit neither does to blame one or the other. Thinking about the emergent features of the synchrony appears to provide a better way of considering problems such as pain, stress and other conditions.

RS — Specialist Pain Physio Clinics, London