04Nov/13
Specialist Pain Physio Newsletter

New Malden Diagnostic Centre Autumn Newsletter 2013

Here’s the New Malden Diagnostic Centre Autumn newsletter with a feature on Specialist Pain Physio Clinics: New Malden Diagnostic Centre | Autumn Newsletter 2013

The New Malden Diagnostic Centre – see here

A state-of-the-art diagnostics and treatment centre situated in New Malden, Surrey.

The centre offers the very latest in diagnostic imaging along with consulting rooms giving us the ability to diagnose and manage a comprehensive range of conditions for babies, children and adults.

Built in 2010, The New Malden Diagnostic Centre offers private outpatient consultations, diagnostics and treatment in modern surroundings for patients who are insured, sponsored or self-funding.

We have a team of highly experienced consultants working across all specialties who ensure that all patients receive high quality, personalised care. Our consultants are supported by a dedicated team of nurses, radiographers, health care assistants and technicians.

The Spine Clinic at NMDC

The Specialist Pain Physio Clinics are held on Thursdays at The New Malden Diagnostic Centre – call for appointments 07932 689081

23Oct/13
Neuroscience

The dark side — the brain’s creations

NeuroscienceThe popular press is awash with neuroscience, now to the point that some authors are becoming ‘anti’. We need debate, so hats off to those contributors who rightly ask questions. We should never sit back and accept a ‘fact’ but instead, test, test, test. Despite this fresh discussion, we do accept that the brain has a great deal to do with our experiences of life.

A single centre for consciousness has not been identified in the brain and is not likely to be discovered. Instead, our unique sensory and emotional experiences are created by vast, interconnected networks of brain cells, maintained and influenced by immune cells that populate the brain and spinal cord. The pain matrix theory of Ron Melzack is a great example of such a functioning network. From these networks emerge feelings, thoughts, movements, senses and pain to name but a few. Where we actually experience these emergent properties can vary enormously, although one could argue that the role of the brain is to create the most biologically appropriate experience for that given moment and context.

Recently, Mick Thacker and Lorimer Moseley wrote a brief paper discussing the idea that pain is emergent. This is a relevant and sensible calling upon philosophy to help us explain pain to patients at a time when there has been a trend to suggest that the brain is at fault. Indeed we need a brain to feel pain — see Lorimer talk here — just as we need a brain to see and hear, but how helpful is this to the patient with back pain? Even if they grasp the concept of the pain neuromatrix, to suggest that the pain is coming from the brain can be a challenging leap. Preferable is the explanation that pain emerges from the body but there is a significant part played by a widespread web of neurons and immune cells in the brain and spinal cord; this requiring a careful description to give meaning to the individual.

DepressionTo take this a stage further, one could argue that a depressed state underpinned by ruminating thoughts is emergent from a network of neurons within the brain, yet often felt deep within the body in a multitude of unique ways––visceral. The heaviness of thought is usually reflected within the physical self via posturing, movement and gut instinct. Our minds that exist within the brain networks––who knows where––stream with thoughts that are occasionally useful, frequently the same, and always driving bodily responses. The brain does not discriminate between thinking about being somewhere and actually being there; a similar response ensues. This can be wonderful if the memory or thought cultivates the tape of a happy time. How often does this happen in comparison to a train of worrying or troubling thoughts? Especially if one’s mood is low, the impact of a negative situation or comment is far greater. This is the dark side of the brain’s creation of our multisensory experience; seeing, hearing, feeling, thinking.

The depths to which one can slip or drop are seemingly endless. It does appear modern life is contributing to this endlessness as the figures on depression rise. Perhaps it is the expectation that we should be happy, with all the convenience of immediate service and advancing knowledge, yet there is greater striving for this state. Bookshelves are packed with self-help books, Facebook and Twitter saturated with quotations about how to think positively, and the growing industry that is life coaching all pay homage to the fact that we are not achieving as ‘alchemists of joy’.

Where neuroscience can make a contribution is to give us the understanding of the mechanisms that can be translated into practical tools for everyone. There have been numerous steps in the right direction with some great discoveries that inform; for example: the similarities of physical and social pain (e.g. rejection, isolation), neuroplasticity, the way in which immune cells prune synapses, communication between the gut and the brain, and mirror neurons (a deliberately provocative inclusion — see here) to name but a few.

The light out of the darkThe idea that experiences are emergent from a neuronal network influenced by many factors including epigenetics (the blend of genetics and experience), is a very credible way of thinking about how we can re-shape our thinking, feeling selves. The basic neuroplastic characteristic of our neuroimmune system, or the ability to learn, means that by creating the right conditions with the right understanding and individualised strategies based upon fact, we can cultivate change. This does not preclude the use of medication or other medical interventions but this alongside sensible and wise action based on sound science to move us into the light.

** Please note that this is not an exhaustive discussion of either depression or neuroscience but rather an observation. I am aware that this may trigger thinking and discussion that are both welcome in the hope of advancement.

Specialist treatment, training and coaching for persisting pain, chronic pain and injury in London – call for appointments 07932 689081

 

21Oct/13
Hippocampus

How do you know where you are? | Neil Burgess speaks

HippocampusIt is useful to know where you are. Neil Burgess spends his time studying this important function by looking at the brain, the hippocampus to be specific.

It would appear that the same brain cells that create our sense of where we are and recalling that information for practical use are also at play when we imagine movement, such as a motor imagery task for a painful condition.

19Oct/13
Beliefs

Pain beliefs need tackling first

BeliefsWe have many beliefs that construct our perception of the world. Beliefs about pain are no exception as we try to make sense of an injury or the emergence of the painful experience within the context of a situation. The significance of our own pain beliefs cannot be underestimated when it comes to treatment and training. They need to be elucidated and often sculpted to enable change and hence pain relief, in particular when the pain has been in existence for some time.

Commonly, patients who have been suffering persisting pain become increasingly vigilant to body sensations. This is called ‘hypervigilance’ and often comes hand in hand with ‘catastrophising’, another long word that means the belief system has kicked in and considered the body signal to mean something dangerous.

To change a persisting pain state we need re-training of the systems that process the information from the body and those that create our conscious experiences; what we feel, what we see, what we hear etc. There are a number of body-focused strategies that we can use to target the process from simple rubbing of the painful area to more specific sensorimotor training techniques. We often refer to this as ‘bottom-up’. We can enhance the effects of the bottom-up therapies by preparing the brain so that it is receptive to the body work. We call this ‘top-down’, which is like ploughing a field so that it is ready for the seeding.

Preparing the brain is a way of desensitising the processing systems by diminishing the threat. Pain is a response, an output from the body resulting from the conclusion that there is something posing a threat to the integrity of the self. Initially this means that the patient must understand their pain and symptoms, including why they persist and what we can do about it. It is clear how this would start to reduce the threat value and hence pain in many cases—people frequently report an easing of the symptoms at this point.

Returning to hypervigilance and catastrophising, we tackle these problems with education and positive experiences. Developing knowledge of the biology of pain and the skills to deal with both body sensations and the thoughts that follow is absolutely key in the early stages, for this is what drives the next behaviour. In the case of fear, usually the next behaviour is avoidance. Avoidance maybe useful in the very acute stages to protect the healing body, but in a persisting pain state, inactivity becomes a problem and a barrier to recovery.

A route forward

A route forward

Many body feelings are normal. When we are sensitised these feelings can be amplified and linger. In part this depends upon how what we think about the sensation and how much attention we put on the area. Where our attention lies has a big impact upon our pain perception, so being able to say to ourselves, “that is ok, it’s just a normal body feeling”, e.g./ pins and needles, allows us to move on without rumination that creates further fright or flight responses.

It has become clear with the continued reconceptualisation of pain that we must rehabilitate both the body systems and our thinking. Our thinking is based upon beliefs that are grooved throughout life—genes plus experiences—and these drive our behaviours, most of which happen automatically, i.e. they are habits. Creating awareness allows an opportunity for change, something that long-term pain sufferers relish as they are desperate to break the cycle and move forward. Blending awareness with knowledge and skills means that the habits of hypervigilance and catastrophising can be broken and new habits formed that create the conditions for wellness, performance and living.

For further information or to book an appointment to learn how you can move forward call us now on 07932 689081

18Oct/13
Pain beliefs

The virus that is pain beliefs | A brief view on the ‘meme-osity’ of pain

Pain beliefsWe develop beliefs about pain very early in life through experience of injury, by the things we are told by significant others and via observation. These become ingrained and emerge later on when we experience a painful situation. This is part of how we decide what we should do when we are injured. At some point, we have learned that if we knock our elbow on the door frame, we should check it out by having a look, rub the area to make it feel better and move it to ensure that it still works.

Our culture plays a significant role in the development of our beliefs. This includes the meaning of pain and what is signifies and how you should respond; e.g./ ‘the stiff upper lip’. These messages like many others are passed down through the generations. In a sense, the beliefs spread much like a virus, or others such as Richard Dawkins describe the ‘meme’, which is a construct that is passed from person to person, and much like a gene can self-replicate and mutate.

The meme that is, “Don’t bend your back if it is painful” has become a widespread belief that I often hear in the clinic. If you have acute low back pain with accompanying spasm, the chances are it is going to be difficult to move, so bending may not be an option. We do condition very quickly as humans and construct a story from the facts, albeit the story may not be true, but it makes sense at the time. For example, on sending an email, the response does not come back immediately and therefore the receiver is rude, uncaring etc. That is the story whereas the fact is that you have merely sent an email. There is a significant difference, the former creating discomfort whereas the latter is easy to accept.

On bending if we experience acute pain we can quickly assume that bending is dangerous. This maybe confirmed by someone you go to see for some help and very soon this is a strong belief that guides our choices of how to move.

This message has spread across many cultures and could be termed a meme or even a virus. How can we change this? Through education and creating positive experiences for people to then inherently know that they are safe to move in particular ways. All of this takes time and perseverence as the message predominates. However, as we know that memes can mutate as can viruses, we should seek to culitvate accurate understanding of pain with the continuance of resaerch and translation into clincal practice. The idea of the meme then, can be a useful way of thinking about the reconceptualisation of pain for better treatment and care.

 

17Oct/13
Specialist treatment programme for fibromyalgia in London

Surgery for breast cancer and a strange feeling arm

Breast CancerOne of the most terrifying moments in life must be when you hear the words, “I’m afraid that you have cancer”. The message would naturally trigger a cacophony of thoughts and emotions that could only be somewhat controlled by the knowledge that there is treatment that will tackle the cancer.

In the case of breast cancer, the treatment options depend upon the individual circumstances, for example:

  • The type of breast cancer you have
  • The size of your breast tumour
  • The stage of your breast cancer
  • The grade of your cancer cells
  • Whether you have had your menopause
  • Whether your cancer cells have particular receptors
  • Your general health

Source: Cancer Research UK website

Many people diagnosed with breast cancer will have surgery. There are different types of breast surgery that are performed and this is fully discussed with the individual, taking into consideration their circumstances and wishes.

Following breast surgery, either a mastectomy or involving the armpit, you will be encouraged to start moving your arm that can become stiff and sometimes painful. There can also be swelling as a result of the procedure. Of course these symptoms are common after any surgery but the arm is affected due to the removal of tissue that involves the chest and the arm and will certainly impact upon the local nerve network. There can also be cording that is tissue that becomes ‘cord-like’ through the axilla that can sometimes be seen on lifting the arm.

After your breast surgery

Understandably there is some pain after the surgery, this being controlled with medication. There are several mechanisms that can contribute to this experience, from both the wound and from the local nerves that become sensitised; neuropathic pain. These different pain mechanisms need different approaches and thought behind the therapies that can help.

Neuropathic pain is often described as burning, lancinating, spontaneous (ectopic firing that results in sudden pain with no obvious provocation) and altered sensation. This type of pain can lead to central sensitisation that in short can result in amplified responses to painful stimuli, painful responses to normally innocuous stimuli and a reduced ability to inhibit signalling. Concurrent with the pain, one can also experience an altered sense of the affected area, a frequent feature of persisting pain–although often not volunteered by the patient for fear of disbelief.

The change in the sense of body is a genuine and significant part of the scenario–I always ask patients. If a patient describes an altered perception of their body, a wise therapist takes note as this description demonstrates a change in the way that the brain is constructing the sense of self. Following surgery for breast cancer it is often the arm that feels strange; perhaps detached, alien, larger or lacking in control. This is a characteristic that needs attention and specific training as part of the desensitisation process and restoration of function, or normality. Understandably, there maybe other concerns following breast surgery, such as coping and adapting to a different body shape and form and in particular what this signifies to the individual.

Post-operative physiotherapy and rehabilitation in these cases necessitates techniques and strategies that focus on tissue health and healing, but also upon the controlling systems that process the signals from the body and create the experiences: the nervous system and the immune system. The development of modern therapies for persisting pain play a significant role in retraining normal body perception so that the affected area can once again feel part of the integrated self and function normally.

If you have had breast surgery and have had difficulty restoring normal movement and control of your arm, please contact us on 07932 689081

16Oct/13
Change your pain and live your life

Move over Mindset | Guest Blog from Gary Stebbing – Performance & Conditioning Coach

Exercise for health

Thanks to Gary Stebbing, Performance and Conditioning Coach, for this guest blog.

Exercise is almost uniformly recommended as fundamental to good health, so why do so many people live basically sedentary lives?

Why is behaviour change still such a puzzling conundrum within health and medicine?

As a practical coach one has to adapt and refine these questions to something more relevant….

How can one get better as a behaviour change agent; and more specifically how can one assist in creating a movement habit for clients or patients…..?

But is trying to change behaviour the wrong approach? Should we shift our personal mindset towards a focus on changing beliefs rather than behaviours……?

In their fascinating book Switch, authors Chip and Dan Heath use a very intriguing analogy to explore change:

Imagine a small rider sitting on top of a very large elephant walking through the jungle. The jungle is the environment that we live and function in – a very powerful influence on our lives. The elephant is our beliefs and attitudes – very powerful in driving our daily behaviours and actions. What happens in daily interactions is that we often try and intervene at the level of the rider. You can shout as loud as you like at the rider, what chance do you think the rider has of getting the elephant to change direction if it doesn’t want to?

Perhaps strategies to influence the elephant might have more success…..

Stanford psychologist Dr. Carol Dweck has used another approach to studying mindsets and their impact. Her work explores what she has defined has the ‘fixed’ and ‘growth’ mindsets.

Exercise for healthThose with a fixed mindset tend to like to appear smart to others and adopt more of a ‘this is the way it is’ type of attitude. Her work suggests amongst many things that they avoid risk of failure, lack resilience when things get tough and may feel threatened if others achieve success around them.

In contrast those with a growth mindset tend to be happy to try new things, be more robust when things aren’t going well and inspired by success around them.

If you follow this thinking into the path of exercise, what might be the differing outcomes for the fixed vs. growth minded individual.

Exercise is often tough at the beginning, negative feelings due to poor fitness levels, difficulty in grasping how to do new movements, watching others around you who seem to be more competent and finding it easy……it is easy to see how a fixed mindset might see exercise as not for them, while a growth mindset experiences the same things yet relishes the challenge!

Everyone loves working with growth mindset individuals….

So the true coaching challenge is to find the strategies to keep the fixed mindset in the game long enough to help them adapt the way they view and experience exercise and movement.

Perhaps the target is to help all individuals build something you might call the “movement mindset”.

For further information you can contact Gary on 07949 472142 or email: [email protected]

12Oct/13
Treating back pain in London

Back pain | why does it persist? (1)

Why does pain persist?

Why does pain persist?

The ‘why does it persist?’ series looks at the reasons why painful problems often continue despite treatment and the healing process. With 1 in 5 people experiencing on-going aches and pains, it is vital that we think widely about the causes of persisting pain and how we can tackle them more effectively.

Here’s the first maintaining factor—the early message given to the acute back pain patient, “don’t bend your back”. What’s the problem with this message?

Frequently the acute pain starts on bending over, usually whilst doing something innocuous such as picking up a pen or leaning slightly to clean your teeth at the basin. In this case, the pain is immediately associated with the position or the movement, this being laid down as a new rule: ‘bending is dangerous’. If, as often happens, the initial advice given is to avoid bending, this confirms the original thought, “Ah yes, I knew that bending was dangerous and now he/she has told me that as well, so it’s definite”. This belief becomes ingrained quickly and has consequences for behaviours, or rather, how we then move. The guarding that can be useful at the start of a problem persists as you continue to avoid normal movements beyond a time that is adaptive, i.e./ are you still bending from the knees weeks later?

When we don’t move our body it becomes stiff and often painful. Think about getting out of a car after a long journey or even pulling your thumb back for a few minutes and letting go. The blood flow slows and the tissues creep, there is less oxygen and more acid, all ingredients for aches and pains. But this is normal and the pain a prompt to move and resume normal service.

When we have acute pain we often immobilise the affected area to reduce the range of motion that we use for the purposes of protecting the damaged tissue. The ‘unused’ range becomes stiff and painful and as we reach it sooner with normal movements, it is easy to evoke sensitivity. Again, this is normal in the early stages of an injury and useful for healing, but as time goes on, continuing to use strategies that are appropriate for acute pain will create barriers for recovery. And importantly, these strategies are based upon beliefs about pain, hence taking us back to the point that early messages are key players in what happens next.

At the first meeting with a patient there are a few basic ingredients to ensure that the first steps to recovery are in the right direction:

1. The welcome; to make sure that the patient feels as comfortable as possible.

2. The narrative; allow the patient to tell their story in their own words, with a few pointers so that all the relevant information can be gathered. This is the Sherlock Holmes section.

3. The meaning; explanations create a sense of meaning; “Why has this happened? All I did was bend over to pick up a pencil!”. Explaining that pain is not an accurate indicator of tissue damage, how pain is created, what can influence pain, how these problems typically evolve over time and of course what can be done.

4. Validate the narrative and any investigations that may have been undertaken; make sense of the language and put it into perspective remembering that many people have changes in their spine with little or no pain; and a structure is not pain anyhow, one is objective and one is subjective.

223390-andy-murrayThe patient must feel better in terms of knowing the nature of the pain and the problem, what you can do about it, what they must do about it and how long it is likely to take. Knowledge is power and gives a sense of control, and we all like to be in control. Conversely, cultivating fear with strong and inaccurate visual metaphors triggers further protection in terms of sensitivity and the way in which the patient approaches the problem is usually passive rather than proactive. The latter is the more effective way to recovery.

Anatole Broyard’s brilliant essay on the doctor-patient relationship highlights the fact that as a healthcare professional one can believe that you are in the driving seat, but actually, the patient is assessing you as much as you are assessing them!

If you suffer with persisting back pain or other aches and pains, contact us to find out how you can move forward: 07932 689081

11Oct/13
OA

Arthritis and pain – beyond the joints | #arthritis #pain

“…osteoarthritis is so common, it would make us think that we would be very good at treating it, but we aren’t”.

Why is this the case?

OAAs with many painful conditions that persist, most of the therapies used to treat osteoarthritis (OA) primarily target the tissues. In some cases this provides relief and improves the function of the affected joint. However, there are many individuals who receive such treatments and do not experience any significant change in their pain or ability to move. So, what is happening in these folk?

The first point to understand is that we need a brain to feel pain – see Lorimer Moseley talking about this here. Of course the pain is experienced in the body tissues as this is where the sensation emerges, however, neuronal networks in the brain play a significant role in creating the feeling. Usually something happens in the body to begin the process of sensitisation such as an inflammatory process when we injure tissue or it degenerates as in arthritis when the joint structures change-worth noting is the fact that all of our tissues change as we age and this is entirely normal yet of course can be a painful process. 

The brain wants to know about inflammation and does so via the danger signals sent by nociceptors from the tissues to the spinal cord before reaching the higher centres. On scrutininsing these signals, the brain has to conclude that there is a threat to the integrity of the body based on the current status, prior experiences and a prediction of what this could mean, for pain to emerge in the area deemed to be in danger. The question that the brain asks is, “how dangerous is this?”. The answer to this question will determine the response. Perceived danger triggers pain but as part of an overall protective set of measures that include changes in movement, e.g. guarding and limping, autonomic activation in ‘fright or flight’, hormonal responses and immune system activity.

All of these responses are normal, adaptive and desirable albeit accompanied by unpleasant conscious experiences such as pain and spasm. Pain is meant to be unpleasant as it drives behavioural change to promote survival. Typically, if we injure ourselves we expect the body to hurt although the intensity of the pain can vary enormously depending upon the context of the situation. There are many reports of people in casualty with significant trauma yet they describe a lack of pain. This is because pain is not an accurate indicator of tissue damage. One only has to consider phantom limb pain to see how we can experience pain in a body part that is no longer present. The representation of the limb still exists in the sensory cortex creating a conundrum for the brain as it seeks confirmative data from the periphery that does not show up. Maybe 80% of people who lose limbs will describe pain in the space once occupied. Something similar can happen following a joint replacement. Some patients report feeling on-going pain in the joint as if it is still present rather than the shiny new titanium joint surfaces actually in situ. Therefore, it has become apparent that to feel pain, the brain does not even need to receive danger signals but rather determines a threat value for a particular situation or context.

Many people experience relief once they have a joint replacement but some do not. Prior to a replacement, the sensitivity that arises can cause changes throughout the nervous system similar to other persisting pain states. This is called central sensitisation, the term defined by plastic remodelling of neurons in the central nervous system that underpin widespread pain, amplified responses to normal stimuli and a reduced ability to inhibit the process of nociception. There are clinical ways in which we can test for this mechanism alongside listening to the clues from the patient’s narrative that is usually very revealing. On detecting this form of sensitivity, a different approach is required to tackle the pain and influencing factors.

So, we need the brain to feel pain that emerges from the body. What does this mean for OA? In particular, those who continue to suffer with joint pain and stiffness despite treatment or surgery need to be considered as having a more centralised aspect although all pain patients should be thought about in terms of the brain’s perception of threat. The bottom line: reduce the threat, reduce the pain; and conversely, increased threat, increased pain. Therapies and strategies must bear this in mind in order to change the pain experience and improve the functioning of the joint.

All too often patients are told that a joint is degenerate and that there is nothing that they can do. Of course we have acknowledged that some people will need surgery, but either way, there is plenty that they can do to proactively seek to gain control and change their experience. The fact that we have identified the role of the brain in pain, that the brain is plastic and designed to change (neuroplasticity) and that we have techniques that target the known changes (e.g. cortical reorganisation) and mechanisms provides great optimism.

Below, Dr Tasha Stanton talking about osteoarthritis and the brain, describing the mechanisms and highlighting the altered sense of the affected area that is so common. The change in body schema, that is how the brain constructs the sense of self, is often part of a persisting pain state yet many patients do not volunteer the experince for fear of disbelief. Knowing that the area feels bigger, smaller, missing or detached is a vital clue that reveals features of the conidion that must be targeted with therapy and hence patients should be encouraged to fully express their story using their own language and metaphors.

With the knowledge of these mechanisms we are making headway in treating conditions such as arthritis. We are all going to experience joint and tissue changes in our bodies as we age, so it is vital that we improve the way in which we tackle the issues.