25Jun/14

Where have ‘I’ gone?

Neuroscience focuses upon the brain. Neuroscience has shown us that the brain is involved with pain. Consequently the brain has been blamed for pain, the unpleasant motivator that is designed to grab our attention and enforce action that protects us from a threat, actual or potential.

Recent thinking that sensibly gathers paradigms from both neuroscience and philosophy challenges us to re-consider the brain-based explanation for pain, even if we are bringing other body systems into the frame. Mick Thacker argues that pain must come from the whole person, not a part of that person. Whilst I have always subscribed to a holistic view, considering all the dimensions of a pain experience (physical, cognitive, emotional), I have been guilty of the journeying on the brain train. As ever though, our knowledge and ways of thinking and using the knowledge evolve and now pain must be thought of as a holistic expression of the whole person.

My left buttock has been hurting for the last three days, so this has provided me with an opportunity to explore this pain and what it means for my ‘self’. It is of course me that is in pain, a localised feeling in the buttock, but nonetheless it is me, myself and I. The pain invades my attention, thoughts, decisions and plans that all involve me and my interaction with the immediate environment in this particular context. Yes this involves my brain, but my brain is me. One organ or one thought does not define me, yet I need both to sense myself.

Listening to a patient describe their pain is to listen to them describing themselves. What I hear and observe in people with persisting pain such as fibromyalgia, is a story of suffering. Suffering is a loss of the sense of self, and that is a whole, not a part. Pain is a feature but so is loneliness, avoidance, fear, anxiety and isolation. So are we just trying to change pain as this is the most frequent request made by patients? In my view, we are seeking to create the conditions for change in a direction that reduces suffering, this of course including the easing of symptoms. We can only achieve this by working with the whole person and not a part.

Although there is much talk about the pain during a session, what is often verbalised and demonstrated is a change in sense of self. We do not feel the same as before, and certainly as pain persists, this sense alters further. Yes we can identify mechanisms that underpin such change such as adaptations in the brain maps, however it is still the entire person who has the experience. Only by keeping this in mind will we be in the right track with treatment, training and mentoring patients to guide them forward. It must be their whole person that is proactively involved in this journey, cultivating a sense of self that fits with expectation and the vision of how things should be.

RS
Specialist Pain Physio Clinics, London — empathetic treatment, training & mentoring for chronic pain

21May/14

Pain and tiredness

Pain is tiring and being tired worsens pain. It is a cycle with these two bedfellows, each begetting the other. But, not only does fatigue increase our sensitivity, we also have less resilience and powers of coping. A double whammy indeed.

Sleep is often disrupted in chronic pain states. Either having difficulty getting to sleep or waking through the night, the disturbance over time leads to progressive tiredness. Put simply, we need sleep to function normally, to refresh our body systems and to cement memories and learning. Considering that changing pain is a re-programming process akin to learning, it is sleep that allows the new lines of neural communication to be grooved.

The sleep-wake cycle is affected by stress. Pain is a stressor as can be the consequences of pain. Stress is a physiological response to a perceived threat that prepares us to take action. The mechanisms are basic survival instincts that allow us to face danger and fight, or flee from the threat in flight. This is fine in the short term and useful if there is a threat, but if this system is continually ‘on’, there are a host of problems that ensue. They include increased and on-going muscle tension, raised blooded pressure, enhanced use of energy, altered blood flow, slowed digestion and cessation of reproductive function — think aches and pains, feelings of anxiety, raised body temperature, irritable bowel and infertility.

We know about feeling irritable when we are tired. Add pain to the mix and it is understandable how mood is affected. Coping with day to day living is challenging in chronic pain states and there needs to be a plan. Coping when fatigued is difficult, and therefore part of the plan must include best action on these days. Of course, a consistent programme of graded activity and desensitising techniques target the underlying biology of pain, but we also need a tool box for different hurdles that are faced. Developing resilience is an important part of that tool box.

Here are a few things to consider:

1. A sleep habit or routine that you stick to each night. Going to bed at the same time, when you are tired so that bed and sleep become associated.
2. Three good things: write down 3 good things that have happened during the day. For example: a sunny day, I met an old friend, someone smiled at me.
3. If you wake with an active mind, write down the problems on a note pad by your bed.
4. If you wake with pain, in part this can be due to a drop in blood pressure and blood flow through the nervous system. It can become sensitive under these circumstances as blood and oxygen flow diminishes. Sitting up and moving helps to raise blood pressure and the perfusion of oxygen through the nervous system.
5. Mindful breathing is a potent technique of focused attention training that allows you to become aware of your body, your thinking and emotional state. This is as opposed to being on the autopilot. How does this help? Instead of becoming embroiled in thoughts and emotions, we observe them with curiosity. In other words, we are riding the wave rather than being tossed and turned within the wave. In doing so, we promote activity in the parasympathetic nervous system that is responsible for restorative processes: sleep, digestions, healing etc. Increasing parasympathetic activity reduces sympathetic responses, those that we are familiar with in tense and stressful situations: tension, increased heart rate, vigilance, anxiety etc.

Visit the website for more information or call us now to book your appointment: 07932 689081

08May/14

Fibromyalgia — creating conditions for change

Pain and symptoms can and do change. They can change moment to moment and day to day, but if you suffer persisting symptoms, all of the variations can blend into a long physical and mental struggle. Striving for change needs understanding, motivation, resilience and a plan of how to reach your goals.

Fibromyalgia is biology in action. An integrated response of the nervous system, immune system, autonomic system and endocrine system, all of the manifestations of fibromyalgia are the outputs, the end result of how those systems operate together. Unpleasant and troubling as the pain and symptoms are, this is the body trying to recover and making the individual aware. Most of the processes happen beneath our conscious level, but those that don’t cause suffering, whereby suffering is a loss of a sense of self.

Together the sensations that we feel, the thoughts that we have and the environment around us are the experience. Edelman calls this the econiche, the interaction and end result of this interaction being the individual’s reality. The reality has to be unique: what I see and what you see in the same scene can be different based upon what we know, what we expect, current mood and attention to name a few variables. The same could be said for pain that will be influenced by similar variables. There is a biology of pain and the biology of the influences upon the pain.

My farming analogy that is based upon my belief that pain can change (neuroplasticity — the ability of the nervous system to adapt and learn; it is always changing….there it goes again, it’s just changed. And again), is a useful way of explaining to patients how we think about these systems and interactions, how we have to create the right conditions for change. Much as a farmer will prepare his field and cultivate the best soil for his crops to grow, the individual must take conscious action for the body systems to work towards wellbeing. This is the ‘why?’, with the ‘how?’ being a comprehensive approach that targets the physical, cognitive and emotional dimensions of pain.

Come and see us to find out how you can create the right conditions for changing your pain and symptoms: call 07932 689081

06May/14

London Fibromyalgia Clinics | London FMS Clinics

London Fibromyalgia Clinics — I think differently about fibromyalgia, functional pain syndromes and chronic pain. Believing that there is a need to challenge the way these problems are addressed, I created a specialist clinic that draws upon neuroscience, philosophy and other disciplines to create innovative and effective ways for individuals to move forward in their lives.

Fibromyalgia is known as a functional pain syndrome, sharing a common biology with other problems such as migraine, irritable bowel syndrome (IBS), pelvic pain, musculoskeletal pain and painful bladder syndrome. This common biology is an adaptation in the central nervous system called central sensitisation with changes in the excitability of the nervous system alongside on-going responses of the immune system. The way that the body systems and the brain adapt and learn means that it has become persistently protective, igniting painful and other responses to a range of normal cues and situations. The sensitivity results in on-going pain and general sickness responses (e.g./ aches and pains, tiredness, fatigue, appetite changes, mood changes, anxiety, loss of concentration, brain fog, altered body sense); the latter just like a feeling of the flu.

Stress often plays a role. Stress is a response to a perceived threat, the meaning of which we give to the situation as an individual. The physiology that follows is designed to protect us from wild animals — either to run away or fight. Whilst this is useful when danger presents itself and in the short-term, if these responses continue, they impact upon the immune system, switch off the digestive system and reproductive system (neither eating or digesting a meal are useful in the face of danger; reproduction is not useful in the face of danger — resulting in a sensitive and/or sluggish gut, and fertility problems), prepare the motor system and mobilise energy in preparation for flight or fight.

It is a combination of genetics and experience that results in the condition. Our genes are moulded by these experiences and to what we are exposed: stress, injury, pathology. Protection is triggered but not turned off, the responses continuing as if there is a problem, even when it is resolved. These on-going responses then create further changes, for example chronic inflammation, and a continued loop that maintains the condition. That is until the circumstances are changed and the conditions created to move out of the loop and onto a route of wellbeing.

Believing that pain can and does change via neuroplasticity, I create bespoke treatment and training programmes for individuals who visit the clinic from all over the UK. The programmes ensure that you fully understand the problems and comprehensively target the biological mechanisms addressing the physical, cognitive and emotional dimensions. I help you to develop the knowledge and skills that you need to move forward in your life with a range of proactive strategies, techniques and treatments grounded in neuroscience.

Call now for more information or to book an appointment: 07518 445493

27Apr/14

Never give up — a motivational talk

Diana Nyad swam 100 miles across a stretch of water between Cuba and Florida. She just kept going. The internal drive and the support that fuelled this drive kept her going in some of the most dangerous waters on the planet.

Rehabilitation and recovery from an injury or painful problem requires dedicated perseverance. But to optimise this perseverance we need to be motivated and inspired. We need to understand and know why; we need a purpose to drive us forward and keep moving forward. There are plateaus, flare-ups (when the symptoms and pain can increase), good days and bad days — life’s normal variation. Knowing why this happens, what we can do and why we are doing it keeps us moving forward.

Listen to Diana Nyed speak here about her experience and keeping going.

For information about our pain treatment programmes that are driven and inspired by neuroscience, explore the website and contact us on 07932 689081 to move forward

25Apr/14

When do we seek help for our pain?

When do we seek help?

I am interested in the point at which an individual decides that they need help. The timeline varies enormously from the initial feeling of pain to years of discomfort that finally become intolerable or limiting. Each person will have their own view that is grooved by prior experiences, culture, beliefs about health and pain, access to healthcare, the impact that the problem is having upon lifestyle and tolerance of the pain at any given moment. These factors blend to create the individual’s experience of pain that contains their own personal meaning, or lack of, the sensory and emotional dimensions.

The initial meeting presents the opportunity to explore the story of the problem. It is not just about the pain but how it affects the person, those around him or her and the interactions with their environments. The brain, the body and the environment are co-dependent and influence each other, described by Nobel Prize winner Gerald Edelman as the econiche. Each must be explored within the context of the narrative to gain an insight into the reasons for seeking help.

Over the desk I hear people tell me that they have had enough, previous treatment hasn’t worked, surgery has failed, their spouse is sick of the moaning, they cannot play with the kids, work or play sports. They have reached their coping threshold and now want change.

In most cases, the story extends into the past, sometime before the patient arrives. The problem may have been ignored or attempts have been made to ease the symptoms. The majority whom I see will have had numerous attempts to get better via medical or surgical routes but with limited or no success. This leads to frustration, anger, lowered expectations, all of which can be understood. We must also acknowledge that the body and the brain have really tried to deal with the problem but require increasing conscious involvement to move forward. The lack of progress usually means that the biology of pain has not been fully targeted, along with the vast array of individual influences upon the pain. The need for a comprehensive approach is tantamount to success in changing pain and one’s ability to engage with life once more.

The first meeting is a point in time. This is not in isolation to the complete story, similarly for the physical assessment that is a snapshot of what is going on at that particular moment. With pain and body physiology changing from moment to moment as the systems respond to the internal and external environments. The interactions of brain-body-environment are fundamental to the expression of how we feel and experience the world around us. The brain is constructing all that we experience, hence the significance of this organ when addressing pain.

So when do we seek help? This is individual and based upon our beliefs about ourselves, the world and our health. These are not separate entities but rather consistently interacting modules. Thinking in these terms helps us to devise a route forward and a way of creating the right conditions for the body systems to change in the way they are functioning. We are designed to evolve, change, grow and develop. Comprehensively addressing pain and the influences upon pain provides a tangible, measurable and effective way forward, whenever the patient decides it is the right time to engage.

For further information about our comprehensive treatment and training programmes for chronic pain, please call us now on 07932 689081 and discover how you can change and move on.

22Apr/14

An ode to the receptionist

I once had a conversation with a member of staff who told me that she was ‘just a receptionist’. Anyone who has considered the patient journey will realise that this statement is untrue. There is no ‘just’. There are important people involved with the patient’s experience from the start, and usually the receptionist is the first person encountered.

The initial patient interaction moulds the journey. The first few words, the tone of voice and the attitude of the person making the booking will flavour the way the patient experiences the service. This is the same in the National Health Service as a private clinic. In this sense, there is no one more important at that moment than the receptionist. They can affect the relationship between patient and caregiver before the parties have even met.

Consider two types of conversation: pleasant, welcoming and efficient versus abrupt, cold and monosyllabic. It is clear which will be more therapeutic. In my view, the therapy begins with the first few words uttered on the phone or over the counter.

Treatment and interventions used in the clinic room are not in isolation to the administration of the patient journey. Priming is a feature of any experience, in other words, both conscious and subconscious stimuli will affect the way our body systems are working via our feelings and emotions. A word or any other sensory input that influences our thinking will drive our physiological responses. Dependent upon these responses and the mode of the body systems, in particular the nervous, immune, endocrine and autonomic, will impact upon the therapy applied.

When a patient enters the clinic room, we must and should wish to ensure that the person feels as comfortable as possible, thinking about our greeting, manners, posturing as much as the temperature and lighting within the treatment area. This may require a few moments if a patient is anxious or irritated, the latter perhaps by a wait or difficulty finding a car parking space. In fact, we often don’t know what thoughts and feelings the patient is bringing with them and we should work hard to shed any judgements that we hold. The mindful approach to therapy is one way of achieving a non-judgemental environment.

At every opportunity we should be thinking about how we can gain the most leverage to create the conditions for change and recovery for the patient. There are a vast number of variables, however if we can conceptualise the patient journey from start to finish and consider all those involved and the significance of their input, we will be going about our business in the best and wisest way. This is especially the case in the therapeutic setting but actually the same for any service provider.

Since that conversation and studying the patient journey it has always been my belief that there is no ‘just a receptionist’ or anyone else who works in the clinic or hospital, but rather a group of people all adding their input in different ways to create an environment that nourishes, encourages and points the patient in the direction of change for wellbeing.

For further information about seminars and training for staff on the patient or client journey, please contact us on 07932 689081

08Apr/14

The habitat — multisensory memories

Running in the woods today I was taken back to school days when we would go down to the habitat to learn about nature. Our enthusiastic science teacher, whose laboratory experiments would invariably go wrong, led us down the hill, across the playing fields and into a small wooded area that surrounded a murky pond. This was safer than a bunsen burner, and I do not recall anyone ever falling into the water.

In the habitat we would collect data on flowers, plants and insects. In particular I recall that we should note down the irritability of insects, in other words, how reactive they were to a stimulus — the stimulus being a group of excited kids. Generally they flew away; the insects.

My point here is that whilst running I was taken back by the context of where I was, especially the smell of wild mustard. It was this olfactory experience that evoked a clear memory of the habitat, most likely helped by the fact that I was in a wood.

Recently I was talking to a patient about an experience that he had when visiting a hospital where he had been in ITU. On entering the building and walking the corridors, he was hit with a storm of emotions and memories that triggered a need to escape. He did not understand why this happened.

We are unaware of the vast majority of the things going on around us. Our brain filters and draws our attention to what is important right now. We can only focus on a limited amount of data otherwise it would be impossible to function. You may now be thinking about your right butt cheek, but probably not before I mentioned it. And whatever you do, do not think about a white elephant…

The brain stores memories that can be retrieved when it thinks that a reminder is useful. In the case of re-entering the hospital, although the feelings of panic are unpleasant, it is a useful set of responses to a threatening environment as this is where the brain recorded the events in the first instance. Knowing that this is a normal response allows for control to be re-gained. Not understanding often kick starts further thinking that evokes further protection via the autonomic nervous system — increased heart rate, dilated pupils, sweating etc. This demonstrates the importance of understanding our biology.

In chronic pain the same mechanisms are on alert. As we are multisensory, any of the senses can evoke a protective response. Sounds, smells, touch, taste and sights can all evoke emotional and physical responses. Think of that song, the one that perks you up or brings you down. It is a song, yet it is the meaning that you give to the song that determines how you respond.

Pain being an output from the individual, from the brain, in response to a perceived threat is no different. The more protective the systems, the wider the range of cues that can trigger a pain and stress response. This is equally true in anxiety. Our individual interpretation of a situation or a thought effects the response. We notice butterflies in the stomach (a change in blood flow through the gut) and know that we are anxious before realising what is making us feel anxious; or we have a thought and this leads to feelings of anxiety. It is bi-directional.

From a survival perspective, the brain registering information from all the senses during an experience is useful. Learning is vital. The next time we are in that situation, or one that is similar, the brain will use prior experience to work out if a threat exists, or a potential threat. On concluding that there is something dangerous going on, or about to happen, the brain will initiate protective responses that drive protective behaviours. Whilst this is entirely appropriate in acute pain, on going protection is a problem in chronic pain. Pain is always a normal response to what the brain thinks is going on, but in persisting pain it is often the underlying processes in the nervous and immune systems that are problematic and need targeting for effective treatment.

Memories play a fundamental in how we live and learn. We can actively search our archive but often reminders seemingly just pop into the mind’s eye. There will always be a reason why your brain thinks this is useful but that may not be immediately obvious.

RS

Specialist Pain Physio Clinics, London — for chronic pain and complex pain — 07932 689081

28Mar/14

Relieving low back pain — keeping it simple but effective

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

25Mar/14
physiospot

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