Category Archives: Athletes

27Aug/14

Murray’s attack of the cramps

Most active people have suffered the agony of cramping. The uncontrollable vice-like spasm squeezes the blood out of the muscle, the acids build and the oxygen level drops. End result: writhing or hopping around until the tightness eases and pain gradually subsides. It is not uncommon for the effects to be felt for a day or so afterwards, much like post-exercise soreness. Usually there is one affected part of the body whilst Murray reports to have felt the cramping in his thighs, his trunk and forearms, a more widespread pattern.

Murray’s health team will monitor his electrolyte levels closely and implement a diet that optimises his needs. Widespread symptoms that are more suggestive of a systemic biological response is then, less likely to be explained by an issue of ions through dietary or liquid deficiency. However, we cannot totally eliminate this factor as the demands of any particular game are unique, both physically and psychologically — the two being inextricably linked as the whole person responding to a situation. As Murray says, you cannot really prepare for a game via practice. Practice is just that, practice. Hence the requirements are always different.

Nothing happens in isolation. The cramps did not just come on. They were the end result of a mass of biological activity in many body systems before emerging as a response by the whole body and person in an attempt to stop Murray playing at that moment. Inconvenient as this was at the time, Murray’s biology prevailed as it must, and he is subject to his biology as are we all. This biology is influenced enormously by cognition, that is, the way we are thinking, and the way we are thinking about our thoughts (metacognition), how we feel, and how we are thinking about how we are feeling. Understood? For there are chemical underpinnings to thought as much as movement, and movement is far more complicated that one may think. Our motor system is really a sensorimotor system. Actually, it is a ‘sensorimotorimmunoendocrinogastroautonomomusculoskeletal system’. That is no joke either. We are complex.

A thought, ‘I am thirsty’ initiates action in this system because the plan begins at that point — to get out of this chair, walk to the cupboard, pick out a glass etc etc. You may not even do this, but the plan is enacted. In some people with sensitivity, these thoughts and plans alone trigger pain. The system responds to watching others move as well. This is usually
below our conscious level but affects the way we move. In fact, movement is affected by where we are, who we are with, what we are thinking about doing, what we have done, how we are feeling and many other factors. Fortunately this data is scrutinised by the brain on our behalf before producing the required movement. When all is well, the systems work magnificently. When things go awry, it can range from inconvenience to catastrophic. And if it is at the inconvenient end of the spectrum, catastrophic thinking can have a dramatic effect upon the pain. I wrote about Messi’s experience of severe knee pain in 2012 when he collided with the goalkeeper. He thought his career was over because of the intensity of the pain. Examination revealed a bruise. He was playing again the next week. Pain is moulded by the situation, past experience and immediate thoughts.

Having seen huge numbers of people with chronic pain, complex pain and dystonia (a movement disorder that is characterised by unwanted and involuntary movements), one could think of a sportsman’s cramp as a transitory form. In rare cases, paroxysmal exercise-induced dystonia (PED) is diagnosed. This is a type of dystonia that is triggered by physical exertion and characterised by a sudden onset of dystonia movements: involuntary, painful spasms, torsional movements. They come and they go.

Another problem that is familiar is the yips. Arguably best known in golf, this is when a well rehearsed and automatic movement becomes conscious and falls apart. This can only happen if you are an expert. On addressing the ball, the ensuing swing is so natural, honed via thousands of rehearsals and practices, under normal circumstances. When the yips grips, this is forgotten and literally, the player does not know what to do. This is a problem of conscious thought and focus but also an issue of movement, an example of how mind-body are so integrated and bidirectional in terms of influence.

Hopefully Murray will not suffer a further bout of widespread cramping. I am sure that the medical team are looking at the footage and talking to him to establish the possible explanations and causes. It may be a one-off but thought needs to be given to why this happened and what has happened to learn and then reduce the risks of recurrence.

25Aug/14

Greatness, smoothness & injury

In response to @simonrbriggs excellent article in the Telegraph (see here) contrasting Federer and Nadal in respect of their physical longevity on the court, I wanted to agree with Simon’s subsequent tweet about the many factors involved with an injury — the line I frequently quote being: ‘no injury happens in isolation’. Whilst I am no tennis expert, I understand that these two masters have very different approaches on the court that define their games. The wicket is more familiar territory, and I would equate this observation to the games of Tendulkar versus Gilchrist. Both masters of the willow, yet styles that illustrate very different means and modes of dominating the ball. 

Sport enthusiasts and pundits alike gush with awe at the ease with which a stroke player caresses the ball. The expert appears to have all the time in the world to position themselves in perfect balance, to be able to effortlessly time the touch, and send the ball at a speed that is vastly out of proportion to the effort applied. Federer fits this mould, and whilst he undoubtedly trains to be fit and strong, he has a technique that is so efficient and so thoughtless that he can focus entirely upon the whole game as if viewing from a point up above. And to take nothing away from the skill of Nadal, his explosive force delivers excitement as he thunderously strides across the court in Zeus-like fashion. As Simon points out, if Nadal were to maintain a physical wellness, his dominance would surely prevail. Who you would most like to be conqueror would then be down to a preferred style, and we love to talk about style.

Returning to the construct of injury that is always embedded within a context and never in isolation to a range of factors that create a situation — no injury happens in isolation. The meaning of an injury is tantamount, and certainly impacts upon the intensity of pain. Cast your memory back to Messi believing that his career was over after he collided with the goalkeeper. He had merely bruised his knee yet the pain was so intense he had to be carried from the field of play in hushed silence.  A violinist who cuts his left index finger will suffer more pain than if I slice the skin on my same digit. There is a different meaning attached to his finger, even with a paper cut. 

Whilst both Federer and Nadal will be accustomed to the pain of hard training and playing, the pain of injury is different. The way we think about the pain at the time of injury sets up the on-going responses and how we chose to behave — it is not the injury itself, but the way we think that counts. Spraining an ankle usually means limping, and this is a sensible behaviour as partial weight-bearing reduces the strain through healing tissues, and is more comfortable. When we know that all is well, in other words that the injury is healing normally (and this is meant to hurt, however unpleasant or inconvenient), there is an acceptance of the necessary steps back to normal movement and activities. The early messages after an injury then, are vital to set up a positive route forward. Excessive fear, anxiety and incorrect messages at the start can set up a pathway of obstacles to recovery. 

Drawing together the smoothness of action that interweaves with other characteristics that construe the greatness of Federer: the technical self-efficacy, rehearsed movements that require no conscious processing and a baseline of fitness and mobility, all of which create a context that minimises the risk of injury. The sublime control, gliding easily across the surface and a ‘oneness’ with the occasion offers only the smallest opportunity for breakdown that most can only dream of, including Nadal whose vigorous assault upon ball and opponents opens the door for stress and strain to emerge, persist and potentially dominate.

Whilst we can swoon over the masters of any game, the vast majority of us play amateur sport. At the level of the masses, I always feel that the risks of injury are outweighed by the benefits of participation — physical fitness, the offsetting of cardiovascular disease, the cathartic outlay against stress and of course the social element (after the game: the 19th, the clubhouse, the curry house…). Equally, whilst the professionals are honing their skills and prowess, amateurs spend a great deal of time around their occupations and families to improve on the fields and courts, imagining achievements on the great meadows of Lords and Wimbledon. I too dream and envision, but returning to diminishing the risk of injury, as the principle is the same whether pro or amateur. And there is no reason why the latter should not acquire the same knowledge and receive the same principled care.

One of the first actions I take is to ensure that the injured person’s knowledge and thinking are in alignment with what we know about pain and healing, and that their choices of behaviour always take them toward and not away from recovery, no matter the start point.  My fundamental belief in our ability to change pain drives my over-arching mission to deliver pain education to all. Understanding pain will inform positive and healthy actions across the board from professional athletes to children to stakeholders (more on this in subsequent blogs). 

Recovering from an injury is straight forward. Most of the problems arise from the wrong early messages and a desire to move on faster than the healing process, thereby disrupting mechanisms that have inherent intelligence. We literally get in the way of our own recovery. We are the problem, yet the injury is blamed. Know the injury, know the pain, know the time line and know the action to take. Simple. One of the issues that Nadal may suffer, as do many professionals, is the rapid return after injury without full recovery, or a lack of time for the body to adapt. This latter problem disrupts the balance of breakdown and rebuild that is constant in the body. Tipping towards breakdown, inflammation persists and causes persistent sensitivity, even at a low level. This manifests as the on-going niggles, gradually becoming more widespread as time progresses and often without an obvious injury. Familiar? Perfectly solvable when you know how and respect the time lines of healing and recovery. Time is money some may argue, but then stepping back and thinking about the longevity of a career provides a different perspective. Deal with this bout of aches and pains completely and create the opportunity for more years of competing as opposed to the stop-start, partial recovery that affects performance and confidence, the two being utterly related. Over-thinking movement and lacking confidence both affect quality of movement — manifesting as the yips in some cases. Is Nadal smashing his way through because he fears that one day he will finally breakdown? Only he knows. Feeder on the other hand as we have seen, has a smooth style that glides him across the courts of the world. 

In summary, to look at the differing styles of play that define Federer and Nadal, it is clear that the smooth approach taken by the former has played a role in his longevity in terms of fitness (lack of injury) and success, the two being related. Simply, the more games you are able to play without a physical hinderance or even the thought that you may have a physical hinderance, for mere thinking affects the way we move, the greater the opportunity for winning titles. So surely, the planning of any athlete’s training and career must consider the ways in which maximum participation can be balanced with time required to adapt and recover. This is the same for both the professional and the amateur athlete, beginning by understanding pain and injury. 

24Jul/14

It’s time to bring what we know about chronic pain into sport

I recall a time when a consultant told me that chronic pain does not exist in private medicine. I was somewhat dumbfounded that an intelligent person could have such a thought. As a far as I was (and am) concerned, pain is classless. This was some years ago, however I am reminded of this when I think about the lack of recognition of chronic pain in sport.

Injury and pain are part of sport and we all know this well. Healthy people engaging in regular physical activity gain the physical and psychological benefits of exercising, but there is a risk of injury. And whilst many people who are injured will heal and recover, resuming their sport, there are a cohort who do not return to full participation and suffer on-going pain. Persisting pain affects one’s ability to perform, self-confidence, self-efficacy and in the professional case, a career. This is no different to the situation with a non-athlete with chronic pain.

There are a number of reasons why an athlete fails to recover including the context of the injury, early management, the development of fear, the understanding of the pain and injury, and the intensity of the pain at the outset. When lecturing on this subject, I tell the story of Messi who believed that his career was over because of the pain he experienced in his knee having collided with a goalkeeper. He was immediately taken for an MRI scan that revealed no injury. Recovery was swift when Messi knew he had not damaged his body. The pain he experienced on the field when he thought his footballing days were over was intense with a meaning that drove into the heart of his emotions, and that of the silenced crowd.

The reasons that pain persist are no different in the non-sporting person: the context of the injury, the state of health at the time, prior pain and injury and how they were dealt with, initial management etc. This being the case, we can bring the modern thinking about chronic pain into the sports arena for two reasons. One is to look at how injuries are dealt with in the early stages, and the other to take a broad perspective in tacking the on-going or recurring injury.

The early management of sports injuries is well known. The aspect to which I refer is the communication about injury and pain. In fact, even before an injury, providing education for players and athletes would impact upon those first vital moments that can prime and set up the recovery. At the point of injury, a whole body, all-system response kicks in, and recognising these processes in their entirety will maximise the recovery potential from the outset. All the necessary processes for recovery are in the human body. The main proponents of disruption are over-zealous treaters, fearful potential recoverers and those who ignore what the body is orchestrating. A careful explanation of the injury, pain and what will happen to aid recovery goes a long way to calming excited protective body systems.

Changing a pain state is entirely possible. Understanding that pain emerges in the body but involves the whole body is vital when considering all the factors necessary to set up recovery. When pain persists there are many habits and behaviours that become part of the problem. These need identification and re-training as much as the altered body sense, altered movement patterns, altered thinking, altered emotional state, altered immune responses, altered endocrine responses, altered autonomic responses, altered self-awareness, altered perception of the environment — we are altered in this state and it involves a host of responses, not set in stone but instead, adapting and surviving. On spraining a knee ligament, it’s not the ligament as much as how the body is responding to the detection of chemicals released by the injured tissue, the perception of threat and how the individual responds to the conscious feelings created by the whole body that drive thoughts and behaviours.

In the light of this knowledge (that has existed for many years), far more comprehensive treatment and training measures have been devised in small quarters. This approach delivers vastly improved outcomes because the problem is being addressed in a way that recognises that pain emerges from the whole. This notion was crafted from the merging of neuroscience and philosophy and is now taking our thinking forward (thanks to Mick Thacker and Lorimer Moseley for bringing this mode of thinking to physical therapy and beyond). I no longer refer to ‘pain management’ as this implies we are not trying to change pain, and I believe that we can and do change pain.

Pain is changing all the time as is every conscious experience. What patients believe is what they will achieve: “Whether you think you can, or think you can’t, you’re right”, Henry Ford. Let us draw upon the psychology of success, create a clear vision and go for it. Every action and thought can be challenged with the question, “Will this take me towards my vision?”. This is the same in sport as it is in the general population and we can use exactly the same principles, just with different end points — everyone has a different end point, hence my push for recognition that chronic pain exists in sport and remains a huge and costly problem for individuals and clubs.

How can we go about this? Initially we must create awareness of the extent of the problem, recognising that a wider approach is needed and subsequently implementing contemporary treatment and training methods that work with the whole person. Understanding the pain mechanisms, the pain influences and the context of the pain for the individual orientates thinking that creates a route forward toward the identified vision. Blending specific training (e.g./ body awareness, sensorimotor control) with techniques that boost self-efficacy and maintain motivation for the necessary steps towards recovery. The recovery is part of the vision and is determined by prioritising the programme and working consistently.

Using comprehensive measures and thinking, we can create the conditions that allow for pain to change in the whole person by allowing body systems to do their work. Our role is to facilitate this biology by what we say, do and advise. Drawing upon the contemporary way persisting pain is approached in the general population, sportsmen and women can access the same benefits, optimise their potential to return to exercise and reduce the risks of recurrence.

Richmond specialises in creating the conditions for people with chronic pain and injury to recover and move forward. When he is not seeing patients, Richmond spends his time writing and talking about pain with the aim of bringing the modern understanding of pain into the public domain for better treatment

Specialist Pain Physio Clinics, London

23Sep/13

A few thoughts on Andy Murray and his ‘minor back surgery’.

The news that Andy Murray is to have a minor back operation hit the back pages last week. It is understood that he will undergo a microdiscectomy, a technique that minimises the tissue trauma in order to access the injured disc and the nerve that is being impacted upon by this structure.

Microdiscectomy – what is it?

For the decision to be made, it is likely that a disc has been seen on a scan to be affecting the health and physiology of a nerve root (where the nerve emerges between the vertebrae). In some people this will occur without causing pain but if pain and sensitivity does arise, then it is due to a gradual change in disc health over many months. Of course, it is very possible that repeated movements and in particular rotations with force will impact under certain circumstances. In fact, with any injury that is gradual, one has to consider the combination of circumstance (‘environment’) and genetics–termed epigenetics.

It seems that Murray has been experiencing back pain for several years. Many people who I see are in a similar situation having had pain for some time, often punctuated with more acute episodes. These acute bursts of pain are highly unpleasant and can make moving, working, sleeping and functioning very difficult for a few days and sometimes longer. When it comes to sports people, we can think about the injury or pain as threatening their career, however this is the same for others who plan to return to work following a back operation. Clearly the end point is different but the preparation and early rehabilitation need not be.

Preparing for surgery – see here

I make a point of encouraging a proactive approach to pre-op preparation both physically and mentally. Where possible, you want to be fit and healthy with ‘prehabilitation’, which is a structured programme of exercises to maximise tissue function. Picking up on the rehabilitation after surgery can be far easier if this is done in an orgainsed manner.

Equally, dealing with the mindset and fears that can encroach on one’s ability to train is as important. Understanding the pain, procedure, goals of the surgery and the recovery process will go a long way to reduce the stress and anxiety of an operation – or rather, the thought of an operation prior to the procedure. Using techniques such as mindfulness and relaxed breathing can be potently effective in reducing stress that occurs as a result of negative thinking. Certainly catastrophising about pain can lead to greater inflammation and thereby affect the healing process. We are seeking to optimise healing and therefore dealing with thinking that is overly worrisome can impact upon the immune system in the right way.

Early recovery

This will vary from person to person but in the initail stages it is all about allowing the tissues to go about their healing process, orchestrated by the neuroimmune system and certainly affected by other body systems. Beyond the gradual increases in movement, and tissues certainly need this for good healing, considering factors such as adequate rest, relaxation, good nutrition and a positive outlook are all key ingredients in creating the best possible conditions for moving forward. A range of strategies and techniques can be used including simple mobilisations but alongside motor imagery,  mindfulness, movement of other body areas, the use of music and motivational techniques and cognitive tools to fortify resilience and coping to name but a few.

Rehabilitation is not just about exercising. It is about understanding, learning, motivating, creating the right context for movement with confidence and many more factors that can lead to optimised outcomes.

* Naturally, you should take the advice of your health professional when it comes to your treatment and rehabilitation.

If you are about to have an operation or are recovering, contact us now to learn about our comprehensive treatment and training programmes: 07932 689081

16Jul/13

Two excellent talks for athletes

Both talks are inspiring and demonstrate courage, perseverance and motivation in the face of the enormous challenges that were presented. In performance and rehabilitation, mindset is a key determinant and in many cases several skills must be developed, including resilience and coping strategies.

In the first video, Janine Shepherd talks about her experience of recovery following a severe injury.

In the second, Aimee Mullins talks in 1998 about her record-setting career as a runner, and about her carbon-fiber prosthetic legs.

Call us now to find out about our comprehensive treatment and training programmes to tackle persisting pain, recurring injuries and chronic pain: 07932 689081