Category Archives: Chronic pain

26May/16
UP | Understanding Pain

Children, pain and school

UP | Understanding PainPeople are usually shocked to hear how many children suffer persisting pain, and quite naturally there is an impact upon school as much as the school environment plays a part in the pain experience. The education system needs to acknowledge this fact and institute a change of thinking that of course begins with understanding pain. Pain is a societal issue not a medical issue in isolation. Maintaining pain in the medical realm is one of the reasons that it is such a big problem. Looking at pain through but one lens means that the bigger and truer picture is missed and the natural opportunities for change are minimised when reliant upon limited options.

Children, pain and schools

Maybe 1 in 4 or 1 in 5 children suffer persistent pain. That is an awful lot of kids struggling along with their families. If there was greater understanding then the right thinking and actions could help these individuals to improve their lives by overcoming pain — not just managing or coping.

The current education systems place an enormous and continual strain upon children. Many rise early, spend all day at school and then come home to do homework. Hours and hours. Then there is the pressure, the unspoken pressure to achieve the best marks and anti thing else is failure. The greatest demands are usually placed upon oneself but this thinking emerges via the system and the culture. We should be doing the best we can and putting in effort of course but not just into schoolwork. Carrots are good for you, but would you eat them all day, every day? The internet is useful but is it healthy to be doing this every day, all day? The continued strain shifts the child into protect and survive mode so no wonder we are seeing the following list of ailments and issues: tummy pain, IBS, headaches, migraines, painful periods at the onset of this development, widespread musculoskeletal pain, anxiety, sleep disruption, low self-esteem, altered body sense and image…..just to name a few. Will we look back and ask ‘what were we thinking?’

So as we hit revision time and kids are preparing for exams, we need to make sure they are being nourished — meet the basic needs: food, drink, rest, sleep, exercise, movement, belief in themselves…you are good enough!!!! We want good marks, you may say. Of course you do. But you also want a child who believes in themselves, feels good enough and is not scared of getting things wrong. This can only be fostered within society.

Going to school is normal and healthy. School offers a context for learning how to be you — communicating, laughing, playing, problem solving, thinking clearly, changing state, how to be healthy, how to be a good citizen in a community, insight into the way I think etc etc. Wow, what a wonderful time and opportunity. So when pain is a problem (and it almost always comes hand in hand with more anxiety than is helpful — some anxiety is of course normal and a motivator to take action), missing school becomes part of the issue. The school environment can become a threat when the thought of returning to the busy corridors, the demands, sometimes unsympathetic staff, is enough to trigger pain and anxiety. However, this can be overcome with a comprehensive approach and indeed gradually building up time at school is part of the way that the child gets better. Much like an adult returning to work; this is part of getting better instead of waiting to get better to go back to work. The thinking needs to change with understanding of why it is important. It is important because we want normal; the resumption of normal ‘self’ and this self is the one who goes to school and become part of that environment.

To enact this needs understanding and communication between the child, caregivers, the school and parents. There is no reason why this cannot happen. Gradually building time whilst working on a programme that is making the child feel better and better — this includes working knowledge of pain to create a sense of safety, movement, exercises, mindfulness, relaxation, but the child becomes their own coach, knowing what they need to do at any given moment. Their confidence builds, they feel better and head towards their desired outcome.

We all know that our world is fast changing and the life that a child leads now is very different to ours when we were growing up. But there are still the same biological needs and these are being impacted upon by connectivity on social media, the devices themselves, the demands from society and their thinking that is being mounded by all of the aforementioned. In relation to the problem of pain and children and schools, we can start by helping all those to understand pain. It should be part of their education as we all feel pain at some point and our understanding of it and what it means frames how we behave and react. That would be a great start.

15May/16

Simple guide to CRPS

CRPSMany people have not heard of complex regional pain syndrome (CRPS), and many who have heard of CRPS do not understand the nature of the condition, so here is a simple guide to CRPS.

— What is CRPS? Types of CRPS and common confusions:

  • C – complex: CRPS is a complex condition in that it involves many body systems and a range of signs and symptoms must be present for the diagnosis (Budapest Criteria — see here).
  • R – regional: CRPS emerges in a region of the body, most commonly affecting a hand or a foot.
  • P – pain: CRPS is typically very painful — things that would normally hurt really hurt, and things that don’t normally hurt now also hurt. The pain can often be excruciating and incredibly disabling.
  • S – syndrome: a syndrome is simply a collection of signs and symptoms

There are two types of CRPS, Type 1 and Type 2:

  • Type 1 – CRPS evolves from an injury such as a sprain or a fracture. Sometimes the injury is innocuous with the resulting symptoms of CRPS being an over-response, especially the pain that is out of proportion to the injury.
  • Type 2 – CRPS evolves from a nerve injury

Common confusions

The pain

The pain of CRPS is vastly out of proportion to the seen injury. Pain does not have a reliable or direct relationship with pain in any circumstance; pain is simply not an accurate indicator of tissue damage. Believing that more pain equates to more damage results in wrong thinking and wrong management. People describe the pain of CRPS in many ways.

Pain is often the main focus and reason why the person seeks help. Drugs are frequently viewed as the way to control and ease pain and indeed medication can and does have a role. However, there are many other ways to change pain, including a range of strategies and techniques that steer the person back to meaningful living.

Pain is an ultimate example of a conscious experience that grabs our attention and compels action. Pain is all about protection and is related to the level of perceived threat. In CRPS there is a high threat value associated with the region being protected, both in terms of our biology in the dark and the way we think about the pain and problem; i.e./ we raise the threat value by the way we think about our pain and the meaning we give to the pain, which is why understanding the problem and knowing you can change it is the vital start point.

Pain is complex and involves all the body systems that detect possible threat and then protect us: nervous system, immune system, endocrine system, sensorimotor system, autonomic nervous system (fright or flight). Consider the way in which CRPS presents and you will begin to see how these systems are all playing a role. There is no pain system or pain signals. Pain is about perceived threat: reduce the threat by thinking in the right way and taking healthy action, and the pain changes.

How it looks

Of course you cannot see pain but you can see when the region is inflamed — red, swollen, shiny etc. Inflammation plays a significant role in CRPS as in some people there is an over-inflammatory response to injury. Inflammation is normal but the volume is pumped up in some people, perhaps due to genetics but it can also be due to prior learning. The body systems that protect us have learned earlier in life to respond in a particular way and each time we need them to work, the do but with a bit more volume. Some call this kindling or priming. Examples of prior and existing conditions include: previous injury in the area and the sensitivity has persisted, irritable bowel syndrome, pelvic pain, migraine. A further consideration is the state of the person and the context of the injury. A traumatic injury, such as a car accident, can trigger over-responses as can a more straight forward injury occurring at a time of stress or anxiety. Understanding the person and knowing their complete story is key to gathering insight into what has happened and how it has happened.

How it feels

The affected region commonly feels different. It can feel alien, like it is not attached, not part of self, look different to how it feels. This can be strange and worrying but is characteristic of CRPS (and many other painful problems). It is due to a change in the sense of the body that is in part created by representational maps in the brain. We have many of these representations that allow us to perform tasks every day — imagining what we will have for dinner, thinking about how we will take the penalty or mow the lawn for example. However, when we have pain and move differently, i.e. we are protecting ourselves, the maps change thereby giving us a different ‘sense of self’. People don’t usually volunteer this information for fear of disbelief, however it is such an important part of identifying the problem and deciding upon the approach needed to overcome CRPS. Envisioning a normal sense of self is important before deciding on the right course of action: the aim is to feel oneself again after all.

Summary

CRPS arises within a circumstance, often an injury (but this can be minor), but the context in which the injury is embedded and prior experience determine how our biology in the dark responds. Pain is in the face of perceived threat hence the need to reduce threat to change the pain. We do this in a range of ways begining with understanding and thinking the right way before taking action (a coaching, treatment & training programme) to overcome the problem in as much as the person feels themselves and leads a meaningful life.

** If you think you have CRPS or have any concerns, you should always seek the advice of a healthcare professional who understands your condition.

Pain Coach Programme for CRPS and persisting pain | t. 07518 445493

 

14May/16
Pain distraction

Kids know about pain distraction

Pain distractionI overheard an interesting conversation this week that demonstrated kids know about pain distraction.

Driving my kids to swimming, my eldest daughter was giving us an update on her wobbly tooth and the fact that it hurt. She was concerned that it maybe too painful to go swimming. My youngest daughter, 6 years, then piped up with an insightful suggestion: don’t worry about your tooth because when you are in the cold water you will forget about it’.

To me, as a pain-head (a term sometimes used to describe someone who is obsessively interested in pain and what it is), this was fascinating. Life in action, a natural comment based on some experience that my youngest must have had at some point, or at least heard about. I would think the former is more likely as the message surely stuck with her to the extent that her model of the world in relation to safety-threat has been updated to consider distraction as a way of changing pain and reducing the threat value — pain is a lived experience, compelling action in the face of a prediction of a perceived threat based on the hypothesised causes of the sensory information in relation to prior experience.

RS

10May/16
Pat Wall Lecture 2016 | British Pain Society ASM

Pat Wall Lecture 2016

Pat Wall Lecture 2016 | British Pain Society ASM Listening to Professor Stephen Hunt give the Pat Wall lecture 2016 this morning at The Pain Society ASM evoked a number of thoughts. The meat of the talk addressed recent molecular experiments that could provide new forms of treatment; very much a mechanism-based approach to modifying peripheral and central adaptations (sensitisation) — of course the two are not exclusive, instead being part of a spectrum of changes in respect of an initial insult (usually), and in those vulnerable, a state of persistency ensues. Whilst fascinating and relevant of course, it was the references to Pat Wall that really interested me due to the insights that still hold true.

I was struck by Professor Hunt’s point that many do not consider pain to be a need state. A need state that is a conscious means of motivating action that is the thin slice atop biology in the dark that prepares and operates the healing process, most of which is unbeknownst to us — we feel pain, note swelling and the feel of swelling as it occupies space, changes in the way we move, feel and think. The notion of pain being a need state has been a big part of my thinking over the years, and to me it would seem strange not to consider pain this way. Having been educated by Dr Mick Thacker, who spent a great deal of time with Pat Wall, it is no surprise that these messages have been handed down.

Everyone has examples of the unreliable relationship between injury and pain if they stop and think for a minute. Often quoted are phantom limb pains, paper cuts and battlefield wounds to illustrate the enormous variance. The tissues themselves simply do not explain pain. So what does explain pain? The meaning, the context and ultimately the level of perception of threat (predicted top-down): more threat = more pain, which is why it usually hurts more when you don’t understand your pain and worry about it! And why pain feels better when you, the person feels better. Again it was Pat Wall who provoked this realisation.

It is always valuable to go back to the original lectures and writings as they remain so relevant. We desperately need to address pain globally, it is the reason for so much suffering. New questions to provoke new thinking and research will add to the already gathering hope, steering society towards a modern understanding of pain: what is pain? What is it’s purpose? Knowing that it changes and taking action to enact that change. The coming together of philosophy and neuroscience is really helping us to see pain in a different light, explaining it to patients so they can understand how they have got from A to B and then how to coach themselves to overcome their suffering.

09May/16
GB: Get Better

Get better

GB: Get Better

GB: Get Better

Regular readers will know that I firmly believe in getting better when it comes to pain and persisting pain. This should be our aim with each person. This thinking also needs to underpin research, policy making and clinical decision making across the board.

Recently I was asked to speak at an event that considered the question ‘how do tendons get better’, and my area of focus was the brain and pain. More on this shortly, but it was a pertinent question because for some time I have been pondering why people do get better (from persistent pain), what does getting better actually mean and who gets better?

To answer these questions experientially, I thought through many cases that I have seen to identify the common features. Not especially scientific, but a start point. People getting better meant that they would report that they felt more like themselves. A common phrase that we use, ‘I don’t feel myself today’, tells the world that all is not well, and equally saying ‘I feel myself again’ reports that what is happening in my world is what I expect to happen; a match up in other words. And who are these people who get better from a persisting pain state in the face of messages from society that chronic pain is here to stay and needs to be managed or coped with?

In short, these are people who take on board the true messages about pain and what it really is based on our modern understanding. Not only do they listen and put in into perspective within their lives, but they use the new information as working knowledge to be applied consistently, challenging previous thinking to drive new actions that are congruent with being healthy. With this working knowldge, moment by moment they are able to make clear decisions and groove new habits, pointing themselves via their perceptions and actions towards their desired outcome, as defined by themselves at the outset.

Everyone has experienced success in one or more arenas of their life, whether at home, at school, in work or playing sport. This success is achieved by focusing upon the desired outcome and then taking every opportunity to get there, even if things go wrong along the way. Distracting (unhelpful) thoughts and unforseen events are dealt with as learning experiences, and soon enough the person is back on the path towards their vision of success. Take a moment to recall a success and note how you did it. What strengths did you use? How could you bring them into this arena? The people that use their strengths and focus on their vision consistently, get better.

The tendon debate resulted in agreement that people needed to understand their problem and pain as a foundation from which different strategies could be used. The strategies chosen for the individual must reflect their needs and desired outcomes. I was asked if brain and pain could explain why a tendon gets better, and I argued that we are more than a brain, and in fact the construct of self is made up of a number of facets: my physical presence, how I experience that presence, the story I tell myself about me, the sense of the environment in which I reside in this moment, my past (perhaps unreliably retold to me by me) and my anticipation to name but a few. It is the person who gets better and not the tendon or the back or anywhere else in the body, because we are that body as much as we are the mind (the mind does not just exist in the head or brain, instead we are our mind, often using our body to think — embodied cognition). We are necessarily all of these things together: body-brain-mind-environment.

The overaching aim must be that the person gets better as defined by themselves as only they know what it is like to be better. And when the person is better, they feel themselves again, which in terms of pain emerging from me (felt in a body area), it exists less and less in the thin slice of awareness that is consciouness — most we are unaware of; externally and internally (the biology in the dark). When we are better, we don’t think so much, if at all, about our body until we have an itch or have sat too long and become uncomfortable. Then we scratch or move and resume a state of non-body awareness, just focusing on what it is that we need to in that moment.

Pain Coach Programme to get better: t. 07518 445493Get better

 

26Apr/16

Why tendons get better or not…

Why tendons get betterWhy tendons get better or not… was the question posed. Six of us were lined up to look at potential answers, the areas including isometrics, movement, injections, brain and pain. I was asked to consider brain and pain. Here are my thoughts.

To feel, to think, we need a brain but we are not just a brain. We are of course much, much more. We are a whole person and hence the brain is not the answer to the question why tendons get better, or worse. My main clinical focus is upon those that have not got better, looking at why (the back story, the primers and vulnerabilities) and then what thinking and action is needed now to change course. So most people I see are those who have got worse and in fact, we need to know as much about getting better as we do getting worse. Both are complex but then I argue, we have a greater opportunity to intervene.

The emphasis in my 10-minute talk, a format that is increasingly popular, was upon the fact that it is the person who gets better and not the tendon. What is getting better? What does this mean? I asked myself this question some time ago and followed up with asking ‘who gets better?’ for a talk at a CRPS conference. It has to be the person because it is the person who is conscious and ‘rating’ themselves as being better. The tendon cannot do this — a tendon does not know if it is better or not. Semantics you may think, but important I would say on the basis that we ‘treat’ a person.

A sense of being better results in a person being able to fully engage in their lives as they wish — meaningful living. However, much of our day to day existence is unremarkable, punctuated by situations we remember unreliably. However, we tell ourselves a story about ourselves over and over, with the ‘self’ as the main part in the film. It is strongly argued that the ‘self’ is an illusion: ask yourself where your ‘self’ exists? When you have finished pondering on that small questions, consider again getting better — ‘I’ must rate myself as getting better, meaning that I am able to focus on the task at hand and not be regularly drawn to unpleasant sensations in the space where my tendon (and other tissues) lie or be thinking about the implications of the pain — I can’t do this or I can’t do that etc. So, I concluded that the person gets better when they judge it so and hence the person being more than a brain, but certainly needs a brain, then we have to think wider.

On brain, I also briefly cleared up the seeming confusion between talking about the brain and central sensitisation. Because I argue that we need to address the person (a brain, a body, a context, an environment — unified) to address pain, and that this includes the brain, this does not mean we are saying it is central sensitisation. Without a thought that I have a tendon pain, there is no tendon pain, and hence we must address the top down processing (e.g. thoughts that are underpinned by beliefs, because of what we have been told or learned) because they impact upon the prediction as to what the sensory information means in this moment; the brain’s best guess, which is what you and I are feeling right now. Changing this prediction by minimising the prediction error by taking action is most likely how we are going about getting better.

In terms of pain, this is usually the driver that takes the person to seek help. The pain is stopping the person performing and motivating or compelling action because it hurts. The pain itself is flavoured by thoughts, sensations, thoughts about sensations as a unified experience involving many body systems that have a role in protecting us. Pain is about protection yet is part of the way we protect ourselves with other adaptations including changes in sense of self via altered body sense, altered movement, altered thinking and perception of the environment. With these adaptations occurring over and over, adapting to adaptations and onward, we need a programme that matches pain as a lived experience. What do I think and do now in this moment? The person needs to become their own coach to think and act in a way that takes them towards their vision of getting better, over and over. This means creating new habits, and that is the training programme aspect.

There is much more that can be said on this area, which has many common features with other persistent pain states. We can summarise by agreeing, as we did on the night, that there is no single answer but instead we must draw upon different areas of science and philosophy to ask the right questions and create the wisest programme that addresses pain as the unified experience that it is — physical, cognitive and emotional — but in that person with their story.

 

 

11Apr/16

Hands-on treatment for pain

Hands-on treatment for pain should form part of the therapy programme for painful conditions including chronic or persisting pain. A line of thought exists that the hands-off approach for chronic pain is best yet there are some clear ways that clinicians can use their hands with great effect. It is also expected when a person goes to see a physiotherapist that they will receive manual treatments as a way to feel better, and indeed people often do feel better when such therapies are used wisely.

There is no certainty as to why hands-on treatment works but it is safe to assume that touch has an effect that is likely to be underpinned by a change in the interpretation of sensory input from the body. Modern concepts of brain function suggest that what we experience is the brain’s best guess about what the sensory information in that moment means, based on prior experience. This based upon probability that the sensory information infers something, i.e. something pleasant and hence the touch feels good, comforting, soothing etc., or something unpleasant and therefore the touch can feel painful or uncomfortable.

Touch is deemed important for healthy development and is certainly an act that is used commonly to communicate. In the same way then, touch can be used to communicate in the therapeutic setting as well as create an opportunity to change pain and sensitivity. We are changing constantly with each moment being fresh and new — in fact, this is one of only a few definites in life, is that we change. We are designed to change and hence the feeling we are feeling now is only temporary. The sense of ourselves, ‘me’, is something that we feel is constant yet it changes as time passes and we gather new experiences, learning and developing.

It is worth pointing out that the mention of brain does not mean that we are only a brain. I am a whole person made of my body, brain, mind and environment, none of which is any more important as it is the sum that makes me and who I feel I am at any given moment. The false division of mind and body certainly does not hold up. My mind is not in my head or my brain, I ma my mind, which is why when I think I use my body and my brain together as ‘me’ within a particular context (environment) in a particular moment (that has just passed). This may seem like play with words, yet it is fundamental to successfully addressing pain because this understanding gives both hope and a practical way forward as we use this knowledge to create a programme of treatment, training and movement to overcome pain so that it does not dominate but instead has its place as a survival mechanism. Briefly, pain is a motivator to take action on the basis that I am predicting the need for protection against a perceived threat. More threat, more protection, more pain — not more pain = more damage as was traditionally thought. Hence, the reduction of threat is our aim.

Now back to touch: how we can use it and how it plays a role in reducing pain. Preparing the recipient of the hands-on treatment is important, priming them with an explanation and positive expectations. This can be done by simply describing why it is useful, saying that it is usually a pleasant experience to ease symptoms whilst dropping in calming, soothing words into the conversation. Addressing concerns, especially if they have had a painful treatment beforehand, is also part of the preamble, in essence ploughing the field before sewing the seeds. Then the contact begins.

The clinician can do a few things to prepare him or herself so that the first contact is felt to be compassionate and soothing from the outset. This is of course the aim — to be soothing and to create calm, changing the way that the recipient’s brain is predicting what the sensory information means, i.e. it means safety. And safety in turn means less, or no need for protection, and no protection = no pain.

  • Prepare clean, warm hands
  • Take a breath or two and let muscles relax on the out-breath (we are not always aware of how much tension we are holding, especially if we have been using manual therapy often through the day)
  • Let go of any distracting thoughts and be entirely focused on the touch and responses of the person; again, the out-breath is good for focusing on the present moment

On starting the hands-on part of the session, having prepared the recipient and being present oneself, the first touch allows the therapist to note how guarded and protective the person is in respect of the body. The image of pushing a cork in a barrel of water is a useful visualisation of how to ease into, and respond to the person. It is worth considering that it is the person experiencing the touch and not the body part itself. It is the person who is conscious and gives meaning to the touch, and hence it is the person to keep in mind as you lay hands on. The treatment then becomes a dance or an art form as the hands and the body form an alliance that aims to transform sensory signals into the experience of relief; soothing, calming and peaceful. This would be the same whether the technique more soft tissue (the many forms of massage) or mobilising a joint.

  • Prepare the person
  • Prepare yourself
  • Apply the treatment
  • Conclude the treatment, making it obvious with the hands before uttering a few soothing words (consider tone, volume etc) that allows the person to realise the completion
  • Give a few moments for orientation and shift of state before inviting them to sit up or change position

Of course, hands-on forms only part of the programme with the other facets addressing the different dimensions of pain in an integrated manner: addressing the whole person. However, a key point made here is that in order to be as effective as we can, recognising our role as individual clinicians with our own characteristics and style, we must pay attention to the person, ourselves and the context in equal measure.

***

  • Pain Coach Programme — complete care for persistent pain
  • 1:1 Pain Coach — mentoring for clinicians
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02Apr/16

Repetitive strain injury

Repetitive strain injury — it’s not just about the arms

Repetitive strain injury (RSI) is a blight on the working world affecting the individual’s ability to perform. Personally RSI can cause great suffering on a number of levels and financially there can be significant cost to both the individual and the business. For all of these reasons it is important that the understanding of RSI evolves. Similar to other persistent pains, when society realises that pain can change when you understand it and know what to do, there will be a vast shift. The shift will mean less suffering as people learn how to overcome their pain.

RSI often begins with mild symptoms that include pain, soreness, stiffness and altered sensation that build up over time. There is usually a point when the pain motivates the person to seek help or deterioration in performance enforces action when they are unable to do their work as needed. In the early stages, typically there is a search for an actual injury or evidence for inflammation with varying results. In other words, some people will discover that there is an injury but most will not. The reason for this is simply that pain does not accurately reflect tissue injury. So what is pain?

This is the ultimate question that needs answering and like most problems, to solve them we must ask the right question to create an opportunity for understanding. What is pain? Pain is all about protection. The amount of pain we experience in that moment (we can only experience pain in the present moment, the rest being a memory or an anticipation that something will hurt, both of which impact on what is happening now; i.e./ remembering a painful time can evoke pain now, and thinking that something will hurt causes us to experience more pain) is dependent upon the level of perception of threat. More threat predicted results in more pain experienced regardless of tissue damage. This is why a soldier can suffer great injury without experiencing pain because escape from danger is more important, hence feeling no pain allows for such escape to a safe place.

Pain that is attributed to RSI then, is all about the perception of threat to the arms and hands (sometimes as far up as shoulders, neck and upper back). In fact, it is a threat to the person that is pertinent enough for the brain (we are our brain of course, so this is just for convenient description) to predict that the self needs protecting in its entirety. I say entirety because we are a whole person, experienced moment to moment as the ‘self’, which is the brain, the mind, the body and the context (environment) blended and unified into this single experience now. It is this that takes the problem of RSI or any other pain emergent in the body beyond just where the pain is actually felt. Pain in the arm or hand is more than just the feeling, the sensation, the lived experience; it equally involves what we think about the pain (cognition), how we feel about the pain (emotion) and the meaning that we attribute. All of these dimensions create the experience we call pain. So, even from this brief insight into the modern blend of neuroscience and philosophy to help us ask the right questions to which we can discover answers.

The right questions also include posing those that allow the person to tell their story. Creating the environment for this is the vital first step in understanding the person’s lived experience, listening to their words and the way in which they express them. This picture that is drawn allows the clinician to decide how together they can form a partnership that forms the basis of the person overcoming their pain.

As the narrative emerges, the clinician is able to validate and give meaning to events and moments that have shaped the current context (many of which will not be realised). From thereon in, a comprehensive programme is created to address all dimensions of the problem in an interrelated manner. Pain being a lived experience moment to moment, the person needs to know what to think and what to do at any given moment. In effect they need to become their own coach, which is the Pain Coach concept — the Pain Coach coaches the person to become their own coach so that they successfully coach themselves to overcome their pain. We are change with every new moment that passes as our biology updates, and similar to a sports coach, we aim to optimise that change in the direction of health: the healthy vision of me.

The main areas that a comprehensive programme focuses upon are the person’s understanding of the problem (their working knowledge), addressing fears and worries to put these resources into developing the ‘healthy me’, normalising movement and body sense, and creating the conditions for a healthy existence. There are many different strategies and techniques to use alongside treatment that also creates the conditions for health (hands-on, movement and other desensitising ways). Overall though, the programme gives you the know-how to overcome pain and resume a meaningful life.

In summary, RSI similar to other persisting pain problems involves much more than the area that hurts. Pain involves the person, the whole person and hence to address pain comprehensively, the programme must also be whole person. In other words it must reflect the fact that we are thinking, feeling and moving as an expression of who we are, the self that we ‘feel’, emerging from the unification of these dimensions. The programme thereby creates a way forward.

Part 2 will look at what happens in RSI

Pain Coach Programme for persistent pain problems: t. 07518 445493

23Mar/16
Women in pain

Women in pain

Women in painI see more women in pain than men in pain. Naturally, it depends upon the individual as to whether they seek help or not, yet as a general observation it appears that women in pain are more likely to take some action.

The most common presentation is a female aged between 30 and 55 years, who has suffered pain for some time, months or even years, which is now impacting upon her life in a number of ways. Typically the pain is affecting homelife, particulalrly looking after young children,  and worklife, or both in some cases as the pain pervades out into every nook and cranny. Sometimes this happens over a few months but often it is a slow-burner that is suddenly realised. When we have a conversation about the pain, cafe style*, it becomes apparent that there have been painful incidents punctuating a consistent level of sensitivity, building or kindling. The pains emerging in the person include back pain, neck pain, wrist pain, knee pain, foot pain — any joint pain — muscular pain; and can be accompanied by a range of pains known as functional pain syndromes: pelvic pain (dysmennorhoea, period pain, endometriosis, vulvodynia), irritable bowel syndrome, migraine, headache, fibromyalgia, jaw pain. The person, whilst unique and has a unique story to tell, is often hard on themselves by nature, a perfectionist, anxious and a worrier.

There are many, many women suffering a number of these problems that appear to be unrelated, but this is not usually the case. Upstream changes, or biological adaptations, play a role in the symptoms emerging, yet of course the way a condition manifests is dependent upon the individual themselves, with the uniqueness of each person, their tale, beliefs and life experiences.

Nothing happens in isolation. In other words, there is a point in time when we experience a sensation that we label and communicate, but this is not in isolation to what has been before. The story that the person tells me is vital because it reveals both the unfolding of how the individual comes to be sat in the room and allows me to begin giving some meaning to the experience; i.e. helping the person understand their pain and how it sits within their lifestyle and their reality. I say within because pain should not define who we are, yet it often appears to and hence needs to be put into perspective; the first step to overcoming the problem.

So, there are priming events that often begin much earlier in life than the pain that eventually brings the person along to the clinic. These priming events are biological responses to injuries, infections and other situations that are also learning situations. Learning how to respond at time point A then ‘primes’ for time point B as a response kicks in based on how our brains predict the best hypothesis for what ‘this all means’–what we are experiencing now is the brain’s best guess about what all the sensory information means based upon what has happened before, probability playing a role. One of the reasons for a good conversation is to identify the pattern of pain over the years, how it has gradually become more intrusive as the episodes intensify and become more frequent. The pattern can then be explained, given meaning and then provide a platform to create a way forward.

We are designed to change and each moment is unique. This gives us unending opportunities to steer ourselves towards a healthier existence and leading a meaningful life. To get there though, we must have a belief that we ‘can’ and be able to hold that vision. This vision of the healthy me is one that allows us to ask ourselves the question ‘am I heading towards the healthy me with these thoughts and actions, or not?’. If we are not heading in that direction, then we are being distracted and need to resume the healthy course, actively choosing to do so. How are you choosing to feel today? This is an interesting question to ask oneself.

We still have a certain amount of energy each day and a need for sleep and recuperation. Exceeding our capacity means that we are not meeting our basic needs — security, nutrition, hydration, rest. There is only a certain amount of time that we can keep drawing on our energy before we must refresh. Failing to attend to the basic needs leeds to on-going stress responses that are meant only for short bursts. Prolonged activation begins to play havoc in our body systems as we are in survive mode, not thrive mode. In particular, systems that slow down include the digestive system and the reproductive system. Many, many of the women I see have issues with both — e.g./ poor digestion, bloating, sensitivity, intolerances, fertility problems. The biology that underpins behaviours of protection (fright or flight) are preparing you to fight or run away. Having a meal or trying to conceive are low on the biological agenda when you are surviving.

Too much to do, too little time. Modern day living urges us to be busy being busy. Demands flying in from all quarters, yet it is the way we perceive a situation, the way we think about it that triggers the way we respond, not the situation itself. This gives us a very handy buffer. By gaining insight into the way we automatically think and perceive, this being learned over years (i.e. habits), we can become increasingly skilled at choosing different ways of thinking, letting thoughts go, and focusing on what enables us to grow. This very quickly changes our reality, our body, our environment and the sum of all, which is the lived experience.

With on-going pain we develop habits of thought and action, including the way we move that is integral to the way we sense our bodies. Our body sense and sense of self changes in pain, as does our perception of the environment (things can look further away when we have chronic pain or steeper when we are tired), all of which add up to provide evidence that we are under threat. More threat = more pain because the amount of pain we suffer is down to the level of perception of threat and not the amount of tissue damage. We have known this for years, yet mainstream healthcare and thinking remains steadfastly into structures and pathology. It is no mystery then, as to why chronic pain is one of the main global health burdens when the thinking is wrong! So what can we do?

If you are a woman suffering widespread aches and pains, tiredness and frequent bouts of anxiety, there is good news! As I said earlier, we are designed to change, and change is happening all the time. We need to decide which way we wish to change and then follow a plan, or programme, that takes you towards your vision of the healthy you. Pain is a lived experience and hence the programme must fit your life and unique needs as the techniques, strategies of thought and action interweave your life, moment to moment, taking every opportunity to create the right conditions. The blend of movements, gradually building exercises, mindful practice, sensorimotor training, recuperation, resilience, focus, motivation and more, together form a healthy bunch of habits that are all about you getting healthy again, which is the best way to get rid of this pain. No threat, no pain.

* the cafe style conversation is my chosen way of unfolding the person’s story. How do we chat in a cafe? It is relaxed and open, allowing for the full flow of conversation.

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24Feb/16
Dystonia

Chronic fatigue syndrome

Chronic fatigue syndromeAn excellent article by Jo Marchant addressing chronic fatigue syndrome recently appeared in The Observer. Interestingly, the following question was posed, “Is it physical or mental – or a combination of the two?”, highlighting the on-going dichotomy that is seen to exist in both society and in healthcare.

I spend a fair amount of time helping people to understand their perceptions and experiences, usually involving pain and suffering. This is about giving a meaning to their pain, validating their lived experience before looking at the ways in which they can change direction towards a healthy and meaningful existence. Importantly, a vital part of this working knowledge is understanding that there is no body-mind separation. There is a general shift towards people’s acceptance of this fact, yet there is still some way to go before this could be seen as mainstream thinking across society. However, this is certainly not alternative thinking, as we have a significant amount of scientific and philosophical literature that is dedicated to this very question.

To answer the question quoted at the start of my blog, chronic fatigue syndrome is not physical, it is not mental and it is not a combination of both. Chronic fatigue sydrome is a whole person experience, much like pain, when the symptoms emerge in the person, in a location or in locations felt and described anatomically for convenience. Yet the biology of both CFS and pain exist well beyond where the feelings are felt. Similar to the notion of mind that does not only exist in the head, or the brain or behind the eyes as can be thought. There are no controllers pulling knobs and turning dials behind our eyes, although there can be the sense that we ‘see’ the world, the perceived world, through these eyes, creating the illusion that the thinker is in the cranium. Fascinating.

However, my mind exists in me, the whole person. I think and I am my whole body and my whole body is the thinker, hence there being no separation. As a simple example, anxiety is usually viewed as a psychological state of mind, yet where do we feel anxious? The stomach, the gut, the chest perhaps. Not in my head, that’s for sure. Same for pain — it is not in the head!!! I am sure many readers have either heard this about pain, either as a patient or a patient tells you that is what they have been told because no ’tissue’ or structure has been found to explain their pain. This is actually because structures do not explain pain as many now know.

Accepting the notion of a whole person opens a range of avenues for therapeutic purposes as we seek to give the person suffering symptoms the knowledge and skills to resume a meaningful and healthy life. The key principle and underlying thinking (with my whole person as the clinician or therapist) is that the individual in front of you is complete and the sum of parts that only exist as a whole — e.g./ as we are conversing or exploring movements (also known as tests, assessments etc.), seeing how the that person moves and experiences movement or expresses themselves with certain words and gestures that illustrate the meaning that they wish to convey.

The aim of a health-giving programme is to provide the individual with the knowledge and skills he or she need to overcome their problem and steer their change (we are designed to change; it is one of the very few definites) to a meaningful life. There maybe treatment within this programme, but in essence it is about giving the person the independence with regard to thought and action, which they understand are emergent from themselves as a whole person, enabling and empowering decisions that lead to action that is congruent with health. Understanding this means that the individual knows which levels they can use, combining movement and thought for best outcomes. This would include working knowledge of symptoms allowing for wise thought and selecting best action, specific techniques and strategies that promote the meeting of basic needs (i.e./ nutritional intake, fluid intake, security, movement, rest), movement and exercise for health and building tolerance for activity, resilience and motivation, and skills to deal with unhelpful and distracting thoughts (e.g./ practical mindfulness). These are some of the key elements of the Pain Coach Programme, when you become your own coach, conceptualised as a compass that one can use to determine current direction and motivate a shift in direction when needed, moment to moment. Essentially, with chronic fatigue and pain as lived experiences, it is the moment to moment thinking and actions that are vital in heading towards the healthy you.

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