Category Archives: Chronic pain

20Feb/17

Pain is whole person

Pain is whole person

There is only one way to approach the problem of chronic pain as it emerges in the individual, and that is by addressing the whole person. This way demonstrates a true understanding of pain: the lack of any pain system, pain signals or pain centres and that the vast majority of the biology of pain is not where we actually feel it in the body or body space in the case of phantom limb pain. Much like when you watch a film in the cinema, most of what you need is not on the screen.

With pain being absolutely individual, coloured by the context, the environment in which it is being phenomenologically experienced, prior experience and beliefs (about pain, health, danger, ‘me’, the world etc.), the action we are motivated and compelled to take, existing health and level of threat perception to name but a few. In short, this includes activity in the brain and central nervous system, immune system, endocrine system, sensorimotor system, visual system, and the autonomic nervous system. Most of this is not where the pain is felt.

Pain and injury are notorious for being poorly related. There are countless stories of people suffering great trauma (tissue damage) and reporting minimal or no pain, some sustaining minor injuries and describing agonising pain and a huge variation in between. Considering the factors in the previous paragraph, one can start to understand why. In essence it is due to pain being a better indicator of the level of perception of threat; i.e./ more threat, or existence of threat = pain.

Bearing this in mind, and this is the current understanding of pain, you can see why the whole person approach is necessary. It is as much about the person as the condition, as Oliver Sacks wrote and practiced, and indeed this is a vital principle to work to. Understand the person and their circumstances and you go some way to seeing a way forward. Listening deeply in the first instance creates the opportunity to gain insight into the reasons for the person’s suffering — the reasons for pain and what is influencing that experience. From this foundation, one develops a rapport, not just as a clinician or therapist but as a trusted advisor, giving the person the knowledge and skills to overcome their pain and live a meaningful life.

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Pain Coach Programme to overcome chronic pain ~ t. 07518 445493 or email: [email protected]

 

18Feb/17

Pain and choice

Pain and choice

There is one thing that pain does and that is narrow down our choices. A sense of choice has a major role in the sense of ‘me’ and who I am. Losing choice impacts upon us significantly as we feel less and less like ourselves and who we are meant to be. This is a very common description of the impact factor that I hear when listening to people enduring states of chronic pain.

Talking to people with pain as we seek to gain insight into the causes of their suffering. This provides a way to offer support, guidance and a way forward. Of course we can only move forward, but sometimes it does not feel like that! Groundhog day.

Enabling one to see their choices then, becomes a valuable and important exercise. We have many, but sometimes we just need a little help to realise and then actualise. I believe that the greatest steps are taken when this happens as the person feels empowered to steer their ship once more.

We need to know where we are going of course, a direction created by clarifying what we want as opposed to what we do not want ~ “I don’t want pain” versus “I want to live well”. Focusing upon living well motivates actions and behaviours in line with this whereas thinking about getting rid of pain keeps our attention on pain. We will only be successful, and we can be, if we have the right approach, mindset and attitude that we may have to cultivate and practice. Most I see do need to work upon these skills of attention, resilience, self-belief and determination. That is the first choice.

We can choose our approach. We can choose to engage in healthy activities. We can choose to take every opportunity to live well. We can choose to create the conditions to feel better. We can choose to have meaningful interactions. We can choose to leave some thoughts alone if they make us feel bad. We can choose to move and gradually move more as we adapt. We can choose to learn about our pain and our responses to pain, and then change them if need be. There are many choices we can make.

Of course it sounds easy when written and the doing is different. It is an experience. However, it is perfectly do-able. We are designed to change and do so every moment that passes. We can harness our potential and opportunities with simple measures, practices and skills based on new knowledge. Achieving success is with everybody’s reach although sometimes we need some help and guidance. But we can do it. This is the ethos of UP. Let us make choices to live well, create joy and face challenges with a sense of ‘I can’.

Choose ‘I can’.

18Feb/17

Why am I running the London Marathon?

Why am I running the London Marathon?

We are 10 weeks away from the London Marathon and I am getting excited about the day. The training is going well, and I am using others experience and knowledge as a yardstick, reaching 16 miles so far. A bit more nudging in March and I’ll be set to join the thousands of other runners, coursing round the great city of London.

So why am I doing this? The answer is simple. To raise awareness and money to address the biggest global health burden, chronic pain. It costs us the most economically but of course the amount of suffering worldwide is immeasurable. This must change and we can change it by shifting our thinking to be in line with what we know about pain. With an understanding of pain, individuals realise their potential to overcome their pain and live meaningful lives. This is achievable, and in this day and age we have the means to reach across the globe to give people the knowledge and skills. This is the story of UP | understand pain, which was co-founded by myself and Georgie as a pain awareness campaign. Now we have big plans to take the project to another level to achieve our aim of changing the way society thinks about pain.

Complex Regional Pain Syndrome (CRPS) can be a terribly disabling condition, characterised by intense pain. Many people have not heard of CRPS and within healthcare diagnosis is often delayed. This is a problem because like most conditions, early identification allows for treatment to begin. The treatment must be based upon the person’s understanding of the signs and symptoms, for there is an understandable fear that drives on-going protection. Therefore, as with any injury or pain problem, the early messages must be right and make sense.A person’s belief drives their behaviours and subsequent thinking, so a good working knowledge of pain is vital ~ understand pain to change pain.

CRPS UK gained a place in this year’s London Marathon, and having spoken twice at their conferences and being in regular contact, I ‘volunteered’ to be the runner. I was very excited to be chosen and gratefully accepted, which is now why I am out in the Lycra every other day (I will not be posting a picture of that!). CRPS UK is a charity dedicated to advancing the understanding of the condition and supporting people with CRPS. The people involved are doing incredible work to raise the profile and have achieved so much through their dedication. Please visit their website here.

You may be someone suffering chronic pain or know someone who is regularly in pain. Most of us do know someone and can see the effects upon their life. This is not just pain from backs and joints but pain related to cancer, heart disease, arthritis, irritable bowel syndrome, headaches, migraines, rheumatological diseases, pelvic pain and many other conditions that hurt. The work being done by CRPS UK and UP aims to change this and provide resources and training that gives individuals and society a way forward, to overcome pain and live well.

Please show your support here and donate generously

Thankyou!!

01Feb/17

The inner dialogue

The inner dialogue ~ what do you listen to and what do you tell yourself?
You are beautiful by La Melodie https://flic.kr/p/99ACEa

You are beautiful by La Melodie https://flic.kr/p/99ACEa

One of the things that makes us human is the inner dialogue or inner voice that is fairly continuously ‘speaking’ to us. Of course the voice is part of each and everyone of us and is not an outside agent. To some people it can appear to be coming from somewhere or someone else as in the case of psychiatric disorders. That must be frightening.

The inner dialogue is part of the workings of our mind. Our minds play a significant role in our actions and perceptions but it is not a one way street. The physicality of our existence can impact upon the way in which we think. The branch of philosophy named embodied cognition has much to say on this matter, addressing the notion that our thinking is embodied. A simple example is when thinking about hunger and food, we would typically feel that in our body, interpreting the sensations as being in need of food. A further example is the way we gesture with our hands to demonstrate a point, freeing up resources for further thinking. Consider how you feel when you think of a loved one or a difficult situation in the past — where do you experience it? Certainly not ‘in the head’.

There is a skill in choosing whether to listen to and act upon our inner dialogue or our thinking. It is true that we do not choose the workings of our mind, however we can learn about how it works, our habits of thought and realise how we embody these thoughts. In so doing, we have the opportunity and responsibility to become increasingly skilful in deciding whether to pay attention or to let go of thoughts and the inner dialogue. Being mindful is just that. We are aware of the thoughts, noticing their impermanence, recurrent nature, the way they create feelings in the body, but we are not engaging or becoming embroiled. There is a monumental difference between being in the film and watching the film. You are still experiencing the full richness of the feelings and emotions but with curiosity, with compassion and with an intent to only act with kindness, towards self and others.

Learning to be observant of the inner dialogue allows you to make choices. We have choices and often need to realise them. How am I choosing to feel or think about a particular situation? Even asking yourself that question gives you space to decide what you can do. Shifting the thinking to take another perspective can give a very different feel to the experience. Knowing that you can do this is very empowering, as you know that you can face challenges with skill and insight.

The story we tell ourselves can be so impacting upon our reality, lived experiences and ultimately our health and sense of well-being. If you persistently tell yourself that you are not good enough, have not tried hard enough or blame yourself for all sorts of things that may not actually be your fault, this will create a range of unpleasant feelings in the body as well as paint a bleak picture of life. Being hard on oneself causes our protect systems to switch into action. A range of common ailments manifest if these systems are ‘on’ too much without adequate refresh and renew time. Such problems include chronic aches and pains, sleep disturbance, gut issues, mood variance and exhaustion; very common presentations in my clinic. This need not be the case by learning some simple skills of well-being and day to day practices that stoke up our healthy systems. This is the bulk of the work we do to overcome pain and health problems — see here.

The inner dialogue and pain

Pain and the inner dialogueThe inner dialogue can tell us our story; the story of me. The self that I experience moment to moment, which is continually updating. Our implicit ability to change creates great hope as we can transform our suffering by gaining knowledge and insight into our existing habits. From this awareness we can choose to create new habits that are based upon our value system (what is important to you in life) and are by design all about sustainably living a meaningful life.

Many people with chronic pain have received messages that suggest pain must be managed or that they must just cope. This lowers expectations and hence our story and the inner dialogue is based on this belief. We can and must do better. Changing our story, and this is applicable to any story we tell ourselves, creates a new way onward. This begins with understanding pain. Countless people have told me how much better they feel on starting to understand their pain when we discuss their experiences at the first meeting. There is no magic here. We feel better when we have understanding of a problem and insight into how we can address the issues — feelings of agency, choice and empowerment feed and motivate us to take action; the right action. The Pain Coach Programme is all about the right action based on the right thinking. Understand your pain, write and see a new story and then live it. This is the story of your success, whether it be overcoming pain, setting up a business, writing an essay, doing an exam or playing a game of football. Use the story wisely, make it count and use every moment in a way that encourages and motivates more and more great action.

The Pain Coach Programme is a blend of strengths based coaching and pain sciences for your to achieve your success | t. 07518 445493

 

30Jan/17

CRPS Diagnosis

CRPS Diagnosis

CRPSComplex Regional Pain Syndrome (CRPS) is a collection of signs and symptoms that define this particular condition. A syndrome according to the Oxford Dictionaries, is a ‘group of symptoms which consistently occur together, or a condition characterized by a set of associated symptoms’. Therefore, we can clump together any set of symptoms and give it a name, which is really what has happened over the years in medicine. The important point is that when we use the term, we should all know what we are talking about and know what we should look for to make a diagnosis. In other words, a set of guidelines.

The Budapest Criteria delivers guidelines for CRPS, which you can read about in this paper by Harden et al. (2013). The clinical criteria (see below) acknowledge the sensory, vasomotor, sudomotor/oedema and motor/trophic categories that really highlight the complexity of CRPS. Pain is often the primary concern, with people describing their incredible suffering in a range of graphic ways. However, it is not just the pain that causes suffering but the way in which the life of the person changes together with their sense of who they are and their sense of agency seemingly lost. One of the roles of the clinician is certainly to help restore that sense of who I am, a construct that is built from many of life’s ‘components’.

Budapest Criteria

1. Continuing pain, which is disproportionate to any inciting event

2. Must report at least one symptom in three of the four following categories

  • Sensory: Reports of hyperalgesia and/or allodynia
  • Vasomotor: Reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry
  • Sudomotor/Edema: Reports of edema and/or sweating changes and/or sweating asymmetry
  • Motor/Trophic: Reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)

3. Must display at least one sign at time of evaluation in two or more of the following categories

  • Sensory: Evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or deep somatic pressure and/or joint movement)
  • Vasomotor: Evidence of temperature asymmetry and/or skin color changes and/or asymmetry
  • Sudomotor/Edema: Evidence of edema and/or sweating changes and/or sweating asymmetry
  • Motor/Trophic: Evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)

4. There is no other diagnosis that better explains the signs and symptoms

Importance of diagnosis

A diagnosis made in the same way, based on the same criteria means that clinicians, researchers and patients alike are all discussing the same condition. This may seem pedantic but in fact it is vital for creating a way forward. Clinicians mus know what they are treating, patients must know what they are being treated for and researchers must know what they are researching. Sounds obvious but let’s not take it for granted. So the Budapest Criteria has pointed all those with an interest in the same direction. Consequently we can focus on creating better and better treatments.

As with any painful condition, the start point must be understanding the pain itself. The following questions arise that we must be try to answer:

  • why am I in pain?
  • why this much pain?
  • why is it persisting?
  • what influences my pain?
  • what do I, the bearer of the pain, need to do to get better?
  • what will you do, the clinician or therapist, to help me get better?
  • how long will it take?

New thinking, new science, new models of pain over the past 10 years has advanced our knowledge enormously. Understanding how we change, how our body systems update, how we can make choices as individuals, and the practices we can use to change our pain experience to name but a few, create great hope as we tap into our amazing strengths and resources as human beings. Detailing the treatment approaches is for another series of blogs, but here the key point is that the first step in overcoming pain is to understand it. It is the misunderstanding of pain that causes erroneous thinking and action, which we can and must address across society — pain is a public health issue. Chronic pain is one of the largest global health burdens (Vos et al. 2012). It costs us the most alongside depression, and I believe that this need not be the case if and when we change how we think about pain, based on current and emerging knowledge.

“The first step to overcoming pain is to understand it”

upandrunThis is the reason for UP | understand pain, which we started in 2015 with the aim of changing the way people think and then approach their pain, realising their potential and knowing what they can do. We are about to launch the new website that is packed with practical information for the globe to access online. Alongside this we have plans to create a social enterprise that will purport the same messages, coming from the great thinkers and clinicians who are shaping a new era in changing pain.

In April I will be running the London Marathon to raise awareness of the work of both UP and CRPS UK. You can support the work that both are doing to change pain by donating here

Thank you!

 

29Jan/17

Pills, injections & surgery don’t teach you how to live

Pills, injections & surgery don’t teach you how to live ~ pain is a public health and social issue
Important Message by Patrick Denker | https://flic.kr/p/a9iUAG

Important Message by Patrick Denker | https://flic.kr/p/a9iUAG

In chronic pain, everything changes. The way you think, feel, move and body sense are all impacted by this on-going state of protection that keeps you in a defensive mode. Even the world looks different as perceptions of the environment are distorted (Ref). The changes that we live and experience have biological underpinnings that have and continue to be studied. Clarifying what is happening at this level aims to give rise to new clinical approaches, both pharmacological and non-pharamcological.

This short article is by no means anti-medicine or anti-surgery because these methods have their place. In that place they must remain, viewed as an option within an overall plan or programme that delivers the outcome of overcoming pain. My point is simply that understanding pain means that we realise that explanations relying upon tissue structure or pathology do not hold up. Pain is not a structure and pain cannot be seen on any scan or x-ray. Pain is a lived experience emerging in a person, which is a culmination of multilevel neuroimmune processing and consequent prediction of the existence of a possible threat. Pain exists within our perception of the current moment that is informed by context and past experience (priors): what we are thinking, what we are doing, who we are with, where we are.

Only I can experience my pain under these circumstances, with some ‘components’ being conscious and many being subconscious. For example, I know that I am anticipating pain in the form of a thought: ‘I expect my back to hurt when I put on those shoes’. Yet I do not know and cannot ‘feel’ the activity of my brain, instead living the biological processing as a conscious experience of what it is like to exist in this moment. Here if course we are contemplating consciousness and what it is like to be me, and we do not know how biology becomes this experience.

Pain emerging in the person makes it as complex as the person; and we are complex! Equally, pain relief or achieving a pain frePain Coach Programmee state is as complex. Neither are permanent states as we are continually changing as our body systems and models of the world update. Our ability to shape our body systems with experience creates such opportunity and with that hope. But it is the individual who shapes their systems by making choices based on understanding. This is why understanding pain is so important as a starter. By this I don’t mean knowing all the chemicals and receptors, instead a working knowledge of pain that can be used practically at any given moment so that the person knows what to think and do. In essence, they learn to coach themselves, which is the basis of my Pain Coach Programme.

There are many influences upon the pain experience itself as well as the likelihood that we will feel pain. Unsurprisingly these include stress, anxiety, thoughts, emotional state, environment, other people, fear, context, memory, tiredness and past experience. The person can understand these influences and develop practices that lessen and ease their impact, learning new habits that are pointed towards health and happiness. This is a significant part of the programme of getting and living well. Pills, injections and surgery do not provide such a learning opportunity. Indeed there maybe relief in the short term and there is a potential role here, yet we are interested in long term change in a desired direction.

Suffering chronic pain has many effects upon the person. Certainly their biology has adapted and changed meaning that they can be in a protect or vigilant state more often, and therefore more reactive with emotions and behaviours. Body sense often changes resulting in altered movement patterns, which in turn cause issues navigating the world as well as providing sensory information that can be continually interpreted as evidence of a threat. Recall that pain is in the face of a perceived threat: more threat = more likelihood of pain. Learning the skills of wellbeing together with specific training sculpts biology towards that underpinning lived experiences of health and wellbeing. Again, pills, injections and surgery do not provide such an opportunity.

Overcoming pain to live a meaningful life requires understanding, effort, practice, resilience, motivation and the right attitude. Everyone has the ability to use their strengths and values to motivate actions (thoughts and acts — remember that a thought is an action) that steer change in a positive direction. It is realising that we can choose. We can choose the attitude we take towards a challenge, and the challenge of chronic pain can be one of the greatest faced by an individual.

Rightly so, an argument has been put forward that pain should be considered an issue of public health. Pain is certainly a societal problem, and in looking at it in this way, we are more like to be able to address the issue that costs us an extraordinary amount of money each year. Financial cost is one thing, but the amount of suffering across the globe and in particular in poorer regions, is another. We are compelled to think differently and we can to do this with the knowledge that we have about pain emerging from science, social and philosophical fields. This is a desperate situation needing collaborations between countries and organisations. Fundamentally, the picture of the modern pain epidemic can be changed, beginning with changing society’s thinking about pain. This involves practical and engaged education projects.

Pain education has been trumpeted and righty so. However, there has been a focus on the neuroscience of pain, especially the role of the brain to the point that the brain is described as somehow being separate from the person. Very contemporary philosophical thinking together with neuroscience has nudged us towards the whole person and viewing pain as a lived experience emerging in the person. This allows us to consider a range of ways to educate the person about how they can change their pain, overcome their pain and live a meaningful life. Of course this is always work in progress and it continues with great gusto. The emphasis on chemicals and receptors has moved on. Whilst interesting to know the microbiology of pain, what the person on pain really needs are practical ways of changing their pain in that moment.

Reflecting on the points made, one can see that the biomedical approach to pain is limited by the fact that pain is a social and public health problem, not a medical problem. Some of the recent best thinking about pain has come from historians, public health experts, English scholars, philosophers, artists, and poets. People ask me how they can learn more about pain. The answer lies in listening and looking at society and people who live the experience. Pain and suffering are ubiquitous. They do not live in a book and certainly not a medical textbook!

So what next?

UP | Understanding PainAt UP | understand pain we are working on several projects that will deliver the latest information and thinking about pain to society. Very soon the new UP website will be launched, giving us an online reach across the globe, allowing people to access this information. UP is a social project, working to evolve the way societies think about pain so that suffering can be reduced. With pain being such an individual matter, when only I can feel my pain that is defined by my knowledge, beliefs and experiences to date, the projects must be culturally sensitive. This does not mean going about it carefully, indeed we need to be shouting the current understanding of pain from the rooftops, instead referring to the fact that there is a significant cultural dimension that blends with all other dimensions of the pain experience.

For example, one place that I intend to have an impact is Cambodia (I will explain my reasons in a later blog). The first steps have to include a deeper insight into the current thinking and what factors and beliefs underpin that thinking. We know that it is not simple to replace an existing model with another, even if the latter is more logical and accurate.

Delivering skills and knowledge to people suffering and to those providing the care in principle is straight forward. Much of what is delivered is straight forward, understandable and does not rely on expensive or complicated equipment. The Pain Coach Programme is easily taught and scaled for example, not only giving people what they need to point themselves towards being healthy but creating habits from which emerges healthy, meaningful living. In so doing, pain becomes less and less of a feature, simply because the person is engaged with their life, feeling that sense of being able to make a choice, having meaningful interactions with others, resulting in fulfilment.

Pain is a social issue, a public health issue. Pills, injections and surgery will not solve this problem and in fact can be the cause of increasing reliance on such measures, meaning the individuals have no understanding of what they need to do to get better. Medical interventions do not teach people how to live and whilst there maybe a place for this kind of relief, it must be within the bigger picture, a model of that person’s life that includes all dimensions: e.g./ social, psychological, cultural, gender, biological. The risks of using medication have been well publicised in terms of opioids and this remains a significant social issue.

It is the person who feels pain, the whole person, not the body part. Society’s thinking can evolve in line with what we really know about pain and make a huge impact upon the vast amount of suffering that comes at such great expense. This starts now.

26Jan/17

Pain Coach Tips

Pain Coach Tips

Pain Coach ProgrammeThe Pain Coach Programme is the complete approach to chronic pain and painful conditions. The programme addresses the specific changes and adaptations that occur in on-going pain, together with skills to sustainably create the conditions for health and happiness. Here are a selection of tips that you can use straight away.

Before getting into the tips, it is important to understand that our knowledge about pain has moved on significantly over the past 10 years. Pain is not something that is only referenced by where we feel it, and it is certainly not observable on an investigation such as a scan or x-ray. Pain is subjective, unique and emerges in the person when there is a perceived threat to that person. The focus here is upon simple Pain Coach tips, so if you are needing to understand pain further, keep checking back for future blogs or read through the library here.

Pain Coach Tip 1

Clarify your picture of success ~ what does it look like? What are you doing? How are you feeling? This gives you a direction, a steer, and orientation. Write it down and share it with someone, making a commitment. We need meaningful direction, something to aim for.

Pain Coach Tip 2

Frame your thinking in positive terms. Set out your intentions: what do you actually want? For example, instead of thinking about how to get rid of pain, think about how you can feel good. When we focus on feeling good and well, we will orientate our subsequent thinking and actions towards that end.

Pain Coach Tip 3

Think about a success you have had in your life. How did you achieve this success? What strengths did you use? Consider how you can use these strengths each day, building them as you would a muscle. Then think about how you can use these strengths to develop your wellbeing, health and happiness. Make the choice to adopt this approach.

Richmond Stace | Pain Coach & Specialist PhysiotherapistThere are many strategies and techniques to work to your potential to overcome pain. Setting the scene by understanding your pain, what influences your pain, knowing what you can do and how you can do it gives you the confidence and belief to focus on what you CAN do.

The Pain Coach Programme | t. 07518 445493

25Jan/17

CRPS ~ a condition of great suffering

CRPS ~ a condition of great suffering

HandsUndoubtedly CRPS is a condition of great suffering. The pain and array of symptoms that characterise complex regional pain syndrome present one of the greatest challenges to the person as they try to live their life. Having worked with many people diagnosed with CRPS (see Budapest Criteria here), I have seen great and courageous effort put into getting better and overcoming the problem. Overcoming a problem means that the condition is not defining the person, that they are much more than the condition and are widening their focus to engage in meaningful activities. There maybe pain at times, but they know what they can do to increasingly minimise the impact or transform the pain skilfully with different techniques. We are always changing and our body systems updating, which creates potential and opportunity. It is this we can work with to seek to overcome pain.

Suffering is simply defined as ‘the state of undergoing pain, distress, or hardship’ (Oxford Dictionary). A deeper definition by Cassell (1982) describes suffering as ‘a state of severe distress associated with events that threaten the intactness of the person and stated that suffering occurs when an impending destruction of the person is perceived; it continues until the threat of disintegration has passed or until the integrity of the person can be restored in some other manner.’ One of the key elements of Cassell’s definition is the reference to the integrity of the person. In any condition, we must consider and refer to the person and not just a part of the person. No part of an individual can exist without the whole, and indeed it must be the person who suffers and not their arm, hand, leg or back. These are the locations in the body where we experience sensations, yet there are workings behind the scenes that are vitally part of this experience that we cannot see or indeed perceive on a day to day basis, for example the activity of the brain.

Pain after joint replacementAs clinicians we are focused on easing the suffering of the people who come to see us. Pain is one cause of suffering that is the sensation and qualities that we can interpret as ‘bad’ or a sign that something is wrong. The actual ‘what it is like’ to be in pain is not separate from the way in which we think about it. An individual well practiced in contemplative techniques may be able to differentiate and sit with the feeling of pain, concentrating on what it is like without becoming embroiled with the thoughts and emotions, and indeed this eases suffering immeasurably. This skill requires regular practice of mindfulness meditation, and in so doing, the person can be more observant of the pain, without the judgement that makes it ‘bad’ rather than it just being the pain itself. The second arrow idea helps to clarify this phenomena.

The first arrow, piercing the body, is the feeling of pain. The second arrow, landing in the same place, is when we cause further suffering by the way we choose to think about the pain with the subsequent feelings and emotions. The second arrow is arguably when most of the suffering occurs and is addressed with simple measures such as really understanding pain to reduce the fear and anxiety, both of which fuel pain, developing a working knowledge of pain that gives the person the skills to think in the right way and to choose the best action in that moment, gaining insight into the causes of one’s own suffering and choosing a different path for a different experience and steering a course towards the vision of a meaningful life. This last skill is primarily about being able to focus and maintain attention on a vision, this being the model of success, and address any distractions that usually emerge in the form of unhelpful thoughts.

The first arrow also needs attention as we must create the conditions for healing. There are a number of well known biological changes in CRPS and other chronic pain conditions, and these are addressed in different ways. Medication and interventions are sometimes chosen, but always needed are ways to navigate each moment, day to day, specific training to improve body sense, movement and tissue health, together with practices that promote the general health and well being of the person. The skills of well being are a fundamental part of the Pain Coach Programme simply because they create the right conditions for being well. As we become healthier and as the person feels better in themselves, which can happen in many different ways, the pain and suffering ease. This comes back to the absolute need to address the person, the whole person.

There is much greater understanding of CRPS and chronic pain now. We can cut through some of the complexity with explanations and ways forward. Understanding that pain can and does change like any experience, knowing what one can do in any given moment builds confidence and belief, and developing the skills of well being mean that it becomes easier to focus on the necessary training and strategies to create the conditions for health and gradually resume meaningful activities. A focus on ‘what I can do’, even if it is a small amount to begin with, and then building up the time/amount, alongside the training and day to day techniques takes the person forward in their chosen direction.

CRPS is a condition of great suffering but there are ways to ease suffering that can be learned and practiced, all on a basis of understanding pain and the condition. This builds confidence and belief and a sense that ‘I can’, which is developed together with training to move better, become fitter and feel well. We are designed to change, and we can make choices when we know that they exist. Clinicians are in a position to unpack the complexity of pain, and in so doing show people that they do have choices and how to harness their potential for getting better and living meaningful lives.

I am running the London Marathon this year (2017) for CRPS UK and UP | understand pain. Please support their work to change the problem of pain by donating here

The Pain Coach Programme to overcome chronic pain | t. 07518 445493

21Jan/17

Engaged physiotherapy for pain

Engaged physiotherapy for pain and the modern world

Engaged physiotherapyEngaged physiotherapy is an approach embracing full awareness of oneself as a clinician, full awareness of the person you are working with, full awareness of the context and past, compassion (self and others), insight, and modern sciences (the facts ~ what we know). I have ‘borrowed’ the term from Thich Nhat Hanh who describes engaged Buddhism, which is the practical use of the philosophical principles such as mindfulness, mindful breathing and mindful walking.

Cultivating our awareness as clinicians and gaining insight into the causes of suffering affords us the opportunity to think clearly about the best action for the individual, in this case in pain. Together with an understanding an use of modern sciences, especially pain science, cognitive science and neuroscience (there is vast overlap of course), and philosophy, we can consider each person’s story and create a way onward that is grounded in understanding, compassion, belief and the right attitude to succeed.

There are simple practices that clinicians can use each day that develop and grow awareness and insight. Here are some examples:

  • The greeting
  • Being present during a consultation using the breath
  • Deep and active listening
  • Compassionate speech
  • The creation of a calm and peaceful environment
The greeting

The initial contact often sets the scene. We can think about how we present ourselves with posturing, gestures, language and the simple smile. I would suggest always going to the patient to greet them in the waiting area, and behaving very much like you are welcoming an old friend into your home.

Being present

Using the breath we remain present and aware of what is happening right now. What is passing through me (my mind)? Any bias? Preconception? Judgement? Being aware allows us to let these go so we can focus on active and deep listening. Practicing mindful breathing each day formally for 5-10 minutes helps us to develop this skill that we can use through the day, every day for professional and personal relations to benefit

Deep listening

One of the most valuable gifts we can give to another person is ourselves and our time. Being fully present to listen to the patient (or colleague or family member or friend) creates the conditions for a meaningful interaction. All involved parties benefit from meaningful interactions as we release certain healthy chemicals in these contexts. In deep listening we can hear and understand the suffering of the other, enabling the best and wisest course of action, which may simply be to continue to listen without interruption. Learning to be comfortable with silence is a valuable skill. Much can emerge from moments of silence. (Reading here)

Compassionate speech

Choosing our words carefully, considering their effects, is an important skill to develop. The words we utter have potent effects on others as they hear, process, imagine, think and react. Of course using kind, compassionate words can create the conditions for calm and insight, enabling the person to see a way forward. A focus on health and being well maintains the desired direction, hence the use of words that encourage this thinking and vision helps the person to orientate themselves towards a desired outcome.

We have the spoken word and we have the inner dialogue. Being skilful with both is important as we need to consider which thoughts we are fuelling, or which seeds we are watering by the way we think and what we say. An example would be the effects of engaging in idle gossip. In the long-term, gossip can create issues of trust and miscommunication that breeds suffering.

As a clinician, we should always be thinking about delivering the right messages based on truth, and that provide a compassionate way forward. Helping the patient develop their skills of self-compassion is frequently needed in cases of chronic pain. Understanding that self-compassion is one of the skills of well being helps individuals to practice and benefit from the nurturing of the care-giving systems in the body that play such a big part in our health and happiness.

Creating a calm environment

We are very responsive to the environment. Consider how you would feel working in an office with no windows and in the basement of a block compared to an office with a view over a park or a river.

Clinicians need to think about how the patient might think and feel coming into the clinic. We seek to create a peaceful space for people to experience feelings of calm and gain insight into how they can be, how they can transform their state of being and how they can use these practices in their day to day lives.

The simple practices are just some of the ways we can use our knowledge and skills to create the conditions for people to get better. We no longer have to think about managing or coping, instead use engaged physiotherapy and approaches to give people the belief, understanding and skills to coach themselves, fostering independence and a sense of agency, restoring choice and meaningful living.

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These practices are part of the Pain Coach Programme, which is a focus upon getting better and achieving success in overcoming pain. The programme for patients is a comprehensive way forward addressing a pain problem by focusing on getting healthy and well, and the programme for clinicians is to develop their skills and knowledge to coach patients. If you would like further information, please email us: [email protected] or call 07518 445493.

16Jan/17

Pain after joint replacement

Pain after joint replacement

Pain after joint replacementA number of people experience pain after joint replacement, therefore it is important to identify those who are potentially at risk, devise ways to minimise the risk and ensure that post-operatively each individual receives what they need to resume a meaningful life. Knee and hip replacements are being increasingly performed and hence we are likely to see more people suffering persistent pain. Pain is already one of the largest global health burdens, so understanding pain and what we can do is vital for the global community.

2016 was the Global Year Against Pain in the Joints

There are several key facts to understand about pain:

  • The pain that we feel is poorly related to the extent of tissue damage, tissue changes or injury.
  • Pain is contextual and the likelihood of feeling pain is determined by the perception of threat, both consciously and by body systems that are designed to protect us. In essence, any situation that is judged to be threatening will have implications for a pain experience. This is why stress (a perceived threat) and tiredness play such a role in pain.
  • There is no actual, specific biology of pain, instead a state of protect. In the case of chronic pain, this state is ‘on’ much of the time (a habit) and the person must learn how to change this with different types of training (The Pain Coach Programme). There are no pain signals, pain receptors, pain molecules or pain centres. The biology that is involved with the experience of pain is largely found NOT where we actually feel the pain. Much like when you watch a film in the cinema, most of what you need is not on the screen.
  • And now for some good news! Pain can and does change, but you need to understand it and know what to do.
Risk factors for chronic postoperative pain ~ what to look out for
  • Preoperative pain: if uncontrolled, high intensity and impacting, there is a risk of chronic pain after joint replacement (Arendt-Nielsen et al. 2015). The pain and the person must be addressed before the procedure.
  • Widespread pain is associated with chronic pain after joint replacement (Petersen et al. 2016; Wylde et al. 2011).
  • In some cases of osteoarthritis (OA), temporal summation has been shown to be associated with pain after joint replacement, so evidence of this should be noted.
  • People with fibromyalgia tend to have a higher risk of suffering postoperative pain (D’Apuzzo et al. 2012).
  • When the person has OA that affects a number of joints (Perruccio et al. 2012).
  • Catastrophising about the pain and a lack of effective coping strategies predicted postoperative pain after knee replacement (Baert et al. 2016).
  • Genetic factors, prior experiences (previous surgeries and the quality of the experience and outcomes), beliefs and other influences should be considered.
What can we do?

On deeply listening to the person, we will hear about their experiences and understand the causes of their suffering. If indeed a joint replacement is indicated, then we must ensure the person who will live the experience has a working knowledge of what will happen, who will do what, their role and what they can do to focus on being healthy and well for the best possible recovery.

A simple preoperative education session with the relevant information, an opportunity to ask questions and to learn practices that create the best conditions for healing and recovery would benefit all, but in particular those with identified risk factors. Understanding pain is a key skill and will put the person in a good position to recover whilst they are administered the right pain medications.

The early days set the scene for the coming rehabilitation. Simple breathing and mindful exercises, movements, motor imagery and pain relief all have a role to play. Monitoring how the person is feeling and gauging their belief in their own ability to recover provides insight and opportunities to motivate, encourage and guide compassionately.

Simple, low cost interventions such as these are very likely to make a difference. We can identify the needs of the individual, address any areas of concern before and after the joint replacement and then closely observe the recovery and rehabilitation plan.

Pain Coach Programme ~ preoperative assessment and practices | t. 07518 445493 or contact us using the form below

Common terms used include total joint replacement, total hip replacement, total knee replacement and total joint arthroplasty