Category Archives: Chronic pain

18Jun/16
Pain now

Biology of pelvic pain

Pain nowMost of the biology of pelvic pain does not exist in the pelvis. The same is true for any pain — back pain, knee pain, neck pain etc. Much like the screen turning blank in the cinema, the problem itself is not the screen but instead the projector or the power source. In other words, to think about pain requires us to go well beyond the place where it is experienced.

Pain is of course lived and whilst it must have a location, the relationship between pain and injury is unreliable. With a huge number of factors influencing the chances of feeling pain in any given circumstance, there is a requirement for a perception of threat that is salient and exceeds other predictions in terms of a hierarchy. Once felt, pain compels action much like thirst and hunger. Again, like thirst and hunger, context and meaning we give to the sensations influence that very experience, which clarifies to a greater extent the difference between on-going (chronic) pain and that of labour.

To feel pain we need a concept of the body, which itself is constructed elsewhere as the sensory information flowing from the body systems is predicted to mean something based upon what is already known and has been experienced, we need a nervous system, an immune system, a sensorimotor system, a sense of self and consciousness to name but a few. Where in the pelvis do these reside?

This is not to ignore where we may feel pain as this is an ‘access’ to the pain experience that should be used in terms of movement and touch. However, it is the person who is in pain and not the body part. My pelvis is not in pain, I am. My pelvis does not go and seek help, I do. My pelvis does not ease its pain, I do. So when ‘treating’ a person, we must go beyond the place where the pain is felt to be successful. And it is vital that the person is considered a whole; there is no separation of mind-body. The notion of physiological, body, psychological division etc. etc., just does not fit with the lived experience; I think, and I do so with my whole person — embodied cognition.

Locally one will usually find evidence of protection and guarding, which themselves manifest as the tightness, spasm, painful responses to touch and movement. This is all manifest of an overall state of protection, co-ordinated largely unconsciously accompanied by a range of behaviours and thinking that quickly become habitual — they are certainly learned from priors, our reference point. This is simply why delving gently into the story is important, as we can identify vulnerabilities to persisting pain such as previous experiences of pain, functional pain syndromes, stressful episodes in life; all those things that put us on alert when the range of cues and triggers gradually expand so now I am vigilant and responding to all sorts of normal situations with fear.

The start point is always developing the person’s working knowledge of their pain, which also validates their story. So many people still report that they feel that they have not been believed, which I find incredible. How can someone work in healthCARE and not believe what a person says? Baffling. Once the working knowledge is being utilised and is generating a new backstory, new reference points emerge. We create opportunities for good experiences over and over, moment to moment, day after day, in line with their desired outcome, the healthy ‘me’ that is envisioned from word go. This strong foundation that opens choices once more then permits exploration of normal and desired activities supported by sensorimotor training and other nourishing movements, alongside techniques in focus, relisience and motivation. Realising and actualising change in a desired direction must be acknowledged as the person lives this change knowing that they can.

Pain can and does change when you understand it, know where you want to go and how to get there, quickly getting back to wise, healthy action when distracted (i.e./ flare ups, mood variance, loss of focus etc). The biology of the pain is one aspect, hidden in the dark within us, and the lived experience is another. The two are drawn together to give meaning and to develop an understanding of the thinking and action that sculpt a new perception of self and pain, resuming the sense of who I am, as only known and lived by that person.

09Jun/16
Pain and injury

Pain and injury

Pain and injuryPain and injury are poorly related. Unfortunately most of society continues to believe in a stimulus-response relationship between these factors, but in reality it does not exist. This was raised by Pat Wall in his classic 1979 article entitled ‘On the relation of injury to pain’.

Since then we have learned an enormous amount about pain; what it is and the purpose it serves. Why should the relationship between pain and injury be so unreliable? The answer is because pain is contextual, motivating appropriate action for that moment depending upon a range of factors. These include the injury itself and what it means, prior experience, beliefs about pain, the environment, who is there, how one is feeling before and at the point of injury and what is going on at the time. Here are some examples:

* a carpenter hitting his thumb with a hammer — despite the fact it will hurt, this is not unexpected, an occupational hazard if you will, and soon dismissed.

* an electrician electrocuting himself — similar to the carpenter; the context is key

* spraining an ankle in a cup final — there are many reports of injuries being sustained whilst playing sport that are not painful at the time, because playing on is more important

* battle hospital reports — severe injuries but no pain initially; the same in many accident and emergency reports

* a concert violinist who cuts his left index finger the day before his most important gig — what do you think this experience could be like versus a chef?

These examples demonstrate the variability in lived experience despite the biology of healing being similar (effectiveness may vary depending upon existing and prior health) — the two lives, that of our biology and that of our lived experience. The clinician’s role is to marry the two for the person so that they understand the hows and whys before focusing on what needs to be done to get better.

When my knee hurts, or any other body area, the vast majority of the biology that is involved resides elsewhere. Pain is located to my knee, although I can’t possibly know from where exactly; where is the stimulus? Yet to feel pain in my knee I need the systems that protect me to detect certain sensory activity, predict that the causes are threatening and then translate this to a sensation that is pain; i.e./ the biology becomes ‘conscious’. Whilst there are signals from the knee to the spinal cord and onwards, this is not necessary for us to feel pain. Think about phantom limb pain.

There are many levels whereby signals and predictions are modulated until the most credible prediction emerges as a lived experience. This is why prior experience, beliefs, emotional state and our thinking play such a role in pain as all can modulate the meaning and level of perception of threat.

An analogy is watching a film at the cinema. The film is on the screen yet for this to happen and be experienced, there must be a projector, electricity into the projector, and this electricity comes from the grid. Most of the necessary elements are not where you watch the film. The same can be said of pain, when it is made up of many non-pain factors that come together to create that lived experience. The point there is that when we address these in a comprehensive treatment and training programme, we can change pain and get better. But to do this we must think beyond the structure (the cinema screen) and consider the person, their beliefs, their thinking, their lived experience, the phenomena of their life, in order to be successful, which we can.

Pain is not related well to injury, but instead to the level of predicted threat.

Pain Coach Programme for persistent pain | t. 07518 445493

 

08Jun/16
Space

Space

SpaceThere are things that we know are good for us: sleep, water and space. Of course then we need quality sleep, water and space. I’m interested in space, and not the kind that is out there, but rather the space we choose to place ourselves day to day and how this impacts upon us consciously and subconsciously. In particular I am keen to understand how we associate with certain environments and in fact how our brains predict the meaning of a given environment and the experiences that emerge.

Here are a couple of classic examples that I hear about:

1. RSI — repetitive strain injury: I am using this term for ease, although I have issue with it, but that’s for another time. I refer to pain and other symptoms that people attribute to repeated use such as typing, clicking a mouse and texting. In the vast majority of people I see with this burdensome condition, we can evoke their symptoms by just thinking about certain environments! Their desk at work for example. When we close our eyes and think about a place, we are in essence there and it feels like it. When a place or space becomes associated with a threat value because of a link that has been established, then it makes sense to feel a warning when we think about it. However, when this persists, this becomes an increasing problem due to the behavioural aspects — altered movement, restricted use and guarding, all of which perpetuate the threat value and hence the on-going pain. Thankfully, this cycle can be broken with the right understanding and training.

* This is not unique to RSI, but any pain problem is contextual and becomes associated with certain places, positions, movements, activities etc etc. A significant part of overcoming persistent pain is by creating new habits.

2. A place in nature: a pleasant image comes to mind, unified with feelings of comfort in the body to make it an overall calming and soothing experience. This is why visualisation is so effective as we can choose to shift into our resource state whenever we need: when anxious, stressed or in pain for example. This is a technique that I blend with others to create the necessary calm we need to refresh and renew, particularly if we are suffering pain or tiredness.

Placing ourselves in an environment has enormous effects upon us as we become part of that very environment. In fact, what you experience as that environment you are creating using at least your brain, your mind and your body, and importantly how they unify. Using a film analogy, you are the film maker, the script writer, the star and the audience all rolled into one. Wow! How do we explain that? Using the very same unified processes to explain themselves! So, in becoming part of threat environment, the importance of choosing the right space is vital. Each day we should absorb ourselves in a nourishing place such as a park, by a river, in a forest or at least in a space where there is plenty of exactly that, space! And if you can’t do this on a particular day, then you can use imagery and visualisation and feel the resulting great feelings.

On a moment to moment basis, where we spend a lot of time, perhaps home and office, these spaces need to be nourishing and promote the feelings we want to feel — e.g./ at work to concentrate, focus, think, write, communicate; at home to feel comfortable, warm, safe etc. This may take some thought and some re-organising but it will be worth it — see here, a professional organiser: Cory Cook. Remember that the environment you choose to put yourself in impacts upon you enormously: the way you feel, the way you think, the way you interact. Something similar could be said for the people you spend time with.

So, when you are at work, at home, choosing a new job or accommodation, think carefully about the environment in which you will be living moment to moment experiences, because they will be shaped somewhat by that very environment. Get out into a big open space and move around in it, see it, smell it, feel it, using all your senses. And if you can’t, then take a deep breath, slowly let it go, do it again, close your eyes and take yourself to a space where you will feel great.

Pain Coach Programme for persistent pain | t. 07518 445493

07Jun/16
Pain, loneliness, poverty and health

Depression and inflammation

Depression and inflammationFor some years there has been thinking about depression and inflammation being related in as much as when we are in the throes of inflammation, our mood changes. Think about when you feel unwell and how your mood drops, which is part of the well known sickness response. In some people, probably a large number, these sickness responses are the norm. In other words, they endure a level of this sickness response consistently that is underpinned to an extent by on-going inflammation.

Reports today about a study at Kings College London describe how inflammatory markers in the blood could identify a ‘type’ that would benefit from a certain antidepressant drug — read here. This would make the prescription specific for the person, so rather than trialing a drug, we would know which would be most likely to be effective for that person by identifying the blood markers.

Many people I see with persistent pain are low in mood and some have been diagnosed as being depressed. In my mind, it is entirely understandable why someone suffering on-going pain, who cannot see a way out, would be in such a state. In simple terms, the person with chronic pain may well be chronically inflamed. We know that people who perceive themselves to be under chronic stress will be inflamed as the body continues to protect itself via the immune system and other systems that have such a role. Typically and understandably, someone in a chronic pain state is stressed by their very circumstance and hence can be inflamed.

It is very common to suffer an enduring pain state and generally feel unwell; a sickness response. We all know what a sickness response feels like — we don’t feel ourselves, aches and pains, loss of appetite, irritability, emotional, sleepy, tiredness, poor concentration etc. This is underpinned by inflammation and how this drives a range of experiences and behaviours, all designed to create the conditions for recovery. In the short term this is adaptive but if prolonged, the symptoms are enormously impacting and potentially maintaining a cycle of stress and anxiety.

Like any problem, understanding its nature is the start point so that problem solving can be effective; i.e. think about it in the right way and take the right action, congruent with recovery and the desired outcome. Realising the links between health state, depression and inflammation helps to distance oneself from the lived experience, being less embroiled with that particular ‘film’, instead focusing on what needs to be done to overcome the problem.

A loss of the senses of self is often a part of a persisting condition such as chronic pain or dystonia. The overarching aim of a followed programme is for the individual to resume living their life with a sense of self worth which they can identify: I feel myself again. This self feels normal to that person, and only that person knows how that experience is lived. As best they can, I ask them to describe that experience, and this forms the desired outcome. The sense of self is at least a unification of body sense, interoception, exteroception, the inner dialogue and our past experiences. Improving body sense with exercises, some general and some specific, is a simple way of stepping towards that outcome. And of course there are all the other benefits of exercise to consider.

It will undoubtedly be very useful to identify who will benefit from which antidepressant drug, yet we must still consider each (whole) person. A comprehensive programme of treatment for pain for example, includes developing working knowledge of pain so that the person can independently make effective choices as well as eradicate fears, specific training, general activities, gradual progression of activity, and mindfulness to name but a few. However, it is not just the exercises that are important. The person also needs to be motivated, resilient and focused, all strengths that they have likely used before in other arenas but now need to employ here and now with their health — this is the strengths based coaching aspect of the Pain Coach Programme. In cases of depression, the chosen drug maybe more specific and hence more efficacious, yet there are other actions that are also important such as understanding the links as explained and consistent physical activity. Great work in the aforementioned study; it will be interesting to watch how this progresses.

Pain Coach Programme | t. 07518 445493

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.