Category Archives: Chronic pain treatment

08Mar/17

Find peace

In a sense I think that we are all trying to find peace. We week to find peace within ourselves and the world in which we find ourselves — the two are entwined.

We often hear the word peace nowadays. This is because peace is a state we strive for globally in the face of threats that are often purported in the media. There are fewer who seek the polar opposite; people who appear to welcome violence, war and other destructive states. This can only be because of wrong perceptions of the world resulting in wrong thinking and wrong actions.

In terms of chronic pain, perhaps we can say that we strive for a state of peace. This is an idea that came from a conversation with a learned friend some months ago. It was based upon thinking about the ‘opposite’ of pain, which cannot simply be pain free. When we are pain free, we are not thinking ‘I am pain free’, instead just acting, thinking and perceiving as a blended trio within each moment. To find peace seems to be a good place to start overcoming pain.

What is a state of peace?

By definition, peace means ‘quiet, tranquility, mental calm, serenity; a state of friendliness’ (Oxford Dictionary). Consider how we feel and think when in pain. We are suffering, fighting, surviving, emotionally turbulent, living the storm of physical sensations and the turmoil of the thoughts and feelings about these sensations. The former appears to be a good place to be in comparison. There is however, one issue, and that is the effect of resistance to what is happening right now.

Resistance itself causes great suffering. Not wanting to be here, instead wanting to be there. Not wanting to look like this, instead wanting to look like that, are two common examples. This is being non-acceptant and fighting the present moment. But it does not necessarily seem natural to do anything else other than resist. Why would you not want to feel better? Look better? etc etc.

This is an issue of desire and the grip that it can have upon us that causes suffering. The problem is that if you are strongly focusing upon how you want to be and resisting how you are or what you have, you are missing the opportunity that exists now. This is in the form of acceptance, which is simply acknowledging and being open to what is happening right now without resistance. Accepting what is happening right now relieves the suffering and allows us to take the right actions to find peace. These actions can only happen now because now is the only real moment. Thinking about what you might do or what you did only exist in your (embodied) thoughts. Concrete action can only be in this moment.

By being present we can find peace. This emerges from simple practices such as mindful breathing and mindful activities that mean you are present, aware, open, insightful and accepting in a compassionate way.

Where is peace?

There is only one place that we can find peace. That is within ourselves. I recall a pertinent moment a few years ago when a friend said to me ‘I hope you find peace’. It is something we appear to look for, yet we don’t need to look because it is right here. We simply need to create the conditions for peace to emerge and be felt. Does this mean no pain? No, not necessarily. Can you feel pain and be at peace? Yes, absolutely. And in this state, the pain transforms and our suffering eases. So, when we find peace that was already there, just overladen with our day to day fears and worries, the pain rents less and less space. Then we can concentrate our efforts on living well, which is the way to overcome pain.

How can I be present and find peace?

Everything that ‘happens’ does so now, in this moment. It is called being present and we can be fully aware, attending to this moment to gain all the rewards. To be present we can start with a few simple practices:

1. Take our attention to our breathing, even just 4-5 breaths, and do this regularly through the day ~ set a reminder

2. Fully attend to what we are doing, whatever that may be. ‘An unhappy mind is a wandering mind’ was a recent study title. We are happier when we are attending to what we are doing in this moment.

You may also choose to regularly practice mindfulness and other meditations such as metta, or loving kindness meditation. The formal practice each day develops our ability to accept, let go, be open, be tolerant, gain insight into our own and others’ thinking. In so doing, in the wake of the practice comes a sense of peace and calm that deepens in time. There are well described healthy benefits of regular mindfulness practices yet it is important that we practice for the sake of practice and not to ‘become’ something else. This is a challenge but you will recall that trying to be someone else or be somewhere else creates resistance. By far the best way to begin practice is with a teacher but there are some excellent apps and videos aplenty on you tube; for example Thich Nhat Hanh, The Dalai Lama, Matthieu Ricard, Ajahn Brahm, Jon Kabat Zinn.

Pain and peace

Pain is as complex as any other lived experience. It involves the whole person, their biology, their consciousness, their past experiences and their genetics to name but a few factors — it is complex! Equally as complex is pain relief that involves all the same factors. Where we feel pain is not where pain is ‘generated’, instead this is where there exists a perceived threat.

Regular readers of modern pain science literature will know that pain is related to being threatened or potentially threatened, acting in the name of survival. The location of the pain is really a projection of all the biology involved with protecting us, emerging in a specific place where we are compelled to attend. If there is actually an injury there it seems to make sense. Often in cases of chronic pain there is no obvious injury or pathology. This is because pain and injury are poorly related. Despite this, the pain felt is the pain felt. Pain cannot be seen so we must listen to the person as it is the individual who feels the pain.

“Pain and injury are poorly related

Existing under a state of threat results in a range of thoughts and behaviours that can be combatant in nature. Consider what we have said about peace. To find peace we must be acceptant, open and demonstrate compassion towards ourselves and others. If we ‘fight’ the pain, we are only fighting ourselves. Creating a sense of peace allows us to choose to focus on the actions (e.g./ exercises, re-framing our thinking to reduce fear, socialising, practicing mindfulness, gradually becoming more active, and many more) that create the conditions for living well.

Overcoming pain is an active task. The person needs guidance, motivation and support but the to begin with the basics to sustainably move in the desired direction. This includes a working knowledge about (your) pain with skills and practices to use day to day, moment to moment. The new knowledge about pain creates a sense of safety rather than threat, peace if you like. This clarity that emerges from understanding pain means that the person can truly focus on what they need to do to get better. This starts with thinking like the healthy person who is living well: ‘what would they think and do here?’ you can ask yourself, before doing exactly that, albeit with certain limitations at the start. These limitations can and will be worked upon: ‘can I?’ turns to ‘I can’ and ‘will I?’ turns to ‘I will.

From a place of peace and clarity come right perceptions about oneself and the world. To find peace is to find it in oneself. It is there and may need uncovering. When you do, the world looks to be a different place. One that is far less threatening and one in which to thrive and to live a meaningful life.

The Pain Coach Programme to address suffering by learning to live well | t. 07518 445493
07Jun/16

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

16Apr/15

George Clooney’s back pain

George Clooney’s back pain — Back pain can affect anyone, and does affect most at some point in a lifetime. In fact, it is probably more unusual not to suffer back pain!

George Clooney has been suffering persisting back pain since 2005 when he sustained an injury whilst filming. Reports described a torn dura that can result in severe pain, and certainly did for Clooney. With so many nerve endings, an injury will trigger excitement locally. Danger signals are transmitted from the area to the spinal cord and then to the brain–note that there are no pain signals, but rather danger signals.

It is the normal inflammatory response (the release of inflammatory chemicals) that causes increasing excitement (sensitivity) in nociceptors, reducing their threshold for firing. This means that it becomes easier to stimulate the nerves to fire the danger signals. The bombardment of danger signals causes (plastic) changes in the spinal cord that in effect operates as a volume switch.

So if all these responses are normal, how does pain persist and become chronic? This is the BIG question. The answers are complex as is a pain response, but I would argue that within this complexity lie opportunities to change pain and overcome the problems.

Pain is not a structure, it is a response to a perceived threat — very different! Pain is a response that is influenced by context, environment, beliefs, prior experiences, the state of protective systems at the time of injury, gender, intentions to move, fatigue, emotional state and more. Pain is not a disc or a joint or a dura. Pain does not come from a disc, a joint or a dura. Yes, that is where you may feel it, in that part of your body, but those structures do not have the properties of pain. Your nose does not have the properties of a common cold, yet it will stream. There is an upstream biology that involves many body systems that are designed to protect. This biology is a complex blend of all the influences I have mentioned, interpreting a situation as being threatening and hence protecting: pain, altered movement, altered thinking, altered emotions–if you suffer on-going pain, how rational are you when in pain? Can you think clearly? We lose precision.

We lose precision of movement, sense of the body, where a stimulus is being presented to the body, where we feel pain (does yours move or grow?), as well as precision of thought and emotion. Our discrete ability to plan and execute thoughts and actions is marred, ‘smudged’, blurry.

So, to the way we can overcome pain and in particular chronic pain. It has to start with thinking differently, and changing our relationship with pain. On doing so, the way that pain is experienced changes. This, alongside strategies and training the develop precision of thought, movement and sense all reduce the perceived threat. Reduce the perception of threat, reduce the pain — you are answering the demands of your body. The caveat of course is that we are not separate in body and mind. There is no separateness to pain as it is part of you, part of every cell. To overcome pain then, you must become aware of what you are currently thinking and doing (habits) and then consciously change until it becomes unconscious and normal.

Pain Coach ProgrammeThis is an insight into the Pain Coach Programme that addresses the whole person as we must to overcome chronic pain. We are constantly changing and those who suffer chronic pain have been changing towards more and more protection in response to normal activities–how many normal activities now hurt? They shouldn’t!

It is time to take the science of pain and translate it into action to change your pain. Call us to start your programme for chronic back pain or chronic pain. 07518 445493

14Mar/15

Overcoming pain – key skills (1)

Pain CoachOvercoming pain requires us to understand it and have a range of skills that we use moment to moment to change the direction in which we are going. To be able to change gears once we are aware what is happening is vital. Cultivating awareness is the first step, followed by adopting a new behaviour and subsequent change for the better. ABC.

3 steps: 

  • A- Awareness
  • B – Behaviours
  • C – Change

I like ‘threes’, and the ABC above is one that I use to guide individuals from where they are when they arrive to where they want to be. Each encounter (session) that we have will be unique and designed with specific aims using ABC.

We are continuously adapting to our situation, internally and externally. Much of this happens without us really knowing about it in the form of habits. When we have suffered pain for some time, there are a number of protective habits that have been created and whilst these maybe useful with a new injury, they prohibit recovery in time. Identifying these habits and then working hard to create new healthy ones is a key skill.

The world is constantly changing, we are constantly changing and the people around us are constantly changing. We are not in isolation to others and the environment in which we are situated at any given moment, which is why both are so influential. Whilst we are subject to these influences, we can also use them to our advantage and in particular to change the social dimension of pain. One of the most significant features of the social dimension is isolation.

One becomes isolated through withdrawal and avoidance. Isolation is simply not good for health — the way you think and the behaviours that follow. And it worsens with time, so certainly a dimension of the pain problem that must be addressed. Gradual resumption of social activities, similar to gradual increase in physical activities, allows the individual to realise that they are safe to progress. We do not function in isolation to others and the world around us. I think that we define ourselves in relation to others and the environment, for who are we without another?

The moment to moment decision making has to be based upon clear thought. Clear thought emerges from awareness of self, others and the environment — the ‘econiche’ (Edelman) or the concept of emotional intelligence being utterly relevant. ABC it is. Learn these skills and see how you can move forward. The range of training methods and techniques used all base their effectiveness on the ABC.

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The Pain Coach programme is available at all clinics, addressing all dimensions of pain (physical, emotional and thinking) for the complete way forward to overcome chronic pain. Call us for details: 07518 445493 — Pain Coach website coming soon

 

26Jan/15

About Specialist Pain Physio

Richmond M. Stace Specialist Physiotherapist & Pain Coach

Richmond M. Stace
Specialist Physiotherapist & Pain Coach

In 2006 I started the Specialist Pain Physio Clinic concept in London and Surrey to deliver innovative, neuroscience-based physiotherapy to tackle chronic pain and injury.

The treatment, training and pain coaching programmes are based upon the latest sciences and understanding of pain. The biopsychosocial approach that I use is the contemporary way of addressing persisting pain and suffering — considering the biology, psychology and social impact.

About Richmond

I am a Chartered Physiotherapist and registered with the Health Professions Council. Originally training as a Registered General Nurse, I developed an interest in pain whilst observing the varying responses in recovery after operations. I continued to train as a physiotherapist, I have a further degree in Sport Rehabilitation and a Masters Degree in Pain Science. My passion is in providing the best journey for you by using the latest therapies for chronic and complex pain. Seeing and hearing about your relief from symptoms, your development of healthy habits and sustained change is my aim for you.

Outside of the clinic, I write and talk about how we can globally change pain by understanding it, communicating about pain accurately, creating a definite plan and how to implement the plan in the most effective way.

I am part of the editorial team for the Physiotherapy Pain Association (PPA), a member of the International Association for the Study of Pain (IASP), The Royal Society of Medicine and the Acupuncture Association of Chartered Physiotherapists.

18Nov/14

Caring for our carers

My simple message with this blog is that we need to care for the carers. Undoubtedly the individual with pain or ill-health is suffering, but so are the carers who may be partners, family members and friends. They may also be professional carers who are not immune to the stress of looking after someone.

In brief, here are some of the reasons why carers will suffer:

  • Seeing a loved one in pain
  • Feeling helpless
  • Mirroring pain — it is not uncommon for someone to feel pain in their body having observed another person in pain. Biologically this may be quite useful as a learning tool, similar to learning that touching the oven causes a burn injury; ‘I won’t do that again’.
  • Becoming absorbed in negative thought patterns
  • The physical demands, including the number of hours dedicated to caring and what it involves; e.g./ helping to move the patient, household chores — this often in addition to their own needs
  • Disturbed nights
  • A lack of respite
  • Feeling a lack of support
  • Financial worries
  • Own relationship issues

There are many other reasons, however the key point is that the demands upon carers are immense. One of the biological consequences is inflammatory activity in the body due to chronic stress. This inflammation underpins and affects the widespread aches and pains, the compromised health (feeling under the weather), limited resilience and motivation, varied and unpredictable emotional responses and difficulty thinking with clarity — see the interesting study below.

Carers are vital for both the person in pain but also for society at large. There are not enough resources to provide for all those with chronic pain and health issues on a day to day basis and hence we need to care for our carers.

For this reason, I offer treatment, training and mentoring sessions for carers. Ranging from the treatment of aches and pains to creating ways of constructively adding to the therapy for their charge, we also work upon resilience, problem solving and motivational techniques. These strategies are for that person to cultivate their own wellbeing, but also that of the person they are caring for at home. Partners commonly ask how they can be involved in helping the patient move forward, and I gladly reach them about pain, health and what they can do to contribute in a potent way.

If you are a carer, or would like your carer to be more involved, contact me to book the initial session: 07518 445493

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Greater inflammatory activity and blunted glucocorticoid signaling in monocytes of chronically stressed caregivers. Miller et al (2014).

Abstract
Chronic stress is associated with morbidity and mortality from numerous conditions, many of whose pathogenesis involves persistent inflammation. Here, we examine how chronic stress influences signaling pathways that regulate inflammation in monocytes. The sample consisted of 33 adults caring for a family member with glioblastoma and 47 controls whose lives were free of major stressors. The subjects were assessed four times over eight months. Relative to controls, caregivers’ monocytes showed increased expression of genes bearing response elements for nuclear-factor kappa B, a key pro-inflammatory transcription factor. Simultaneously, caregivers showed reduced expression of genes with response elements for the glucocorticoid receptor, a transcription factor that conveys cortisol’s anti-inflammatory signals to monocytes. Transcript origin analyses revealed that CD14+/CD16- cells, a population of immature monocytes, were the predominate source of inflammatory gene expression among caregivers. We considered hormonal, molecular, and functional explanations for caregivers’ decreased glucocorticoid-mediated transcription. Across twelve days, the groups displayed similar diurnal cortisol profiles, suggesting that differential adrenocortical activity was not involved. Moreover, the groups’ monocytes expressed similar amounts of glucocorticoid receptor protein, suggesting that differential receptor availability was not involved. In ex vivo studies, subjects’ monocytes were stimulated with lipopolysaccharide, and caregivers showed greater production of the inflammatory cytokine interleukin-6 relative to controls. However, no group differences in functional glucocorticoid sensitivity were apparent; hydrocortisone was equally effective at inhibiting cytokine production in caregivers and controls. These findings may help shed light on the mechanisms through which caregiving increases vulnerability to inflammation-related diseases

29Aug/14

There is no pain system

Many writers in health journals and magazines continue to refer to pain systems, pain pathways, pain signals, pain messages and pain receptors. There is no pain system, there are no pain pathways, there are no pain messages and there are no pain receptors.

Pain emerges from the body (or a space that has a representation in the brain in the case of phantom limb pain) and involves many body systems and the self. Where does pain come from? Well, it comes from the person describing the pain. Does it come from the back or the knee or the head? That is where you could feel it, but in order to feel it in a location we need our body systems to be in a protective mode and to be responding to a potential threat.

Pain is allocated a space where the body requires attention, and whilst this is a vital survival device when we have an injury, it is less useful when the injury has healed or there is no injury. This is the case in chronic pain, although there are reasons why the body continues to protect based on the fact that the perception of threat exists.

Pain is part of a protective response. Many other systems are also working to protect us: the immune system, the endocrine system, the autonomic nervous system, the sensorimotor system etc. — and all the systems that these impact upon, such as the gastroenterological system (how many people suffer problems with their gut at the same time as having persisting pain?).

So, in chronic pain we need different thinking because tissue or structurally based therapies do not provide a sustained answer. Instead we need to address the fact that persisting pain is as a result of the body’s on-going perception of threat. It is this that requires re-training alongside any altered movement patterns and a shift in body sense in order to successfully deal with pain and move on.

Specialist Pain Physio Clinics – transforming a life of pain to a life of possibility 

Call us to start now: 07932 689081 or email [email protected]

 

 

30Jul/14

When is a door not a door? When it’s a jar – a perspective on back pain

This old joke springs to mind when I think about back pain. We can think simply about a door and create an image of how it appears but in fact a door consists of at least some of the following: a piece of wood (or another material), a handle, some hinges, a lock and a frame. All of the physical components need to be made from raw materials and require the skills of an individual or a machine to make door. These skills must be learned or a machine need be designed for the specifics of making a part. In this sense, a door is not a door until all these come together. In fact, this can only make a door when the person looking at the door or using the door knows that it is a door and has the function of a door. Otherwise it is just a collection of abstract items. We can say the same for many things that we take for granted when we know what they are and their purpose.

Back pain is such a common problem that it seems as though we should experience this pain at some point in our lives. Certainly the way we live nowadays has a huge impact on the likelihood of suffering back pain. There are many simple habits that we can form to deal with the problem but all too often, we just don’t. Why? Because it is not at the top of our priority list. That said, when is back pain not back pain? When it’s understood. So this must be the start point. Understanding pain and back pain can make an enormous difference to the suffering that spans from mild discomfort to disabling agony.

Back pain is pain in the back — this may sound obvious and it is, yet there is much more to it, somewhat analogous to the door. What is the back? It is made of many components that together form the back. To know it is the back, we must have a construct of the back. We must know what is the back and what is ‘my’ back; the ‘mine-ness’. Similarly with pain, we must have a construct of pain that is learned. These are both the ‘what’, yet we need a ‘how’ to experience them. In the case of back pain, the way in which we are experiencing the back is with pain. Pain is how we feel the back at that moment.

Just as the back is constructed by physical ‘parts’ with a conscious aspect that is non-physical (the two create the whole), the ‘parts’ involve all the systems of the body as much as the self. Back pain is the end result of an enormous amount of multi-system activity, emerging in a body location that is felt. This is the ‘is-ness’ of the experience produced by the whole person that is the sum of every cell in the body. Pain as an emergent property of the whole person is a biological response to a perceived threat. This includes when the body is injured, pathologised and in anticipation that something could be dangerous. Consider a moment when you anticipate that it will hurt. What do you think? What do you do?

Practically, what does this all mean? It means that we cannot use a structural or component basis for treating back pain. The relationship between the body tissue state and the pain state is poor, perhaps even non-existent. Pain is emergent from a whole person who is embedded within a social setting, a culture and a context that all create a meaning for that individual who has a mind that needs a brain, yet the mind is unlikely to reside simply in that brain. The mind resides in that whole person much as the pain that emerges. Hence we must think about the whole if we are to be successful in treating pain.

If you are suffering with chronic pain, come and see us and discover what you can do to understand and change your pain

t. 07932 689081

Specialist Pain Physio Clinics, London

24Jul/14

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

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

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

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

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

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

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

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

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

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

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

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

Specialist Pain Physio Clinics, London

25Jun/14

Where have ‘I’ gone?

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

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

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

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

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

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