Category Archives: Pain Education

30Jul/14
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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 doorBack pain 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

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

08May/14

Fibromyalgia — creating conditions for change

Pain and symptoms can and do change. They can change moment to moment and day to day, but if you suffer persisting symptoms, all of the variations can blend into a long physical and mental struggle. Striving for change needs understanding, motivation, resilience and a plan of how to reach your goals.

Fibromyalgia is biology in action. An integrated response of the nervous system, immune system, autonomic system and endocrine system, all of the manifestations of fibromyalgia are the outputs, the end result of how those systems operate together. Unpleasant and troubling as the pain and symptoms are, this is the body trying to recover and making the individual aware. Most of the processes happen beneath our conscious level, but those that don’t cause suffering, whereby suffering is a loss of a sense of self.

Together the sensations that we feel, the thoughts that we have and the environment around us are the experience. Edelman calls this the econiche, the interaction and end result of this interaction being the individual’s reality. The reality has to be unique: what I see and what you see in the same scene can be different based upon what we know, what we expect, current mood and attention to name a few variables. The same could be said for pain that will be influenced by similar variables. There is a biology of pain and the biology of the influences upon the pain.

My farming analogy that is based upon my belief that pain can change (neuroplasticity — the ability of the nervous system to adapt and learn; it is always changing….there it goes again, it’s just changed. And again), is a useful way of explaining to patients how we think about these systems and interactions, how we have to create the right conditions for change. Much as a farmer will prepare his field and cultivate the best soil for his crops to grow, the individual must take conscious action for the body systems to work towards wellbeing. This is the ‘why?’, with the ‘how?’ being a comprehensive approach that targets the physical, cognitive and emotional dimensions of pain.

Come and see us to find out how you can create the right conditions for changing your pain and symptoms: call 07932 689081

25Apr/14

When do we seek help for our pain?

When do we seek help?

I am interested in the point at which an individual decides that they need help. The timeline varies enormously from the initial feeling of pain to years of discomfort that finally become intolerable or limiting. Each person will have their own view that is grooved by prior experiences, culture, beliefs about health and pain, access to healthcare, the impact that the problem is having upon lifestyle and tolerance of the pain at any given moment. These factors blend to create the individual’s experience of pain that contains their own personal meaning, or lack of, the sensory and emotional dimensions.

The initial meeting presents the opportunity to explore the story of the problem. It is not just about the pain but how it affects the person, those around him or her and the interactions with their environments. The brain, the body and the environment are co-dependent and influence each other, described by Nobel Prize winner Gerald Edelman as the econiche. Each must be explored within the context of the narrative to gain an insight into the reasons for seeking help.

Over the desk I hear people tell me that they have had enough, previous treatment hasn’t worked, surgery has failed, their spouse is sick of the moaning, they cannot play with the kids, work or play sports. They have reached their coping threshold and now want change.

In most cases, the story extends into the past, sometime before the patient arrives. The problem may have been ignored or attempts have been made to ease the symptoms. The majority whom I see will have had numerous attempts to get better via medical or surgical routes but with limited or no success. This leads to frustration, anger, lowered expectations, all of which can be understood. We must also acknowledge that the body and the brain have really tried to deal with the problem but require increasing conscious involvement to move forward. The lack of progress usually means that the biology of pain has not been fully targeted, along with the vast array of individual influences upon the pain. The need for a comprehensive approach is tantamount to success in changing pain and one’s ability to engage with life once more.

The first meeting is a point in time. This is not in isolation to the complete story, similarly for the physical assessment that is a snapshot of what is going on at that particular moment. With pain and body physiology changing from moment to moment as the systems respond to the internal and external environments. The interactions of brain-body-environment are fundamental to the expression of how we feel and experience the world around us. The brain is constructing all that we experience, hence the significance of this organ when addressing pain.

So when do we seek help? This is individual and based upon our beliefs about ourselves, the world and our health. These are not separate entities but rather consistently interacting modules. Thinking in these terms helps us to devise a route forward and a way of creating the right conditions for the body systems to change in the way they are functioning. We are designed to evolve, change, grow and develop. Comprehensively addressing pain and the influences upon pain provides a tangible, measurable and effective way forward, whenever the patient decides it is the right time to engage.

For further information about our comprehensive treatment and training programmes for chronic pain, please call us now on 07932 689081 and discover how you can change and move on.

22Apr/14
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An ode to the receptionist

I once had a conversation with a member of staff who told me that she was ‘just a receptionist’. Anyone who has considered the patient journey will realise that this statement is untrue. There is no ‘just’. There are important people involved with the patient’s experience from the start, and usually the receptionist is the first person encountered.

The initial patient interaction moulds the journey. The first few words, the tone of voice and the attitude of the person making the booking will flavour the way the patient experiences the service. This is the same in the National Health Service as a private clinic. In this sense, there is no one more important at that moment than the receptionist. They can affect the relationship between patient and caregiver before the parties have even met.

Consider two types of conversation: pleasant, welcoming and efficient versus abrupt, cold and monosyllabic. It is clear which will be more therapeutic. In my view, the therapy begins with the first few words uttered on the phone or over the counter.

Treatment and interventions used in the clinic room are not in isolation to the administration of the patient journey. Priming is a feature of any experience, in other words, both conscious and subconscious stimuli will affect the way our body systems are working via our feelings and emotions. A word or any other sensory input that influences our thinking will drive our physiological responses. Dependent upon these responses and the mode of the body systems, in particular the nervous, immune, endocrine and autonomic, will impact upon the therapy applied.

When a patient enters the clinic room, we must and should wish to ensure that the person feels as comfortable as possible, thinking about our greeting, manners, posturing as much as the temperature and lighting within the treatment area. This may require a few moments if a patient is anxious or irritated, the latter perhaps by a wait or difficulty finding a car parking space. In fact, we often don’t know what thoughts and feelings the patient is bringing with them and we should work hard to shed any judgements that we hold. The mindful approach to therapy is one way of achieving a non-judgemental environment.

At every opportunity we should be thinking about how we can gain the most leverage to create the conditions for change and recovery for the patient. There are a vast number of variables, however if we can conceptualise the patient journey from start to finish and consider all those involved and the significance of their input, we will be going about our business in the best and wisest way. This is especially the case in the therapeutic setting but actually the same for any service provider.

Since that conversation and studying the patient journey it has always been my belief that there is no ‘just a receptionist’ or anyone else who works in the clinic or hospital, but rather a group of people all adding their input in different ways to create an environment that nourishes, encourages and points the patient in the direction of change for wellbeing.

For further information about seminars and training for staff on the patient or client journey, please contact us on 07932 689081

04Mar/14
Protect the body with armour - the muscular system

Pain – the unseen force

Le Horla“Do we see the hundred-thousandth part of what exists? Look, here is the wind, which is the strongest force in nature, which knocks men down, destroys buildings, uproots trees, whips the sea up into mountains of water, destroys cliffs, and throws great ships onto the shoals; here is the wind that kills, whistles, groans, howls–have you ever seen it, and can you see it? Yet it exists.” Guy De Maupassant – the monk talking to the author at Mont Saint-Michel.

Pain, have you ever seen it, and can you see it? The unseen power of pain that is the cause of suffering is one of our greatest enigmas. We are understanding where pain comes from with greater precision but with every painful experience being unique, the pattern of activity in the brain is rightly different on each occasion. The widespread networks of neurons that are active when we are in pain are not specific to hurting, there is no pain centre. It is fascinating that we can see similar brain activity during a pain that results from nociceptive stimulation of the body and from social isolation. Neither pain can be seen from the outside, only the facial expression and verbalisation with the hundreds of words that can describe the feeling.

Is this the reason why people are disbelieved? Because pain cannot be seen. How can anyone truly measure the pain of another? Hurting is subjective. I know and only I know how much it hurts and how it affects me. All too often a patient describes returning to work and feeling a sense that colleagues do not believe or understand their suffering. This can only increase the threat and elucidate further protective responses that feed into the cycle of thoughts–physical responses–emotions–thoughts.

Thoughts cannot be seen but they are real as they play in the mind, each one creating a body response: “I am hungry,”, the stomach rumbles; “I don’t know my lines,” the stomach tightens and tingles; “I have pain, what does it mean?” the body tightens, the pain intensifies. None of these can be seen but they exist as much as the wind that can bend a tree.

Protect the body with armour - the muscular system

Protect the body with armour – the muscular system

Pain is embodied. We feel pain in a location in the body, even if the body part no longer exists such is the case in phantom limb pain. The brain networks ensure that we attend to the body region deemed in need of protection, creating the unpleasant experience that is pain so that action is taken to resolve the issue. In the early stages of an injury we actively protect the area by reducing movement, guarding with increased tension, warning others away with bandages and crutches. If you are travelling in London on the tube, this may even afford you a seat in rush hour. Persisting pain is not related to the extent of tissue damage, if it ever really is–for pain is not an accurate indicator of tissue damage. Chronic pain can feel like a fresh injury and drives the same behaviours: attention towards the painful area, guarding with the musculoskeletal system by tightening up the muscles–our natural armour, and avoidance. These behaviours feed back into the body systems that tell the brain something is up and the brain responds by continuing to protect. The cycle continues until there is a good reason for it to stop because a safe state has been achieved.

The challenge of tackling chronic pain means that we must look beyond the tissues. Exploring the brain, the immune system, the endocrine system, the motor system and how they interact to create our moment to moment experiences, the interface with life and how we respond at any given time. Nothing is permanent. Pain can come and pain can go. Cultivating the conditions for pain to change is the contemporary way of thinking and each person requires a unique approach based on sound scientific principles. So, much like we can harness the wind to create power, we can harness our biology to create a meaningful life.

RS

To book an appointment or for information about our bespoke treatment and training programmes for pain and chronic pain, contact us today: 07932 689081

 

 

08Jan/14
Turn 'no' into 'yes'

Too many cases of “I can’t” — the effects of persisting pain

Turn 'no' into 'yes'

Turn ‘no’ into ‘yes’

Frequently patients tell me at the first meeting that they cannot do x, y and z. Naturally, when something hurts we avoid that activity or action because pain is unpleasant. It hurts physically and mentally. In the acute stages of an injury or condition, it is wise to be protective as this is a key time for the tissues to heal, and although some movement is important for this process, too much can be disruptive. As time goes on, gradually re-engaging with normal and desirable activities restores day to day living. However, in some cases, in the early stages of pain and injury, the protection in terms of the thinking about the pain and subsequent behaviours becomes such that they persist beyond a useful time. The longer that this continues, the harder it becomes to break the habits.

Don’t feed the brain with “I can’t”, feed it with “I can” — cultivate the natural goal seeking and creative mechanisms of the brain

The vast majority of patients who come to the clinic have had their pain for months or years. I would like to have seen them earlier so as to break the habits of thought and action that are preventing forward movement. As a result of the longevity and severity of the pain, the impact factors, distress and suffering, a blend of experiences, expectations and thinking about the problem, it is common to slip gradually into a range of avoidances that are strongly linked with thoughts that “I can’t do …. or …..”. These thoughts may have been fuelled by messages from care providers.

As a general statement, most activities that someone avoids because they fear that it will be damaging or painful can be approached with specific strategies that address both the thinking about the activity and the actual task itself. Recalling that pain is a protective device, an emergent experience within the body in an area that is perceived to be under threat and requiring defence, by diminishing the threat we can change the pain. And there are many ways of doing this on an individual basis — as pain is an individual experience with unique features for that person.

One of the main aims of our contemporary approach is to ensure that the individual understands their pain and problem so that the fear and threat value dissolves away. This leaves a more confident person willing to engage in training that promotes normal activities and re-engagement with desired pass-times.

To learn how you can do this, call us now 07932 689081

07Jan/14
Hypermobility

Hypermobility – Ehlers Danlos Syndrome and gastrointestinal problems

Hypermobility

Hypermobility

Hypermobility is common and is certainly a feature that we often see in patients at the clinics. Some patients have been diagnosed with hypermobility but do not know what it really means and need clarification, some are suffering aches and pains that are limiting and troublesome and still others visit with chronic pain and hypermobility is seen at the assessment.

See hypermobility blogs — blog 1 — blog 2 — blog 3

I always begin with an explanation that includes pointing out that many top athletes are hypermobile and hence there can be advantages. Per se, hypermobility is not necessarily a problem and in fact many who come for advice do not have any significant issues. They may need a programme that includes spatial awareness training, balance and proprioceptive exercises, but in essence, they can continue as normal.

Those patients who suffer pain and on-going pain, often widespread, require a different approach that considers the pain source and the influences upon pain. The training will include proprioception and spatial awareness exercises, but the baseline start point will be different. Before this even, there is often a need to tackle the sensitivity in several ways, termed top-down and bottom-up. Top-down refers to how we can target the brain including education, strategies to deal with thoughts that create anxiety and adaptations to the body maps that change our body sense and experience. Bottom-up is the use of the body tissues to change sensory processing and hence pain and sensitivity. There are many ways of doing this, and altering the combinations of the top-down and bottom-up  strategies creates potent ways of tackling pain.

Frequently, those who suffer persisting musculoskeletal pain will also bare pain through other body systems, especially the gut. See this recent review:

BKW5H0_stomach-ache_342x198Functional digestive symptoms and quality of life in patients with ehlers-danlos syndromes: results of a national cohort study on 134 patients. Zeitoun JD et al.

Abstract

BACKGROUND AND OBJECTIVES:

Ehlers-Danlos syndromes (EDS) are a heterogeneous group of heritable connective tissue disorders. Gastrointestinal manifestations in EDS have been described but their frequency, nature and impact are poorly known. We aimed to assess digestive features in a national cohort of EDS patients.

METHODS:

A questionnaire has been sent to 212 EDS patients through the French patient support group, all of which had been formally diagnosed according to the Villefranche criteria. The questionnaire included questions about digestive functional symptoms, the GIQLI (Gastrointestinal Quality of Life Index), KESS scoring system and the Rome III criteria.

RESULTS:

Overall, 135 patients (64% response rate) completed the questionnaire and 134 were analyzable (123 women; 91%). Mean age and Body Mass Index were respectively 35±14.7 years and 24.3±6.1 kg/m(2). The most common EDS subtype was hypermobility form (n=108; 80.6%). GIQLI and KESS median values were respectively 63.5 (27-117) and 19 [13.5-22]. Eighty four percent of patients had functional bowel disorders (FBD) according to the Rome III criteria. An irritable bowel syndrome according to the same criteria was observed in 64 patients (48%) and 48 patients (36%) reported functional constipation. A gastro-esophageal reflux disease (GERD) was reported in 90 patients (68.7%), significantly associated with a poorer GIQLI (60.5±16.8 versus 75.9±20.3; p<0.0001). GIQLI was also negatively impacted by the presence of an irritable bowel syndrome or functional constipation (p=0.007). There was a significant correlation between FBD and GERD.

CONCLUSIONS:

Natural frequency of gastrointestinal manifestations in EDS seems higher than previously assessed. FBD and GERD are very common in our study population, the largest ever published until now. Their impact is herein shown to be important. A systematic clinical assessment of digestive features should be recommended in EDS

It is routine in our clinic to ask about other body systems as this tells us a great deal about the level and type of sensitivity, which in turn guides the comprehensive treatment and training programme.

Increasingly, patients are being referred for irritable bowel syndrome and other functional pains (e.g./ migraine, headache, chronic back pain, chronic joint pain, pelvic pain, vulvodynia). Due to the underpinning sensitivity residing within the central nervous system — this is not a disease but rather an adaptation; neuroplasticity at play — we can target these mechanisms with a range of effective strategies to re-learn or re-programme the way in which the neuroimmune system is expressing itself. These systems are fundamentally designed to change, learn and grow. They simply need the right conditions to do so, and all too often there is a belief that a situation cannot change and hence all the choices and behaviours prevent any form of forward movement. This is just not true and through our understanding of the body systems and their adaptability, we are creating increasingly effective and diverse ways of tackling pain and suffering.

If you have been diagnosed with hypermobility or are suffering with chronic pain, call us now to discover how you can change your experience and move on: 07932 689081 — Specialist Pain Physio Clinics in London: Hypermobility Clinics

01Jan/14
The patient journey

Humanising the patient journey

The patient journeyModern healthcare features innumerable methods of technical investigation such as the MRI scan, blood tests and nerve conduction tests. All provide detailed information about structures and physiology state yet none tells us about the person, the human being.

Many people will undergo tests and often this is necessary to determine whether there is a serious pathology or changes in body that require specific procedures.

No matter what the test or investigation, it must never be forgotten that it is a human being ‘tested’, not a number in a line, or a condition, but an individual with thoughts, beliefs, expectations and fears. It is by addressing these that we can make the patient journey a human one that has meaning.

The patient journey usually begins when something feels wrong: a pain, a change in the way the body works or is experienced, a sudden incident or a gradual realisation that there is an altered sense of self. This threshold and realisation prompts action. A visit to the doctor or in the alarming situation a rapid transfer to a hospital, may be the first encounter with the healthcare system.

Those first moments of the experience, the thoughts, the feelings, the interactions, the words, the fear evoked by all of these, will impact upon the trajectory of the journey and of course the immediate care for an emergency.

At each of these points, when there is an opportunity to reassure, calm, listen, just be, they should be taken. These simple yet potent interjections that can be administered with ease in amongst the hullabaloo of tests, wires, medical language, white coats, stethoscopes, needles, injections and trolleys. Let them not be lost.

As we stroll into 2014, as the science progresses, it is reassuring to see some authors drawing upon philosophical thought, in particular phenomenology, so we can keep a firm footing in the patient’s experience, for this is where the real story resides. The patient narrative is the key thread that must be given room for expression via firm description, vague terms and bodily expression. The examination that follows; who examines who? The connection, the information flow that requires sound mind, as this is the function of the mind that must interact with the examiner.

So let us in healthcare be mindful of the human being at the centre of the story. The experience that they share with us is unique and an expression of their perception build upon a set of entrenched beliefs about their life, the World and their expectations — and hopes and dreams. We are in a strong position to oil the wheels that need to turn smoothly for a patient journey to lead anywhere meaningful.

01Jan/14
Specialist Pain Physio Clinics in London for pain, complex pain and injury

Mindfulness programme

The light out of the darkMindfulness commonly forms part of a comprehensive treatment and training programme for pain, anxiety and stress. The origins of the practice stem from many years ago but in a modern sense, mindfulness is mind training that is akin to physical training used to improve fitness. A great deal of time is dedicated to physical activity for health, less so on the mental side, however the two are inextricably entwined. For one you simply need the other, and to combine the training is the most potent way of cultivating the conditions for healthy living or recovery from pain and injury.

The modern day use of mindfulness is to create health, foster clarity of thought, increase awareness of thoughts and actions for self-improvement and to reduce stress, anxiety and pain that occurs as a consequence of simple practices. Mindfulness is not steeped in religion, but is a philosophical framework to attain a more fulfilling existence.

See Vietnemese Buddhist monk Thich Nhat Hanh speaking here 

Thich Nhat HanhA programme of mindfulness activities, followed week by week over a period of 8-10 weeks is an excellent way to groove the habit. It is a learning process that increasingly develops awareness in order to make the necessary changes to promote health. Many activities and thought processes are automatic or habitual, but do not point us towards a positive, fulfilling existence. To change this situation requires practice, in essence to re-wire the way we are working via the characteristic neuroplasticity, a feature of the nervous system that underpins learning and adaptation.

Over the 8-10 weeks the practice of a variety of mindfulness activities creates a healthy habit. Several daily sessions of 12-20 minutes focused training is the goal. In addition, forming a routine of performing tasks in a mindful way is a powerful way of regularly enrich awareness; this is simply by paying attention to a normal activity such as cleaning, making a drink or walking. Attend to the sounds, the feel, the aroma and physical sensations thereby standing in the present moment rather than drifting automatically into the past or building a future.

Typically over the period of training, the practice of mindful breathing to cultivate awareness of the effects of thoughts upon the body and vice versa, the body scan to regain a sense of the physical body and how it constantly changes and responds, mindful movements that combines awareness with comfortable motions that nourish the body tissues, working with the pain and suffering and developing compassion towards oneself and others.

For further information or to book, please call us: 07932 689081