Category Archives: Pain Psychology

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

04Mar/14

Pain – the unseen force

“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.

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

 

 

11Feb/14

20 years in healthcare — what have I learned?

Reflecting back on over 20 years of time spent in healthcare there are a few things that stand out as being important. Much of what is learned has been pruned and will continue to be sculpted as knowledge emerges from the research.

Here are my top three:

1. Harnessed from the great writing of Oliver Sacks: it is as much about the person as it is the condition.

2. The effects of any intervention are affected by the patient’s perception and expectation, moulded by prior experiences and their belief system.

3. Communication sits at the heart of successful therapy, both verbal (this includes body language) and written.

RS

The Specialist Pain Physio Clinics in London deliver the very latest in treatment and training for chronic pain, persisting and recurring injuries 

Call us for information or to book an appointment: 07932 689081

01Jan/14

Mindfulness programme

Mindfulness 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 

A 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

23Dec/13

Thoughts can be threatening

A threat can arise in many forms. Years ago, it would have been a wild animal that posed a potential danger, responded to with a fight or by running away — flight. Nowadays we don’t often face the physical threat of an animal attack, more likely it being the menace of street crime or the risk of an injury whilst undertaking activity. The context of each of these scenarios is very different with distinct and personal meanings that result in varying responses.

The key point about a threat is that is must be interpreted as being dangerous in order to arouse activity in the autonomic nervous system. This system is the link between what we think, the meaning we ascribe to a circumstance and how the body responds. With connections that reach far into the body systems, in particular the cardiovascular system and the gut, the autonomic system is a major player in creating awareness that something is potentially unsafe and hence drives behaviours to approach or avoid.

Most of the time we do not face a physical threat. However, familiar feelings in the body signify anxiety most likely on a daily basis: tension, butterflies in the stomach (actually changing blood flow that triggers neural activity), increased heart and breathing rates and perhaps a sense of panic. Why? Because of our thoughts.

Thoughts can be threatening. A thought that is lived, given significance, engaged with or is considered to be self-defining, will evoke emotional and physical responses. If the thought is one that plays a tape of an unpleasant past experience, fashions an image or a story that is troubling or builds a future of uncertainty, the autonomic system will be aroused. This happening over and over ensures that the system becomes more easily switched on and vigilant to a range of cues, even normal situations that can become threatening in some cases.

Feeling anxious is normal. It warns us that we need to place our attention upon the trigger and take the necessary action. Once this has been done, there is no need to continue to feel anxious, but often the association continues. Automatically there is a response to a thought, or waves of thoughts, and without control over this, the spiral continues. How can we gain control?

Mindfulness is a very potent way of tackling stress. The bodily feelings of stress are triggered by our perception of a situation being negative, risky, dangerous and somehow threatening to our beliefs about ourselves and our world. At the point where a thought or a situation prompts an automatic thought that is negative, these emerging from our belief system that has been evolving from a very young age, this propels us into greater suffering, pain, and sensitivity with increasing impact. Mindfulness practice refines the awareness of this process, maintaining a presence that prevents the dwelling upon the past or a leap into the future. Neither of these actually exist as they are constructs of our mind. The problem is the brain’s response to past or future thinking is very similar to actually being there — a lack of discrimination means that the same autonomic actions are triggered.

In the short-term, the autonomic responses are adaptive and useful. If they persist, the chemicals released over and over become problematic as certain systems are shut down due to the perception of danger. For example, the gut and reproductive system are not needed when we are escaping the clutches of a wild animal. But, similarly, chronic stress from an on-going negative assessment of a situation, thinking, will have the same effect. This is often a feature of infertility when the reproductive system is being impacted upon time and again.

The biological reality then, is that no matter what the situation, it is the individual interpretation that is key in determining what happens next. In developing mindfulness practice and emotional intelligence at the fulcrum point that is the automatic thought popping into consciousness, suffering, pain and on-going stress responses can be subdued and dissolved as presence and awareness rules over.

For further details about our treatment and training programmes for persisting pain and stress, call now 07932 689081

10Dec/13

Uncomfortably numb

Feeling numb can mean that the self has lost its physical presence, or in an emotional sense, feelings have become blunted. These are both different constructs of loss for which we are compelled to seek an answer, often causing great angst. To step out of the normal sense of self is profound, difficult to define and causes suffering, whereby one has lost his or her role.

Physical numbness, if we can say this, will usually be described in terms of a body region feeling different. Altered body sense is a common finding in persisting pain states and in post-traumatic stress disorder (PTSD). In extreme situations, an out of body experience can be described where the person views themselves from an outsider’s perspective, in the third person. Often though, one refers to numbness as an area with reduced or no sensation. This can be objective such as when a stimulus (eg/ a pin prick; a light brush) is applied to the body surface and the sensation is lacking; or subjective when an area is felt to be numb yet a stimulus can be felt normally.

Although numbness in the the body is not painful per se, it is often tarnished with an aversive element that is described as unpleasant. This seems to be a particular issue in the extremities; conditions that involve nerves such as Morton’s neuroma. The mismatch between what is physically present and can be seen yet not felt, is difficult to understand and compute until the construct is explained.

An explanation: the body is felt via its physical presence in space, interacting with the immediate environment, yet is ‘constructed’ by networks of neurons in the brain. These neurons or brain regions are integrated, working like superhighways in many cases, thereby enhancing certain experiences or responses. At any given moment, the feelings that we feel and the physical sensations that we experience are a set of responses that the brain judges to be meaningful and biologically useful. The precision with which we sense our physical self and move is determined by accurate brain (cortical) representations or maps of the body. These maps are genetically determined yet moulded with experience, for example the way the hand representation changes in a violinist. Similarly, when pain persists we know that the maps change and thereby contribute to the altered body sense that is frequently described. It is worth noting that patients can be reluctant to charge their altered body experiences for fear of disbelief when in fact they are a vital part of the picture.

Emotional numbness is consistent with physical numbness in the sense of a stunted experience, whereby the expected or normal feeling in response to a situation fails to emerge. Rather, something else happens thereby creating a mismatch between the expected feeling and that which occurs. This experience manifests as a negative and is not discriminatory, affecting a range of emotional responses. A sense of detachment from the world often accompanies the lack of feeling. One could argue that this is a form of protection against feelings of vulnerability where we can also use our physical body, our armour, to shield us from the threat. Of course the threat is down to our own perception of a situation, another example of a brain construct. A situation is a situation but we provide the meaning based upon our own belief system and respond accordingly, often automatically.

Cultivating a normal sense of self is, in my view, the primary aim of rehabilitation and this encompasses both the physical and emotional dimensions. Both are influenced by thoughts, the cognitive dimension, that emerge from our belief system that drives behaviours. Hence, a programme design must reflect the interaction as it presents in the individual, most of the clues residing in the patient’s narrative that we must attend to in great detail. Validating the story and creating meaning is the first step towards a normal sense of self, to be enhanced with specific sensorimotor training and cognitive techniques such as mindfulness based stress reduction and mindfulness per se.

Wider thinking and practice is desperately required in tackling the problem of persisting pain. One of many responses to threat, pain is part of the way in which we protect ourselves along with changes in movement and other drivers to create the conditions for recovery. Sadly, many people ignore or miss these cues in the early stages through being fed inaccurate information about pain and injury. Many common ailments that can become highly impacting and distressing such as irritable bowel syndrome, headaches, pelvic pain, widespread musculoskeletal pain, anxiety, fertility issues and low mood, gradually creep up on us as the sensitivity builds over a period of time; the slow-burners. An answer to these problems that are typically underpinned by central sensitisation and altered immune-endocrine functioning, is to create awareness and habits that do not continually provoke ‘fright or flight’ responses that essentially shut down many systems in readiness for the wild animal that is not present. Actually, the wild animal is the emotional brain that when untamed can and does create havoc through the body, affecting every system.

The ever-evolving science and consequent understanding now puts us in a great position to trigger change. Initially discussing numbness, I have purposely drifted toward a more comprehensive view looking down on the complexity of the problems that we are creating in modern existence, manifesting as common functional pains. As much as we are knowing more and more about these conditions, we are actually describing the workings of the different body systems in response to a perceived threat that may or may not exist. This is always multi-system: nervous, immune, endocrine etc. and all must be considered when we are thinking about a pain response. But let’s not just think about pain as this is one aspect of the problem, one part of the emergent experience for the individual — think movement, think language, think body language, think ‘how can we reduce the threat’ for this individual so as to change their experience of their body responses. It is at this point that we see a shift and it is possible in all of us. We are designed to change and grow and develop, so let’s create the conditions for that change physically, cognitively and emotionally.

19Oct/13

Pain beliefs need tackling first

BeliefsWe have many beliefs that construct our perception of the world. Beliefs about pain are no exception as we try to make sense of an injury or the emergence of the painful experience within the context of a situation. The significance of our own pain beliefs cannot be underestimated when it comes to treatment and training. They need to be elucidated and often sculpted to enable change and hence pain relief, in particular when the pain has been in existence for some time.

Commonly, patients who have been suffering persisting pain become increasingly vigilant to body sensations. This is called ‘hypervigilance’ and often comes hand in hand with ‘catastrophising’, another long word that means the belief system has kicked in and considered the body signal to mean something dangerous.

To change a persisting pain state we need re-training of the systems that process the information from the body and those that create our conscious experiences; what we feel, what we see, what we hear etc. There are a number of body-focused strategies that we can use to target the process from simple rubbing of the painful area to more specific sensorimotor training techniques. We often refer to this as ‘bottom-up’. We can enhance the effects of the bottom-up therapies by preparing the brain so that it is receptive to the body work. We call this ‘top-down’, which is like ploughing a field so that it is ready for the seeding.

Preparing the brain is a way of desensitising the processing systems by diminishing the threat. Pain is a response, an output from the body resulting from the conclusion that there is something posing a threat to the integrity of the self. Initially this means that the patient must understand their pain and symptoms, including why they persist and what we can do about it. It is clear how this would start to reduce the threat value and hence pain in many cases—people frequently report an easing of the symptoms at this point.

Returning to hypervigilance and catastrophising, we tackle these problems with education and positive experiences. Developing knowledge of the biology of pain and the skills to deal with both body sensations and the thoughts that follow is absolutely key in the early stages, for this is what drives the next behaviour. In the case of fear, usually the next behaviour is avoidance. Avoidance maybe useful in the very acute stages to protect the healing body, but in a persisting pain state, inactivity becomes a problem and a barrier to recovery.

A route forward

A route forward

Many body feelings are normal. When we are sensitised these feelings can be amplified and linger. In part this depends upon how what we think about the sensation and how much attention we put on the area. Where our attention lies has a big impact upon our pain perception, so being able to say to ourselves, “that is ok, it’s just a normal body feeling”, e.g./ pins and needles, allows us to move on without rumination that creates further fright or flight responses.

It has become clear with the continued reconceptualisation of pain that we must rehabilitate both the body systems and our thinking. Our thinking is based upon beliefs that are grooved throughout life—genes plus experiences—and these drive our behaviours, most of which happen automatically, i.e. they are habits. Creating awareness allows an opportunity for change, something that long-term pain sufferers relish as they are desperate to break the cycle and move forward. Blending awareness with knowledge and skills means that the habits of hypervigilance and catastrophising can be broken and new habits formed that create the conditions for wellness, performance and living.

For further information or to book an appointment to learn how you can move forward call us now on 07932 689081

18Oct/13

The virus that is pain beliefs | A brief view on the ‘meme-osity’ of pain

Pain beliefsWe develop beliefs about pain very early in life through experience of injury, by the things we are told by significant others and via observation. These become ingrained and emerge later on when we experience a painful situation. This is part of how we decide what we should do when we are injured. At some point, we have learned that if we knock our elbow on the door frame, we should check it out by having a look, rub the area to make it feel better and move it to ensure that it still works.

Our culture plays a significant role in the development of our beliefs. This includes the meaning of pain and what is signifies and how you should respond; e.g./ ‘the stiff upper lip’. These messages like many others are passed down through the generations. In a sense, the beliefs spread much like a virus, or others such as Richard Dawkins describe the ‘meme’, which is a construct that is passed from person to person, and much like a gene can self-replicate and mutate.

The meme that is, “Don’t bend your back if it is painful” has become a widespread belief that I often hear in the clinic. If you have acute low back pain with accompanying spasm, the chances are it is going to be difficult to move, so bending may not be an option. We do condition very quickly as humans and construct a story from the facts, albeit the story may not be true, but it makes sense at the time. For example, on sending an email, the response does not come back immediately and therefore the receiver is rude, uncaring etc. That is the story whereas the fact is that you have merely sent an email. There is a significant difference, the former creating discomfort whereas the latter is easy to accept.

On bending if we experience acute pain we can quickly assume that bending is dangerous. This maybe confirmed by someone you go to see for some help and very soon this is a strong belief that guides our choices of how to move.

This message has spread across many cultures and could be termed a meme or even a virus. How can we change this? Through education and creating positive experiences for people to then inherently know that they are safe to move in particular ways. All of this takes time and perseverence as the message predominates. However, as we know that memes can mutate as can viruses, we should seek to culitvate accurate understanding of pain with the continuance of resaerch and translation into clincal practice. The idea of the meme then, can be a useful way of thinking about the reconceptualisation of pain for better treatment and care.

 

16Oct/13

Move over Mindset | Guest Blog from Gary Stebbing – Performance & Conditioning Coach

 

Thanks to Gary Stebbing, Performance and Conditioning Coach, for this guest blog.

Exercise is almost uniformly recommended as fundamental to good health, so why do so many people live basically sedentary lives?

Why is behaviour change still such a puzzling conundrum within health and medicine?

As a practical coach one has to adapt and refine these questions to something more relevant….

How can one get better as a behaviour change agent; and more specifically how can one assist in creating a movement habit for clients or patients…..?

But is trying to change behaviour the wrong approach? Should we shift our personal mindset towards a focus on changing beliefs rather than behaviours……?

In their fascinating book Switch, authors Chip and Dan Heath use a very intriguing analogy to explore change:

Imagine a small rider sitting on top of a very large elephant walking through the jungle. The jungle is the environment that we live and function in – a very powerful influence on our lives. The elephant is our beliefs and attitudes – very powerful in driving our daily behaviours and actions. What happens in daily interactions is that we often try and intervene at the level of the rider. You can shout as loud as you like at the rider, what chance do you think the rider has of getting the elephant to change direction if it doesn’t want to?

Perhaps strategies to influence the elephant might have more success…..

Stanford psychologist Dr. Carol Dweck has used another approach to studying mindsets and their impact. Her work explores what she has defined has the ‘fixed’ and ‘growth’ mindsets.

Those with a fixed mindset tend to like to appear smart to others and adopt more of a ‘this is the way it is’ type of attitude. Her work suggests amongst many things that they avoid risk of failure, lack resilience when things get tough and may feel threatened if others achieve success around them.

In contrast those with a growth mindset tend to be happy to try new things, be more robust when things aren’t going well and inspired by success around them.

If you follow this thinking into the path of exercise, what might be the differing outcomes for the fixed vs. growth minded individual.

Exercise is often tough at the beginning, negative feelings due to poor fitness levels, difficulty in grasping how to do new movements, watching others around you who seem to be more competent and finding it easy……it is easy to see how a fixed mindset might see exercise as not for them, while a growth mindset experiences the same things yet relishes the challenge!

Everyone loves working with growth mindset individuals….

So the true coaching challenge is to find the strategies to keep the fixed mindset in the game long enough to help them adapt the way they view and experience exercise and movement.

Perhaps the target is to help all individuals build something you might call the “movement mindset”.

For further information you can contact Gary on 07949 472142 or email: [email protected]

02Oct/13

BBC Horizon ‘The Secret World of Pain’ | #pain

BBC’s Horizon programme in 2011 that looked at the latest research in pain. Understanding has rolled on since this time, but some interesting features nonetheless. It is worth remembering that pain is a conscious experience that emerges from the body although the actual representation is within the brain–a widespread matrix of neurons in the brain. The bottom line is ‘threat’. When the brain determines that our body is in danger, we will feel pain in the area that needs protecting. This is of course very useful biologically in an acute situation (although the intensity of the pain or even the existence of pain is hugely–consider the many tales in A & E and on the battlefield where significant trauma causes no pain) but not so if it persists. The underlying activity and certainly the focus of treatment is very different.