Category Archives: Pain treatment

22May/16

The physiotherapist’s hands

Physiotherapist's handsSynonymous with physiotherapy are exercises and hands-on treatments. And rightly so, because these are our basic interventions that we are expert in delivering. However, it is not just the manual therapy and massage that we use our hands for in the clinic. No, no. There is much more as I will describe below as we consider the diverse role of the physiotherapist’s hands.

The hand shake

In many cases, we shake hands with the patient at the start and end of their session. A hand shake is important and must be right — don’t crush the other person’s hand but equally there needs to be some firmness to communicate confidence and sincerity. The hand shake is accompanied by an appropriate greeting, definitely a smile and followed by an invitation to enter the room or sit down. Think about how you would invite someone into your home, wanting them to feel welcome and comfortable. Not everyone receives a hand shake though, so a different gesture is used to imply the same welcome.

The welcome gesture

Hand shake or not, we indicate that the person can enter the room or sit down by gesturing towards the door or chair. A soft, smooth movement obvious enough for the person to understand your message, and soon the person will feel more relaxed, particularly if you use some words of welcome.

Gesticulation

When talking I use a great deal of gesticulation, both with patients and when lecturing. It is thought that we gesticulate to reduce the cognitive load on the brain — one of many ways that we think by using our body (embodied cognition). Moving one’s hands, we do this to make a point, to act, to demonstrate a movement, to point, to emphasise, to distract, to guide, to communicate, to sympathise….and much more. We can learn to use these movements with great skill as part of the art of communication. So much of our work as physiotherapists is about communication, whether this be helping someone understand their pain, move in a different way, create calm or guiding a mindful practice.

Washing our hands

This is a demonstration of cleanliness and the patient seeing this act is important. We can also use it as a natural break, feeling the pleasure of running water and a light massaging effect.

Writing and typing

There is always plenty to type and write. I have an online note taking system, which means that I type whilst the patient talks but I use a paper body chart to scribble notes about the symptoms. My hands are well occupied with these tasks, transmitting the patient’s words onto the screen or the chart without thought as I concentrate on the story that they tell me.

Guiding movement, reassuring touch and pointing

We may support a body area, or lightly apply pressure to guide the patient as he or she re-trains normal movement. Pointing to where the person needs to stand, signalling the direction of movement and gesturing encouragement are all important jobs for our hands.

Clapping, punching the air, slap on the back…

I love to celebrate someone’s success and will choose an appropriate action along with congratulatory words. It is important that the person knows that their efforts have resulted in successfully overcoming their pain problem. Praising the work that they have done, their courage and resilience will make them feel good about what they have achieved.

Wave

Goodbye for now.

Pain Coach 1:1 Mentoring Programme for clinicians and therapists | t. 07518 445493

07Dec/15

Pain Coach for vulvodynia

VulvodyniaPain Coach for vulvodynia and other persisting pains is an approach based on a blend of the latest thinking in pain science and strengths-based coaching. What does this mean?

Modern thinking about pain considers that the lived experience of pain is ‘whole person’, in other words, it is ‘me’ who is in pain and not the body part/area. By addressing the person, in effect steering thoughts, feelings and behaviours towards health, pain is overcome and a meaningful life is resumed, as defined by the individual themselves. Bearing this in mind, we can seek to achieve this with strategies that parallel the lived experience, becoming new habits that nurture change in a way that is healthy. Pain is embedded with the person, their life, their reality and how this is created by their whole self — body systems (including the brain, immune system), their body and the environment.

With pain being part of who we are at that moment, we need to be able to think clearly and logically about that moment, seeing it for what it is, and then respond in the best and wisest way. We are continually updating, with a fundamental design that means we change with every passing moment. The brain predicts what will happen next and the sum of the best guessed meaning to all sensory information is what we perceive in that moment. Each moment is of course in passing, with a new one on the way. Nothing is permanent, and this is also true for pain. Having a baseline understanding creates a new layer of thinking, which creates a new layer of lived experience each moment, and this is how we can overcome pain. You may ask why, if we are always changing, has my pain persisted; and this is a great question.

Why does pain persist? On one level, it is because there is on-going prediction of the need for protection against a perceived threat. The range of cues and triggers widens over time, as does vigilance and habits of thinking that underpin and flavour the lived experience. The sensory and sampling systems adapt and suggest threat, and the prediction goes on and on, until you take decisive action and create new thinking and behaviours to take the continual change in a new direction. To do this, as I said earlier, the new awareness and habits need to match the lived experience, and be employed moment to moment–in any given moment you need to be able to be witness to your thinking, emotional state and bodily sensations, then using this awareness to decide upon the best action (UBER-M is one of my self-coaching strategies that I have previously written about).

Putting this into practice for vulvodynia, we begin with the development of a working knowledge of the individual’s pain and what influences their pain (e.g. stress, anxiety, context, environment, anticipation, expectation, attentional bias, catastrophising, hypervigilance — to name but a few). Using this working knowledge, the person creates a sense of safety that is the foundation of the precise actions taken: specific exercises, training, general exercise, breathing/mindful techniques, re-charging (energy), movements that all form the healthy actions. This is becoming your own coach, so that at any given moment you can think and act to cultivate healthy habits, and in so doing, replace those that have been predictive of the need to protect.

The most frequently described pain experience is during intercourse with the clear impact upon the person and potentially affecting relationships and an ability to conceive. All are greatly emotive. There is often, rightly or wrongly, a sense of wanting to be healthy once again for their partner’s sake. Within this thinking, there can be a sense of guilt with the individual being hard upon themselves, the latter being a common characteristic, and one that needs to be addressed by developing kindness towards self.

UP | understand painAnticipation that a movement or activity will hurt sets up a cycle of protection — priming, expectant thoughts that drive tension and changes in perception, predictions of the need for protect then predominate and sure enough, the experience is painful and the cycle maintained through habit of thought and action. There are many points when new habits can be created from the moment of initiation of intercourse to during intercourse at different points (an anticipatory thought, a sensation of pain) and developing new thinking and reactions by practicing at other times — in essence reconfiguring the whole experience to resume the intimacy rather than fear of pain.

Pain Coach ProgrammeWe are designed to change, and we are changing continuously — it may not always seem like it, bit if you stop for a moment and note how your thoughts, feelings and body sensations shift and move like Constable’s skies, even within a minute or two, you will be aware of this in action. This awareness opens an opportunity to consciously decide to make changes in a direction of health, and in so doing, change your pain with new realisation and action. This all begins with the understanding of pain so that you can take wise action at every moment. The skills that you develop for overcoming vulvodynia you have probably noticed will be transferable to many areas of life because this is about your lived experience, moment to moment. Many women report feeling calmer, noticing more, responding and thinking with greater clarity and generally feeling well and healthy.

Pain Coach Programme to overcome persisting pain problems — t. 07518 445493

23Sep/15

Repetitive strain injury (RSI)

r.nial bradshaw |https://flic.kr/p/fBm85W

r.nial bradshaw |https://flic.kr/p/fBm85W

Repetitive strain injury (RSI) is one of the office blights so it may seem. Of course you do not have to work in an office to suffer on-going arm or hand pain, or as some call it: WRULD (the rather clunky ‘work related upper limb disorder). You may have tennis elbow or golfer’s elbow, of course without playing either sport — then it should be lateral or medial epicondylalgia! Words aside, this is a big and costly problem for individuals who bear the brunt of the pain, symptoms and their consequential limitations, and for businesses that have employees on light duties or off sick. So how does typing cause an injury?

Well it may not. We are not really designed to be sat, hunched over a desk (as I am now I have just realised), poking away at small buttons, getting quicker and quicker so that we don’t even have to think about where our fingers are going in order to produce a document. The ‘noise’ created by all these small, precise movements of the fingers (signals flying up from the joints and muscles about movement, pressure, touch etc) can be difficult for the brain to gather into a tangible meaning. We start to develop different sensations, perhaps a change in temperature, some tingling, numbness or a sense of size difference (my hands are now warm and a bit tingly). If you interpret this as strange or mildly worrying because you have heard of RSI and you don’t want it because your job involves typing all day…..you can perhaps see how the worry and concern and vigilance and responses begin to amplify and amplify; this without any notable injury. However, the tension that builds, the stress responses that affect tissue health, the change in blood flow and nerve function when anxious, all impact and can create a threat value that is perceived as dangerous and hence the body systems that protect kick in — this may well mean some pain. And pain is useful and normal, even without a significant injury, because pain is a need state, motivating action: maybe I should take breaks? Perhaps I should type less at the moment? Maybe I need to work at changing my thinking about a  situation that is making me stressed? Maybe I should start exercising regularly? Maybe I should seek some help and advice?

On-going use without adequate recovery can lead to an imbalance between tissue breakdown and rebuild, the natural state of change that is constantly occuring to all of us. The inflammation that results can of course add to the level of sensitivity or activate it, leading to aches and pains that can begin in specific locations but with time expand up and down the limb and even be noted in the neck and shoulder. This is not the spread of a ‘disease’, but rather the volume switch being turned up, meaning that increasingly normal stimuli (touch and movement, thought of movement, particular environments) can result in pain. Associations build with stimuli, and we get better and better at certain habits of thought and action that can perpetuate the problem — e.g./ avoidance, expectation, changes in movement, extra muscle tension unbeknownst to us.

There comes a point when the symptoms can begin so quickly that it becomes difficult to type, text, hold light objects and even gesticulate. This makes work life and socialising very challenging as well as frequently occupying much of our thinking, planning and our mental resources from the emotional impact. A comprehensive approach is needed to change direction and begin recovering, from wherever your start point. Certainly if you are feeling a few aches and pains that are becoming more frequent, you would be wise to seek advice. Or if you are struggling, then the right treatment and training programme can help you to resume meaningful activities.

Due to the biology of RSI, like all persisting pains, being upstream in the main, i.e. away from where the pain is felt, any programme must address this as much as improving the health of the tissues locally with movement and use (gradually). Once you undertand your pain, you realise that pain is not an accurate indicator of tissue damage, and that there are many things you can do to take you towards a better life. Asking yourself why you want to get better gives you the answer as to where you want to be going; your direction. We need direction and then the know-how to get there, dealing with distractions on the way, so that we remain focused on the right thinking and actions.

You will have been successful before, using your strengths (e.g./ concentration, empathy, dedication, motivation) and values. Using these same strengths and values to perform the training and to think in the right way leads you to a better outcome. What are your strengths and values? The exercises, training and treatment are all straight-forward, but their effectiveness is impacted upon by the way you think about your pain and your life. There are many factors in your life that are affecting your pain: e.g. tiredness, stress, anxiety, people, places. Understanding these and your pain puts you in a position to make changes and groove healthy habits and in so doing take the focus away from pain and worrying about pain to the doing and enjoying and living. There is only so much you can attend to in a passing moment, so why not focus on the good stuff? And if you are in pain, you can learn how to create conditions for ‘pain-off’ over and over whilst you get healthier and fitter generally as well as specifically training to resume meaningful activities: common problems are typing, texting, carrying etc.

This is an insight into modern thinking about pain and how to overcome pain. We understand so much more and this knowledge is ever-expanding. Passing this knowledge to you with practical ways of using it to overcome pain is our role, and treating you with techniques that calm and ease symptoms whilst you get fitter and stronger. Together we can use your strengths to resume a meaningful life.

Call now to start your programme if you are suffering RSI or if you are a business wanting to reduce risks or develop a programme for your staff: 07518 445493

 

12Aug/15

Using your strengths to overcome pain

Trust Strength Focus | DiddyOh | http://bit.ly/1ToCvPt

Trust Strength Focus | DiddyOh | http://bit.ly/1ToCvPt

Using your strengths to overcome pain is a fundamental principle of the Pain Coach Programme. Everyone has strengths such as focus, creativity, self-confidence, compassion and empathy. We have used these strengths during our lives to achieve success, at work for example. What I find however, is that people are not using their strengths to overcome their pain, and instead fall into a passive role and hope that something or someone will help — medication is a common one of these! ‘That will solve my problem’, but of course pills do not teach you how to return to a meaningful life, that only comes from the lived experience.

In the first meeting we discuss your pain, problems, story and life so that we can identify where we must begin and the strengths that you have that will enable the necessary actions. You will be using strengths in certain arenas, but probably not in that of your health and pain. The focus is absolutely on your ‘cans’ and not your ‘can’ts’, developing these with strategies and progressions so that the former facilitate the latter with time, practice and perseverance.

One very common example of practicing a strength on a day to day basis but not for oneself is compassion. This means that the person is kind, caring and giving, but not towards themselves. To give is rewarding and health giving, but you must be kind to yourself to do this with most effect. In fact, it is distinctly unhealthy to be repeatedly hard on yourself as it creates much angst, worry and anger that creates chronic stress that in turn creates a chronically inflamed state. Developing kindness and compassion towards oneself then is part of developing your strengths to overcome pain.

The Pain Coach Programme is all about developing your strengths and using them to effectively face the moment to moment aspects of pain as well as an overall approach to desensitising and relieving pain. To follow the programme of exercises and techniques, you need motivation, resilience, focus, energy and an ability to deal with distractions from your end goal. Pain Coach prepares you and guides you so that you become your own coach and move forward to a meaningful life once again. There is only one person who changes and transforms pain and suffering, and that is the person who is currently suffering. They just need to know how to do it!

To start your Pain Coach Programme for chronic and persisting pain, call us now: 07518 445493

Common reasons for starting the programme: back pain | neck pain | RSI | CRPS | sports injuries | arthritis | pelvic pain | IBS | migraine | headache | dystonia | chronic pain | sciatica

05Aug/15

Messages about pain

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

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

When someone seeks help for their pain and injury, they will be given messages about pain that are potent. They are told a, b and c, and hence often take these messages and become them via their own thinking and actions. This is the reason why the early messages about pain need to be accurately based on what we really know about pain and that they motivate people to focus on what they must do to recover. The way in which we think about and hence perceive our pain has tremendous impact on the extent of suffering and how we actually experience the pain itself. Put simply, a lack of understanding that can create concern, worry and anxiety, will raise the threat value of the whole situation, and therefore the body (you) protects further, including an increase in the intensity of the pain itself. All these experiences of thought and action are chemically based — depending on which chemicals are working with which receptors determines how the body systems are functioning and underpinning what we live out.

So what should the messages contain?

1. Facts about pain and the injury, including the poor relationship between the two, that pain is part of a protective response that includes other protective means such as altered movement (e.g. limping) and that the way we think and feel influence both the amount of suffering we endure as well as the actual intensity of the pain itself.

2. The person has an active role in overcoming pain — based on (new perhaps) understanding of pain and person, what is happening, why it is happening and what action needs to be taken.

3. Other relevant information to develop the person’s understanding, and in so doing, gain their trust, respect to follow a programme that motivates through positive thinking and experience towards their vision of how they want to be and live their life.

Undoubtedly, as with any problem we must understand it before we can deal with it. In the case of chronic pain, explanations incorporate the biological changes, behavioural changes and cognitive-emotional changes afoot and how to address these comprehensively–whole person.

The whole person approach recognises that there are many inter-related dimensions of that person, and that we must consider the individual as a whole rather than a back or a knee or any other structure or pathology. The experience of pain and other symptoms is a conscious leap from the underpinning biology, and no-one fully understands how our bodies, our ‘selves’, make that leap from biology to the lived experience. However, listening carefully and compassionately to the individual provides many clues as to why they are in protect and survive mode, emerging as pain and other symptoms, behaviours, thought processes and ultimate actions. This becomes the start point for designing a bespoke, proactive programme, beginning with the right messages.

Whilst the first meeting may identify where the actions taken by the individual are incongruent with recovery, it is worth remembering that this person is doing their very best with the knowledge and skills that they possess at that moment. Everyone has strengths with which they attained success in a range of arenas. Elucidating these strengths creates a start point and also allows that person to know and start feeling that they have the tools to overcome pain, but need guidance on how to best use them. That is our job.

This approach is part of The Pain Coach Programme for individuals to overcome their pain problem and for clinicians seeking to learn the Pain Coach approach for chronic pain. Contact us for more details if you are suffering chronic pain or a therapist wanting to advance yourself in the field of chronic pain: 07518 445493

20Jul/15

Zen and the art of human maintenance

Kitty Terwolbeck | https://flic.kr/p/nJ3oH4

Kitty Terwolbeck
| https://flic.kr/p/nJ3oH4

Zen and the art of human maintenance is not a spiritual blog but rather a practical one that considers a way of approaching hands on treatment–this is whether you are a massage therapist, a physiotherapist, an osteopath or any other clinician who uses their hands for examination and treatment. Equally it could apply to a person comforting a loved one.

How you bring yourself to the act has a huge impact upon the act itself. Setting the scene both in terms of the environment and the focus of your intention will play out through the treatment in subtle ways that effect the overall experience. A moment’s preparation in that vain allows the therapist to focus and be present meaning that the full experience is had, allowing for a sensitivity (via the therapist’s hands yet experienced through their whole person) that enables gentle responsiveness to adapt the treatment to the recipient’s needs. A classic example is being aware of how the muscles react to different levels of touch. Being aware means that you can detect even gentle guarding that indicates protection and need for both nourishment (improved blood flow and oxygen delivery to over-working muscles that are being told to tighten in an attempt to protect–yet this comes at a cost, both of energy and a build up of acids) and a sense of safety so that the systems that are protecting the body can ease up.

Take a moment: before you begin the treatment, 3 easy breaths to become aware of what is happening now, how you are feeling, what you are thinking; continue to maintain awareness of the present moment, letting go of distracting thoughts that interfere with your focus.

Zen is a sense of oneness with the present experience, what is happening right now, free from distractions and letting life flow. There are many situations when this state of simply being is very useful–before exams, interviews, when negotiating, discussions with your employer, before performing etc. However, cultivating this skill on a moment to moment basis is hugely beneficial as it allows you to see and think clearly, even when thinking about the past or future, which can cloud what is really happening now. These are all just thoughts, but when we become embroiled, the body reacts and responds because we are our body as much as we are our mind, and all that this means. So, just thinking about being in an argument or giving a speech creates similar responses in the body as if you are there; but you are not.

In giving treatment to another person, being fully present means that you fully experience the moment. You will be completely engaged in all that is happening ‘now’, creating a potency that cannot be otherwise reached with a wandering mind that has no connection with the treatment. This is undoubtedly a practical skill that can be developed, some calling it ‘focused attention training’ and others ‘mindfulness’. Everyone has the ability to focus, even for short periods, and to enhance the skill with practice. There would be some benefit of simply taking a few breaths as described above, yet there is even greater advantages to be had from further practice with 5-10 minutes of mindful breathing each day; more if you are so inclined.

Not only does being present whilst treating enhance the treatment through a more responsive selection of pressures and movements, the clinician also benefits from the calm created, and the clarity of thoguht offered by being present and aware. In effect, the whole experiecne means that while you are treating, you are being treated. A good way to measure this is by noting how you feel at the end of the day. A mindful day will end with energy, and non-mindful day with fatigue. I know which I prefer.

* These are skills to be learned and developed in the Pain Coach Mentoring Programme for clinicians | call 07518 445493 for details

11Apr/15

50 strokes

Ajahn Brahm tells the story of a monk who thought he deserved punishment for breaking a monastic rule. He had knowingly done wrong and expected reprimand, yet this was not the way. The monk insisted, so Ajahn Brahm prescribed 50 strokes. The thought of this ancient punishment undoubtedly filled the monk with fear yet he knew this was his fate. However, no whip was produced but instead a cat, which the monk was ordered to stroke—50 times. After the 50 strokes of the cat there was peace and calm and the passing of a learning experience. Change was afoot.

In physiotherapy we use our hands to treat and create calm in a body that is protecting itself, perceiving a range of cues to be threatening. It has been thought that moving joints, muscles and nerves bring about the desired changes (or not if unwisely applied) because of a change in the structures. Science has since taught us otherwise, and that in fact what we are really doing is changing the processing in the body systems and then the recipient has a different and better experience—pain eased and movement more natural and thoughtless.

Touch is very human. Touch is a part of the way we develop in the early years, a lack of touch being detrimental to normal development. So potent when the meaning is aligned with a sense of creating wellbeing and soothing woes both physical and emotional, touch should be part of therapy for any pain condition. Interweaving hands-on treatments during sessions, teaching patients how to use touch themselves, teaching carers and partners how they can use touch, all create the conditions for healthy change.

Touch send signals from the nerves in the skin and muscles to the spinal cord and then onwards to the brain. In this way, the body is an extension of the brain and the brain an extension of the body, demonstrating  how we are  a whole person with no system or structure being in isolation to any other. Using touch is literally sculpting the representation of the body that exists in the brain, like moulding clay into a humanly shape. And of course, a shape has a function and the two are not distinct. The more precise the shape, the better the function. The manifestation of this being a normal sense of self in how we think and feel and a move. Normalising, desensitising, to me are one and the same.

— 50 strokes of the area of the body being protected, much like stroking the cat then, sculpts our ever changing brain and sense of physical body. The physical body exists and occupies space with the ever-potential of action, yet this does not exists without thought—it is my thought, the meaning that I give to my body that creates what it is in any given moment. When the strokes feel pleasant, or at least not painful, then this is your body and brain perceiving the action as being non-threatening and learning that the area is safe. The more of this the better. The same applies with movement: any action that is tolerable or feels good is the body (your whole self) saying ‘yes, that’s ok’. And that’s what we practice and practice.

To overcome and change pain is to normalise and to alter one’s relationship with pain and overall perception. We have much more say in this than most people realise but once they understand their pain, what pain really is and what they can do, change occurs in the desired direction.

Puuurrrrrrrrrrrrrrrrrrr.

02Oct/14

CRPS Research Update | October 2014 #CRPS

Welcome to the Complex Regional Pain Syndrome Research Update for October, a summary of the latest studies. 

If you are suffering with CRPS, I am here to show you how you can move forward — come and visit the CRPS clinic page here.

Spinal cord stimulation for complex regional pain syndrome type 1 with dystonia: a case report and discussion of the literature.
Voet C1, le Polain de Waroux B2, Forget P2, Deumens R3, Masquelier E4.

Abstract
BACKGROUND:
Complex Regional Pain Syndrome type 1 (CRPS-1) is a debilitating chronic pain disorder, the physiopathology of which can lead to dystonia associated with changes in the autonomic, central and peripheral nervous system. An interdisciplinary approach (pharmacological, interventional and psychological therapies in conjunction with a rehabilitation pathway) is central to progress towards pain reduction and restoration of function.
AIM:
This case report aims to stimulate reflection and development of mechanism-based therapeutic strategies concerning CRPS associated with dystonia.
CASE DESCRIPTION:
A 31 year old female CRPS-1 patient presented with dystonia of the right foot following ligamentoplasty for chronic ankle instability. She did not have a satisfactory response to the usual therapies. Multiple anesthetic blocks (popliteal, epidural and intrathecal) were not associated with significant anesthesia and analgesia. Mobilization of the foot by a physiotherapist was not possible. A multidisciplinary approach with psychological support, physiotherapy and spinal cord stimulation (SCS) brought pain relief, rehabilitation and improvement in the quality of life.
CONCLUSION:
The present case report demonstrates the occurrence of multilevel (peripheral and central) pathological modifications in the nervous system of a CRPS-1 patient with dystonia. This conclusion is based on the patient’s pain being resistant to anesthetic blocks at different levels and the favourable, at least initially, response to SCS. The importance of the bio-psycho-social model is also suggested, permitting behavioural change

RS: With CRPS we absolutely need to consider ‘multilevel’ modifications and adaptations within the nervous system but also how all the other systems that have a role in protecting us are functioning. This often manifests as habitual thinking and activities that maintain protection. Realising these habits, automatic by the nature of being a habit, and making changes with specific training creates new patterns of activity that head towards health.

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Longstanding Complex Regional Pain Syndrome is associated with activating autoantibodies against α-1a adrenoceptors.
Dubuis E1, Thompson V2, Leite MI3, Blaes F4, Maihöfner C5, Greensmith D6, Vincent A7, Shenker N8, Kuttikat A9, Leuwer M10, Goebel A11.

Abstract
Complex Regional Pain Syndrome (CRPS) is a limb-confined post-traumatic pain syndrome with sympathetic features. The cause is unknown, but the results of a randomized crossover trial on low-dose IVIG treatment point to a possible autoimmune mechanism. We tested purified serum immunoglobulin G (IgG) from patients with longstanding CRPS for evidence of antibodies interacting with autonomic receptors on adult primary cardiomyocytes, comparing with control IgG from healthy and disease controls, and related the results to the clinical response to treatment with low-dose intravenous immunoglobulins (IvIG). We simultaneously recorded both single cell contractions and intracellular calcium handling in an electrical field. Ten of 18 CRPS preparations and only 1/57 control preparations (p<0.0001) increased the sensitivity of the myocytes to the electric field and this effect was abrogated by pre-incubation with alpha1a receptor blockers. By contrast, effects on baseline calcium were blocked by pre-incubation with atropine. Interestingly, serum-IgG preparations from all four CRPS patients who had responded to low-dose IVIG with meaningful pain relief were effective in these assays, although 4/8 of the non-responders were also active. To see if there were antibodies to the alpha1a receptor, CRPS-IgG was applied to alpha 1a receptor transfected rat1-fibroblast cells. The CRPS serum IgG induced calcium flux, and FACS showed that there was serum IgG binding to the cells. The results suggest that patients with longstanding CRPS have serum antibodies to alpha 1a receptors, and that measurement of these antibodies may be useful in the diagnosis and management of the patients.

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A CRPS-IgG-transfer-trauma model reproducing inflammatory and positive sensory signs associated with complex regional pain syndrome.
Tékus V1, Hajna Z1, Borbély É1, Markovics A1, Bagoly T1, Szolcsányi J2, Thompson V3, Kemény Á1, Helyes Z2, Goebel A4.

Abstract
The aetiology of complex regional pain syndrome (CRPS), a highly painful, usually post-traumatic condition affecting the limbs, is unknown, but recent results have suggested an autoimmune contribution. To confirm a role for pathogenic autoantibodies, we established a passive-transfer trauma model. Prior to undergoing incision of hind limb plantar skin and muscle, mice were injected either with serum IgG obtained from chronic CRPS patients or matched healthy volunteers, or with saline. Unilateral hind limb plantar skin and muscle incision was performed to induce typical, mild tissue injury. Mechanical hyperalgesia, paw swelling, heat and cold sensitivity, weight-bearing ability, locomotor activity, motor coordination, paw temperature, and body weight were investigated for 8days. After sacrifice, proinflammatory sensory neuropeptides and cytokines were measured in paw tissues. CRPS patient IgG treatment significantly increased hind limb mechanical hyperalgesia and oedema in the incised paw compared with IgG from healthy subjects or saline. Plantar incision induced a remarkable elevation of substance P immunoreactivity on day 8, which was significantly increased by CRPS-IgG. In this IgG-transfer-trauma model for CRPS, serum IgG from chronic CRPS patients induced clinical and laboratory features resembling the human disease. These results support the hypothesis that autoantibodies may contribute to the pathophysiology of CRPS, and that autoantibody-removing therapies may be effective treatments for long-standing CRPS.

RS – as ever we must consider the role of the immune system but in the light of other systems as no system works in isolation to the others. There is vast interaction between the immune system, nervous system, endocrine system and autonomic nervous system to the point where I believe we are a single system interpreting and responding. One response maybe pain as part of protection and our systems become very good at protecting us — this is not to suggest that our systems and ‘me’ are separate entities. Whole person is the only way we can sensibly think about this.

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Local Anesthetic Sympathectomy Restores fMRI Cortical Maps in CRPS I after Upper Extremity Stellate Blockade: A Prospective Case Study.
Stude P, Enax-Krumova EK1, Lenz M, Lissek S, Nicolas V, Peters S, Westermann A, Tegenthoff M, Maier C.

Abstract
BACKGROUND:
Patients with complex regional pain syndrome type I (CRPS I) show a cortical reorganization with contralateral shrinkage of cortical maps in S1. The relevance of pain and disuse for the development and the maintenance of this shrinkage is unclear.
OBJECTIVE:
Aim of the study was to assess whether short-term pain relief induces changes in the cortical representation of the affected hand in patients with CRPS type I.
STUDY DESIGN:
Case series analysis of prospectively collected data.
METHODS:
We enrolled a case series of 5 consecutive patients with CRPS type I (disease duration 3 – 36 months) of the non-dominant upper-limb and previously diagnosed sympathetically maintained pain (SMP) by reduction of the pain intensity of more than > 30% after prior diagnostic sympathetic block. We performed fMRI for analysis of the cortical representation of the affected hand immediately before as well as one hour after isolated sympathetic block of the stellate ganglion on the affected side.
STATISTICS:
Wilcoxon-Test, paired t-test, P < 0.05.
RESULTS:
Pain decrease after isolated sympathetic block (pain intensity on the numerical rating scale (0 – 10) before block: 6.8 ± 1.9, afterwards: 3.8 ± 1.3) was accompanied by an increase in the blood oxygenation level dependent (BOLD) response of cortical representational maps only of the affected hand which had been reduced before the block, despite the fact that clinical and neurophysiological assessment revealed no changes in the sensorimotor function.
LIMITATIONS:
The interpretation of the present results is partly limited due to the small number of included patients and the missing control group with placebo injection.
CONCLUSIONS:
The association between recovery of the cortical representation and pain relief supports the hypothesis that pain could be a relevant factor for changes of somatosensory cortical maps in CRPS, and that these are rapidly reversible

RS – we are either in pain or not in pain. If our focus is elsewhere and we are not experiencing pain, then we are not in pain. Whilst this may sound obvious, many people tell me that they are in pain all of the time. When I ask about times that they feel no pain, an oft given answer is that the pain is hidden at times when they do not feel it. Pain cannot hide. It is on-off, binary. At any given moment, we are either in pain or not in pain. Every moment changes and hence pain can change in a moment — referring to the rapidly reversible change in maps in this article; and why wouldn’t we have the ability to rapidly adapt? I believe we can change and it happens in a moment — our thinking, actions and experiences. Consider how we can be happy in a moment, and sad in a moment. Happiness is a feeling, pain is a feeling. Both have a purpose, to motivate us to do something or think in a particular way. There is a desperate need to change the globe’s thinking on pain, this being my main purpose. In doing so, we can alleviate a vast amount of suffering from pain, narrowing it down the pain that we need for survival and eliminating the pain that persists for no good reason.

01Aug/14

When in pain, the World looks different

When in pain, the world looks different — We are familiar with the notion that the World is always changing. In fact, change is one of the few certainties in life that we can rely upon. However, change is only possible if there is someone present to experience how things are evolving, and that person is also changing. No two moments are the same.

To experience change we need to know what has happened previously and to recognise the difference in the now. As humans we have complex systems that work together as a whole (the ‘me’) to make sense of what is going on within us and around us, and in so doing, create a perception of the World and where we are within that World. When these pieces fit well, we feel good.

For those suffering chronic pain the World changes in a way that makes it appear threatening, distant, disjointed and sometimes intolerable. We know that places appear to be further away when we have persisting pain, and that stairs look steeper when we are tired. Both of these altered perceptions are protective as they motivate defensive behaviours that can manifest as avoidance. Whilst this is an important strategy in the early stages of an injury, as time passes, this way of operating becomes a problem in itself as engagement with life diminishes. This choice, sometimes conscious and sometimes subconscious, becomes conditioned quickly. Often the decisions about whether to approach or avoid are based upon a belief that pain equates to tissue damage. Understanding pain counters this problem.

I as an individual, with a set of beliefs about myself and the World construct the perception that I have of that World. The reality that I experience is mine, and only mine. This reality can be suggestible and is certainly influenced by many factors, including how I am thinking right now. Is a sunset the same experience when I am happy compared to when I am sad?

Pain is part of the perception of the World, my World. The pain I feel is the ‘how’ I am experiencing the present moment, and I am feeling the pain in a part of my body. This is ‘how’ I am feeling my body, and often the painful area to which I am drawn is the only part of my body that I am feeling. The pain is not separate from the World I perceive, instead it is embedded within the context of my perceived World. Pain is changeable and is a different experience when I am at home compared to when I am at work. Pain is moulded by the environment as much as the perception of my environment is moulded by my pain. We are not, and cannot be separate from the environment in which we reside.

We can use this understanding to our advantage when designing rehabilitation, training and treatment programmes. Considering the environment from where the patient has come, and certainly the environment created for face to face therapy sessions. This is both the space in which the treatment is happening and that cultivated by the therapist through language and posturing. Treatment is embedded within the place where it happens and therefore, creating a place of positive meaning can empower recovery.

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