Category Archives: Pain

20Feb/17

Pain is whole person

Pain is whole person

There is only one way to approach the problem of chronic pain as it emerges in the individual, and that is by addressing the whole person. This way demonstrates a true understanding of pain: the lack of any pain system, pain signals or pain centres and that the vast majority of the biology of pain is not where we actually feel it in the body or body space in the case of phantom limb pain. Much like when you watch a film in the cinema, most of what you need is not on the screen.

With pain being absolutely individual, coloured by the context, the environment in which it is being phenomenologically experienced, prior experience and beliefs (about pain, health, danger, ‘me’, the world etc.), the action we are motivated and compelled to take, existing health and level of threat perception to name but a few. In short, this includes activity in the brain and central nervous system, immune system, endocrine system, sensorimotor system, visual system, and the autonomic nervous system. Most of this is not where the pain is felt.

Pain and injury are notorious for being poorly related. There are countless stories of people suffering great trauma (tissue damage) and reporting minimal or no pain, some sustaining minor injuries and describing agonising pain and a huge variation in between. Considering the factors in the previous paragraph, one can start to understand why. In essence it is due to pain being a better indicator of the level of perception of threat; i.e./ more threat, or existence of threat = pain.

Bearing this in mind, and this is the current understanding of pain, you can see why the whole person approach is necessary. It is as much about the person as the condition, as Oliver Sacks wrote and practiced, and indeed this is a vital principle to work to. Understand the person and their circumstances and you go some way to seeing a way forward. Listening deeply in the first instance creates the opportunity to gain insight into the reasons for the person’s suffering — the reasons for pain and what is influencing that experience. From this foundation, one develops a rapport, not just as a clinician or therapist but as a trusted advisor, giving the person the knowledge and skills to overcome their pain and live a meaningful life.

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Pain Coach Programme to overcome chronic pain ~ t. 07518 445493 or email: painphysiolondon@gmail.com

 

01Feb/17

The inner dialogue

The inner dialogue ~ what do you listen to and what do you tell yourself?
You are beautiful by La Melodie https://flic.kr/p/99ACEa

You are beautiful by La Melodie https://flic.kr/p/99ACEa

One of the things that makes us human is the inner dialogue or inner voice that is fairly continuously ‘speaking’ to us. Of course the voice is part of each and everyone of us and is not an outside agent. To some people it can appear to be coming from somewhere or someone else as in the case of psychiatric disorders. That must be frightening.

The inner dialogue is part of the workings of our mind. Our minds play a significant role in our actions and perceptions but it is not a one way street. The physicality of our existence can impact upon the way in which we think. The branch of philosophy named embodied cognition has much to say on this matter, addressing the notion that our thinking is embodied. A simple example is when thinking about hunger and food, we would typically feel that in our body, interpreting the sensations as being in need of food. A further example is the way we gesture with our hands to demonstrate a point, freeing up resources for further thinking. Consider how you feel when you think of a loved one or a difficult situation in the past — where do you experience it? Certainly not ‘in the head’.

There is a skill in choosing whether to listen to and act upon our inner dialogue or our thinking. It is true that we do not choose the workings of our mind, however we can learn about how it works, our habits of thought and realise how we embody these thoughts. In so doing, we have the opportunity and responsibility to become increasingly skilful in deciding whether to pay attention or to let go of thoughts and the inner dialogue. Being mindful is just that. We are aware of the thoughts, noticing their impermanence, recurrent nature, the way they create feelings in the body, but we are not engaging or becoming embroiled. There is a monumental difference between being in the film and watching the film. You are still experiencing the full richness of the feelings and emotions but with curiosity, with compassion and with an intent to only act with kindness, towards self and others.

Learning to be observant of the inner dialogue allows you to make choices. We have choices and often need to realise them. How am I choosing to feel or think about a particular situation? Even asking yourself that question gives you space to decide what you can do. Shifting the thinking to take another perspective can give a very different feel to the experience. Knowing that you can do this is very empowering, as you know that you can face challenges with skill and insight.

The story we tell ourselves can be so impacting upon our reality, lived experiences and ultimately our health and sense of well-being. If you persistently tell yourself that you are not good enough, have not tried hard enough or blame yourself for all sorts of things that may not actually be your fault, this will create a range of unpleasant feelings in the body as well as paint a bleak picture of life. Being hard on oneself causes our protect systems to switch into action. A range of common ailments manifest if these systems are ‘on’ too much without adequate refresh and renew time. Such problems include chronic aches and pains, sleep disturbance, gut issues, mood variance and exhaustion; very common presentations in my clinic. This need not be the case by learning some simple skills of well-being and day to day practices that stoke up our healthy systems. This is the bulk of the work we do to overcome pain and health problems — see here.

The inner dialogue and pain

Pain and the inner dialogueThe inner dialogue can tell us our story; the story of me. The self that I experience moment to moment, which is continually updating. Our implicit ability to change creates great hope as we can transform our suffering by gaining knowledge and insight into our existing habits. From this awareness we can choose to create new habits that are based upon our value system (what is important to you in life) and are by design all about sustainably living a meaningful life.

Many people with chronic pain have received messages that suggest pain must be managed or that they must just cope. This lowers expectations and hence our story and the inner dialogue is based on this belief. We can and must do better. Changing our story, and this is applicable to any story we tell ourselves, creates a new way onward. This begins with understanding pain. Countless people have told me how much better they feel on starting to understand their pain when we discuss their experiences at the first meeting. There is no magic here. We feel better when we have understanding of a problem and insight into how we can address the issues — feelings of agency, choice and empowerment feed and motivate us to take action; the right action. The Pain Coach Programme is all about the right action based on the right thinking. Understand your pain, write and see a new story and then live it. This is the story of your success, whether it be overcoming pain, setting up a business, writing an essay, doing an exam or playing a game of football. Use the story wisely, make it count and use every moment in a way that encourages and motivates more and more great action.

The Pain Coach Programme is a blend of strengths based coaching and pain sciences for your to achieve your success | t. 07518 445493

 

28Aug/16

Simple skills

simple skillsThere are a number of simple skills that can be practiced to become a better clinician. In essence, when we are fully present and engaged, we are communicating this to the patient thereby creating a nourishing environment. This environment sets the scene for new understanding and new habits, beginning the transformation of the suffering person.

We are not separate from the environment in which we reside and hence we, the clinicians, have a role in how the environment supports the person getting better. Arranging the treatment space is important then, enabling the patient to feel welcome, heard, comfortable and free to express themselves. This expression is the story to which the clinician must listen deeply as all the information is contained within the narrative. Allowing the person to speak in their own language with occasional prompts and guidance is the basis of the onward journey towards their vision of a desired outcome.

For the clinician to practice mindfulness is a simple way of maintaining presence and engagement with the patient. This simply means that you are listening deeply and using insight to see the causes of suffering that are revealed as the person speaks freely. Add to this compassionate speech and the communication facilitates the way forward. Communication is part of the treatment as the clinician helps the patient understand their pain and suffering — what has happened so far, what is happening now, what is influencing their pain, what they can do, what the clinician will do and how they will go about it.

Practicing mindfulness is a simple skill. As a starter, the clinician can take 4-5 breaths between patients, paying attention to the rise and fall of their chest. On the out-breath you can consciously let go of unhelpful and distracting thoughts. As soon as your mind drifts into the past or future, you are no longer present and your engagement dissolves. During the session, recognising this happening and bringing your attention back to your breath is a way of re-engaging once more.

Taking a break midway through the day to move, breath and nourish is an important refresh and renew point. A period of deep relaxation for 10-20 minutes gives us energy to be present once more and focus on the patient: their words, their gestures, their messages. We must develop our abilities to gain insight into the causes of the patient’s suffering so that we can guide and treat, enabling them to get better and ease their pain and suffering. In fact, by gaining insight ourselves, we can then help the patient to develop their insight into the causes of their own suffering and create new healthy habits around their thinking, choices and actions to actively infer new experiences.

Practical point: start by taking 4-5 breaths between patients, and at the start of the day express gratitude for the opportunity to help people get better.

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Pain Coach 1:1 Mentoring Programme — develop yourself and your insights to coach people overcome their pain | t. 07518 445493

27Aug/16

If pain

If painIf pain was understood, there would be less suffering.

If pain was understood, the right messages would be given from a young age, sculpting behaviours based on what needs to be done.

If pain was understood, there would be no fear about it.

If pain was understood, we would focus on what we can do to feel better.

If pain was understood, it would be known that listening deeply is the first step to help someone transform their pain.

If pain was understood, it would be known that understanding pain changes pain.

If pain was understood, there would be an enormous amount of money available for a better society.

If pain was understood, it would sit in the realm of public health and not medicine.

If pain was understood, there would not be the reliance on medication.

If pain was understood, what would the world be like?

— this is the mission of UP | understand pain; to globally change the understanding of pain, because put simply, the world would be a better place if pain were understood.

www.understandpain.com

23Aug/16

Inequalities in pain relief

A brief article in yesterday’s Guardian highlighted one of the inequalities in pain relief. The author, Grace Rahman, focused on the question why black patients are given less pain relief in the light of recent research. With pain being the most common cause of Emergency Room visits, there is plenty of data to analyse. This is likely to be the same in the UK, pain being the primary vehicle that takes people to seek help. As a significant aside, it astounds me that pain is so low on the public health agenda in terms of funding for research as well as overall recognition.

Depression and chronic pain take the first two positions in global health burdens — they cost us the most. Yet where are the campaigns? Where is the TV coverage? They do not exists despite the fact that pain is a universal experience, except in an unlucky few with a rare genetic disorder, which is normal and necessary for survival but so deeply troubling when it persists. Therein lies a major issue contributing to the question penned by the journalist: why are black patients given less pain relief?

Previously, young babies may not have been given pain relief and older people may still not receive adequate pain relief, especially those who are cognitively impaired. The aggression seen in someone suffering dementia may well be due to pain that a simple analgesic would relieve. The misunderstanding of pain underpins all of these contexts, resulting in poor treatment that is based on the wrong thinking. The lack of pain education is incredible when you consider it in this light.

A study quoted by the author highlighted the knowledge gaps of white medical students who rated pain levels to be lower in black people when looking at case studies. Why would this be the case? It was thought to be due to ‘entrenched ideas’ about how people differ biologically and about how they behave in relation to using medication.

Each person is unique with their own personal experiences and narratives of their life to date. This makes an individual’s pain unique, and at any given moment our lived experience that could include pain, is also unique. I have never had this moment before and never will again. So even in the individual, the pain is never the same. We are always changing as we build up prior experiences with every passing moment in time. Understanding this is important and also delivers hope, because when combined with a working knowledge of pain and what we can do to actively steer a desired course within realistic parameters, we actualise change.

Therefore, as clinicians and as a society we must appreciate that each person’s experience of pain is unique and just as they person says it is — listening deeply is vital to gain an understanding with the required compassion. Just spending those moments with the person, allowing them the time and space to describe their experience allows a calming. We must certainly appreciate culture, gender and beliefs as we impart the truth behind someone’s pain, giving them knowledge and skills to overcome their pain and what fuels the sensations. This is the same for every person — whatever the colour of your skin, age or sex. Deep listening, compassionate speech and a focus on what action to take in this moment.

Much suffering comes from how we think about our pain, which is why we feel better when we understand pain and the fear dissolves. When the fear and worry decrease, so the pain eases and we can focus on what we need to do to get better. Fear, worry and depression are based on the contents of our thinking from the past or the future, neither of which exist except in our embodied minds. The only real moment is this one, now. Practicing being present and seeing what is actually in front of you by using the breath for example, allows the person to let go and concentrate on this moment. This is the foundation for moving onward in a chosen direction.

Medication is part of overcoming pain. It can be useful when used wisely within a plan that includes how and when the drugs will be reduced. Of course this is individualised to the person, their condition and their needs. Many people choose not to use pain relief, and certainly the opiate based drugs. Everyone wants relief and this should be a primary aim of any treatment programme, however, the person needs to understand how they themselves via their own thinking, perceptions and actions can change their pain. This is the main bulk of the work for that person as they need to be able to coach themselves at any given moment, each day. The strategies and exercises become healthy habits formed through practice that interweaves into the day. Continuing with normal activities in tolerable chunks maintains a sense of living a life and I often say to people that they can only get only get back to living by getting back to living — doing the things you want to and starting doing the things you have not been doing, bit by bit; thinking ‘can’ instead of ‘cannot’. It is just that you need some ways and means to do so as you build up tolerance by following a programme. A simple analogy is all the background work that an athlete would do in order to perform their sport. The programme is the background work.

Bearing this in mind, there is only one way and this is to consider and treat the unique person as much as the condition. In doing so we learn about their suffering and guide them forwards with treatment that gives the person working knowledge of their pain and skills so that they can coach or mentor themselves forward by thinking and acting in such a way as to take them forwards.

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Pain Coach Programme for persistent and chronic pain | t. 07518 445493

 

18Aug/16

Trauma

TraumaAll injuries have a degree of trauma, but some more than others. The moment of injury is just that, a moment. Part of the experience is an urge to do something in a way of protecting the self both in thought (what shall I do here?) and action taken. The thoughts and actions, unified into a lived experience of action-perception, are based on prior knowledge and situations as we try to make some sense of what is happening now. As humans, we have a tendency to flavour the present moment with thoughts of the past or future, neither existing beyond the thought itself. The problem lies in the fact that the thought is embodied, resulting to a greater or lesser degree from the current body state, which we then fully experience with sensations in the body, feelings and emotions; embodied. For example, purposefully thinking about a prior happy occasion usually fills you with the same feelings of joy and pleasure as if you were there again. The same is true for thoughts of an unhappy situation in the past. However, this body state is continually updating and hence we are in a position to steer our change in a desired direction by thinking-acting in a way that aligns with our values and vision of how we want to be. We purposely put ourselves into situations to get better.

Understanding the state of the individual before the trauma and at the time of the trauma provides important insight into the subsequent unfolding of events. A person experiencing persistent pain continues to suffer despite the tissues (body) healing, which they do to the best of the body’s ability, because the systems designed to protect us continue to be vigilant to potential dangers. These potential dangers soon become normal day to day situations, now regarded as posing a threat to the individual’s survival, hence the pain to motivate defensive thoughts and behaviours. The longer these habits persist, the more suffering. But, this is not set in stone and indeed the practice of new, healthy habits steers a new course. We are designed to change and we can decide on the direction, using new habits to get there. Not always a smooth route, it is the one that takes you towards a meaningful life as you overcome the challenges with new understanding of pain and the best course of action. Maintaining this course also relies upon recognising distractions (unhelpful thoughts that affect mood and motivation — old habits) and re-orientating to the desired route.

Healing is not simply about the muscles, bones and other tissues repairing. It is about the person resuming their sense of self — ‘I feel like me’. This is a process of understanding, adapting, gaining insight into the causes of suffering, the practice of new habits and gradually engaging once more in normal activities including socialising. I think about this as getting back to living, by getting back to living instead of waiting for pain to subside before re-engaging. The re-engaging itself has a role in getting better and pain easing. This comprehensive approach, or whole-person approach, is key to success.

A pure focus on tissues means that the person living the experience is neither acknowledge nor addressed. There is the pain, the injury (the two are not well related) and the person’s appraisal of both, which if not validated and considered, means that a huge source of suffering is neglected. This does not mean in-depth psychological assessment, instead recognising that there is an individual with a story that needs guidance towards getting better. We are more than an injured leg or back. Insightful and compassionate clinicians will work in an egoless way as they focus on the person getting better by helping them to understand how they create the conditions for their health — environment, surrounding and influential people, their programme. We often use the phrase ‘I want to go back to how I was’, but of course this is impossible as we cannot go back in time. What we can do is adapt and focus on getting fit and healthy, and in so doing the body, the self, predicts less and less need to protect and hence the pain changes as we get better.

On first seeing a person who has experienced a trauma and on-going suffering from their persistent pain, we must consider prior health, pain experiences and beliefs about how we overcome problems. It is common to have had or to have other sensitivities, sometimes for many years, which exemplify a pre-existing state (or pain vulnerability) that has been primed by painful episodes over the years. This means that a new injury or situation deemed in need of protection will arouse a more vigorous and potentially prolonged set of protective responses, vigilant and fear-based behaviours. Knowing this from the outset means that the new issue can be addressed fully. Examples of common prior conditions include irritable bowel syndrome, migraines, jaw problems, persistent aches and pains (e.g. back pain), pelvic pain or period pain. These sensitivities can have arisen as part of an overall protect state following early traumas in life that have triggered the protect state, which has continued to emerge in many circumstances including normal ones. We learn to avoid and look out for trouble and can see it in the face of day to day activities, resulting in persisting pain and anxiety. However, with change occurring every new moment, we are able to transform this suffering by seeing things for what they are as opposed to being lost in thoughts about the past or future that arouse unpleasant sensations and emotions (in the body — we are embodied).

In discussing emotions and thoughts, this does not mean that we only focus on these dimensions. As stated earlier, we must focus on the person and their unified experience that is constructed by their brain, mind, person, body etc. On shifting a thought purposefully, inferring something different, we immediately feel differently about that situation. ‘How are you choosing to think about this?’, you could ask yourself. ‘Is there another way I can look at this?’. Recall the experience of where you feel emotions. It can only be in the body as thoughts are embodied. They are not ‘out there somewhere’, they are here, in me. My body state determines my thinking as much as my thinking determines my body state. Sit up for a while and notice how your thinking and feeling changes. You can gain insight into how someone is feeling by observing their posturing and manner. Imagine going into a business meeting to find the person you are about to discuss a deal with, sprawled across his chair with his feet up on the table. He has not said anything yet you gain insight into his approach, character and manner. Will you do business with him? Further, force a smile by gripping a pencil longways between your teeth, look in the mirror and notice how your feelings and emotional state change.

We are complex, predicting what needs to be experienced in any given context based on what we know. There are a huge number of variables that we cannot account for as we are only aware of a very thin slice of what is going on in any given moment — what we are conscious of, making many assumptions from prior learning. In terms of persistent pain, the intensity, the impacting nature of the experience usually far outweighs any signs of ‘damage’ or injury. Often there is evidence of natural degeneration that slowly evolves, quietly informing body systems which predict the meaning of the information, eventually reaching a point of conscious protection when it hurts. This is a slow burner with a point in time when pain is noted. 

In trauma, there is an obvious incident, which is embossed upon the person at that moment in time. The reverberating effects from there on depend upon that person: what they have experienced before, how their body systems predict the causes of the sensory barrage, urges manifesting as behaviours and actions taken, thoughts about the situation (meaning, attribution of causes etc.), emotions that emerge and the onward unfolding of these experiences unified as the story. Naturally the time frames vary according to the conscious awareness of the person, wherein a head injury would impact on memory of the event. In an emergency situation, clearly there are priorities for the medical team to protect the person and maximise the chances of survival and sets the scene for recovery and healing.

From the earliest possible time point, the right messages about what has happened and what needs to be addressed should be purported. The person needs to understand their pain and problems so that they can focus on the right action to get better. This is day to day, moment to moment as the advice and education are taken, internalised and become second nature as new healthy habits are practiced. The notion of the Pain Coach emerged from this thinking, blended with a strengths-based approach. Strengths-based coaching focuses upon developing a person’s existing strengths and managing their weaknesses. On the basis that we are seeking to focus and perform to the best of our ability, the strengths coaching method offers an effective modus operandi stretching across recovery from injury to sports and business performance. Strengths are many, and can include perseverance, attention to detail and compassion. People often realise that they use these strengths in other areas of their life but not in relation to getting well again.

Experiencing trauma in life presents the person with a challenge in many different ways. It also presents a challenge to those around them including family and friends as we are not in isolation to others or the environment in which we reside. There may be a region of the body that has been injured or affected, however, it is always the person who has to deal with the situation and recover. This is a key point that can often be missed, particularly when the injury is complex and multiple parties are involved in the treatment planning. Whilst we discuss the incident, the injuries, the symptoms and the impact upon that person’s life, they are living that life and only they know what that experience is like. This is the reason why deep listening is so important from the outset. It is the person who heals and recovers. It is the person who gets better, and hence it is the person we must know and treat as much, if not more, than the condition because each of us will experience our life events in our own unique way.

The Pain Coach Programme to overcome persistent and complex pain | t. 07518 445493 

15Aug/16

Get the most out of your exercises

get the most out of your exercisesIt is highly likely that when you visit a physiotherapist you will be given exercises and hence here is a brief guide to how you can get the most out of your exercises. The training is important, setting the scene for a desired change, but in order to be successful, we need to think about how we will be doing the exercises. In the Pain Coach Programme, we look at this in the necessary detail so that the individual can achieve the best outcome. Usually the exercises themselves are very straightforward, with the most complicated piece of equipment being the person, followed by a mirror. That’s it. We need to set the scene, focus, attend to what is happening now, practice, put in maximum effort, perform and learn. Sounds easy!

1. Create the right environment

Where do you do your exercises? How does that environment affect you? Are you doing some of the exercises at home, at work or outside. Notice where you can concentrate with ease and where makes you feel good about what you are doing. We are not separate from the environment in which we find ourselves and hence it can work for us well in creating the conditions to get better. It should be light, spaceous enough to move freely and as calming as possoble without stimuli that trigger survive responses. This includes phones, computers etc that can grab your attention and make you think about something else.

2. Take a moment to be present

To truly concentrate you must be present and aware of what you are feeling, thinking and doing. From there you are able to learn by gathering insights into what you are doing versus what you want to do, making corrections to movements for example. Mindful presence means you are present and aware, rather than being lost in thoughts about the past or the future that are embodied. In other words, our thinking is affected by our body state and vice versa as there is no separation. As an experiment recall a happy time: where you were, who you were with and what you were doing. This is a thought, but how do you feel in your body? So, how to be present? Simply take a breath and notice the in-breath and then notice your out-breath. We can only breathe now so gently concentrating on the breath is a simple way of being both mindful and present. Anytime you notice your attention drifting away, kindly bring it back by noticing your breath.

3. Connecting it all together

We must be fully aware of our mind and our body as a unified experience. How can you learn about your body and how it moves if you are thinking about a meeting yesterday or dinner tonight? You can bring your attention to your breath, saying to yourself ‘I am breathing in’ as you breathe in and ‘I am breathing out’ as I breathe out. Notice how you become aware of this moment, which is the creation of the right conditions for recovery and for learning. You can then expand your attention out to your whole body, thereby connecting it all together in a nourishing way. This only takes a few moments, but without the right attention, the exercise will have a limited effect as you will not realise what you have done.

4. Write a learning diary

‘What we focus upon we have more of’, is a useful way of being. When we notice our positive emotions, which can be subtle, and purposefully attend to them, our thinking broadens. There has been a good amount of research looking at this effect. Keeping a diary is a way of documenting the way we feel and what we have achieved so that when we look back and read what we wrote, we have an accurate view of what was happening at that time. Our memory of what happens is poor, but we do convince ourselves that certain things happened or we felt a particular way. Whether or not it happened like that becomes irrelevant as it is the memory we think we remember that counts. On this basis, writing down each day something that we have learned from our practices of training is a useful insight that motivates further learning as we focus on our achievements and strengths. This is encouraged by positive psychologists as well as featuring in mindfulness practices and strengths based coaching, and for good reason — focus on your strengths and manage your weaknesses, but you have to know what they are first!

5. Accepting where you are now as a stepping stone towards a desired outcome

To accept that I am here in this moment allows you to focus on what needs to be done right now that is in alignment with your desired outcome. Being really great at all the things that you need to do now will naturally allow you to move to the next step as you continue to transform. We are changing all the time and hence need to ensure that our change is in a desired direction. For this we need a vision of where we are going; a vision of a successful outcome that we visit often to ask the question to ourselves: ‘is this taking me towards my desired outcome or am I being distracted by thoughts of the past or future?’. Acceptance does not mean giving up, instead just saying ‘here I am right now’ and ‘this is what I need to think and do to keep myslf going in the right direction’.

The Pain Coach Programme to overcome chronic pain and injury | t. 07518 445493

05Aug/16

Facial pain

Facial painYesterday I spent the day in Leicester and Northampton seeing several people suffering facial pain with a colleague who has been working in the field. All pains are unique to the person, however, I feel that there are some particular features of facial pain, which are similar to those of facial dystonia. Identifying these shared characteristics has guided treatment and training techniques that aim to improve sensorimotor function as part of adapting and restoring a sense of self.

The loss of the sense of self is a significant part of suffering in my view. People describe how the pain or dystonia impacts upon their lived experiences and their choices, narrowing both. This means that they are not doing what they wish to and hence do not feel themselves as they feel they should. A shift has occurred, part of which is constructed via the ‘physical’ sense of the body. Of course we have a unified experience of ‘me’ including the sense of the body, a sense of a past, a projected future and the inner dialogue that strings it together.

We literally face the world with our face and hence anything that affects our perception of how we are doing this will impact on how I feel, think, the actions I take and perceptions I perceive. There is a spectrum: a red spot through to jaw dystonia — something visible to others that makes us second guess what they may or may not be thinking. Quite easily this can mean we avoid going out or seeing people. The isolation that ensues then gathers momentum, affecting us on many levels including genetically.

In cases of facial pain there may be no clear and consistent visible signs such as the involuntary movements of facial dystonia, however there are often habitual posture and facial expressions — tension, attempts to relax by opening the mouth, rubbing, speech impediments. When we are in pain, our body sense can be different, the perception of the environment can be different, the way we plan changes and our emotional state is one of protection, as is that of our underlying biology. Whilst this is vital for survival when there is an actual threat (an injury or pathology), in most cases of persistent facial pain and other pains, there is no significant injury. The pain is a habitual response to perceived threats that increase in number with time via learned responses and expectations. Things that would not normally pose as a threat now do, including the way we think about ourselves and the world. With a sensory system detecting changes internally and externally, in survive mode we can be jumpy and very responsive.

Facing the world with a painful face is challenging. Understanding pain is the first step to steering change in a desirable direction — how do you want to be? When the person understands that pain can and does change, and that they are the drivers of that change, then new habits can be formed — new habits of thought and action that are practiced over and over to create the right conditions. Likewise in dystonia, the practice of new habits to change the way in which the sensorimotor system is working but integrated with training that addresses the influences upon this system — e.g./ the environment, thinking, emotion. Learning to recognise and let go of unhelpful and distracting inner dialogue, focusing on what you can do, noticing positive emotions and how you evoke them, re-training sensorimotor function, gradually doing more normal and desired activities are all part of a comprehensive programme based upon the neuroscience of pain and using your strengths to be successful.

07Jun/16

Depression and inflammation

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

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

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

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

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

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

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

Pain Coach Programme | t. 07518 445493

14May/16

Kids know about pain distraction

Pain distractionI overheard an interesting conversation this week that demonstrated kids know about pain distraction.

Driving my kids to swimming, my eldest daughter was giving us an update on her wobbly tooth and the fact that it hurt. She was concerned that it maybe too painful to go swimming. My youngest daughter, 6 years, then piped up with an insightful suggestion: don’t worry about your tooth because when you are in the cold water you will forget about it’.

To me, as a pain-head (a term sometimes used to describe someone who is obsessively interested in pain and what it is), this was fascinating. Life in action, a natural comment based on some experience that my youngest must have had at some point, or at least heard about. I would think the former is more likely as the message surely stuck with her to the extent that her model of the world in relation to safety-threat has been updated to consider distraction as a way of changing pain and reducing the threat value — pain is a lived experience, compelling action in the face of a prediction of a perceived threat based on the hypothesised causes of the sensory information in relation to prior experience.

RS