Category Archives: Rehabilitation

27Apr/14

Never give up — a motivational talk

Diana Nyad swam 100 miles across a stretch of water between Cuba and Florida. She just kept going. The internal drive and the support that fuelled this drive kept her going in some of the most dangerous waters on the planet.

Rehabilitation and recovery from an injury or painful problem requires dedicated perseverance. But to optimise this perseverance we need to be motivated and inspired. We need to understand and know why; we need a purpose to drive us forward and keep moving forward. There are plateaus, flare-ups (when the symptoms and pain can increase), good days and bad days — life’s normal variation. Knowing why this happens, what we can do and why we are doing it keeps us moving forward.

Listen to Diana Nyed speak here about her experience and keeping going.

For information about our pain treatment programmes that are driven and inspired by neuroscience, explore the website and contact us on 07932 689081 to move forward

08Jan/14

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

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

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

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

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

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

08Jan/14

A quick note on… skiing — pain and injury

It is that time of year when many set off for the slopes for the joy of being on a mountain, the freedom of sliding, or bumping, down the piste and finishing the day with a favoured tipple, preferably in the sun. Sadly this is not always the case as there will be aches and pains, to be expected, and more serious injuries that require medical and surgical attention.

Firstly, the aches and pains. When we are active in a different way it usually hurts and that is normal. Waking up and trying to get out of bed with stiffness is never fun but it commonly eases off by the time a shower has been had and movement has been initiated. By and large, these aches and pains lessen as the week progresses and we are used to all the physical labours of carrying skis, poles and general clobber by the time we are heading home. I do not know how many people actively seek to improve their fitness before going skiing but many threaten to do so. If you are preparing, starting the week before will probably not do too much, but you may as well give it a go. Don’t go mad and pull a muscle. Ideally, several months before you should be undertaking exercises that in some way replicate skiing. Simple measures such as warming up and cooling down are often forgotten. Warming-up should involve easy mobilisation exercises of the whole body and cooling down in a similar way interlaced with a few stretches of the back and legs. Please note that you should always seek specific advice on exercises that are appropriate for you.

The more serious injuries involving ligaments, bones and tendons will need accurate diagnosis, good early management — that includes you knowing what has happened and everything that you should be doing physically and mentally to optimise healing; and there are many many things that you can do — pain control and a clear route forward of what needs to be done.

If you wish to prepare for your skiing trip and want to know more, or if you’ve suffered an injury that requires rehabilitation, please contact us now to find out how to go about getting back on the slopes and to normal living: 07932 689081

21Oct/13

How do you know where you are? | Neil Burgess speaks

It is useful to know where you are. Neil Burgess spends his time studying this important function by looking at the brain, the hippocampus to be specific.

It would appear that the same brain cells that create our sense of where we are and recalling that information for practical use are also at play when we imagine movement, such as a motor imagery task for a painful condition.

28Sep/13

You’ve had an intervention for pain – what is next?

Many people with persisting and chronic pain elect to have an intervention for pain relief. This can include steroid injections, facet joint injections, nerve root blocks, epidurals, denervations and sympathetic blocks to name but a few. These procedures are usually administered by a pain consultant (a doctor who specialises in pain management), an orthopaedic surgeon, a radiologist or a rheumatologist.

Undoubtedly, the interventions can afford pain relief but of course the results do tend to vary from person to person. Ideally, the procedure forms part of a multidimensional treatment programme that aims to reduce symptoms, increase activity levels and improve quality of life in the patient’s eyes.

So, what happens next?

In some cases nothing and in others patients are advised to reactivate with the help of a physiotherapist. In the former scenario, the expectation is that the procedure will solve the problem, the pain will ease and life returns to normal. Unfortunately there is an error with this thinking as in the vast majority of cases this leaves the patient with a host of unanswered questions: how much should I do? Can I do this or that? Is it safe? etc etc. If the pain persists in any shape or form, this increases the threat value of these questions. They must be answered with practical solutions.

Undoubtedly to follow a comprehensive programme that addresses the physical and cognitive dimensions of pain is desirable. The intensity and length of a programme will vary from person to person, but as a minimum, the patient should know what they can do and how they can do it as a way of moving forward.

Within the programme there are fundamental issues that must be tackled. For example, in many cases of persisting pain, the way in which movement is controlled has changed as has body perception. This has to be retrained and there are specific ways of achieving this goal. We know that these mechanisms play a role in sensitivity and hence need to be targeted.

Concurrent with physical training is the absolute need to create the right mindset and deal with any associated fears of movement. This may include working upon resilience, motivation and coping so that the training outcomes are optimised.

In summary, the understandable use of pain interventions should be part of a multidimensional treatment and training programme that tackles the physical, cognitive and emotional aspects of the pain problem.

20Jul/13

Creating the right conditions to move forward

3 key points

1. Nothing happens in isolation.

2. We are designed to change, grow and develop.

3. Nothing is permanent.

Bearing these fundamental points in mind, we seek to create and then cultivate the right conditions so that we may move forward in life. In terms of rehabilitation, we also look to create the conditions to achieve wellness that manifests in an ability to perform at home, at work and on the field of play.

Nothing happens in isolation: we are on a continuous pathway with an underpinning genetic make up that is sculpted by our experiences and environment (epigenetics). So when we experience a pain or an injury, the immediate physiological and behavioural responses that so affect the pain perception, will be determined by what we know and by what our brain knows (we do not know all the things that our brain knows. Or our nose knows). When designing and implementing a training programme for a painful condition, this is an important principle as the patient will have a story leading to the point when they exercise that will determine the response including what they have done physically, how they are feeling and what they are thinking. Anticipation and expectation must be addressed.

We are designed to change: neuroplasticity is a feature of the neuroimmune system that allows us to learn and change. However, the mindset around this is key. We must understand the we can change and have a belief that it is possible in order to behave in a way that will promote forward movement in life. This must be addressed in any rehabilitation programme and indeed it may be that thinking needs to be ‘rehabilitated’ as well.

Nothing is permanent: the concept of impermanence comes from Buddhism. Nothing is permanent, even pain and other symptoms. They change as does our thinking, emotional state and body sense. We may not think it does and particularly in suffering on-going pain. However, the intensity, quality, location and nature of pain changes regularly and this is because the neuroimmune system is dynamic, ever-responding to the internal and external environments. This is why the context of the situation is so key in pain. We must think about this in rehabilitation: the context of the training.

In summary, the natural processes within the body are simply designed for us. To maximise their potential we must create the right conditions for these processes to act and this means considering the physical, cognitive and emotional dimensions of the pain experience and how they interact. A single leg squat is a single leg squat, but what is the person thinking about the single leg squat, have they done it before, will the brain consider it to be safe, where are they doing it, when are they doing it……..the list of considerations goes on. Lets consider them.

For further information about our treatment and training programmes or to book your first session, call us on 07932 689081

16Jul/13

Two excellent talks for athletes

Both talks are inspiring and demonstrate courage, perseverance and motivation in the face of the enormous challenges that were presented. In performance and rehabilitation, mindset is a key determinant and in many cases several skills must be developed, including resilience and coping strategies.

In the first video, Janine Shepherd talks about her experience of recovery following a severe injury.

In the second, Aimee Mullins talks in 1998 about her record-setting career as a runner, and about her carbon-fiber prosthetic legs.

Call us now to find out about our comprehensive treatment and training programmes to tackle persisting pain, recurring injuries and chronic pain: 07932 689081

21Oct/12

Groove is in the brain – watching strictly come dancing to exercise those neurons

Strictly Come Dancing is great entertainment. Increasingly I have been drawn into watching the professional dancers and admiring their immense skill and body control. The precision, posturing and awareness, blending with glamour, grace and such defined movement demonstrates perfectly the art of motion to music.

The celebrities have a mix of backgrounds, some clearly having had previous experience of dance. Despite this, they are all having to learn a specific routine that must be taught, learned and practiced. The rehabilitation of a painful condition or injury necessitates training of normal movement and motor control, following a similar pattern to the celebs in many respects.

When we watch the dancers, we are actually being more active than you may think. Our brains are very active and in a way that is similar to when we would actually be moving. In other words, our motor systems are provoked into action by observing someone else move. For those in pain with a certain level of sensitivity, the initiation of activity in the motor areas in this way can be actually be enough to elicit a painful response. As a test, I sometimes ask a patient to watch me move to see how they respond. Not uncommonly they wince, feel a pang of pain or demonstrate an aversive response. And these are all very real experiences that people are having each day. Sitting having a coffee and watching a delivery man carry a box into the cafe may start to prime the nervous and immune systems in relation to movement with resulting discomfort or pain. It may be thought that the sitting position is to blame and indeed this is part of the experience, but so is watching someone else move.

Imagery is used in sport and business for good reason. Research has demonstrated that strength can improve with imagery and Jack Nicklaus famously spoke about his use of imagery for preparation and skill development.  On imagining a movement (motor imagery), the motor system is activated as described above. So either just watching or thinking about the movements of the dancers are not such physically idle activities. Our brains are involved and therefore using opportunities such as watching Strictly or other programmes involving physical activity can form part of the rehabilitation process.

“I never hit a shot even in practice without having a sharp in-focus picture of it in my head. It’s like a colour movie. First, I “see” the ball where I want it to finish, nice and white and sitting up high on the bright green grass. Then the scene quickly changes, and I “see” the ball going there: its path, trajectory, and shape, even its behaviour on landing. Then there’s a sort of fade-out, and the next scene shows me making the kind of swing that will turn the previous images into reality and only at the end of this short private Hollywood spectacular do I select a club and step up to the ball.” Jack Nicklaus

The neurons that underpin this very real experience of observational activity are commonly called ‘mirror neurons’. They were discovered in monkeys a few years ago and have provoked many studies looking at their role in planning movement, watching others, developing relationships and autism. These neurons may make up 30% of the brain. Next time you are chatting to someone, see if either of you start posturing in the same way or indeed yawn together.

When the professionals are demonstrating and teaching the dance moves, see how they position themselves in relation to the celebrity. It makes a difference as some will struggle to ‘see’ and copy the pattern of movement. Watch how they re-orientate themselves in a first person perspective so that the dancer’s right is their right and vice versa. When teaching any new skill we should allow the learner to see from this 1st person perspective, i.e. experience it from their position, e.g. sit alongside so your right is their right. More challenging maybe the 3rd person perspective when they watch you and try and copy the movement having had to manoeuver their body, i.e. watching from the front. This can be used as a progression in rehabilitation, firstly using imagery and then actually performing the exercise.

What is happening? The learner’s brain is mentally rotating their representation of their body (that exists in the cortex) to match that of the teacher. This can be difficult and has certainly been shown to be problematic in certain conditions such as back pain and complex regional pain syndrome (CRPS).

Understanding the activity in the brain when we think about moving, watch others move and actually move allows us to design rehabilitation programmes that fully engage the motor and other allied systems in a range of contexts with progressions to develop the challenge.

So for now, keep on dancing. In your chair.

29Mar/12

It’s tight…it’s being protected

Tightness in the muscle is a common complaint. Often part of a profile of symptoms following an injury and frequently a stand alone sense that persists, tightness and stiffness need addressing to normalise movement and control of movement. Normalising movement is a key part of desensitisation in that it is one less reason for the body to protect itself.

Tightness can be an expression of protection – what is being protected and why?

To address persisting tightness we must determine why and what is being protected. There could healing tissue, a pocket of inflammation or sensitivity to movement within the nervous system (mechanosensitivity). A detailed assessment of the problem, the preceding history and prior events reveal the nature and underpinning source(s), i.e. biological mechanisms. These mechanisms are then targeted with appropriate treatment and strategies.

A common treatment method that we use is called neurodynamics. This is a range of hands-on techniques and movement-based exercises that nourish and mobilise the nervous system. Bearing in mind that our tissues will only be as healthy as the nerves that supply them (a general rule of thumb, but other factors are important including the immune system and endocrine system), it is very important that the nervous system be moving and its blood supply patent.

Tightness can be a sign of guarding. Guarding is protection orchestrated by the brain and can occur at a motor planning level. This means that before moving, the brain increases the activity of certain muscles as a way of protecting a body region for when movement actually occurs. A common example of guarding is in the case of back pain when the muscles remain ‘on’ as the spine is flexed forwards. These muscles should switch off and relax, however the fact that they remain active means that the movement is not normal. Addressing this is important for re-establishing motor control.

Local treatments are often used and can help in the short-term. However, these should be used as part of a rounded programme addressing the pain, symptoms, impact, limitations and other dimensions of the problem. Delving into the details and observing the sometimes subtle changes in movement and control of movement allows us to elucidate the reason(s) for protection and deal with persisting tightness.

03Feb/12

Chronic pain in sport – Specialist Clinic in London

Chronic pain is a real problem in the sporting world. The effects of not being able to participate are far reaching, especially when sport is your profession. There are a huge numbers of clinics offering treatments to deal with pain and injury and in many cases the problem improves. However, there are those who do not progress successfully, resulting in on-going pain, failed attempts to return to playing and varied responses to tissue-based treatment (manual therapy, injections, surgery etc). Understanding more about pain and how your body (brain) continues to protect itself is a really useful start point in moving forwards if you have become stuck. We know that gaining knowledge about the problem can actually improve a clinical test and the pain threshold.

When we injure ourselves playing sport the healing process begins immediately. Chemicals released by the tissues and the immune system are active locally, sealing off the area, dealing with the damaged tissue and setting the stage for rebuilding and repair. The pain asscociated with this phase is expected, normal and unpleasant. It is the unpleasantness that drives you to behave in a protective manner, for example limp, seek advice and treatment. Again, that is normal. Sometimes we can injure ourselves and not know that we have damaged the tissues. There are many stories of this happening when survival or something else is more important. This is because pain is a brain (not mind or ‘in the head’) experience 100% of the time. The brain perceives a threat and then protects the body. If no threat is perceived or it is more important to escape or finish the cup final, the brain is quite capable of releasing chemicals (perhaps 30 times more powerful than morphine) to provide natural pain relief. We know that pain is a brain experience because of phantom limb pain, a terrible situation when pain is felt in a limb that no longer exists. The reason is that we actually ‘feel’ or ‘sense’ our bodies via our virtual body that is mapped out in the brain. This has been mapped out by some clever scientists and in more recent years studies intensely using functional MRI scans of the brain.

Unfortunately, the brain can continue to protect the body with pain and altered movement beyond the time that is really useful. Changes in the properties of the neurons in the central nervous system (central sensitisation) mean that stimuli that are normally innocuous now trigger a painful response as can those outside of the affected area. One way to think about this functionality is that the gain or volume has been turned up, and we know that much of this amplification occurs in the spinal cord, involving both neurons and the immune system. Neurogenic inflammation can also be a feature, where the C-fibres release inflammatory chemicals into the tissues that they supply. On the basis that the brain is really interested in inflammation, even a small inflammatory response can evoke protective measures. Changes in the responsiveness of the ‘danger’ system as briefly described, underpin much of the persisting sensitivity. Altered perception is a further common description, either in the sense that the area is not controlled well or feels somewhat different – see here.

As the problem persists, so thinking and beliefs about the pain and injury can become increasingly negative. Unfortunately this can lead to behaviours that do not promote progression. Avoidance of activities, fear of movement, hypervigilance to signals from the body and catastrophising about the pain are all common features, all of which require addressing with both pain education and positive experiences to develop confidence and deeper understanding. An improvement in the pain level is a great way of starting this process, hence the importance of a tool box of therapies and strategies that target the pain mechanism(s) identified in the assessment.

Experience and plenty of scientific data describe the integration of body, brain and mind. This can no longer be ignored. It is fact. The contemporary biobehavioural approach to chronic and complex pain addresses the pain mechanisms, issues around the problem and the influencing factors in a biopsychosocial sense:

  • Biology: e.g./ physiology of pain, body systems involved in protection, tissue health
  • Psychology: e.g./ fears, anxiety, beliefs about the pain, thinking processes, outlook, coping, past experiences
  • Social: e.g./ work effects, effect upon the family, socialising, role of significant others (spouse, family), financial considerations

Specialist Clinic in London and Surrey for chronic pain and injury in sport – call 07518 445493

Chronic pain and injury requires an all-encompassing biobehavioural approach. Although the end aims can be different, the structure and themes within the treatment programme are similar to those that tackle any chronic pain issue. Bringing these principles into the sports arena, we can incorporate traditional models of care and advance beyond the tissue-based strategies to a way of working that addresses the source of the problem alongside the influencing factors that are slowing or even preventing recovery.

If you as a player are struggling to move forwards or have a player on your team who is not recovering or failing to respond as expected to treatment, we would be very pleased to help you. Call 07518 445 493 or email [email protected] for further infomartion about the clinics:

The Specialist Pain Physio Clinics work closely with the very best Consultants and can organise investigations such as MRI scans and x-rays with reports rapidly, an on-site at the New Malden Diagnostic Centre, 9 Harley Street and in Chelsea.