Category Archives: Sports Injuries

16Jul/17
Andy Murray hip pain

Andy Murray’s hip

Wimbledon 2017 ~ the growing injury list

Andy Murray hip pain

The Wimbledon Championship has featured a significant number of injuries this year. On the same day we lost Djokovic and Andy Murray, the former retiring through injury, the latter struggling with hip pain. Sadly for British fans and tennis fans, the intensity of the pain prevented him from progressing. Murray was obviously struggling to move normally as his body shifted into a state of protect.

Why do players breakdown at the tournament?

There are several reasons. The game has become increasingly physical together with the pressure to perform in tournament after tournament. Everybody needs recovery time, and some players may simply have figured in too little within their schedule. It is not just the game time that requires subsequent recovery, but also the training: on court, strength and conditioning etc.

One must ask about the pressures to play, both financially and to achieve a ranking. To earn money, and this is a job that pays the bills, and to be ranked, players need to play. They are also driven to be the best that they can be, which means pushing oneself. The cultural meme in sport ‘no pain no pain’ exists and anyone involved in any kind of physical activity knows that intense play hurts. So when is it normal and when is it a problem?

It is somewhat easier to make that judgement in amateur sport when the stakes are not so high. Your career does not depend on playing that extra game. In professional sport, understanding pain is absolutely key in making this all.

This week a commentator pointed out that all players have some kind of injury and that no-one is 100% fit. What is 100% fit anyway? This will mean different things to different people. Do players feel aches and pains everyday? Yes, everybody does to a greater or lesser degree. Life hurts! But in many cases, the pains come and go, and do not impact upon life or performance. If a pain repeatedly occurs and does have an impact upon performance and life, this is something that does need to be addressed.

Acute injury vs persistent injury vs persistent pain

It is interesting that most of the injuries we have seen this year have not been acute. In other words, the players knew about the problem beforehand as it has been rumbling on for some time. Murray reported that his hip has been something he has been dealing with for years.

This is with the exception of Bethanie Mattek-Sands when her knee injury happened there and then, taking everyone by surprise. This is one of the reasons it was so shocking, because no one expected it, least of all Bethanie herself.

There is a difference between an injury moment and a pain moment. Pain and injury are not the same. Pain is part of the way we are alerted to being in a state of protect, a great motivator compelling action, and an injury is when there is a disruption to our body. An injury can often hurt but it does not have to, and the extent of the pain varies enormously depending upon a number of factors.

Andy Murray's hip

Pain and injury are not the same – read here

The terms pain and injury are often used interchangeably and this is not correct. Persistent or chronic pain and chronic injury are not the same. A chronic injury would mean that the healing process has not completed, taking longer than would be expected. Persistent or chronic pain is not well related to the tissue state, instead being a reflection of an on-going state of protect. There are a number of reasons why the state of protect persists and these are a main focus for the treatment and coaching programme to overcome the problem.

Murray’s hip pain

Whether Andy Murray has an injury or a pain problem we do not know. I hope he knows because this will determine the treatment and the training needed. Undoubtedly when a player is training and playing as often as Murray, there needs to be down time. Has he had this time? Federer took time off and appears to have benefited.

No-one can keep going at a high pace in life without recharging. We all must figure in refresh and renew points through each day, learning how to switch to ‘care-giving’ mode. In this state, our body systems are doing all the vital things for long-term health and well-being. Without this we burnout: chronic pain, poor sleep, low mood, depression, anxiety, irritable bowel syndrome, fertility issues etc etc, many of the common, modern day ills.

A person who presents with a long term hip pain needs to tell their complete story. From there the key points and ‘primers’ are identified. In essence the person does not feel themselves and the aim is for them to be able to say, ‘I feel myself’. In fact, when we feel ourselves and get what we expect, we are in flow and do not really think too much about how we are doing things. They just happen. We do not normally think about walking, but if my hip hurts I will scrutinise every step, the pavement, others walking towards me, hills, steps etc. The world looks different and I feel different. Normalising these is key.

Let’s hope that the nature of the problem can be truly established and then dealt with effectively and with long-term results in mind. Hips, like any body area, are not in isolation to the whole, and typically relate closely to the back and pelvis. Murray has had back issues before, a very common problem in both athletes and the general population, so I am sure this will be considered as part of the bigger picture.

What is your picture of success?

We all have our picture of success and should know what that looks like. This vision becomes a reference point and an orientation as we follow the necessary training programme and learn along the way. One can check in and ask: ‘Am I heading in my desired direction or am I being distracted?’. For Andy Murray, I would imagine his picture involves him consistently playing his best tennis. The key is to focus on what we want rather than what we don’t want. When I ask patients ‘what do you want?’, they often reply at first, ‘I don’t want this pain’.

Whilst this is an understandable response, the pain is actually what you do not want rather than what you do. This may sound all rather semantic, however there is an important practical difference. What we focus upon, we get more of. Think about what you actually want, crystallising the image and doing your utter best to get there.

“Don’t think of red elephants

Andy Murray, like all sports people, has a coach. His coach will work together with him to tap into his ‘greatest self’ so that Murray can achieve his best results. It is no different with overcoming pain. The person suffering chronic (on-going) pain is coached to be their greatest self. They are coached to become their own coach. In other words, because the person is with themselves consistently, they need to know independently how to orientate their thinking and what actions to take to get the best results. On the strong foundation of understanding paincoaching provides a structured way onwards, carving out a fulfilling life.


Pain Coach Programme to live a fulfilling life ~ t. 07518 445493 mailto:[email protected]
09Jul/17
Andy Murray's hip

Pain and injury at Wimbledon

Why is there so much pain and injury at Wimbledon this year?

Pain and injury at Wimbledon

Seven retirements and a very painful injury on-court yesterday at Wimbledon have given the tournament a different feel. Pain and injury are part of sport, but many people have been surprised by the turn of events. Federer has called for a review of the system and several players have complained about the state of the courts. All are factors of course. The game is simply made up of the synergy of players, court and tournament. When all are ticking, we see great tennis.

The very painful moment

Bethanie Mattek-Sands was screaming out in pain this week after her knee appeared to give way. One report suggested that she could have sustained a knee cap dislocation. This can be extremely painful until relocated. Seeing the dislocation can add to the trauma. When our body does not appear as we expect, the sight can trigger feelings of aversion.

Why so much pain?

Pain is a part of the way we protect ourselves. There are many other things going on when we are in state of protect: change in movement, change in sense, altered thinking and emotion, change in perception. In other words, the world looks different and feels different as we take action in the name of survival. This is a normal shift of state in the face of a perceived threat. Pain is a lived experience when there is a perceived threat. Pain is not well related to injury. This is the common misunderstanding. Just because it hurts a lot, it does not mean that the injury is more severe. We have known this for a long time ~ see here: pain in sport, 3 key points.

When thinking about the reasons for the pain response, the context is key. In other words the situation plays a significant part in the pain experience. As well as potential tissue injury, where that possible injury occurs and what is happening is highly relevant — it always has to happen somewhere! The full picture perceived creates a learning opportunity. If this is possibly dangerous, I need to remember what happened and where so that next time I can react differently.

All of this information is processed together with sensory information from the body, based upon what is already known about injury and the situation. In essence we make a best guess about the possible causes of the sensory information on a background of our previous experiences. In effect, we weigh up the evidence: new information vs what we know, which then suggests a scenario. If this is a potentially dangerous situation, pain can then form part of the experience. The more danger perceived, the more intense the pain.

How much danger did Bethanie perceive when her knee gave way at the biggest tennis championship in the world, in front of a big crowd, when each game is career shaping?

Whatever the outcome for Bethanie, I wish her well.

Messi’s knee

In 2012 Lionel Messi was running into the box when he brushed the keeper as he came out to meet him at speed. Messi managed to get a shot away (he missed) before he hit the ground clutching his knee. He was quoted as saying that he thought his career was over because of the pain.

How dangerous was the situation to Messi? Consider: the perceived injury (he did not know about the extent of the damage at that point), the game, the crowd silent, the body part involved, how knee injuries are thought of in the culture of football, the immediate thoughts about injury and what it means and much more.

Messi was taken off the field on a cart and whisked to hospital where he was scanned. What was the injury? A bruise.

Pain and injury are not the same. The terms are often used synonymously, but this is not correct usage. A further example is phantom limb pain. The person suffers pain in a limb that no longer exists.

Pain and injury

Why have there been so many injuries?

We have seen multiple retirements during games at Wimbledon this year. Whilst some people have been frustrated, we must also consider that these players have to make choices. These are based on the culture of the sport, the system, their career, their income and their understanding of pain.

There will be a weighing up of the pros and cons, and each individual will consider different factors before deciding. We do not know what those factors are in each case, so we cannot make any specific assumptions or criticise. In life, how many assumptions are made when someone is being critical of another without knowing the full picture?

“aches and pains are part of sport

In sport, the day to day aches and pains are a well known part of the deal. Simple measures are taken to address theses responses so that the athlete can continue to perform: e.g./ physiotherapy treatment, massage, ice baths, stretching, periodisation. However, despite the level of fitness, each body needs to adapt to the demands of the training and play. Without this time, there can be a tipping of the ‘build-breakdown’ balance towards the breakdown (inflammation). A state of chronic inflammation is likely to explain a range of common problems that can become significant.

When an acute injury occurs in sport, there is pressure to resume play as soon as possible. Do players return too soon? Are they fully ready? Being ready means that the body tissue are robust to withstand the stresses and strains, movement patterns are normalised (and not guarded), body sense is acute and thought patterns focus on the game and not on the body.

“the clues are in the story

We do not know all the factors involved with each player at Wimbledon who had to retire, but the points described above are relevant and need consideration. When clinicians are assessing an injury, this is especially so. Each injury or pain moment (the two are different) occurs in a context as we have established. Nothing happens in isolation, we are on a timeline, and hence we must consider how the person may be primed by prior learning. What are the influences upon this current moment? Some will be obvious and some more hidden. This is why allowing the person to tell their story is vital. The clues lie within their narrative, so we must listen actively and be open.

This is a brief look at some of the key issues. Pain and injury are always going to feature in sport. We need to draw upon the pinnacle of our knowledge of pain and bring this into the athletic world. In other words, we need a shift in the thinking away from the biomedical model, instead looking at the wider picture: a true biopsychosocial, or sociopsychobio model. Here is a reminder of the key points:

The key points:
  • pain and injury are poorly related
  • pain is suffered by the (whole) person not a body part (e.g. tendon pain ~ the primary focus remains on the tendon rather than the person)
  • pain does change when it is understood by the person and they actively create new patterns

04Jul/17
Pain and injury

Andy Murray fit for Wimbledon ~ pain in sport: 3 key points

Andy Murray fit for Wimbledon ~ pain in sport: 3 key points

Andy Murray fit for Wimbledon ~ pain in sport: 3 key points, but first…

What does Andy Murray have in store for fans this year?

Undoubtedly Andy Murray is resilient. He declared himself fit for Wimbledon 2017 and he has just beaten Alexander Bublik to take a step closer to the final: one game down, six to go.

There were concerns in the media about Murray suffering left hip pain during the build up to Wimbledon. Apparently this is a problem he has had for many years, however he is not going to let this stop him from giving his best. We have become used to his determined attitude, one that he has had to develop towards pain and injury in particular.

Clearly performing at the elite level has an impact upon the body, which is why the conditioning must be right to check the physical stresses. But, we are more than a physical shell. We are a ‘whole person’ and hence being resilient to life’s challenges is a key skill. This is an exciting time for Andy Murray as he embarks on his defence of the title whilst expecting a second child with wife Kim. Being able to put aside the hip pain, he could even be using this wonderful news as an inspiration.

In 2013 I wrote a blog about Andy Murray, back surgery and microdiscectomy. It still gets a fair few hits, particularly at this time of year when people are reading about him and Wimbledon. I stated that the rehabilitation “is not just about exercising. It is about understanding, learning, motivating, creating the right context for movement with confidence and many more factors that can lead to optimised outcomes”. Since then Murray has had a remarkable time, currently holding 45 titles.

“rehabilitation is not just about exercising

Murray fans now hope to enjoy (is that the right word?) the next two weeks. The pinnacle would be next Sunday watching a closely fought final with a Murray victory. Who knows? Sport these days chucks out surprises that ultimately keep us all riveted. Look at the Lions last Saturday!

Now, my blogs would not be my blogs if I didn’t somehow turn the thinking to pain. One of my favourite areas of discussion is pain in sport, in particular chronic pain in sport. Yes it exists! (Some people seem to think it may not….). Many times I have given my lecture and talks on the topic, encouraging modern thinking about pain to emerge in the sporting realm. There are some simple principles to begin with, and we can use Andy Murray to illustrate the points.

3 key points

Pain and injury are neither the same nor well related

We have known this for many years. The famous lecture and paper was in 1979! So when you see Murray in pain on the TV, this does not tell you much about the state of his hip. It does tell you that his body systems are in protect mode, compelling a range of behaviours and actions that can be seen. Pain on the other hand, cannot be seen. Pain is a lived experience. Can you see funny? Can you see hunger? All these experiences are whole person, which is my second key point.

“pain has only a weak connection to injury but a strong connection to the body state

Pat Wall (1979)

Andy Murray fit for Wimbledon ~ pain in sport: 3 key points

Pain is whole person

This means when we are treating pain and overcoming pain we have to think about the whole and not reduce it to a body part or some physiology. If my knee hurts, it is ‘I’ who feel pain and not my knee. Much like thirst. It compels action by me, the agent. Think for a moment: where do you feel thirst? Some may say in my mouth or throat. Think again. That is a dry mouth, which you may interpret as a sign suggesting that you need a drink. Pain always exists in a context. The context is the person, the environment, the action, the perception, and prior experience. Of course this changes all the time, as are we, the dynamic and ‘updating’ humans that we are. This gives great hope because when we tap into our incredible ability and resource, we realise that we can chnage pain and transform our experience. And that is my third point.

Pain can and does change, beginning with truly understanding pain

This has become so important to me over the years that I have set up a social enterprise in that name: understand pain or UP. Understanding pain gives you the foundation that you need to be able to take the actions that get results. Build upon a model of success and using the tools of coaching, in particular strengths based coaching, you set out your vision. What do you want? Then you orientate your thinking and attitude towards this picture of success and do your utter best. This is the route that Andy Murray has taken and continues to pursue, just like any elite athlete or person who has achieved.

These 3 key points are fundamental and continue to feature in my talks and writings. They do so because they are vital ingredients in the clinic. There are many others, but to start with these orientates the person in the right direction. As clinicians we may think ‘treatment’ but we offer so much more. We do treat and this is important. We also coach: we coach people to coach themselves in their world and to immerse themselves in the practices that result in living as best they can. Together we create the understanding and conditions for the person to flourish and feel themselves. They live fulfilling lives with all the joys and pleasures that exist whilst developing the resilience and skills to face challenges and learn. We can do this at any age, and we should be teaching kids these skills right now in schools ~ that’s for another time.

So, good luck Andy Murray and all the others chasing the Championship! We will enjoy watching you all over the next two weeks.

RS


Pain Coach Programme ~ treatment, training and coaching to overcome pain and live life 07518 445493

 

 

09Jun/16

Pain and injury

Pain and injuryPain and injury are poorly related. Unfortunately most of society continues to believe in a stimulus-response relationship between these factors, but in reality it does not exist. This was raised by Pat Wall in his classic 1979 article entitled ‘On the relation of injury to pain’.

Since then we have learned an enormous amount about pain; what it is and the purpose it serves. Why should the relationship between pain and injury be so unreliable? The answer is because pain is contextual, motivating appropriate action for that moment depending upon a range of factors. These include the injury itself and what it means, prior experience, beliefs about pain, the environment, who is there, how one is feeling before and at the point of injury and what is going on at the time. Here are some examples:

* a carpenter hitting his thumb with a hammer — despite the fact it will hurt, this is not unexpected, an occupational hazard if you will, and soon dismissed.

* an electrician electrocuting himself — similar to the carpenter; the context is key

* spraining an ankle in a cup final — there are many reports of injuries being sustained whilst playing sport that are not painful at the time, because playing on is more important

* battle hospital reports — severe injuries but no pain initially; the same in many accident and emergency reports

* a concert violinist who cuts his left index finger the day before his most important gig — what do you think this experience could be like versus a chef?

These examples demonstrate the variability in lived experience despite the biology of healing being similar (effectiveness may vary depending upon existing and prior health) — the two lives, that of our biology and that of our lived experience. The clinician’s role is to marry the two for the person so that they understand the hows and whys before focusing on what needs to be done to get better.

When my knee hurts, or any other body area, the vast majority of the biology that is involved resides elsewhere. Pain is located to my knee, although I can’t possibly know from where exactly; where is the stimulus? Yet to feel pain in my knee I need the systems that protect me to detect certain sensory activity, predict that the causes are threatening and then translate this to a sensation that is pain; i.e./ the biology becomes ‘conscious’. Whilst there are signals from the knee to the spinal cord and onwards, this is not necessary for us to feel pain. Think about phantom limb pain.

There are many levels whereby signals and predictions are modulated until the most credible prediction emerges as a lived experience. This is why prior experience, beliefs, emotional state and our thinking play such a role in pain as all can modulate the meaning and level of perception of threat.

An analogy is watching a film at the cinema. The film is on the screen yet for this to happen and be experienced, there must be a projector, electricity into the projector, and this electricity comes from the grid. Most of the necessary elements are not where you watch the film. The same can be said of pain, when it is made up of many non-pain factors that come together to create that lived experience. The point there is that when we address these in a comprehensive treatment and training programme, we can change pain and get better. But to do this we must think beyond the structure (the cinema screen) and consider the person, their beliefs, their thinking, their lived experience, the phenomena of their life, in order to be successful, which we can.

Pain is not related well to injury, but instead to the level of predicted threat.

Pain Coach Programme for persistent pain | t. 07518 445493

 

31May/16

Wrist injury for Nadal

Wrist injuryThe wrist injury for Nadal has been heavily reported in the media. This must be immeasurably disappointing for Nadal, who has suffered with a catalogue of problems over the years, as he seeks to overcome the pain and injury.

Playing sport at this level means that your body is your business. I am going to qualify the term ‘body’ for it is important to consider the body as part of the whole and is in no way separate from the concept of mind — we are our mind; we are our body; the unification has no beginning or end, just emerging as ‘me’, the self.

As we know, to play top flight sport requires immense fitness that necessitates training that blends with that of technique. Nadal has always played an extremely physical game, which is his style, his tennis character or persona. From the first step onto court until the final stroke, physicality predominates but the notion of physicality is not only in the muscular frame, but emerging from the man himself. We can see his body move, but it is he, the man who moves and lives that experience. The point here is that a body does not move in isolation from who we are, what we think and feel emotionally. This factor starts to provide some insight into how we must approach recovery from injury, especially when there are a string of injuries that can appear to be unrelated. I would argue against this, suggesting that there is a commonality in the way we respond to injury and how this governs the recovery.

The way we respond to injury and pain (the two are unreliably related) is individual and dependent upon our beliefs and what we think according to what has happened before. If I believe that pain is related to tissue damage, still the predominant thinking, then I will act in a particular way, and if I know that pain is a normal part of a protective response related to the level of predicted and perceived threat, I will act in another. This highlights the importance of the person understanding their pain to get the best outcome.

When an athlete or a non-athlete suffers on-going injuries or repeated injuries, even in different body locations, one must consider why this is happening and why they are not fully recovering despite their apparent health. One could also ponder on the question of whether they are as healthy as they can be? Chronic stress, where the person consistently perceives threat thereby feeling anxious and tense, changes our chemistry as we operate in survive mode. This does not allow for the most effective healing process as our resources are diverted elsewhere. The athlete in a stressed mode who then sustains an injury will have a different response to the athlete who feels empowered, who is in control and has a high level of resilience at the moment of injury. This is why looking at the whole context of the injury is so vital as important influences and vulnerabilities can be overlooked. Understanding these means that the person and the team can fully address the problem.

Priming or kindling is a good way to think about persistent injuries or the string of injuries scenario. An initial sensitisation is a learning experience for the systems that protect us, meaning that it has a bearing upon the next injury or pain and so on. A string of injuries suggests that a vulnerability has arisen, often due to the prior recoveries not reaching full resolution; i.e./ there remains a perceived threat and on-going protection. In this situation, a further injury, either actual or potential, creates a context for the body systems that protect us to kick in, emerging as pain, altered body sense and movement, a story that we tell ourselves, all unifying to create a change in the sense of self, and not one that is congruent with desired performance outcomes.

The story of a player or athlete being plagued by on-going problems is common in sport as they patch up one area after another. Investigations, treatments, injections etc etc., yet not fully shifting from protect mode to health mode. This must be at the heart of a rehabilitation and recovery programme — the person must get better as a unified experience. I must feel myself again, which means that I am the performance, I am the shot I play rather than over-thinking to anticipating or focusing on another factor that interferes and distracts me from what I am doing.

In summary, completeness of recovery is key and this begins with understanding pain and its poor relationship with injury before creating the right conditions in thought and action. The programme must include threat reducing experiences including the way we think, how we attribute sensations, what we tell ourselves, redefining precise body sense (where I am in space and how I move in relation to the environment) and movements to say the least. Maintaining the desired outcome in mind, remembering that you are your mind (it is not just behind your eyes) and that some of your thinking is done with your body and its movements, both motivates and allows one to question if you are heading towards this or being distracted. Learn and take every opportunity to be on the path of change towards this desired outcome, persevere and dare to be great at what you are doing.

Pain Coach Programme to overcome pain | t. 07518 445493

22May/16

Sports injuries brewing

Sports injuriesHaving seen a couple more cases of sports injuries brewing this week, it reminded me how common this issue is amongst the active population. It goes something like this…..

A minor tweak that improves somewhat, but not entirely, hanging around and occasionally reminding you that there’s something going on. Often dismissed as a pain that will get better in time if I forget about it and think about something else. It goes away for now.

Then another body part or region chimes in, sometimes replacing the first tweak, sometimes in concert. You tell someone who will listen that the pain has moved from A to B, as B now demands some attention now and again. Except now and again becomes more frequent, being more now than again, subtly creeping up on you as a more consistent pain. You may notice that your running style has changed, or that you are not concentrating so much on the activity but instead wondering if it will hurt or why it is hurting. Performance suffers.

I have described a two step story when in fact in most cases the person tells me about their pain and as we look back, there are multiple aches and pains. It is not unusual for there to be a slight change in general health, and most definitely lifestyle patterns influence the problem. This is simply because none of the issues are separate or in isolation. It is the person who lives the experience and hence they are the perceivers of their body and environment (unified) as well as the producers of that perception and the action taken.

What is happening?

Some refer to kindling, like a fire building up over time. There is an injury or inflammatory response during a time of vulnerability (e.g. perceived stress, tiredness, illness), or the person is vulnerable to experiencing an amplified protective response due to prior learning — how their protective systems have learned to interpret the possible causes of sensory input. So each time there is a protective response, the effects grow, the impact increases and all quite gradually in many cases.

How did this happen? This is frequently asked as the gradual nature means we forget about the priming or kindling events on the way to what is happening now.

This is why it is important to fully recover from injuries and illnesses so as not to carry over the effects. To do this, one must restore the normal healthy mode, re-train body sense and movement, develop confidence and technique; in essence feel yourself again, which is to say that the focus is on the performance.

Pain Coach Programme to comprehensively overcome persisting pain and sports injuries | t. 07518 445493

** Common persisting pains from sports injuries include back pain, tendon pain, knee pain, ankle pain, shoulder pain, tennis elbow, wrist pain.

26Apr/16

Why tendons get better or not…

Why tendons get betterWhy tendons get better or not… was the question posed. Six of us were lined up to look at potential answers, the areas including isometrics, movement, injections, brain and pain. I was asked to consider brain and pain. Here are my thoughts.

To feel, to think, we need a brain but we are not just a brain. We are of course much, much more. We are a whole person and hence the brain is not the answer to the question why tendons get better, or worse. My main clinical focus is upon those that have not got better, looking at why (the back story, the primers and vulnerabilities) and then what thinking and action is needed now to change course. So most people I see are those who have got worse and in fact, we need to know as much about getting better as we do getting worse. Both are complex but then I argue, we have a greater opportunity to intervene.

The emphasis in my 10-minute talk, a format that is increasingly popular, was upon the fact that it is the person who gets better and not the tendon. What is getting better? What does this mean? I asked myself this question some time ago and followed up with asking ‘who gets better?’ for a talk at a CRPS conference. It has to be the person because it is the person who is conscious and ‘rating’ themselves as being better. The tendon cannot do this — a tendon does not know if it is better or not. Semantics you may think, but important I would say on the basis that we ‘treat’ a person.

A sense of being better results in a person being able to fully engage in their lives as they wish — meaningful living. However, much of our day to day existence is unremarkable, punctuated by situations we remember unreliably. However, we tell ourselves a story about ourselves over and over, with the ‘self’ as the main part in the film. It is strongly argued that the ‘self’ is an illusion: ask yourself where your ‘self’ exists? When you have finished pondering on that small questions, consider again getting better — ‘I’ must rate myself as getting better, meaning that I am able to focus on the task at hand and not be regularly drawn to unpleasant sensations in the space where my tendon (and other tissues) lie or be thinking about the implications of the pain — I can’t do this or I can’t do that etc. So, I concluded that the person gets better when they judge it so and hence the person being more than a brain, but certainly needs a brain, then we have to think wider.

On brain, I also briefly cleared up the seeming confusion between talking about the brain and central sensitisation. Because I argue that we need to address the person (a brain, a body, a context, an environment — unified) to address pain, and that this includes the brain, this does not mean we are saying it is central sensitisation. Without a thought that I have a tendon pain, there is no tendon pain, and hence we must address the top down processing (e.g. thoughts that are underpinned by beliefs, because of what we have been told or learned) because they impact upon the prediction as to what the sensory information means in this moment; the brain’s best guess, which is what you and I are feeling right now. Changing this prediction by minimising the prediction error by taking action is most likely how we are going about getting better.

In terms of pain, this is usually the driver that takes the person to seek help. The pain is stopping the person performing and motivating or compelling action because it hurts. The pain itself is flavoured by thoughts, sensations, thoughts about sensations as a unified experience involving many body systems that have a role in protecting us. Pain is about protection yet is part of the way we protect ourselves with other adaptations including changes in sense of self via altered body sense, altered movement, altered thinking and perception of the environment. With these adaptations occurring over and over, adapting to adaptations and onward, we need a programme that matches pain as a lived experience. What do I think and do now in this moment? The person needs to become their own coach to think and act in a way that takes them towards their vision of getting better, over and over. This means creating new habits, and that is the training programme aspect.

There is much more that can be said on this area, which has many common features with other persistent pain states. We can summarise by agreeing, as we did on the night, that there is no single answer but instead we must draw upon different areas of science and philosophy to ask the right questions and create the wisest programme that addresses pain as the unified experience that it is — physical, cognitive and emotional — but in that person with their story.

 

 

13Feb/16

Tendon pain

40+60 Feet | Bark |https://flic.kr/p/7rvmbB

40+60 Feet | Bark |https://flic.kr/p/7rvmbB

Tendon pain has been a big topic for some years. The problem is seen commonly in the clinic and frequently poses a challenge because so often tendon pain persists. Local factors and nociception are typically blamed, yet when treatment is focused at the tissue level, the limitations are exposed. As an aside, tissue based strategies are cited, yet there is really no such thing as a tissue based treatment simply because the tissues are not separate from the person. They are the person, and of course the person knows that something is being done to them and hence emotions and thoughts are at play, affecting the outcome — consider the person who observes your hands whilst you mobilise or massage whilst remaining calm and curious versus the person who is anxious, guarded with their hand poised and ready to grasp your hand as you start treatment; the latter person demonstrating why it is vital that the threat value be diminished before starting any intervention.

Pete’s excellent blog about tendon pain acknowledges the person, perhaps for the first time in tendon literature, which is music to my ears. Having been heavily influenced by Oliver Sacks, my philosophy has always been to consider the person as much, if not more than the condition as it explains how a particular issue manifests uniquely in that person. Certainly in my mind, the ‘initial assessment’ for me is about getting to know the person, which then rolls into their own experience of pain.

I first started looking with interest at tendon pain some ten years ago as an example of a persistent condition in sport. With an interest in chronic pain, it appeared that the discussions about tendon pain remained within the boundaries of where the pain emerged, yet our understanding of pain had advanced to the higher centres and many body systems involved in the experience of pain. Even nociception was discovered as being an incomplete picture as this biological process can be afoot with or without pain. Detection of threat does not mean it has to hurt, and indeed nociception itself is not something we actually feel. However, when the brain (which is of course part of the person and not separate, although our language does sometimes suggest this) predicts the need for protection, pain emerges in the person in a location deemed under threat or potential threat. This complex activity, which includes consciousness and the mind (these are both small subjects……..), is a whole person experience that is lived moment to moment and hence a focus on what happens in the tendon is only part of the picture. There is still very little acknowledgement elsewhere within the hierarchy, so here are a few thoughts I would like to share.

Previously I have expressed the view that we treat, advise and educate a person; a whole person. The approach that I favour is one that delivers the (working) knowledge and skills for the individual so that they can overcome their pain problem and resume a meaningful life as defined by themselves. Fragmenting for convenience is common, breaking down a whole into parts, yet this can never give a full picture. Medicine and healthcare typically specialise and whilst this has value, in the case of a persisting pain that often means that people fall between the cracks. For example, a female with fibromyalgia, IBS, migraines and pelvic pain may be seeing a rheumatologist, a gastroenterologist, a neurologist and a gynaecologist, and whilst elimination of anything pathological is important, there is an understood common upstream biology. Interestingly, many of these cases also have tender tendons that can be a surprise to the person when the tendons are pressed, especially considering that they are not the primary reason for seeking help.

Nothing happens in isolation (is one of my favourite phrases), and hence the biological expressions in and around a tendon are not separate from the mechanisms that underpin how pain arises in our consciousness. We cannot explain how this happens — how do chemical reactions in our body become a lived experience? Despite the lack of an answer, it clearly involves more than the tissue or structure alone.

This is not to say that the brain and the mind alone are responsible. Where is the mind? Where is the seat of the mind? Again, we do not know. Yet surely the mind is not just in the brain, an argument put forward by supporters of embodied cognition. It is me that thinks, not my brain or my mind, but me. And I think with my whole person because I am a whole person, and indeed when I feel pain, it is me that feels pain and not the body part where I feel it. Because I am more than that body part, the experience of pain must involve the whole person in that moment in that context. It is also true to say that to be in pain, we must be thinking that we are in pain as much as experiencing the sensory qualities of pain. Thinking draws our attention to the said experience, otherwise it is subconscious and hence not occurring to me.

For tendon pain, practically speaking, we must of course consider the health of the tendon itself and surrounding tissues, but also the person’s general state (who are they, how are they), prior experiences relevant to the problem (e.g./ tendon pain, pain, general health), beliefs, expectations, vulnerabilities to developing persistent pain, their story of how the pain emerged, their movement patterns (and why they are moving in such a way; both at the planning stages of movement and actual movement), body sense and sense of self at the very minimum. This information is gathered within the first conversation, setting the scene as trust and rapport develops naturally from exploration of their story that validates and empathises.

This is a mere and brief overview of my thinking about tendon pain, which poses a significant clinical problem, often persisting for longer than is expected. Whilst the focus remains on the tendon and nociception, there will be limited results in my view as this only tells a part of the story of the person in pain. This is true for any pain, and not just tendon pain. Pain emerges in the person and all that that person means and embodies, hence we must address the person as much, if not more than the condition. As Oliver Sacks wrote on his father, a GP: ‘He knew the human, the inward side of his patients no less than their bodies and felt he could not treat one without the other’. So true and this has always been my abiding principle.

Pain Coach Programme | t. 07518 445493

05Dec/15

Henderson’s heel

40+60 Feet | Bark |https://flic.kr/p/7rvmbB

40+60 Feet | Bark |https://flic.kr/p/7rvmbB

Henderson’s heel has captured the front page of the Guardian sports supplement today. The article claims that he has been told to play through pain as there is no cure for plantar fasciitis–the plantar fascia is a strip of tissue spanning from the heel to the forefoot.

In the general population this problem exists and is typified by first steps soreness on getting out of bed. The pain is often noted on walking, standing and running, in some cases being sore and stiff to begin with before easing and then building again.

The usual explanation is overload, but there is more to it than that. As with any persisting problem, it is not just about the blamed tissue, but much, much more. Similar to tendon problems, when the focus is merely on the structure, the outcomes are limited as are expectations:

“…with my heel there isn’t a timescale, there isn’t really a cure….”, said Jordan Henderson, continuing to describe how he feels, “There have been times when I’ve been pretty down because we couldn’t find the answers”.

Pain problems need to be addressed in line with our modern understanding of what pain really is, a protective device in the face of a perceived threat. The point in time when something hurts is not in isolation to what has been learned or believed beforehand, the meaning, the context and prediction of what may happen. Consider the footballer who attaches great importance to the state and health of their body and their legs and feet in particular. Also think about how these problems are discussed and viewed within the culture of football; all the views and opinions and what they are based upon. An injury deemed to be chronic or long-term has great consequences for the career of a footballer and hence the meaning of this pain is different to an amateur player or someone who does not play football. Much like the violinist who cuts their finger, this is more pertinent when they are about to play a concert — we know that pain threshold is lower in violinist due to the meaning and context. There is no reason to think this is different in footballers and their legs. What is the relevance?

Our pain experience is determined by the extent of threat and not the extent of tissue damage. How threatening to the footballer is the notion of a chronic foot problem? Very. Does this impact on the experience of pain, definitely. Pain tells us little about the tissue state, but much about how the brain is predicting what the sensory input (about the body and the environment) is meaning based on what is thought and believed. Already you should be seeing how the ‘treatment’ of such a problem needs more than local interventions to change the way in which the body-brain-environment interactions are manifesting as pain, in this case in Henderson’s heel.

We are designed to change and hence pain can and does change when you understand it and take the wisest and healthiest action. This action goes upstream of where the pain is felt.

Where do we feel pain? In our body, because this is where we perceive our actions, largely created by brain networks and body systems, yet none in isolation and none predominating. All are vital to have a sense of what is happening right now. And what is happening right now? Our reality in any given moment is created by the sum of all the activity in our body and brain within a certain context. This incorporates habits and associations that create the backdrop for prediction; e.g./ Henderson arrives at the training ground, and even at the thought of running around, the systems that protect us are engaging and priming in preparation so that when he begins to run, threat is assumed based on what is known, what has been and what could be. Result, pain in the heel.

Now, of course there can be an inflammatory response as well, and this may well have been detected on various scans. However, there are different inflammatory mechanisms, the one we know well from injury: think of a sprained ankle; and then neurogenic inflammation that is a feature of on-going sensitivity, when the peripheral nerves are stimulated from on high to release inflammatory chemicals into the tissues they supply, thereby maintaining the cycle. Again, predicting that healing is required, the higher centres trigger this response, and it needs addressing, but not just locally. This is the big problem with tendon treatments currently, the focus on the periphery. There must be an interpretation of what is happening in the tissues and concurrent thinking and feeling to make the experience of pain a conscious one. There is not always central sensitisation at play, but there are always higher centres involved with a conscious sensation.

There is much more to discuss and note in relation to the points raised, but for now we can look at the principles that are important for overcoming an on-going pain problem in relation to Henderson’s heel. Considering that pain is about threat value, the over-arching aim is to reduce the perception of threat and hence the prediction of required protection. This begins with understanding pain so that the individual’s thinking is based on the working knowledge that they are safe. Safe that is, to perform specific and general exercises to nourish the body and move for health. The specific desensitising techniques are tailored to the person who feels the pain, considering the existing associations and triggers. A sensorimotor training programme works to normalise movement from the planning level to the actual execution, thereby creating a new layer of experience that forms the basis for the next prediction; the prediction of safety. Building the tolerance gradually, allowing for adaptation is key. There are a number of ways to go about this, but in essence, the programme is to be lived through the day, moment-to-moment to match the lived experience that is pain.

It is the person who feels pain, not their foot or their tendon. Their tendon or fascia is not a separate entity seeking help. They are merely the place or space in the body where the pain is felt. The biology of the whole experience sits within that that creates who we feel we are, and the richness of that experience in that moment. Hence, we must always work with the person: their body tissues, their environment, their neuroimmune system and how the sum of all of this creates their lived experience. Within each dimension, there are a number of actions that influence the whole. This is how people overcome pain — not their foot; the person. And who are these people that overcome their pain? What do they look like?

They look like you and me. They have a working knowledge of their pain that allows them to exercise and re-train on a basis of the true meaning of their pain, a feeling of safety, diminished threat, the creation of safety in situations once deemed threatening, and they match their lived experience of pain with a programme that is likewise lived, health based, strengths-based and they have a clear vision of where they are going based on their values.

Pain can and does change, beginning with understanding it.

Pain Coach Programme for persisting pain — t. 07518 445493

 

18Sep/15

Sports injuries that don’t go away

Jan-Joost Verhoef| https://flic.kr/p/6qqqCU

Jan-Joost Verhoef| https://flic.kr/p/6qqqCU

There are many cases of sports injuries that don’t go away. They linger on and on, becoming increasingly impacting as the sensitivity builds, often accompanied with varying patterns swelling and stiffness. Understanding what is happening is the key to deciding upon the right action to change course and recover. The way that your body and you respond is determined by the circumstances of the injury, prior experiences (injured the area before? previous injuries?), beliefs about pain and injury, genetics, the immediate thoughts and messages given by others and the action taken at that point, including pain relief. Here are some of the reasons:

  • The circumstances of the injury: how healthy you are, how you are feeling at the time, where you are, how the injury happened (your fault? Someone else’s fault? An accident? In fact, it is how you perceive it that is important, not the actual reality), your first automatic thoughts, the time of the game, the importance of the game — all of these factors come together, physical-emotional to create a memory of that moment, the pain intensity determined by the perceived level of threat, and not the extent of the tissue damage (consider the player who has a break but does not realise until later). The way you and your body respond to an injury will be very different if you are stressed vs relaxed for example.
  • Previous injuries leave their mark in terms of how you think about them and the associated pain. If you have injured the area before, then there is a greater likelihood that it will hurt because the body will protect more readily. If you have had a good or a bad experience before, this affects how your body systems that heal and protect will kick in.
  • Your beliefs about pain and injury that began to be sculpted in the early days of bumps and bruises and in particular how people around you reacted — too much mollycoddling by parents/teachers is perhaps not great for how we learn to deal effectively with injury; that’s both in the way we think but also how our biological systems work. What you are thinking will impact upon the pain (‘I must get up and play on in this cup final’ vs ‘it is the end of my career’ = very different biologies), and hence the early messages given by the clinicians and therapists must be accurate and calming.
  • It seems that we can have a genetic predisposition to over-responding to injury, with inflammation kicking in as it should but more vigorously. Some people are more inflammatory that others so it seems.
  • The early actions after an injury, including the messages as mentioned above, are really important to set up healing. It is normal for an injury to hurt, however in cases of severe pain, this needs to be addressed with the right analgesia. Early high levels of pain can affect the trajectory of the problem.

For these reasons and others, some injuries appear to persist or recur, which is highly frustrating for the individual, and for the therapists. Sometimes the factors mentioned above set into place a level of sensitivity and certain protective behaviours that mean protection is vigorous — this in terms of the way the person thinks, acts and their biology plays out. This needs to be identified as quickly as possible so that the right treatment can be administered alongside working with the player to developing his or her thinking. Whatever is playing out in their minds will be affecting their biological responses, in a positive or a negative way, so we must intervene or encourage depending on the predominant thought processes.

When an individual is experiencing an on-going issue there are a range of factors to consider and address, some relating to the points above. Hearing their complete story is a vital start point, including an understanding of their perception of the events to date, as well as prior experiences that will flavour what happened then and what is happening now.

Here are some examples of the common features:

  • Often the body continues to try and heal, squirting inflammatory chemicals into the area periodically or in response to movement. This is neurogenic inflammation and sensitises just like inflammation from a fresh injury and is part of the sensitised state, but co-ordinated by higher centres
  • Rarely does the person understand their pain, which creates worry and concern. Remember that chronic stress can make us more inflammatory — also consider other life stresses as these will impact; if the body/person is in survive mode (fright-flight), then resources for healing and recovery are limited.
  • Altered movement patterns, in part from fear/lack of confidence but also as part of protect mode. These must be re-trained from the right baseline (often people start too far down the line and fail)
  • A belief that there is a re-injury when in fact it is a flare up, or an increase in sensitivity, not an actual injury

In brief, we must ensure that the individual’s thinking is right — understand pain and injury, their pain and injury — and that they are taking the right actions towards recovery (a negative thought or over-training will not take you towards recovery); but they need to be able to think clearly about this themselves, because they are with themselves all the time whereas the therapist is with them periodically. They need to become their own coach, which is why I developed the Pain Coach Programme — not only are we coaching them, but also teaching them to become their own coach. When the understanding and thinking is in place, the training and exercises are all straightforward. I use no fancy tools or kit to coach and treat, except of course the most fancy piece of kit we all possess, our brains! But let’s not be all brain-centric; we are talking whole person. It is the person who is injured, not their leg or arm; it is the person who feels pain in the context of who they believe they are and in their life, not a leg or an arm. The person feels hungry, not their stomach. Remembering this when educating, coaching and treating creates the right thinking platform.

Pain Coach 1:1 Mentoring Programme for Clinicians — see here or call us 07518 445493