Category Archives: Sports Injuries

25Aug/14

Greatness, smoothness & injury

In response to @simonrbriggs excellent article in the Telegraph (see here) contrasting Federer and Nadal in respect of their physical longevity on the court, I wanted to agree with Simon’s subsequent tweet about the many factors involved with an injury — the line I frequently quote being: ‘no injury happens in isolation’. Whilst I am no tennis expert, I understand that these two masters have very different approaches on the court that define their games. The wicket is more familiar territory, and I would equate this observation to the games of Tendulkar versus Gilchrist. Both masters of the willow, yet styles that illustrate very different means and modes of dominating the ball. 

Sport enthusiasts and pundits alike gush with awe at the ease with which a stroke player caresses the ball. The expert appears to have all the time in the world to position themselves in perfect balance, to be able to effortlessly time the touch, and send the ball at a speed that is vastly out of proportion to the effort applied. Federer fits this mould, and whilst he undoubtedly trains to be fit and strong, he has a technique that is so efficient and so thoughtless that he can focus entirely upon the whole game as if viewing from a point up above. And to take nothing away from the skill of Nadal, his explosive force delivers excitement as he thunderously strides across the court in Zeus-like fashion. As Simon points out, if Nadal were to maintain a physical wellness, his dominance would surely prevail. Who you would most like to be conqueror would then be down to a preferred style, and we love to talk about style.

Returning to the construct of injury that is always embedded within a context and never in isolation to a range of factors that create a situation — no injury happens in isolation. The meaning of an injury is tantamount, and certainly impacts upon the intensity of pain. Cast your memory back to Messi believing that his career was over after he collided with the goalkeeper. He had merely bruised his knee yet the pain was so intense he had to be carried from the field of play in hushed silence.  A violinist who cuts his left index finger will suffer more pain than if I slice the skin on my same digit. There is a different meaning attached to his finger, even with a paper cut. 

Whilst both Federer and Nadal will be accustomed to the pain of hard training and playing, the pain of injury is different. The way we think about the pain at the time of injury sets up the on-going responses and how we chose to behave — it is not the injury itself, but the way we think that counts. Spraining an ankle usually means limping, and this is a sensible behaviour as partial weight-bearing reduces the strain through healing tissues, and is more comfortable. When we know that all is well, in other words that the injury is healing normally (and this is meant to hurt, however unpleasant or inconvenient), there is an acceptance of the necessary steps back to normal movement and activities. The early messages after an injury then, are vital to set up a positive route forward. Excessive fear, anxiety and incorrect messages at the start can set up a pathway of obstacles to recovery. 

Drawing together the smoothness of action that interweaves with other characteristics that construe the greatness of Federer: the technical self-efficacy, rehearsed movements that require no conscious processing and a baseline of fitness and mobility, all of which create a context that minimises the risk of injury. The sublime control, gliding easily across the surface and a ‘oneness’ with the occasion offers only the smallest opportunity for breakdown that most can only dream of, including Nadal whose vigorous assault upon ball and opponents opens the door for stress and strain to emerge, persist and potentially dominate.

Whilst we can swoon over the masters of any game, the vast majority of us play amateur sport. At the level of the masses, I always feel that the risks of injury are outweighed by the benefits of participation — physical fitness, the offsetting of cardiovascular disease, the cathartic outlay against stress and of course the social element (after the game: the 19th, the clubhouse, the curry house…). Equally, whilst the professionals are honing their skills and prowess, amateurs spend a great deal of time around their occupations and families to improve on the fields and courts, imagining achievements on the great meadows of Lords and Wimbledon. I too dream and envision, but returning to diminishing the risk of injury, as the principle is the same whether pro or amateur. And there is no reason why the latter should not acquire the same knowledge and receive the same principled care.

One of the first actions I take is to ensure that the injured person’s knowledge and thinking are in alignment with what we know about pain and healing, and that their choices of behaviour always take them toward and not away from recovery, no matter the start point.  My fundamental belief in our ability to change pain drives my over-arching mission to deliver pain education to all. Understanding pain will inform positive and healthy actions across the board from professional athletes to children to stakeholders (more on this in subsequent blogs). 

Recovering from an injury is straight forward. Most of the problems arise from the wrong early messages and a desire to move on faster than the healing process, thereby disrupting mechanisms that have inherent intelligence. We literally get in the way of our own recovery. We are the problem, yet the injury is blamed. Know the injury, know the pain, know the time line and know the action to take. Simple. One of the issues that Nadal may suffer, as do many professionals, is the rapid return after injury without full recovery, or a lack of time for the body to adapt. This latter problem disrupts the balance of breakdown and rebuild that is constant in the body. Tipping towards breakdown, inflammation persists and causes persistent sensitivity, even at a low level. This manifests as the on-going niggles, gradually becoming more widespread as time progresses and often without an obvious injury. Familiar? Perfectly solvable when you know how and respect the time lines of healing and recovery. Time is money some may argue, but then stepping back and thinking about the longevity of a career provides a different perspective. Deal with this bout of aches and pains completely and create the opportunity for more years of competing as opposed to the stop-start, partial recovery that affects performance and confidence, the two being utterly related. Over-thinking movement and lacking confidence both affect quality of movement — manifesting as the yips in some cases. Is Nadal smashing his way through because he fears that one day he will finally breakdown? Only he knows. Feeder on the other hand as we have seen, has a smooth style that glides him across the courts of the world. 

In summary, to look at the differing styles of play that define Federer and Nadal, it is clear that the smooth approach taken by the former has played a role in his longevity in terms of fitness (lack of injury) and success, the two being related. Simply, the more games you are able to play without a physical hinderance or even the thought that you may have a physical hinderance, for mere thinking affects the way we move, the greater the opportunity for winning titles. So surely, the planning of any athlete’s training and career must consider the ways in which maximum participation can be balanced with time required to adapt and recover. This is the same for both the professional and the amateur athlete, beginning by understanding pain and injury. 

24Jul/14

It’s time to bring what we know about chronic pain into sport

I recall a time when a consultant told me that chronic pain does not exist in private medicine. I was somewhat dumbfounded that an intelligent person could have such a thought. As a far as I was (and am) concerned, pain is classless. This was some years ago, however I am reminded of this when I think about the lack of recognition of chronic pain in sport.

Injury and pain are part of sport and we all know this well. Healthy people engaging in regular physical activity gain the physical and psychological benefits of exercising, but there is a risk of injury. And whilst many people who are injured will heal and recover, resuming their sport, there are a cohort who do not return to full participation and suffer on-going pain. Persisting pain affects one’s ability to perform, self-confidence, self-efficacy and in the professional case, a career. This is no different to the situation with a non-athlete with chronic pain.

There are a number of reasons why an athlete fails to recover including the context of the injury, early management, the development of fear, the understanding of the pain and injury, and the intensity of the pain at the outset. When lecturing on this subject, I tell the story of Messi who believed that his career was over because of the pain he experienced in his knee having collided with a goalkeeper. He was immediately taken for an MRI scan that revealed no injury. Recovery was swift when Messi knew he had not damaged his body. The pain he experienced on the field when he thought his footballing days were over was intense with a meaning that drove into the heart of his emotions, and that of the silenced crowd.

The reasons that pain persist are no different in the non-sporting person: the context of the injury, the state of health at the time, prior pain and injury and how they were dealt with, initial management etc. This being the case, we can bring the modern thinking about chronic pain into the sports arena for two reasons. One is to look at how injuries are dealt with in the early stages, and the other to take a broad perspective in tacking the on-going or recurring injury.

The early management of sports injuries is well known. The aspect to which I refer is the communication about injury and pain. In fact, even before an injury, providing education for players and athletes would impact upon those first vital moments that can prime and set up the recovery. At the point of injury, a whole body, all-system response kicks in, and recognising these processes in their entirety will maximise the recovery potential from the outset. All the necessary processes for recovery are in the human body. The main proponents of disruption are over-zealous treaters, fearful potential recoverers and those who ignore what the body is orchestrating. A careful explanation of the injury, pain and what will happen to aid recovery goes a long way to calming excited protective body systems.

Changing a pain state is entirely possible. Understanding that pain emerges in the body but involves the whole body is vital when considering all the factors necessary to set up recovery. When pain persists there are many habits and behaviours that become part of the problem. These need identification and re-training as much as the altered body sense, altered movement patterns, altered thinking, altered emotional state, altered immune responses, altered endocrine responses, altered autonomic responses, altered self-awareness, altered perception of the environment — we are altered in this state and it involves a host of responses, not set in stone but instead, adapting and surviving. On spraining a knee ligament, it’s not the ligament as much as how the body is responding to the detection of chemicals released by the injured tissue, the perception of threat and how the individual responds to the conscious feelings created by the whole body that drive thoughts and behaviours.

In the light of this knowledge (that has existed for many years), far more comprehensive treatment and training measures have been devised in small quarters. This approach delivers vastly improved outcomes because the problem is being addressed in a way that recognises that pain emerges from the whole. This notion was crafted from the merging of neuroscience and philosophy and is now taking our thinking forward (thanks to Mick Thacker and Lorimer Moseley for bringing this mode of thinking to physical therapy and beyond). I no longer refer to ‘pain management’ as this implies we are not trying to change pain, and I believe that we can and do change pain.

Pain is changing all the time as is every conscious experience. What patients believe is what they will achieve: “Whether you think you can, or think you can’t, you’re right”, Henry Ford. Let us draw upon the psychology of success, create a clear vision and go for it. Every action and thought can be challenged with the question, “Will this take me towards my vision?”. This is the same in sport as it is in the general population and we can use exactly the same principles, just with different end points — everyone has a different end point, hence my push for recognition that chronic pain exists in sport and remains a huge and costly problem for individuals and clubs.

How can we go about this? Initially we must create awareness of the extent of the problem, recognising that a wider approach is needed and subsequently implementing contemporary treatment and training methods that work with the whole person. Understanding the pain mechanisms, the pain influences and the context of the pain for the individual orientates thinking that creates a route forward toward the identified vision. Blending specific training (e.g./ body awareness, sensorimotor control) with techniques that boost self-efficacy and maintain motivation for the necessary steps towards recovery. The recovery is part of the vision and is determined by prioritising the programme and working consistently.

Using comprehensive measures and thinking, we can create the conditions that allow for pain to change in the whole person by allowing body systems to do their work. Our role is to facilitate this biology by what we say, do and advise. Drawing upon the contemporary way persisting pain is approached in the general population, sportsmen and women can access the same benefits, optimise their potential to return to exercise and reduce the risks of recurrence.

Richmond specialises in creating the conditions for people with chronic pain and injury to recover and move forward. When he is not seeing patients, Richmond spends his time writing and talking about pain with the aim of bringing the modern understanding of pain into the public domain for better treatment

Specialist Pain Physio Clinics, London

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

23Sep/13

A few thoughts on Andy Murray and his ‘minor back surgery’.

The news that Andy Murray is to have a minor back operation hit the back pages last week. It is understood that he will undergo a microdiscectomy, a technique that minimises the tissue trauma in order to access the injured disc and the nerve that is being impacted upon by this structure.

Microdiscectomy – what is it?

For the decision to be made, it is likely that a disc has been seen on a scan to be affecting the health and physiology of a nerve root (where the nerve emerges between the vertebrae). In some people this will occur without causing pain but if pain and sensitivity does arise, then it is due to a gradual change in disc health over many months. Of course, it is very possible that repeated movements and in particular rotations with force will impact under certain circumstances. In fact, with any injury that is gradual, one has to consider the combination of circumstance (‘environment’) and genetics–termed epigenetics.

It seems that Murray has been experiencing back pain for several years. Many people who I see are in a similar situation having had pain for some time, often punctuated with more acute episodes. These acute bursts of pain are highly unpleasant and can make moving, working, sleeping and functioning very difficult for a few days and sometimes longer. When it comes to sports people, we can think about the injury or pain as threatening their career, however this is the same for others who plan to return to work following a back operation. Clearly the end point is different but the preparation and early rehabilitation need not be.

Preparing for surgery – see here

I make a point of encouraging a proactive approach to pre-op preparation both physically and mentally. Where possible, you want to be fit and healthy with ‘prehabilitation’, which is a structured programme of exercises to maximise tissue function. Picking up on the rehabilitation after surgery can be far easier if this is done in an orgainsed manner.

Equally, dealing with the mindset and fears that can encroach on one’s ability to train is as important. Understanding the pain, procedure, goals of the surgery and the recovery process will go a long way to reduce the stress and anxiety of an operation – or rather, the thought of an operation prior to the procedure. Using techniques such as mindfulness and relaxed breathing can be potently effective in reducing stress that occurs as a result of negative thinking. Certainly catastrophising about pain can lead to greater inflammation and thereby affect the healing process. We are seeking to optimise healing and therefore dealing with thinking that is overly worrisome can impact upon the immune system in the right way.

Early recovery

This will vary from person to person but in the initail stages it is all about allowing the tissues to go about their healing process, orchestrated by the neuroimmune system and certainly affected by other body systems. Beyond the gradual increases in movement, and tissues certainly need this for good healing, considering factors such as adequate rest, relaxation, good nutrition and a positive outlook are all key ingredients in creating the best possible conditions for moving forward. A range of strategies and techniques can be used including simple mobilisations but alongside motor imagery,  mindfulness, movement of other body areas, the use of music and motivational techniques and cognitive tools to fortify resilience and coping to name but a few.

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.

* Naturally, you should take the advice of your health professional when it comes to your treatment and rehabilitation.

If you are about to have an operation or are recovering, contact us now to learn about our comprehensive treatment and training programmes: 07932 689081

08Aug/13

Suffering surfer

Spending time in the West Country you cannot help but be drawn into the culture of surfing. Whether it be watching the action from the beach, taking a lesson, going shopping in one of the vast array of surf outlets or sitting in a cafe watching footage of surf champs (the most intriguing are those that illustrate the 60s and 70s surfers in sepia without the modern day equipment). So, taking in a healthy infusion of the lifestyle so removed from the metropolis, I asked a local instructor Pete from @KingsurfNewquay (King Surf, Mawgan Porth) about the types of pain and injuries that surfers suffer.

Like most outdoor adventurers, these guys and girls are robust. They don’t moan but rather get on with their pursuit and deal with aches and pains at the end of the season. Of course this may not be the best course of action, however there is a way or perhaps a code that is unwritten but known and communicated with expressions and colloquialisms such as the ‘sea ulcer’. This is not something you find on a rock but rather a breakdown of flesh that struggles to heal despite the fitness of the surfer. Simply due to the repeated friction with certain parts of the board and the hours spent in the sea water, the healing process struggles to keep up with the repeated damage.

Pete tells me that the commonest pains are in the back and knees. Another instructor Nick, adds in shoulders. Both agree that in fact you can experiences aches and pains in different places across the body that seemingly pop up randomly. Of course the reality is that these aches and pains are not random at all, but part of the body’s incredible protective device in action, responding to perceived threats.

Briefly, why would these areas predominate? The paddling action requires a great deal of shoulder use, the back is often held in extension and there is a fair amount of twisting force about the knees. That could be an explanation that would make sense to most people however, we have to ask about those who make the same actions yet feel no pain. We must also consider the fact that any sports or physical activity is accompanied by the pain of exertion that is entirely normal. Most people are familiar with the pain that follows a new exercise regime or an unaccustomed activity that lasts for a few days. This type of pain usually settles, however if you do not allow the body to adapt to the demand, you could further wind-up the sensitivity and see a more persisting pain develop.

Pain is a response to a perceived threat. Who does the perceiving? Actually it is the brain that works out the threat value of what is going on, even if we know the activity is not really dangerous. The problem is that the ‘output’ from the brain when it perceives threat to the body is pain in most cases, and this really feels like you have injured something, even if you haven’t. This is often the situation when we have a persisting problem. In an acute injury, the pain is a vital attention grabber so that we take a course of action to promote survival and healing. It hurts when we move or touch the area which is very useful and adaptive in the first days as the inflammation takes hold and kick starts the process of repair. Other responses include changes in motor control, blood flow and sometimes we are aware the we feel and think differently, more protectively. We guard and make decisions based on how the body feels. This is all entirely normal. As the healing process rolls on, the sensitivity often reduces and movement becomes easier, and we resume activities as before. Often to encourage the right conditions and to ensure that we restore normal control of movement and sense of the body, we follow a rehabilitation programme that may be accompanied by treatment. This is typically effective when we fully understand the injury, the mechanisms and our role in proactively rehabilitating the problem both physically and mentally.

In some cases, and these are the cases that I specifically see, the pain and sensitivity persist or recur. Why is this?

Scientists continue to research why people continue to suffer pain. Approximately 1:5 people have an on-going pain and although many are able to continue with their normal lives, there are those who are unable to work or play. Clearly there is a spectrum and between these ends are individuals who suffer but persevere with their activities. This often includes sportsmen and women who ‘patch’ themselves up and keep going. Admirable though this is, it may not be doing them any favours in the longer term. One major issue is that often it is these individuals who rely upon their body and an ability to be active for their income. This will clearly change the context and as regular readers will know, context in pain is a key factor for the meaning of the pain and consequently the on-going response.

What we do know is that in the early stages of an injury, if the sensitivity builds and causes changes in the central nervous system (central sensitisation) this mechanism will underpin persisting pain. This will typically occur when a nerve is injured. Nerve tissue in the periphery (body) can be damaged like any other soft tissue except that the injury causes changes in the spinal cord and higher centres manifesting as a widened area of pain, changing locations and a reduced ability of the nervous system to inhibit the sensitivity. Altered function of specific cells in the brain stem also affect both the facilitation and inhibition of the flow of danger signals thereby amplifying the sensitivity under certain circumstances. Inflammation can also cause persisting sensitivity from the periphery as the molecules bathe the nerve endings, ramping up their excitability.

The key point to remember is that pain is not an accurate indicator of tissue damage. Phantom limb pain is the classic example with their being no tissue (limb) yet the sensation of pain exists. This is because the brain perceives a threat in a limb that despite not being present, still has a representation in the brain. The body is mapped out in the brain, allowing the brain to know where sensory information is coming from with accuracy and to control precise movement. Motor and sensory function is integrated to create the ‘concrete’ sense of self that we experience. The feeling of our body is constructed by the brain as is the visual field we experience. Both vision and pain share common features in that the brain receives information and creates a reality that we feel and sense to be true. As we know from the great illusionists and many other life situations, our experience of ‘reality’ is hugely variable and often suggestible—how scary is a dark corridor after watching a horror movie? How quickly do we move after repeating a train of words pertaining to youth?

Knowing pain helps us to rationalise fears that we may have and thereby create the right conditions to move forward. To change a state of persisting pain we must be proactive but this requires the understanding of pain, the development of confidence in using the body self-sustaining tissue nourishing techniques and strategies that re-train the way in which the brain is protecting the body on the basis that the real threat is diminishing.

For the surfer who has to keep going for competition or livelihood, gathering knowledge as described above, and integrating a range of strategies into the day will be important in re-learning normal movement patterns rather than guarded postures. Pain has physical, cognitive (what we think) and emotional (how we feel) dimensions, and all must be addressed in an on-going pain state as they are entirely interdependent. For example, regular simple movements of the affected body areas that are tolerable and develop confidence as well as nourish tissues that have often become tense with a consequential poorer oxygen supply, neurodynamic movements to mobilise the nervous system and the interfacing tissues, pacing activities and mindfulness practice. With any exercise routine, it is not enough just to consider the movement itself but also the mindset, any known factors that could prime the neuroimmune system (eg/ fear of movement, stress, fatigue, previous activities) and the timing. I consider a good analogy to be taking a prescribed drug that seeks to alter physiology in the body as does exercise. Except exercise and movement when performed with confidence has a wider positive effect physically and mentally. It is the best drug we know!

Suffering persisting pain is more common than most people realise. With perhaps 20% of the population experiencing on-going pain, we need a wider shift in understanding and knowing our own pain so that we can create the right conditions for change. We are fundamentally designed to change, learn and grow with the neuroplastic characteristics of the neuroimmune system, it is just knowing how to access these mechanisms proactively and in a self-sustaining manner in order to attain the freedom we desire.

If you suffer persisting pain or injury, contact us to learn how you can creat the conditions to move forward: 07932 689081

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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

17Apr/13

London Marathon 2013 | Dealing with the aches and pains

Most runners will have put in the hard yards by now and are set to go. Undoubtedly there have been quite a few aches and pains along the road so far. Sadly this will prevent some people from participating, say in the case of a stress fracture – click here.

It is entirely normal to experience pain as a result of exercising. We expect it after new or unaccustomed activity and recover quickly, often independently and sometimes with assistance (e.g./ physiotherapy, massage). The marathon will be no different as limbs and bodies will be sore on Sunday afternoon and evening, most likely building into Monday and Tuesday before starting to settle. This kind of sensitivity is an adaptive response to the demands placed upon the tissues and physiological systems. In essence it is the body asking for a rest, motivated by the unpleasant sensations.

If there have been more significant niggles during the training period, these may flare-up and require professional attention. For example an issue with a tendon. A diagnosis followed by a comprehensive treatment and rehabilitation programme will be needed to address such a problem or an injusy sustained on the day of the race.

For further information about post-marathon treatment and recovery please contact us on 07932 689081

Clinics in Chelsea – Harley Street – Temple – New Malden

Common running injuries include: shin splints, anterior knee pain, ITB syndrome, iliotibial band syndrome, hip pain, hamstring pain, calf strain, ankle sprain. We see the more persisting and recurring running injuries at our London clinics, delivering comprehensive treatment and rehabilitation programmes that are based on the latest neuroscience.

16Apr/13

‘Get betterers’ and ‘persisters’

Why is it that some people recover from an injury and others take longer than expected or continue to have problems beyond a normal healing time? It’s the latter group that I spend a great deal of time with, helping them to develop understanding of their pain and devising a plan of what they must do to move forward. 

The science of pain has moved on rapidly over the past 5 years with the neuroimmune system revealing some very interesting mechanisms that are fundamental to the pain experience. Groups of researchers around the World are gradually putting together the pieces of one of the most complex puzzles, that of pain, in tandem with modern thinkers who are blending science with philosophy to craft better ways of approaching the problem. This incorporates closing the gap between the individual’s narrative and the objective findings and termed first-person neuroscience.

The evolving understanding of pain as a multidimensional and multisensory experience sounds complex but in fact creates opportunity to tackle pain in different ways. Knowledge of how we prime the neuroimmune system with prior experiences, by the way we think and perceive the World, and how this blends with our genetic make-up is illuminating. There is no moment in isolation but rather a continuum. On sustaining an injury or feeling pain, this is a point in time when a certain threshold of excitability has been reached, triggering a range of protective responses including pain. The pain directs our attention to an area of the body and motivates behaviours that are congruent with healing and survival. Other responses include activation of the autonomic nervous system and changes in motor patterning. How we respond is down to what the psychoneuroimmune systems do to protect us. We feel the effects, sometimes subtly and sometimes like a tidal wave as they take hold. What happens next will depend on what has happened before, how we think and behave, our genetics, the context around the injury or when the pain starts and the state of the neuroimmune system at that point to name but a few. For simplicity I have named responders as the ’get betterers’ and the ’persisters’.

The ’get betterers’ are those who sustain injuries or develop pain (these are different constructs) and simply get better. Sometimes they seek advice and have treatment and sometimes they just modify their activities. The end result is a reduction in sensitivity and a return to normal life. Notably lacking in the early stages of the injury are any signs of catastrophising and excess vigilance to the injured area. Often these individuals have had prior injuries that have successfully resolved, have an optimistic outlook for the new injury and are not too bothered by the inconvenience. Clearly this is a simplified description of a necessarily complex interplay of physiology, behaviour, belief and character. 

The ‘persisters’ often tell a different story. The context of the injury maybe traumatic, the injury may have been poorly

managed and could have created a great deal of fear and anxiety (the latter could be pre-existing). The early focus is surrounded by catastrophic thinking in some cases, accompanied by a set of protective behaviours that although useful as an aid to healing in the acute phase, become problematic as time progresses. Often the early sensitivity and pain are intense and strong, the signals of danger bombarding the neuroimmune system and triggering changes in the properties of these neurons. Subsequent signals are amplified so that normal stimuli (touch, movement) hurt and those that would normally be painful are even more so.

A growing body of evidence suggests that at the point of injury, if the nervous system has been primed by epigenetic factors, the response could be overblown and persist due to the subsequent ‘rewiring’ in the central nervous system. Epigenetic factors are those that are as a result of the effects of the environment upon our genetic make-up. The good news regarding epigenetic effects is that they seem to be reversible if we create the right situation. This is why the thinking around the treatment of chronic or persisting pain must be different.

In a persisting pain state we are not dealing with the acute response to an injury that is unpleasant but normal and necessary. Instead we are tackling an emergent experience (the pain) from the ‘self’ (body) that is underpinned by a complex interplay between the body systems that include the neuroimmune, endocrine and autonomic. This takes a different and multidimensional approach.

How do we do this? We look at the individual and the physical-cognitive-emotional dimensions of the condition and pain. Tackling the problem requires strategies and therapies that target beliefs, behaviours, cognitions, stress, physical health (e.g. tissue mobility, strength etc), motor planning and control (i.e. normal movement), restoration of function, resilience and confidence to name a few.

Following an injury the tissues go through a healing process. Pain and other symptoms can certainly persist beyond the healing time and this is due to changes in the neuroimmune system. There can be little to see on a scan or x-ray in many cases (termed ‘medically unexplained symptoms’, i.e. no pathology or abnormality seen yet the symptoms are fully lived. However, the neuroimmune system is very plastic (neuroplasticity), a feature that allows for adaptation and learning. We can use this to our advantage and create the opportunity  to change the experience of pain and ease the symptoms concurrent with shifting our relationship with pain by changing the meaning. Reducing the threat value of pain (moving from fear/anxiety to ‘so what’) has an enormous impact upon the perception of pain, in a sense disarming the experience.

In summary, some people recover from an injury or painful condition and return to full activities at home, work and in their chosen sports whilst others have difficulty. The latter group require a very different model of care to tackle the problem of chronicity and recurrence, this model being comprehensive, addressing the physical-cognitive-emotional dimensions of pain. Naturally more complex as we must consider (in no particular order) neuroimmune development and priming, genetics, epigenetics, existing beliefs, culture, stressors, altered processing of nociceptive signals, sensory and motor cortical representation changes, altered body sense and the impact upon ‘self’ and lifestyle. Constructing a treatment programme around these factors  creates the opportunity for change, the development of wellness and the optimisation of performance.

 

13Apr/13

Tendinopathy & Tendon Pain | Guest Blog by Dr Peter Malliaras

Thanks to my friend and colleague Dr Peter Malliaras for this blog on tendinopathy – here is his bio

Painful tendon injury or tendinopathy is common and often difficult to manage. Previously this type of injury was known as tendinits, and the suffix ‘it is’ suggesting an inflammatory pathology. For over three decades now researchers have known that longstanding tendon pain may not be inflammatory, so now the popular term is tendinopathy. The pathology that is seen in laboratory studies is effectively a failed response of the tendon to adapt to forces places upon it with daily activities and sport. This is largely because tendon responds very slowly and sluggishly to changes because its infrastructure of cells and blood flow are not as extensive as some other tissues.

It is generally accepted that the key treatment for tendinopathy is exercise. Exercise is the only intervention that can restore a painful tendons ability to take the loads that it needs to in everyday function and sport. A simple formula that I use in clinical practice is to consider the loads that a patient needs to endure in their day to day function and then design an exercise program that progressively allows them to endure these loads without the tendon becoming painful. The key is to make sure that exercise is commenced at a level that will not cause the tendon to become irritable and that it is progressed at a rate that the tendon can tolerate. Every patient that I see is different and how they progress with their rehabilitation and this depends on many complex individual factors, including musculoskeletal, systemic, motivational, psychological factors, etc.

Over the last 15 years the most popular form of exercise that clinicians prescribe is eccentric exercise. This is where the muscle is loaded whilst it is lengthening (e.g. the downwards phase of a biceps curl) and is in contrast to concentric exercise where the muscle shortens whilst under load (e.g. the upwards phase of a biceps curl). An international research group I am involved with, including two physiotherapist PhD clinician-scientists (Dr Peter Malliaras, Dr Christian Barton), a Senior Human Movement Research Fellow (Dr Neil Reeves) and a Public Health Professor (Prof Henning Langberg) recently published a review questioning eccentric exercise treatment for Achilles and patellar tendon injury.

There were four studies that compared loading programs in the Achilles and six in the patellar tendon. Only two studies were rated as high quality. The most surprising finding was that very few studies have actually compared eccentric training to other forms of exercise. For example, only one study had compared eccentric training in the Achilles tendon. Overall, there was no evidence that eccentric training is better than other exercise in treating these injuries. In fact, there was equivalent (Achilles tendon) or more evidence (patellar tendon) to support exercise that involved both eccentric and concentric contractions in combination. So combined eccentric-concentric contractions may be useful in tendinopathy. Clinically, I see mainly second opinion tendinopathy cases and one of the most common reasons they have not improved with eccentric loading is that they have marked weakness of their concentric function. Due to a very well established principle of known as ‘specificity in exercise’, people will tend to get better at the type of exercise they do. So, I always give eccentric-concentric combined loading to patients with concentric weakness. Another important point is that no studies to date have investigated isometric loading in Achilles and patellar tendinopathy rehabilitation. Isometric exercise enables muscle-tendon unit load at a constant joint angle. Clinically, I use this to exercise people at a painfree joint angle that limits compression whilst still loading the tendon. Tendon compression is associated with pathology. It is very effective in the very painful or very compressive tendon presentations, and our review has highlighted that we need more research in this area.

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28Mar/13

Chronic pain in sport | painphysio article in SportEX journal

In the April edition of the SportEX journal you can read my article on chronic pain in sport – click here

Chronic pain and recurring injuries in sport are a huge problem. The modern approach uses the latest neuroscience to tackle the pain and restore normal function required for the particular sport.

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