Category Archives: Sports Injuries

03Feb/12

Chronic pain in sport – Specialist Clinic in London

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

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

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

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

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

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

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

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

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

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

01Feb/12

Can’t get over that skiing injury?

To the skier, the thought of watching friends and family clumping off in their boots towards the lift whilst sitting with a leg up, packed with ice and the daily paper, is intensely frustrating. Injuries happen. In many cases with the right early treatment, perhaps surgery and definitely a thorough rehabilitation programme, the symptoms resolve and the leg works again, good as new. However, there are a number of cases when this does not follow suit and the pain and limitations continue. There are reasons for this occurrence and they extend beyond the health of the tissues that almost always go through a healing process.

There are some complex mechanisms at play in the nervous and immune systems that are really useful when we first have an injury. This of course includes pain that is part of the way the brain defends the body when we damage ourselves. The way in which we go about protecting and treating ourselves is driven in part by the pain that motivates these actions: rest, seek advice or take analgesia. That is what pain really is, a motivator to take action to promote healing and survival. In the early stages of having injured tissues, often ligaments at the knee, this is really useful and important. Briefly, the damaged tissues release chemicals that sensitise the local nerve endings, stimulating a volley of danger signals to be sent to the spinal cord. Here, secondary neurons send this information to the brain for scrutiny. On deeming there to be a threat, the brain engages protective responses including pain, changes in movement and healing. Sometimes we can injure our tissues and the brain decides that something else is more important, perhaps escaping from the mountain, and will send signals down to the spinal cord to interfere with those coming from the tissues. The end result is the feeling of no pain and therefore you can take yourself to safety. Then it can start hurting. All in all, the responses will vary as will our ability to cope.

The early bombardment of the spinal cord and brain with danger signals that can also be influenced by the context of the injury, e.g. really scary, leads to changes in the properties of the neurons in the spinal cord. This means that subsequent signals can be amplified. It also means that normal signals (e.g. light touch) can start to provoke a painful response as can areas not directly involved. In the latter case one can find that the area of pain grows (click here). The on-going activity in the nervous system and other systems such as the immune system, endocrine system and autonomic system underpin the experience of persisting pain and protection, including altered movement that is so important to normalise.

In the case that the problem persists, the treatment is different. The tissues are addressed as one would expect with manual therapy, massage and other local treatments. However, alongside these traditional techniques are a range of strategies and treatments that are based upon the latest pain sciences that target the changes aforementioned and others. These strategies target the mechanisms at play and at source reduce the threat and hence the pain, normalise motor control and sensation of the affected area and restore function so that there can be a progression back to pre-injury activities.

For further information please contact the clinic: 07518 445493

20Sep/11

Problematic Sports Injuries

Sustaining an injury is a common problem for athletes. Unfortunately, a number of these injuries become enduring and the player struggles to regain fitness and cannot return to play. There are known reasons why this can happen, including the effectiveness of the early management, accurate diagnosis of the problem and how the player initially responds to the injury. All of these factors are important and often accounted for within the medical team’s preparation and planning. It is within the screening process that the medical team can gather such player information. This usually includes the usual fitness parameters, a history of previous problems and how they were managed and past medical history. Beyond these considerations I am interested in certain behavioural and physiological characteristics of the player that will give me an insight into how they will respond to pain and injury.

The problem has usually been persisting for some time when the player comes to the clinic. Beliefs, expectations and concerns will already be flying around his or her head. These emotions can be stoked by failed treatments and a lack of a diagnosis. Certain fundamental adaptations will have occurred as a result of the injury, such as changes in control of movement, altered perception of the affected area, pain felt with innocuous activities and other physiological goings-on that are not consciously observable. These vital functions involve the immune system, endocrine system and autonomic nervous system, all of which have a wide range of effects across body systems and play a significant role in healing, recovery and protection.

Protection is a key point. When you are in pain the body is protecting itself. You may also be aware of spasm or tightness and these are also part of a survival strategy that is orchestrated by the brain. When we are injured or have a problem we usually focus on the pain–and so we should. Pain is a motivator for us to take action to promote recovery. It grabs our attention to the area at risk so that we can attend to the injury. This is an amazing device that means we can learn and adapt. However, when this device adapts and creates sensitivity that is prolonged, it becomes difficult to progress and return to play.

The device is really a network of nerves that communicates information about the health of the tissues to the brain via the spinal cord. These nerves also play a role in maintaining tissue health by releasing certain factors into the tissues. On receiving information from the tissues via the spinal cord, the brain then scrutinises this data and responds appropriately. On perceiving there to be a threat to the tissues, the brain creates pain via a widespread network of neurons becoming active. It is this widespread network of neurons with a range of roles that is the reason for the many influences upon the pain including past experience, emotional state, fear, anxiety, vision, sound, genetics, gender and significance of the perceived danger to name but a few.

Returning to the enduring sports injury, these processes are underpinning the persisting sensitivity that is evoked with normal activities and amplified when pushed harder, altered motor control and perception, sensorimotor mismatch and continued tightness. These are common reasons for non-progression and require addressing with a modern rehabilitation programme that addresses the tissues, the aforementioned body systems and the brain with specific techniques and strategies that are based on the latest neurosciences.

If you would like any further information please do contact us here or call 07518 445493. Click here for our programme details.

21Apr/11

Aches & pains, stresses & strains

 

Treatment Programme for life’s ailments

Aches and pains are a normal part of life, reminding us that we are doing too much, too little or something potentially injurious. Classically, sitting at the desk for hours, using a computer mouse repeatedly, texting and emailing on phones with small keypads, going from being sedentary all day to exercising furiously in the morning, at night or at the weekend, all can lead to aches and pains. Much of the time we expect this to be the case such as after a good workout, when re-starting at the gym or following an unusual bout of DIY. We can explain it, the pain has a meaning and often a short lifespan.

Whether we experience pain or not is not as simple as ‘we do some physical activity and then the tissues hurt’, but rather it comes down to the brain’s analysis of whether there is a threat to our tissues or not. So, we can do all sorts of activities, but it will only hurt when there is a perception of danger. The brain receives signals from the body tissues and organs, maintaining an ‘online’ monitoring system via a huge network of nerves that send messages to the spinal cord. These messages are then passed upwards to the brain for scrutiny. If, and that’s a big if, there is a sense of danger based on this information and past experience, the brain will protect the affected area and make it hurt. If there is no perceived danger, it simply won’t be painful. Good examples of this are phantom limb pain that is a sense of pain in a limb that is no longer present and battlefield stories of severe trauma yet no pain. The long and the short of it is that pain is not an accurate indicator of tissue damage as borne out in huge amounts of research that has been done over the years. This knowledge has advanced our ability to understand pain and treat it in a better way (for further information see our page dedicated to pain).

The aches and pains that we feel are influenced by a number of proven factors. These include stress, emotional state, fatigue, hormones, the immune system, past experience, culture, our beliefs about pain, gender and expectations to name but a few. Understanding this is very important for successful management and treatment as these factors need to be identified and dealt with appropriately. This approach is called the biopsychosocial model of care and deemed to be the best way of looking at and treating pain. We consider the biological mechanisms, the psychology and social impact. For example, a violin player cuts his index finger: biology includes inflammation that hurts, healing and changes in blood flow; psychology that would be thought about how this will affect his/her ability to play, ‘it’s a disaster’, anxiety about the future, I believe this will heal quickly; and social impact considers the fact that he/she cannot play and therefore there is no income this wee. Clearly there is more to it but this brief overview helps conceptualise the model and that the components are inter-related.

So the aches and pains of life are there and common and can become persistent, annoying, frustrating and affect ones ability to enjoy life. Our tolerance for the challenges we face may diminish and activity levels can drop and the downward spiral can begin. It could be that it is an old injury that recurs periodically or improved but never really resolved. Whatever the scenario, if the aches and pains, stresses and strains of life are too loud and bothersome or just there in the background nagging away, we have a programme for you that provides integrated treatment, strategies to develop resilience, relaxation and education so that you can understand what is happening to increase awareness allowing for change. The course is based on the latest understanding of pain, stress and health to offer informative, active, fun and effective ways of enjoying your body and life.

The basic programme consists of an assessment to determine the nature of the problem(s) followed by six 30 minute sessions. During these sessions you will receive an explanation of the problem including the causes and influences, treatment (this can include soft tissue massage, joint mobilisation, acupuncture), an exercise programme to focus upon stretching, mobilising or strengthening particular body regions, mindfulness techniques and breathing exercises. The programme parts create a synergy that targets body, brain and mind for better physical and psychological health.

Having completed the programme you are welcome to add sessions for ‘top ups’ on a individual or a single session basis.

To book, call now 07518 445493

Please note that if further investigations or a referral to see a consultant are required, a letter will be provided and recommendation made so that this can be actioned rapidly. Subsequently the programme or specific treatment can be started.

13Mar/11

A point in time…

A point in time….. some thoughts

At a point in time a patient comes for advice and treatment. Often this is at or around the time of a peak in symptoms hence most troublesome and limiting, whether it be a new problem or an acute on chronic scenario. Any consultation is at a point in time and that comes as a result of where we have been, our history. Our history to date is not just about how the injury occurred or the pain started. It includes these important factors but also the preceding circumstances, prior injuries, what we know about injury and pain, what we don’t know that we know (that comes from Lorimer Moseley), what is going on in the body systems (e.g./ nervous, immune, endocrine), our culture, past experiences, beliefs that we develop and learn from significant others, gender and genetics to name but a few. History taking is a vital part of the evaluation and attention to detail can make a real difference. Through verbal and non-verbal communication (e.g. pain behaviours) about the problem, observing movement and posturing, we can build a picture from where a treatment programme can intervene to change the experience of pain and enhance healing. The questions ‘how has this person got here now?’ and ‘what is the wisest course of action?’ are at the forefront of reasoning.

What is it that really brings someone along, often repeatedly over some weeks? The desire to be free of symptoms, to be able to play sport again, to go back to work, to be able to pick up the children or to start going out with friends again perhaps. How has this situation arisen? Perhaps an injury or the gradual build up of symptoms to a point where life becomes difficult. In all of these cases we look at the story, the pathway that has brought the individual to date. What has influenced and moulded the experience and in particular the experience of their body now, in pain, with discomfort and suffering? Work has been done to look at this albeit not under one title, but Maria Fitzgerald considers the effects of early painful experiences in the neonatal period. Arguably we need to understand the patient’s early life, a time when the system that detects danger is developing.

In summary, my assessment is about understanding the current experience (pain & injury) on a background of the functioning of all our systems: body, brain & mind. The systems have reached the present moment via genetics, learning, thoughts, beliefs, cultural memes, movements and many other influences that mould us to who we are at the current time. A point in time…

11Feb/11

Pain in Pregnancy

Pain in Pregnancy

Musculoskeletal pain is a common problem in pregnancy including low back pain, pubic pain (symphysis pubis syndrome) hand and wrist pain. The are a number of known reasons why this occurs and with this knowledge we can offer treatment and management strategies to ease symptoms and movement. Clearly there are a range of factors to consider such as pre-existing painful problems, general health, the stage of pregnancy, any stress or anxiety, any injurious event surrounding the pain and the goals of the individual. Here is a brief overview of the causes of such problems and the modern approached to treatment.

Pain is a normal experience produced by our brains when there is the implicit perception of threat to ourselves. This is part of a co-ordinated response to promote survival and includes changes in movement, blood flow, the initiation of healing if tissues are damaged or gradually and heightened awareness of our bodies and surroundings. With time in many cases this process diminishes and normal function and sensation is restored. However, it is not uncommon for the problem to persist in terms of pain and reduced ability to perform day to day activities. When there is no reason for the body to continue to protect itself, the pain and symptoms are no longer useful but indeed carry on. This latter scenario affects millions of people with back pain, neck pain, recurring injuries and pain for example. Other conditions can involve recurring bouts of inflammation that causes pain, for example arthritis.

Modern treatment of these different scenarios, acute and chronic, requires that the tissues are considered but also the nervous system (spinal cord and brain) where changes in it’s properties and function lead to persisting and recurring pain states. Other body systems are also important and influential including the immune system, homeostatic systems (e.g. restoring balance, effects of stress), endocrine system (hormones) and the autonomic nervous system.

Pain is a sensation that we feel every day in most cases, whether we knock our elbow, experience a headache, receive bad news or sit too long and develop sore shoulders. We take note of the signal and do something about it, seek help, take a pain killer or perhaps move around. That is the purpose of pain, to motivate some action, like hunger and thirst. So, if pain is normal, are you more likely to experience pain during pregnancy? I believe that this is difficult to answer although there will certainly be some short-term pain and understood pain at the end of the journey usually relieved with gas and air or an epidural!

The typical complaints during pregnancy are back pains, pubic pains and upper limb symptoms. Of course the body is changing during the period of pregnancy including size, shape and tissue quality. The first two points are obvious but they do alter the way you move, your centre of gravity and ability to fully mobilise joints. This has short-term consequences that mean the muscles can feel tight or stiff primarily due to restricted movement that leads to these sensations. If you do not move tissues they tighten up. The physical strain increases as time passes and although females have bend assigned to bear this load it is still hard work (I can only say this on the basis of appearance and what I am told!). Similar to when you increase exercising or take up a new activity, the body must adapt and this can be painful. This is a normal response to this type of change in the body tissues.

With greater laxity developing in the tissues there is more demand on the controlling mechanisms in relation to movement. This is controlled by hormones that have a role in preparing the body for birth. Consequently, there can be greater movement at the joints and in the muscles therefore increasing the demand. Again this can be provocative as the brain seeks to let you know that the area is under strain. However, this is weighed against the clear need for greater laxity for the birthing process.

Most mums-to-be are aware of the changing hormone patterns as they ride waves of emotional change, many of which are again normal. Excitement, joy and anxiety are all common emotions during pregnancy as thoughts trundle through the mind. Other life factors play a role including pre-existing worries and stresses. We know much about stress physiology and pain and how anxieties and anticipation amplify pain. Essentially inter-related, in treating pain we must account for stress and anxiety and provide coping measures and strategies to dampen the effects upon the sensitivity. Emotional state has a clear influence upon pain as shown empirically and through defined anatomical links in the brain. In addition, we know that oestrogen can also have a sensitising effect upon the nervous system and therefore have a role in amplifying danger signals and increasing the likelihood of a pain experience.

Bearing the aforementioned in mind we can then offer a range of strategies and treatments that tackle pain at different levels. This includes tissue based therapies such as massage and joint mobilisation help to ease stiffness and pain enabling freedom of movement, exercise therapy to improve and maintain normal movement, cognitive techniques to reduces stress and anxiety such as breathing and mindfulness and developing understanding of the changes to reduce concerns about movement. Pain in it’s modern sense is a multidimensional experience that requires an approach that recognises this fact. Treatment that works on a spectrum of body, mind and brain is called biopsychosocial and considers the biology of pain, the psychological influences and social impact. The scientific literature tells us clearly that this is the best way to manage and treat pain and indeed with pain during pregnancy this is no exception.

It is wise to seek professional advice if you are suffering pain so that you can be reassured and know what you need to do. Keeping physically and mentally healthy is important with a regular routine of exercise, socialising, rest and learning (read, music, language etc). All in all we can aim to thoroughly enjoy the experience and keep suffering to a minimum.

30Jan/11

Graded Motor Imagery

The Graded Motor Imagery (GMI) programme is an evidence based therapeutic approach that falls under the brain training umbrella. This is because the treatment targets changes that have occurred in the brain. We know about these changes from a number of brain scanning studies in recent years. The actual programme has been developed largely through the brilliant work of Lorimer Moseley, so for this we are truly grateful.

The programme runs through three sequential stages, laterality (recognising left and right), imagined movements and mirror therapy. In essence this is graded progression, working the brain to desensitise, habituate and develop function. These areas of the brain are part of the pain matrix which means that they have a role in pain production as well as other functions that are non-nociceptive (nothing to do with danger).

We know that pain is a brain experience influenced by physical, psychological and social factors, hence the biopsychosocial model. Targeting the brain with clinical treatments is offering a very modern approach to pain and chronic pain in particular.

Mirror therapy using a mirror box or standing mirror was initially used for stroke rehabilitation and for phantom limb pain but in fact it can be used for a range of nasty pains and functional problems. The brain ‘sees’ a normally functioning hand, foot or other body part as the affected area is hidden and the unaffected side is moved. Observing the reelection of the unaffected side, the brain thinks that the affected side is working well and looking normal. As the brain uses visual information over and above information from the tissues, it will prioritise what it sees compared to what it feels.

At Specialist Pain Physio we use this programme in its entirety but also the different components. We also integrate the techniques with others to optimise the learning process and changes in the nervous system that lead to pain relief and improved ability.

Rehabilitation is learning and the underlying process is similar to learning a language or a musical instrument. It takes time, practice, motivation and perseverance. Give the brain and the nervous system the opportunity and it can change for the better.

We commonly use GMI for complex regional pain syndrome (CRPS), arthritis, tendon pain and injury, sports injuries and repetitive strain injury (RSI). The principles can be applied in a range of other conditions to provide a more complete bodywide rehabilitation programme.

09Jan/11

Tips for effective rehabilitation

Tips for effective rehabilitation

 

Rehabilitation is absolutely essential in restoring normal activity after an injury or painful event, as part of chronic pain management, improving one’s ability to be active and following an operation or other medical procedure. The programme should be individualised, progressive and be appropriate for the goals of the individual, i.e. functional for work, sport and other activities. The following tips are ways of really enhancing the process of rehabilitation, drawing upon some of the most recent understanding in neuroscience and cognitive science.

Tips

In no particular order:

1. Ensure that you have set goals related to your objectives. Follow the SMART procedure.

2. Keep a rehabilitation or training diary so that you can tick off your exercises and feel good about it as well as mark off goals when they have been achieved.

3. The programme should start at a baseline determined with the help of your health professional. This is the start point from where you move forwards.

4. The programme should be progressive, fitting with your goals, looking to challenge and move forwards but without causing unnecessary flare-ups.

5. Flare-up management should involve understanding what it is, how it can be managed effectively and used as a learning experience.

6. Rehabilitation should include components of education, motor control, proprioception, functional exercise, strength, endurance and posture. Other aspects can be power, speed, agility, work and sports specific tasks.

7. Understand realistic time lines that includes the healing process so that you know what to expect and where you are along the line of recovery. You should ask your health professional to keep you updated on this point.

8. Vary the tasks when you can. By the nature of rehabilitation you have to repeat the exercises, in some cases very often. This is because in essence there is a learning process going on and it takes time, just like learning a language or musical instrument. Changing the context can help to keep the interest.

9. Gaining feedback is really important. This can come from an observer or a mirror. Mirrors are brilliant rehabilitation tools as the brain uses visual feedback over sensory feedback and therefore can help to correct movement patterns. Mirror therapy is a different approach that can be used in certain conditions with good effect when used appropriately by a trained practitioner, for example in stroke victims, phantom limb pain, complex regional pain syndrome and other painful conditions.

10. Using cognitive and motivational techniques has a huge effect and can make a really significant difference to the outcomes. Again this requires an appropriately trained and knowledgeable practitioner who can integrate these methods into the programme. Targeting the brain is a very powerful way of maximising potential. Techniques include awareness, assessing beliefs, education, goal setting and mindfulness.

11. Set up the environment to promote concentration, focus and awareness

These factors and others are fundamental to a successful rehabilitation programme. Enhanced programmes make a difference as they draw upon not just the physical parameters such as altered movement, pain, the healing process and altered neurodynamics, but also the integration of senses, past experience, cognition, immune function, stress, anxieties and other psychological states, personality, culture, understanding and a host of other human characteristics. Looking at rehabilitation in a wider sense is complicated, takes time and understanding, however by drawing upon the knowledge of brain and nervous system function, immune activity, tissue healing and other bodily systems, we can create bespoke, challenging, progressive and fun programmes that maximise potential.

Rehabilitation programmes at Specialist Pain Physio Clinics are thought out based on your experience, presentation and the requirements that you identify. We constantly strive to update our methods by keeping abreast of research and science. Follow the blog and our Twitter page to learn more.