Category Archives: Sports Injuries

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.