Category Archives: Uncategorized

05May/17

Exams, stress and pain tips

Exams, stress and pain tips
Exams, stress and pain tips

Exam exhaustion | Felix Neumann

Exams, stress and pain tips ~ It is that time of year again when kids are preparing for their exams. With the emphasis on high grades reflecting success, the pressure on youth has increased. There is the sense that if they do not achieve all those ‘A’ grades, then somehow they are a failure. What a terribly damaging way to go about it, and indeed one of the major influences upon kids health. Levels of pain, anxiety and depression are on the rise. Social media also has a part to play, not the channels themselves per se but the way in which it is used and relied upon as a source of temporary reward ~ ‘likes’ etc. We can and must change this as a society.

One of the most respected and successful sports coaches of all time, John Wooden, made the key point that each person should be focusing upon what they can control and to do their very best. If your attentions are on doing your very best, you will be successful, for you. If you thinking drifts towards the grade ‘you must’ achieve, then your focus is not on doing your best, it is on the grade. Re-focus on doing your very best: maximum effort. Besides, if you are focusing on and doing your best, there is no worry or anxiety because you are doing. Those feelings only appear when we are thinking about being somewhere else, whilst embodying the feelings and hence suffering. That somewhere else is the past or future, and neither exist.

We can realise that this is not necessary as we learn to make other choices. Ask yourself: How am I choosing to feel? Could you choose to think about the situation in another way and feel better or good? Yes you can. Try it and see!

Read hereJohn Wooden ~ Wooden: A Lifetime of Observations and Reflections On and Off the Court
Choice

You could choose to think about something in life you face as a problem, that it is difficult, perhaps impossible or that your efforts are doomed to failure. How are you likely to feel? Or, you could choose to view the situation as a challenge, an opportunity to learn something and seek to find and practice ways to overcome the challenge. How would this feel? Very different. We feel better when we have understanding and a plan that we action because we are actually doing, and this includes writing a new inner dialogue or script. How are you pre-empting or expecting things to go? How often do they actually turn out that way? Well if so, why not water the seeds of positivity rather than anticipate the worst outcome or a miserable outcome? Re-frame your thinking that is always embodied, i.e. we experience our thoughts with our whole self including our bodies — where do you feel the feelings that you label as anxiety? They are remarkably similar to the feelings of excitement but which label are you choosing? Choose another and see what happens.

Here are some exercises from Mike Pegg on Positive Scripting: click here
The inner dialogue

What are you telling yourself? Are you listening? The two are different. You cannot stop thoughts popping in but you can choose what you do with them. The practice of mindfulness is a way of achieving this as you are aware and open to the different thoughts, feelings and emotions as they pass through rather than become embroiled.

Self-confidence relies upon the inner dialogue. No matter what you have achieved before, what you are telling yourself and listening to now is what determines your confidence. Create a positive script about what you can do and what you can control: my own thoughts, my own actions, where I focus, doing my best.

Developing insight into your own mind creates the opportunity to choose your direction. We are always changing, but which way do you want to go?

Some great reading on how to communicate with yourself and others: Thich Nhat Hanh
Movement and posturing

Movement and exercise are healthy. During periods of revision we need to move to nourish the body but also our thinking — the two are NOT separate but parts of you. Changing position, using some exercises, walking, jogging and other activities punctuated through the day help to keep the focus. Some exercise in the morning before starting, changing posture and position every 30 minutes or so and having a good break every 45-60 minutes can help to keep a certain freshness and concentration.

This is about performance and to perform we need to focus in the present moment. Refresh and renew then, are key ingredients.

Recharging and sleep

You need good sleep patterns for healthy functioning. Make sure you have a routine that you stick to through the exam period. Many important healthy activities occur during sleep, including a kind of physiological cleaning in the brain. When this does not happen we can feel groggy and moody the next day.

If you are tired, focus on mantras such as ‘I need energy’ rather than ‘I am tired’. We notice what is on our agenda and therefore by telling yourself that you need energy, you’ll be orientated towards this as a goal: regular healthy snacks, fresh air, movement, mindful practice, periods of relaxation.

Through the day we need to plug in. Refreshing yourself allows you to focus well for bursts of time.

Pain and stress are body (whole person) states due to a perceived threat

People come to see me because thus far they have not been able to recover from their pain problem. This is inherently stressful, which adds to the biological and behavioural mix resulting in on-going states of protect.

~ pain and injury are poorly related and are definitely not the same

Pain is about protection and not a precise guide for tissue health or state. This is the common misunderstanding that leads to ineffective treatments. Pain and injury are not well related and they are definitely not the same. Pain is a unique perception emerging in the person and belonging to the person. This is one of many we experience but it is a dominant feeling, as it should be, to motivate action in line with getting better.

Persistent pain involves many adaptations that include those in the brain (emotional, reward and emotional centres in particular), the way we perceive the world and ourselves, the way we make decisions, behave and the way we act. The world appears to be far more dangerous than it really is and the rating of threat is applied in normal circumstances, just in case. For example, sitting is not dangerous yet it is often associated with back pain. The body systems in weighing up the evidence and based on prior experience, deem sitting in a chair to be actually or potentially dangerous. It is the result of the weight of this evidence that manifests as pain in the area of the body deemed to need protection and awareness.

Overcoming pain is about changing this weighting of evidence by taking new actions (habits) based upon new thinking (understand your pain), beliefs and expectations.

During exam times there is usually a change in routine. More sitting, less exercise, and potentially more stress depending upon how the individual views the situation. For optimising performance, this must be addressed whether there is pre-existing pain or not.

It is common for pain to increase during times of stress and pressure. This is not because the tissue state changes greatly but instead the perception of threat is raised and hence protection more likely. We can also tend to anticipate certain relationships. For example: ‘sitting will hurt’, which can become a predominant thought pattern unless we work to create a new way forward. We are always changing, it is a matter of which way you choose to go.

Simple practices during exam times can make a significant difference. Starting with understanding your pain, you can choose to use the strategies mentioned previously that include regular movement, appropriate exercise, practicing a positive script, refreshing & renewing, together with mindful practices (that actually enable many of the others), deep relaxation, imagery and visualisation. Making a plan of which to use and when through the revision and exam timetable can make all the difference.

Pain Coach and Wellness Coach ~ to overcome life’s challenges, live well and perform

For appointments or enquires about Pain Coach Mentoring and speaking events, call Jo on 07518 445493
01May/17

High Performance Sport Knowledge Exchange 2017

High Performance Sport Knowledge Exchange 2017

~ some comments following a really engaging day when I was delighted to be asked to speak at the High Performance Sport Knowledge Exchange 2017 held at the Sport Ireland Institute last week.

I was fortunate to share the speaking platform with Dr Brian Cunniffe, Performance Lead from The English Institute of Sport, and Jason Cowman, Strength & Conditioning Coach of the Irish Rugby Football Union.

It was a great day of discussion amongst people involved with optimising performance, both their own and athletes ~ S&C coaches, elite performance coaches, physiotherapists, support staff, doctors, military personnel and more. I say ‘their own’ because the success of an athlete or sportsperson is intimately related to the way in which the coaching and support staff operate. We are all seeking to do our very best, every day.

Here is a brief summary of some of the points that were raised and talked about in relation to my talk and Q&A. Some great questions were asked.

~ Make each day a masterpiece ~ John Wooden

Despite the talks appearing to be very different, there were in fact some common themes. The emphasis was upon how the team can best function to deliver results, considering communication, facing challenges, developing relationships and trust, and creating a team that delivers. At the heart of this of course, are people with differing backgrounds, views, beliefs, experiences, knowledge, cultures and professions. Everyone has strengths and something to bring to the table, which is where the potency arises once these are clarified.

** As you read and take note, consider that these skills of performing and well-being are as relevant to the coach, physio, doctor, support staff as to the athlete.

Language & the inner dialogue

Language is powerful ~ the language we choose to use with others as well as the language we use to ourselves, the inner dialogue or script. Certainly in my talk and in the Pain Coach day on Tuesday I put an emphasis on developing skilful use of our inner dialogue. So much of what we experience and how we experience it comes from what we are telling ourselves. Realising this and harnessing the potential from running a positive script is hugely empowering. This is a skill that a performance coach, a strength and conditioning coach and a physiotherapist (anyone actually!) can foster and nurture in themselves and those they work with, the athletes and colleagues. Here are a couple of great questions to self that allow you to calibrate and make a new choice:

How am I choosing to feel? How am I choosing to think?

What you are telling yourself right now impacts upon your emotional state and quality of life. Which seeds are you watering? The ones that foster positivity, understanding, compassion, openness and patience or the ones that harness anger, frustration, impatience, and resistance? Developing one’s awareness of the workings of the mind and how thoughts are embodied creates a great opportunity to live increasingly well. This includes the ability to focus and hence perform. There is only this moment in which to focus and perform, whereas the inner dialogue can tend to take us off into the past or future. Of course this will happen but there is a difference between the drift away from the now with awareness and on autopilot. We do not have to be slaves to the wanderings of the mind. Simple attentional training and mindful practices help to develop this skill. We know that a wandering mind is an unhappy mind, so this kind of training is a key skill.

Super-teams

Super-teams can be created to nurture the abilities of the athletes. One of the problems of chronic pain is that people can fall in the cracks between different disciplines. This need not happen with a super team in place that has a clear vision of success that has been clarified and stated. This is known by all team members who have identified their strengths, their reason and purpose and their individual roles. Communication is effective, regular and uninhibited. Strengths are developed and areas of improvement identified and worked upon with a complete focus upon growth together. Naturally this includes the athlete ~ there is no separation between team and athlete, athlete and team. Regular meeting and clarification maintains momentum. The team is steered by a leader who is prepared to truly lead and inspire action by exhibiting courage, authenticity and compassion. This takes time but is of course worth the effort in terms of outcomes.

The problem of pain & pain in sport

Pain is a huge global health burden. Pain costs society because of investigations and treatments, many of which are unnecessary or ineffective, and loss of productivity. The suffering for individuals is immeasurable and of course those close by also suffer the consequences.

The existence of such a significant problem in society means that this is a public health concern of major proportions. Without new thinking this will likely worsen. Arguably we are seeing this in the younger generation as they grow in a world that validates materialism, unhealthy communication (e.g. social media), thinking that the individual supersedes everything (i.e. selfishness), success based on ‘A’ grades or income and pressures to conform to practices that do not nourish self-compassion. 1 in 5 children suffer chronic pain and the statistics on mental health are horrific. I do not use that word by mistake.

I do not believe that the term mental health does justice to the reality that the ‘mental’ condition is embodied, which is why in most cases chronic pain and depression or mood changes come hand in hand. Thoughts are embodied, which is why practices that develop healthy use of the inner dialogue are vital. 

This problem reaching across society means that it does exist in sport. One of the challenges is to differentiate between the pain of being an athlete, the pain of a new injury (expected and understood) and the persistent pain that is due to a range of biological and behavioural factors. This will need athletes and coaches to learn about pain and communicate together with the athlete to establish what is happening and what needs to be done. The super-team vision will include these scenarios in the planning.

~ pain and injury are poorly related

There is no single clinician or therapist for pain. This is a problem and indeed perhaps part of the wider problem (the misunderstanding of pain in society), as the person suffering receives many different ideas about the possible causes and suggested solutions. This is the reason for Pain Coach, which is a blend of the latest understanding of pain together with known coaching methods that work to maximise learning and potential. The over-arching aim of the Pain Coach Programme is to change the way society thinks about and hence addresses pain. And there are exciting times ahead on the basis that we need to be talking about and enacting overcoming pain, not just managing and coping.

#upandrun

In relation to sportspeople, we can focus upon an understanding of pain that works for performance coaches, S&C coaches, clinicians as well as the athlete himself/herself. Working together to understand will be key and there is no reason why workshops cannot be run with the super-team that includes all these people. In fact, everyone needs to understand pain ~ the reason for UP | understand pain.

Chronic pain in sport is a blight upon the careers of many. Open discussion and an open forum for athletes to talk and express their fears is important as this provides an opportunity to face the problem, or rather the challenge, learn and overcome. Only by facing our challenges can we truly surmount them and move on. Distracting, avoiding and circumnavigating do no good in the long-term. I acknowledge that there is a place for a ‘patch up’ before an event if need be, but thereafter the challenge must be addressed. Again, the super-team creates the environment and context for this to happen.

Communicating

Language and the content of the inner dialogue has been mentioned but what about delivery: Who? When? How? And there’s the vital part, active or deep listening. Only through listening deeply can we truly hear what is being said. Paying the fullest attention (there’s the practice of paying attention again!) to this moment and what the other person is saying creates a trusting bond and an opportunity to gain insight. This insight delivers all you need to know right now. Sometimes just listening is all that is needed right now. The gifts of ‘you’ and time are two of the most valuable in life. This is easily practiced both at work and at home and soon enough you find yourself to be proficient and increasingly effective.

Some good questions for self:

~ after a training session, who speaks first? Who does the most talking? Who has the key information? 

Summary

There was much more discussed through the day and in the Pain Coach day on the Wednesday before. Hopefully this has provoked some new thinking and realisation. The beginner’s mind is open to possibility and opportunity. We are designed to change and grow as each moment passes. It is a matter of choosing which direction, which begins with realising that we have a choice. The awareness of choice is empowering and exciting but comes with responsibility.

All of us in the room have great jobs that we are passionate about and feel inspired to perform each day. We have meaning and purpose. This drives us to be successful because we always strive to be the best that we can be. That is exciting and fulfilling.

Choose to feel excited.

RS

For further information about Pain Coach training and mentoring, please do get in touch: [email protected]

Facebook & Twitter @painphysio or frequent updates

26Jan/17

Pain Coach Tips

Pain Coach Tips

Pain Coach ProgrammeThe Pain Coach Programme is the complete approach to chronic pain and painful conditions. The programme addresses the specific changes and adaptations that occur in on-going pain, together with skills to sustainably create the conditions for health and happiness. Here are a selection of tips that you can use straight away.

Before getting into the tips, it is important to understand that our knowledge about pain has moved on significantly over the past 10 years. Pain is not something that is only referenced by where we feel it, and it is certainly not observable on an investigation such as a scan or x-ray. Pain is subjective, unique and emerges in the person when there is a perceived threat to that person. The focus here is upon simple Pain Coach tips, so if you are needing to understand pain further, keep checking back for future blogs or read through the library here.

Pain Coach Tip 1

Clarify your picture of success ~ what does it look like? What are you doing? How are you feeling? This gives you a direction, a steer, and orientation. Write it down and share it with someone, making a commitment. We need meaningful direction, something to aim for.

Pain Coach Tip 2

Frame your thinking in positive terms. Set out your intentions: what do you actually want? For example, instead of thinking about how to get rid of pain, think about how you can feel good. When we focus on feeling good and well, we will orientate our subsequent thinking and actions towards that end.

Pain Coach Tip 3

Think about a success you have had in your life. How did you achieve this success? What strengths did you use? Consider how you can use these strengths each day, building them as you would a muscle. Then think about how you can use these strengths to develop your wellbeing, health and happiness. Make the choice to adopt this approach.

Richmond Stace | Pain Coach & Specialist PhysiotherapistThere are many strategies and techniques to work to your potential to overcome pain. Setting the scene by understanding your pain, what influences your pain, knowing what you can do and how you can do it gives you the confidence and belief to focus on what you CAN do.

The Pain Coach Programme | t. 07518 445493

21Jan/17

Engaged physiotherapy for pain

Engaged physiotherapy for pain and the modern world

Engaged physiotherapyEngaged physiotherapy is an approach embracing full awareness of oneself as a clinician, full awareness of the person you are working with, full awareness of the context and past, compassion (self and others), insight, and modern sciences (the facts ~ what we know). I have ‘borrowed’ the term from Thich Nhat Hanh who describes engaged Buddhism, which is the practical use of the philosophical principles such as mindfulness, mindful breathing and mindful walking.

Cultivating our awareness as clinicians and gaining insight into the causes of suffering affords us the opportunity to think clearly about the best action for the individual, in this case in pain. Together with an understanding an use of modern sciences, especially pain science, cognitive science and neuroscience (there is vast overlap of course), and philosophy, we can consider each person’s story and create a way onward that is grounded in understanding, compassion, belief and the right attitude to succeed.

There are simple practices that clinicians can use each day that develop and grow awareness and insight. Here are some examples:

  • The greeting
  • Being present during a consultation using the breath
  • Deep and active listening
  • Compassionate speech
  • The creation of a calm and peaceful environment
The greeting

The initial contact often sets the scene. We can think about how we present ourselves with posturing, gestures, language and the simple smile. I would suggest always going to the patient to greet them in the waiting area, and behaving very much like you are welcoming an old friend into your home.

Being present

Using the breath we remain present and aware of what is happening right now. What is passing through me (my mind)? Any bias? Preconception? Judgement? Being aware allows us to let these go so we can focus on active and deep listening. Practicing mindful breathing each day formally for 5-10 minutes helps us to develop this skill that we can use through the day, every day for professional and personal relations to benefit

Deep listening

One of the most valuable gifts we can give to another person is ourselves and our time. Being fully present to listen to the patient (or colleague or family member or friend) creates the conditions for a meaningful interaction. All involved parties benefit from meaningful interactions as we release certain healthy chemicals in these contexts. In deep listening we can hear and understand the suffering of the other, enabling the best and wisest course of action, which may simply be to continue to listen without interruption. Learning to be comfortable with silence is a valuable skill. Much can emerge from moments of silence. (Reading here)

Compassionate speech

Choosing our words carefully, considering their effects, is an important skill to develop. The words we utter have potent effects on others as they hear, process, imagine, think and react. Of course using kind, compassionate words can create the conditions for calm and insight, enabling the person to see a way forward. A focus on health and being well maintains the desired direction, hence the use of words that encourage this thinking and vision helps the person to orientate themselves towards a desired outcome.

We have the spoken word and we have the inner dialogue. Being skilful with both is important as we need to consider which thoughts we are fuelling, or which seeds we are watering by the way we think and what we say. An example would be the effects of engaging in idle gossip. In the long-term, gossip can create issues of trust and miscommunication that breeds suffering.

As a clinician, we should always be thinking about delivering the right messages based on truth, and that provide a compassionate way forward. Helping the patient develop their skills of self-compassion is frequently needed in cases of chronic pain. Understanding that self-compassion is one of the skills of well being helps individuals to practice and benefit from the nurturing of the care-giving systems in the body that play such a big part in our health and happiness.

Creating a calm environment

We are very responsive to the environment. Consider how you would feel working in an office with no windows and in the basement of a block compared to an office with a view over a park or a river.

Clinicians need to think about how the patient might think and feel coming into the clinic. We seek to create a peaceful space for people to experience feelings of calm and gain insight into how they can be, how they can transform their state of being and how they can use these practices in their day to day lives.

The simple practices are just some of the ways we can use our knowledge and skills to create the conditions for people to get better. We no longer have to think about managing or coping, instead use engaged physiotherapy and approaches to give people the belief, understanding and skills to coach themselves, fostering independence and a sense of agency, restoring choice and meaningful living.

****

These practices are part of the Pain Coach Programme, which is a focus upon getting better and achieving success in overcoming pain. The programme for patients is a comprehensive way forward addressing a pain problem by focusing on getting healthy and well, and the programme for clinicians is to develop their skills and knowledge to coach patients. If you would like further information, please email us: [email protected] or call 07518 445493.

16Jan/17

Pain after joint replacement

Pain after joint replacement

Pain after joint replacementA number of people experience pain after joint replacement, therefore it is important to identify those who are potentially at risk, devise ways to minimise the risk and ensure that post-operatively each individual receives what they need to resume a meaningful life. Knee and hip replacements are being increasingly performed and hence we are likely to see more people suffering persistent pain. Pain is already one of the largest global health burdens, so understanding pain and what we can do is vital for the global community.

2016 was the Global Year Against Pain in the Joints

There are several key facts to understand about pain:

  • The pain that we feel is poorly related to the extent of tissue damage, tissue changes or injury.
  • Pain is contextual and the likelihood of feeling pain is determined by the perception of threat, both consciously and by body systems that are designed to protect us. In essence, any situation that is judged to be threatening will have implications for a pain experience. This is why stress (a perceived threat) and tiredness play such a role in pain.
  • There is no actual, specific biology of pain, instead a state of protect. In the case of chronic pain, this state is ‘on’ much of the time (a habit) and the person must learn how to change this with different types of training (The Pain Coach Programme). There are no pain signals, pain receptors, pain molecules or pain centres. The biology that is involved with the experience of pain is largely found NOT where we actually feel the pain. Much like when you watch a film in the cinema, most of what you need is not on the screen.
  • And now for some good news! Pain can and does change, but you need to understand it and know what to do.
Risk factors for chronic postoperative pain ~ what to look out for
  • Preoperative pain: if uncontrolled, high intensity and impacting, there is a risk of chronic pain after joint replacement (Arendt-Nielsen et al. 2015). The pain and the person must be addressed before the procedure.
  • Widespread pain is associated with chronic pain after joint replacement (Petersen et al. 2016; Wylde et al. 2011).
  • In some cases of osteoarthritis (OA), temporal summation has been shown to be associated with pain after joint replacement, so evidence of this should be noted.
  • People with fibromyalgia tend to have a higher risk of suffering postoperative pain (D’Apuzzo et al. 2012).
  • When the person has OA that affects a number of joints (Perruccio et al. 2012).
  • Catastrophising about the pain and a lack of effective coping strategies predicted postoperative pain after knee replacement (Baert et al. 2016).
  • Genetic factors, prior experiences (previous surgeries and the quality of the experience and outcomes), beliefs and other influences should be considered.
What can we do?

On deeply listening to the person, we will hear about their experiences and understand the causes of their suffering. If indeed a joint replacement is indicated, then we must ensure the person who will live the experience has a working knowledge of what will happen, who will do what, their role and what they can do to focus on being healthy and well for the best possible recovery.

A simple preoperative education session with the relevant information, an opportunity to ask questions and to learn practices that create the best conditions for healing and recovery would benefit all, but in particular those with identified risk factors. Understanding pain is a key skill and will put the person in a good position to recover whilst they are administered the right pain medications.

The early days set the scene for the coming rehabilitation. Simple breathing and mindful exercises, movements, motor imagery and pain relief all have a role to play. Monitoring how the person is feeling and gauging their belief in their own ability to recover provides insight and opportunities to motivate, encourage and guide compassionately.

Simple, low cost interventions such as these are very likely to make a difference. We can identify the needs of the individual, address any areas of concern before and after the joint replacement and then closely observe the recovery and rehabilitation plan.

Pain Coach Programme ~ preoperative assessment and practices | t. 07518 445493 or contact us using the form below

Common terms used include total joint replacement, total hip replacement, total knee replacement and total joint arthroplasty

15Dec/16

Faces

Faces

faces

As I sat and watched the last of my children’s nativity play, I paid particular attention to all the little faces staring out into the room. So many expressions shaped and re-shaped as they performed and watched others perform their parts, telling the traditional story. Then there were those who were looking out to the parents, reacting to acknowledgement and encouragement, and of course the one picking his nose and eating the sticky attachment to his finger. So many faces telling so many stories that collectively gave us the experience of the nativity. Imagine the same play but without any faces. It’s unimaginable as faces are such a significant part of who we are to the world.

We face the world, we face each other, we face off, we pull a face; ‘let’s face it’, you may say to someone. There is a purpose to having a face (including nasal excavation!), which is about recognition, bonding with others and survival. These are all basic aspects of being human and therefore when something goes wrong, it heavily impacts upon the person. One of the most dramatic problems is facial dystonia, within which I include temporomandibular (jaw) dystonia, when the facial muscles are contracting uncontrollably and involuntarily. This form of dystonia has far reaching effects upon recognition, bonding (connectedness) and survival mechanisms as I shall explore. Suffice to say that we are talking about great suffering endured as a result of this condition.

Before describing how dystonia affects these dimensions, I outline my thinking with regards to the purpose of a face. Clearly there is great importance that is supported by the significant representation of the face that resides in the sensorimotor cortex forming part of the so-called homonculus. Our distinct features are recognised by others to identify ‘me’ but I also have a sense of how I look according to those features. My face plays a role in how I meet people and engage with them to form bonds. This is a vital part of our existence, with connectedness playing a role in health and survival as we create communities for mutual benefit. We also bond more intimately, our face and ‘looks’ holding some sway along with how we use the communication functions of the face: verbal and non-verbal. We can gather information about a person by their expression. The person also gathers information about themselves via their felt expression, and indeed can change mood by forcing a new facial position that is predicted to mean something new. For example, if we force a smile, our brain predicts that the most likely cause of the sensory information (from the muscles, joints etc) is happiness, and therefore we feel a sense of joy. The facial role in survival includes breathing, eating and drinking, all specialised and precise activities that are essential.

So what happens when things go wrong?

Aside from dystonia, what else ‘changes’ the face with a consequential impact? I would include conditions such as acne, eczema, facial pain (e.g. trigeminal neuralgia), dental problems, eye complaints (infection, squint, lazy eye, blepharospasm, and other issues that distort the normal or expected configuration and placement of facial features. The Maggie Thatcher Illusion was reported by Professor Peter Thompson in 1980, demonstrating the importance of faces. Both hands and faces have a large representation in the brain, perhaps indicating their significance in our on-going existence. The recent book by Darian Leader, well worth reading, made a study of hands: Hands: What We Do with Them – and Why. The importance of faces and hands then, will amplify the effect when something is deemed to be wrong. Consider the loss of a hand by amputation, and the subsequent feel of what it is like in the frequent case of phantom limb sensations, which can include pain, or the way in which a hand and the digits are experienced following immobilisation.

Recognition

Those that know us will always recognise us because of familiarity and because their brains (we are more than a brain but for ease I will use the term) make a prediction based on prior knowledge. They simply see ‘me’. However, my sense of self in part is determined by how I feel physically. What does my body feel like? What it is like to be me is more than just the physical sensation as the moment is filled with perception, cognition (thinking) and action. The three are unified into this ‘what it feels like to be me’. With a distortion or a sense that something is not right or how I want it to be, there is a mismatch that creates discomfort, rumination, and suffering to a varying degree. We can sometimes say, ‘I don’t feel like myself today’, referring to different reasons as to why this may be, and in fact, perhaps we can consider therapy to be a way to restore a sense of self. Not how I used to be as we cannot reverse time, but gain a sense of who I am, my authentic self. Movement is part of who I am as demonstrated by the way we recognise someone by their walk or other mannerisms. When we are in flow, these mannerisms occur without thought. As soon as we consciously attend to something that we would not normally think about, it can change. The yips in golf is an example as is the way some people find it hard initially to focus on their breathing when practicing mindfulness.

So, when my face changes, or I perceive a change, then I can feel somehow different from the expected or known ‘me’, which then impacts upon how I engage with the world. Self-consciousness is a commonly described, causing a withdrawal from society. Feeding this can be self-criticism and a sense of shame (a concern about losing connections), which both need addressing as these feelings bring about on-going self-protection that includes the way we move. The emotional centres of the brain communicate enormously with the basal ganglia that has such a role in movement disorders. I am not surprised by recent findings in relation to the gut and Parkinson’s disease as the way we feel, the gut, our overall health are so inextricably entwined. A change in gut flora and emotions come hand in hand and with the way in which our emotional state affects the way we move and interact with the world, hence we need to consider the whole person.

Facial expressions are part of who we are and how we communicate with others. When this changes, and usually an enforced change at that, how we recognise ourselves shifts. People who know the person will continue to know them in that ever-evolving way, and those who do not know the person must look beyond the condition and the way it presents to see the whole. As a society we have an obligation to think about the whole individual as they are not defined by any condition or behaviour.

Bonding

We are designed, so it seems, to be connected with others and form communities within which we support each other, care about each other and share experiences. Initial meetings arise for all sorts of reasons but in essence when we come together, we look at each other and learn about the features of that person via their posturing as well as the physical characteristics. Implicitly we will be attracted to some people and less so to others. These natural biases we can overcome as we mature and learn about the essence of people.

To bond we would often spend time with someone and talk so that we can learn about each other. The act of speaking is incredibly complex, involving many movements that allow us to form words and make noises. With the involuntary movements of dystonia this can be extremely challenging. This can become even more the case when talking to strangers, to the extent that it may cause the person to avoid doing so. This is one of the areas that we work upon in the training programme both in terms of the formation of words (sensorimotor exercises) and increasing confidence to go and speak to people.

There is a challenge to bonding in some instances. It means being vulnerable and taking a risk as you put your authentic self out there. This is of course how we gain the reward although sometimes it does not work out and we can learn once the feelings of disappointment subside. Developing our sense of worthiness is important under these circumstances, and perhaps even more so with the additional burden of dystonia. As with chronic pain, it is not just about doing some exercises to get better, instead a ‘whole’ approach that addresses all dimensions of the lived experience ~ e.g./ understanding, thinking clearly, developing confidence and resilience. All of these skills can be practiced as ‘skills of well being’.

Survival

On a simple level, to survive we must breathe and we must eat and drink. These acts can be somewhat complicated when facial dystonia affects how the mouth is controlled and in some cases taking a simple breath in through the nose can be more difficult. This is not to say that the person cannot breathe! The involuntary movements can be distracting and impact upon how the person actually takes a breath in through their nose or mouth. If they have a cold, then this can be exacerbated.

Choice of food can be narrowed as chewing is especially difficult. Chewing is a skill, which requires precision of movement but also with how much pressure to apply via the jaw and manipulating the food with the tongue. Again, like any skill, this can be practiced as part of a training programme to improve the efficiency, economy and precision. One of the reasons that dystonia can be muscularly painful is because of the overworking muscles. This also results in tension and stiffness described. Muscles are working when they do not need to and when they do need to, they are working too much. There is a circular causality to this feature, similarly in chronic pain when the muscles are being ‘told’ by the higher centres to protect the area. This loop continues until a new (active) inference is made with new information (understanding your condition and how it presents or emerges in you) and actions purposely made with the intent of change in a new direction.

With the self-protect system functioning as a result of the threat of the situation, and this is both conscious and sub-conscious, added to by self-criticism and a lack of self-worth that can be evident, there is a state of ‘freeze or fright or flight’ at play. This involves being prepared to run away or fight or express some kind of communication via the face and mouth: shouting, bearing teeth etc. These are very basic instincts and behaviours at play; the so-called old-brain. The self-protect system plays a vital role in our survival but only in short bursts. When there is a persistent state of protect going on, then our health and we suffer in a number of ways. However, there are a number of simple practices that again I would term the skills of well being, which we can adopt each day to gain healthy benefits. This is in essence the antidote to protect and by being able to gain insight into how we think and act, we can use this awareness to learn to regulate our emotions, make choices with clarity, reappraise situations and thoughts and maintain a focus on what we can do to feel well, healthy and live a meaningful life.

This blog merely touches on many areas that are relevant to dystonia, chronic pain and some of the important roles of a face. Why do we need a face? We have looked at several important reasons and made relevant to dystonia. There are different and unique causes of suffering endured by people with facial dystonia that we identify and work on transforming with specific training but within a context of understanding and compassion that is at the heart of what we do.

For further information about the complete training programme for dystonia, please complete the following form:

Pain and Communication

The problem of pain

Pain and communicationCommunication has a large role in pain from the perspective of telling someone that you are suffering but also in the treatment of pain. At the BASRaT Symposium last week I outlined some of the key features that I will summarise here.

Before discussing communication I highlighted what is the one of the most significant and costly problems on the planet: pain. There are vast costs to society and individuals as the numbers of people suffering chronic pain are enormous. The British Pain Society recently called it the ‘silent epidemic’.

It is thought that 20% of the population suffer on-going pain, including 1 in 5 children. Whilst we can say that the former is a significant number necessitating action, the latter absolutely needs to change. We must understand why this is the case. What is it about modern living and culture that is creating a generation of pain and anxiety? There are some obvious candidates: pressure to achieve at all costs, a lack of self-esteem, narcissism encouraged by popular culture, and obsession with social media at the expense of developing connections and communication skills (including addiction to devices).

One of the main reasons for the scale of the pain problem is the misunderstanding of pain through society. The biomedical model still predominates when there is the search for a structure or pathology to explain the pain and extent of the pain. The preferable biopsychosocial model takes into consideration the important psychological and social dimensions, but often the ‘bio’ receives most attention. Modern understanding of pain would suggest that actually, a better framing would be a sociopsychobiological model because whilst understanding the pathophysiology and molecular aspects of pain is important for scientists and clinicians, the person in pain just needs to know what to do when they are in pain. They need a process to follow with an understanding as to why this is important. Neuroscience education has a place in the treatment of pain, but not a primary one.

Pain is a subjective experience emerging in the person, influenced by a range of social, cultural, contextual and environmental factors, past experiences and beliefs, in the face of a perceived threat. Pain is about protection and survival.

Pain & communication

With the size of the problem in mind alongside the understanding that pain is poorly related to injury and tissue health or pathology, we looked at some important aspects of communication.

One of the communication streams that is often forgotten is the inner dialogue. This is the story that you tell yourself about you and life; that little voice that is so familiar and if not trained can be so disruptive. This is the inner dialogue that can cause such suffering when we berate ourselves for not being good enough. This is relevant for the person with chronic pain as self-criticism is a common feature when in fact kindness and self-compassion is a key driver in getting better. Equally, the clinician’s inner dialogue will affect his or her approach and decision making. Think of a scenario when you are tired, you were late for work, you stubbed your toe on the bed and then you are faced with your first patient who has not improved. You need clarity of thought to approach this situation, not a mind cluttered with annoyance and frustration.

What are you telling yourself? What are you convincing yourself? How are you choosing to think?

How we communicate pain to the person has an impact on their understanding, which is paramount in validating their story to date, and in helping them engage with the programme. Firstly we must listen deeply so that we can know the person as much as the condition ~ the two are not separate. Listening deeply is a skill allied with active listening when you are fully present, in contact via body position, your eyes and expressions (verbal and non-verbal), and allowing them the space and time to tell their story. This narrative holds many clues so our full attention is required, jotting down key points and phrases. In sum, there are different communication dynamics co-existing: the inner dialogue of the person, that os the clinician and the (outer) communication between the two.

Compassion and empathy

Cultivating compassion and empathy as a clinician is an extremely worthwhile exercise. Those who have chosen the caring professions have already demonstrated these characteristics by the very nature of the choice ~ we care and want to help others to live their lives. It is interesting and reflective to consider the question: why do I care?

Not only is this important for the clinician, but also for the patient to learn such skills, especially if they are hard on themselves. It is very easy to pick up on this when they speak to you. The problem with being a self-critic without control is that it is very threatening and hence is provoking the self-protect systems that exist to make sure we survive. These systems have a significant role in pain and hence we are aiming to do the very opposite: active the care-giving systems and effect parasympathetic actions. In a sense our job is to help the person realise that they are safe, how they can safely build up their meaningful activities and adapt in a way that means they are living meaningfully.

What are compassion and empathy?

  • Empathy ~ the capacity to share the feelings of others
  • Compassion ~ feelings of warmth, concern and care for the other…with a strong motivation to improve the other’s wellbeing (Singer & Klimecki)

These will be familiar to clinicians and therapists, but what may not be so familiar is the fact that we can train and practice simple skills to improve our capacity.

It will not be a surprise to many that our brains change when we practice and learn, and this is no different for compassion. Neuroscientists have been looking at these mechanisms for some years now, gathering data on these brain changes and how they manifest in the person. Aside from the science, developing a compassionate society has obvious benefits for all:

Love and compassion are necessities, not luxuries. Without them, humanity cannot survive ~ Dalai Lama

These are skills that should be practiced from an early age with purpose, in homes, schools and workplaces. And just to be clear, compassion is not characterised by weakness or femininity as can be said; not at all. Compassion takes courage and is for all.

Simple practices

There are a range of practices that clinicians and therapists can use for both themselves and their patients. Remember that there is an interaction between the care-giver and receiver, both benefitting from a kind action on a chemical level. Fostering and nurturing every opportunity means that we set the scene: the welcome, the greeting, the opening question or comment, the engagement, the demonstration of care, the calm environment, and much more. Being aware of the present moment and crafting each unique session is a skill to be fostered.

It is beyond the scope to describe the following in detail, but as an indicator, these practices are easily started, often a challenge to continue, but immensely worthwhile for the individual and society:

  • mindfulness
  • lovingkindness meditation
  • the practice of gratitude
  • cultivating an ability to control the wandering mind
  • purposefully generating positive emotions

It is worth remembering that as a clinician, you are the treatment as much as any approach you apply. There is no separation. Developing your capacities hence will have a significant impact on your clients and patients as you increasingly set the scene and communicate in such a way that the person feels trust towards you, a sense of being cared for and a belief that they can get better.

Here is a great video from one of the foremost researchers in the field of compassion, Richard Davidson

For further information on the Pain & Wellbeing Coach Programme or clinician/therapist 1:1 Pain Coach Mentoring contact us below or call 07518 445493

06Nov/16

@painphysio podcasts

Recently I have given a couple of interviews about pain ~ @painphysio podcasts. One is in preparation for the BASRaT conference on November 19th in London when I spoke to Steve Aspinall about communication and pain (accompanying blog coming soon) and the other was a conversation with Harriett Seager from the Wellbeing Examiner.

On the BJSM podcast page:

Talk with Harriett Seager:

* Pain Coach Programme 1:1 mentoring for clinicians to develop skills and knowledge when working with chronic and complex pain | t. 07518 445493

* Pain Coach Programme to overcome pain | t. 07518 445493

or contact us via the form below ~

02Nov/16

Trusting hands

HandsTrusting hands — Our hands have many roles, from manipulating tools to communication to soothing another person. We hold a pen and write, we gesticulate, we put our hand on someone’s shoulder. It is the last action that I am interested in here, as we employ touch to make someone feel better by both letting them know we care and changing the sensory activity of the body. There is one aspect of this that is important, and that is meaning. The meaning or intention behind my action and the meaning construed by the recipient. They can be at odds, so setting the scene and making a judgement is important. Certainly in the therapeutic setting, clinicians must judge the right time and the right approach for hands on therapy, especially in chronic pain. Trusting hands is one way to describe them.

In some cases, even light touch can be very painful. Sometimes the pain of hands on treatment can be deemed to be good — ‘that’s a good pain, keep going’ they may say! If the body systems and the person are in protect state, they may well guard the area by tensing up or gesturing to keep people away. They are in fact predicting and expecting that the touch will hurt and therefore put up a defence. There are also people who do not like being touched for a range of reasons beyond whether they think it will hurt or not. This is of course a consideration for the therapist who wants to use their hands.

The notion of trusting hands emerges from a compassionate approach to treating pain. Always beginning with deep and active listening to gain insight into the causes of suffering, the trusting hands become part of the way we communicate our concern and caring before using them to ‘listen’ to the body through touch. This is not an alternative view but instead a way of gaining further understanding of how that person’s body is responding to movement and touch (mechanical forces). We can feel and see the existence of guarding, which demonstrates that protect state is ‘on’ and monitor how this changes as the individual begins to feel safer and more confident. This is in the knowledge that there is no harm or damage associated with the pain, the pain being an indicator of a perception of threat, not a gauge on injury.

The way in which the hands touch the body from the initial contact to the strokes or pressures applied will all imply a certain message. This is why the clinician needs to be aware of their intent and be present when laying on hands. The trusting aspect comes via experience. In other words, the trust results from the recipient knowing that the purpose of touch is to make him or her feel better by changing their experience. They will most likely have some preconceived ideas as to how hands on therapy works and the therapist may have to tweak this thinking in line with what we actually know. In a nutshell, we are seeking to change the way in which the brain predicts the causes of the sensory information coming from the area we are treating. Through this new prediction, or update, as a consequence of an explanation that sets the scene and primes in the right way (think of ploughing a field before sewing the seeds) and then the applied treatment, the person has a new experience, one that is feeling better. I usually explain to people that the feeling better aspect gives them a new reference point so that they know their body can feel different and good. They then use their programme strategies (Pain Coach Programme) to re-enact this feeling over and over as a new habit, which is getting better.

The trust element comes from the whole approach to the person, viewing and treating them as a whole and not a ‘body part’. Respecting their views, beliefs, values and validating their story is vital in creating a trusting partnership. Within this context, the hands play the trusting role of communicating compassion as well as effecting the benefits that have been well studied. Hands on therapies are part of a complete programme of care, and used wisely can facilitate many of the other aspects of the training and treatment.

Each session should result in the person having had a positive experience, feeling inspired and encouraged to practice their training and strategies in their world, their reality. What happens in the clinic is a bubble, often of safety, and then the person needs to take that across the bridge into their world and live. In this way, to resume living a meaningful life requires us to do just that. You get back to living by actually living and knowing how you can do this each day, gradually building up the things you can do and starting to re-engage with things you have stopped doing. With working knowledge of your pain you realise that you can do this with increasing confidence, the fear dissolves and the focus is upon getting better using the strengths that you already have and know. The trusting hands have a role in this science and compassionate based approach to chronic pain.

  • Pain Coach Programme to overcome chronic pain | t. 07518 445493
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24Oct/16

Women in pain

Women in painRecently I gave a talk to a group of female health professionals at the Inspiring Women in Medicine meeting entitled ‘Women in pain’. I spoke about the significant societal problem of women suffering persistent pain, which is one of the issues that comes under the banner of women’s health. Society needs women to be healthy and hence the problem of women in pain must be addressed. Fundamentally at present, society does not understand pain sufficiently to address this enormous public health matter effectively, which is where I believe we must begin: understanding pain.

If society understood pain….

  • individuals would know what to do and think in order to orientate themselves towards getting better
  • it would not be feared; instead the focus would be on overcoming pain
  • healthcare would deliver the right messages early on so that the right actions are informed by correct beliefs about pain
  • the right treatment appraoches would be employed from the outset
  • there would not be the same level of suffering — the figures say: 100 milliion Americans suffer persistent pain; 20% of the population; 1:5 children

Chronic pain is a huge global health burden that costs both individuals and society enormously in terms of finances and suffering. Of course, this pervades out into family and social networks and hence those around the individual can also be suffering through their on-going provision of care. Pain is a strain on society, literally. If it were understood, this can change.

Women in painWomen are reported to suffer more pain and visit their doctor more often about pain than men. Females are more likely to suffer functional pain syndromes. There are still many people, including healthcare professionals, who do not know what functional pain syndromes are or have insight into the basic biology that emerges as a range of painful problems that are very common. They include irritable bowel syndrome (IBS), migraine and headache, back pain, fibromyalgia, pelvic pain (e.g. vulvodynia, painful bladder syndrome, dysmennorhoea) and temporomadibular dysfunction. Other regular features include anxiety, depression, a history of early life events (and later in life when a challenging situation brings about pain and suffering), perfectionism, a person who is very hard on themselves and hypermobility.

This being the case, one would expect that research into how females experience pain and why they feel more pain would be stacking up. Unfortunately this is not the case with most research done in males and male rats. Clearly that has to change alongside the overall attitudes to women in pain.

Women in painRecently the press ran with stories about how women in pain receive different care and approaches to men. Women waited longer for treatment, were less likely to receive opiates for pain (opiates are effective for acute pain — there are big issues with the use of opiates for chronic pain) and were deemed to be more emotional and hence somehow their pain was different in the sense of how it should be treated. Of course this is wrong on every level. Each person has a unique pain experience that is flavoured by a perception of threat within a certain context and enviornment, based on prior experience and beliefs of that person. Therefore, each person needs to be addressed as such and treated according to this principle, man or woman.

There arWomen in paine some ideas as to why men and women should experience pain differently. The most obvious is that of gender biology based primarily around hormones and the menstrual cycle. In particular there maybe an important time at the onset of menarche when sensitisation could emerge in some individuals, thereby priming them for future events such as injuries, viruses and illnesses when the systems that protect us (immune, nervous, sensorimotor, autonomic, endocrine — they work together as opposed to being in isolation) are active in the face of a perceived threat and increasingly vigorously. What the person lives are the symptoms of thee systems working including fever, pain, altered perceptions of the world, altered thinking and emotions. It can sound like these are all separate ‘reactions’ when in fact they are part of an on-going cyclical process: we think, perceive and act as a unified lived experience.

Another observation relates to empathy and how women maybe more empathetic for the purposes of caring for their children. A truly empathetic person is a caring person yet they must be careful and skilled so as not to embody their own versions of observed others’ suffering. As an example, it is not uncommon for me to feel a pain in the same place that a patient is describing their pain to me. Understanding the mechanism, I can rationalise the feeling and it will pass as I actvely change my perception — this is likely the same mechanism that underpins the change from being in pain to not being in pain in all people. I know that others I have spoken to also have this experience, which one could argue is deeply helpful as a healthcare practitioner as we seek to understand the causes of the other person’s suffering.

A described emotion that often appears within conversations about pain, particularly women in pain, is that of guilt. The reasons for expressing guilt are based around the conflict between work, home, partner and children — trying to please all but rarely pleasing or looking after oneself. Being kind to self is important in the sense that being hard on oneself can be the cause of great suffering. This is common and will almost certainly be taking the woman closer to her biological protect line, the point at which threat is perceived and enacted as a pain experience. Learning how to foster the existing compassion towards oneself then, is a typical part of a comprehensive programme for getting better. With many whom I see displaying and admitting perfectionist traits, it is not a surprise that harsh inner dialogue results in repeated negative emotions. Strung together frequently, this forms the basis for chronic stress, which in turn is the means for a pro-inflammatory state, which emerges as aches and pains, troubled tummies, headaches, mood changes, sleep issues, fertility problems and more. The reason is simply that in the pro-inflammatory state, the body is in survive mode that is great when there is a real threat. However, most of the time there is no threat, it is just something we are thinking about that triggers the same response via a prediction taht one exists.

Now, there is nothing wrong in experiencing negative emotions. We need them as much as the others. It is really about the apporpiateness of the emotions: when we feel them, how long we feel them for, how often etc etc. If we consistently think that something bad will happen or ruminate on things that have happened rather than seeing things for what they really are in this moment, then this basic survival biology will keep going. This is where mindful practice is so beneficial, cultivating awareness of existing habits that allows for a reappraisal, a space to see things for what they are and gain insight into the causes of your own suffering and others, from which you can choose a new and healthy way onward. Clearly there is much more to say about mindfulness and its benefits, in particular in the face of mcuh exciting data from studies across the world.

Whilst this blog scratches the surface, it hopefully provides some food for thought. This is a significant public health issue that we can tackle by understanding pain and applying simple and sensible compassion-driven care, which will make a huge difference. Coaching the individual woman to coach herself in a direction that is toward her desired outcome is out role as we empower individuals and allow them to realise their sense of agency in getting better. There are simple measures such as movement, exercise and mindfulness that work in synergy to create a meaningful life to be engaging and enjoyed so that when challenges arrive, they are overcome and used as learning experiences. Science, compassion and sense are at the heart of the Pain Coach approach, one that we can all adopt to change for the better. Ourselves and our patients.

RS

The Pain Coach 1:1 Mentoring programme is for busy clinicians who wish to develop their working knowledge and to be effective in coaching people suffering chronic pain to lead meaningful and fulfilled lives. Contact us on the form below or call Jo for further information t. 07518 445493