Category Archives: Uncategorized

29Aug/16

New thinking in dystonia

New thinking in dystoniaWe need new thinking in dystonia because the treatment of this very troubling condition must improve. This means that people suffering dystonia feel that they are getting better. The same can be said for all conditions that are viewed as persistent, as our understanding moves forward, creating new approaches that must be based upon science. One areas of particular interest that I believe will be highly influential, is the science of consciousness — what is it to be conscious? What is it to be like something?

The patient’s lived experience is something we seek to gain insight into as clinicians so that we can shape a forward trajectory characterised by less suffering. I would argue that this is an approach that we should be taking for all conditions. We may have an injury, a pathology, a disease or a pain yet we can always seek to reduce suffering in a number of ways by taking a broader perspective and look at the causes of suffering that are not directly related to the condition. This could be termed a whole person approach or a sociopsychological approach with a minor contribution from the biological dimensions — is it useful to understand the molecular biology of pain or to know what action to take to feel better? I would argue the latter. To feel better we may need to foster relationships, communicate, move, create a new habit, consider financial or occupational matters, just to name a few. Being able to determine which receptor is being activated is not particularly helpful in this light.

Once a person is diagnosed with dystonia, they may be offered botulinum toxin injections. In some locations, physiotherapy may be recommended but the content of the treatment programme tends to vary. There is no standard set of treating principles resulting in mixed results borne out in the literature. However, as far as I am aware there is scant attention given to sensorimotor training according to the latest understanding of ‘how we work’; a unification of action-perception-cognition, our experiences are our brain’s best guess about the possible causes of sensory information for which we seek confirmation with action.

Exercises alone are not enough. The understanding, the engagement with the programme (meaning), the expectation (what you are thinking will happen as a result of the training in that moment — the tape you play of what will happen with your embodied mind; a prediction) and the focus are all important. The complete programme must incorporate these elements as the person living the dystonia (the twists, the pulls, the tension, the jerks, the imprecision, the inconvenience, the pain, the second arrow that is the way you think about yourself and the condition) needs to be able to coach themselves in any given moment, day to day in order to be successful. There are a number of simple ways of facilitating this mindset.

Identifying with one’s strengths, those characteristics that have led to successes in the past, and employing them in this arena results in resilience, self-motivation and the necessary perseverance. Practice is key in creating new habits of body awareness, movement control and sense of self. Alongside a focus on strengths, one learns to manage weaknesses and distractions so that the direction of travel remains toward the desired outcome. Creating a clear vision of that desired outcome is an important start point to which one can check orientation.

Remaining open with a broad mindset tends the individual towards greater feelings of satisfaction and happiness. It is the the moment to moment emotions that cultivate how we feel and hence to purposefully notice positive emotions and triggers of our positive emotions both maintain a steer towards feeling open. When we are open, we experience the full opportunity that life presents, engaging with people and activities far more effectively, which in turn promotes more consistent positive emotional states. Both of these simple skills form a strong foundation for the sensorimotor training necessary to develop precision of movement, a core change needed to feel better and closer to how one feels one should be feeling in this moment. A further practice is that of mindfulness, which is being aware of what you are feeling, thinking and doing right now in this moment; being present, which by definition removes the suffering caused by our thoughts drifting into the past or future. In so doing, we are robbed of what is really happening right now.

As we understand ‘how we work’ more and more with the unfolding story of the science of the sense of self — who we are, how we function (move and act), how these unify into the lived experience, and how we can reduce suffering by creating the right context for healthy action-perception-cognition with a comprehensive training programme that addresses the lived experience. That is our role as clinicians.

*********

Sensorimotor training programme | t. 07518 445493

 

27Aug/16

If pain

If painIf pain was understood, there would be less suffering.

If pain was understood, the right messages would be given from a young age, sculpting behaviours based on what needs to be done.

If pain was understood, there would be no fear about it.

If pain was understood, we would focus on what we can do to feel better.

If pain was understood, it would be known that listening deeply is the first step to help someone transform their pain.

If pain was understood, it would be known that understanding pain changes pain.

If pain was understood, there would be an enormous amount of money available for a better society.

If pain was understood, it would sit in the realm of public health and not medicine.

If pain was understood, there would not be the reliance on medication.

If pain was understood, what would the world be like?

— this is the mission of UP | understand pain; to globally change the understanding of pain, because put simply, the world would be a better place if pain were understood.

www.understandpain.com

15Aug/16

Get the most out of your exercises

get the most out of your exercisesIt is highly likely that when you visit a physiotherapist you will be given exercises and hence here is a brief guide to how you can get the most out of your exercises. The training is important, setting the scene for a desired change, but in order to be successful, we need to think about how we will be doing the exercises. In the Pain Coach Programme, we look at this in the necessary detail so that the individual can achieve the best outcome. Usually the exercises themselves are very straightforward, with the most complicated piece of equipment being the person, followed by a mirror. That’s it. We need to set the scene, focus, attend to what is happening now, practice, put in maximum effort, perform and learn. Sounds easy!

1. Create the right environment

Where do you do your exercises? How does that environment affect you? Are you doing some of the exercises at home, at work or outside. Notice where you can concentrate with ease and where makes you feel good about what you are doing. We are not separate from the environment in which we find ourselves and hence it can work for us well in creating the conditions to get better. It should be light, spaceous enough to move freely and as calming as possoble without stimuli that trigger survive responses. This includes phones, computers etc that can grab your attention and make you think about something else.

2. Take a moment to be present

To truly concentrate you must be present and aware of what you are feeling, thinking and doing. From there you are able to learn by gathering insights into what you are doing versus what you want to do, making corrections to movements for example. Mindful presence means you are present and aware, rather than being lost in thoughts about the past or the future that are embodied. In other words, our thinking is affected by our body state and vice versa as there is no separation. As an experiment recall a happy time: where you were, who you were with and what you were doing. This is a thought, but how do you feel in your body? So, how to be present? Simply take a breath and notice the in-breath and then notice your out-breath. We can only breathe now so gently concentrating on the breath is a simple way of being both mindful and present. Anytime you notice your attention drifting away, kindly bring it back by noticing your breath.

3. Connecting it all together

We must be fully aware of our mind and our body as a unified experience. How can you learn about your body and how it moves if you are thinking about a meeting yesterday or dinner tonight? You can bring your attention to your breath, saying to yourself ‘I am breathing in’ as you breathe in and ‘I am breathing out’ as I breathe out. Notice how you become aware of this moment, which is the creation of the right conditions for recovery and for learning. You can then expand your attention out to your whole body, thereby connecting it all together in a nourishing way. This only takes a few moments, but without the right attention, the exercise will have a limited effect as you will not realise what you have done.

4. Write a learning diary

‘What we focus upon we have more of’, is a useful way of being. When we notice our positive emotions, which can be subtle, and purposefully attend to them, our thinking broadens. There has been a good amount of research looking at this effect. Keeping a diary is a way of documenting the way we feel and what we have achieved so that when we look back and read what we wrote, we have an accurate view of what was happening at that time. Our memory of what happens is poor, but we do convince ourselves that certain things happened or we felt a particular way. Whether or not it happened like that becomes irrelevant as it is the memory we think we remember that counts. On this basis, writing down each day something that we have learned from our practices of training is a useful insight that motivates further learning as we focus on our achievements and strengths. This is encouraged by positive psychologists as well as featuring in mindfulness practices and strengths based coaching, and for good reason — focus on your strengths and manage your weaknesses, but you have to know what they are first!

5. Accepting where you are now as a stepping stone towards a desired outcome

To accept that I am here in this moment allows you to focus on what needs to be done right now that is in alignment with your desired outcome. Being really great at all the things that you need to do now will naturally allow you to move to the next step as you continue to transform. We are changing all the time and hence need to ensure that our change is in a desired direction. For this we need a vision of where we are going; a vision of a successful outcome that we visit often to ask the question to ourselves: ‘is this taking me towards my desired outcome or am I being distracted by thoughts of the past or future?’. Acceptance does not mean giving up, instead just saying ‘here I am right now’ and ‘this is what I need to think and do to keep myslf going in the right direction’.

The Pain Coach Programme to overcome chronic pain and injury | t. 07518 445493

08Jun/16

Space

SpaceThere are things that we know are good for us: sleep, water and space. Of course then we need quality sleep, water and space. I’m interested in space, and not the kind that is out there, but rather the space we choose to place ourselves day to day and how this impacts upon us consciously and subconsciously. In particular I am keen to understand how we associate with certain environments and in fact how our brains predict the meaning of a given environment and the experiences that emerge.

Here are a couple of classic examples that I hear about:

1. RSI — repetitive strain injury: I am using this term for ease, although I have issue with it, but that’s for another time. I refer to pain and other symptoms that people attribute to repeated use such as typing, clicking a mouse and texting. In the vast majority of people I see with this burdensome condition, we can evoke their symptoms by just thinking about certain environments! Their desk at work for example. When we close our eyes and think about a place, we are in essence there and it feels like it. When a place or space becomes associated with a threat value because of a link that has been established, then it makes sense to feel a warning when we think about it. However, when this persists, this becomes an increasing problem due to the behavioural aspects — altered movement, restricted use and guarding, all of which perpetuate the threat value and hence the on-going pain. Thankfully, this cycle can be broken with the right understanding and training.

* This is not unique to RSI, but any pain problem is contextual and becomes associated with certain places, positions, movements, activities etc etc. A significant part of overcoming persistent pain is by creating new habits.

2. A place in nature: a pleasant image comes to mind, unified with feelings of comfort in the body to make it an overall calming and soothing experience. This is why visualisation is so effective as we can choose to shift into our resource state whenever we need: when anxious, stressed or in pain for example. This is a technique that I blend with others to create the necessary calm we need to refresh and renew, particularly if we are suffering pain or tiredness.

Placing ourselves in an environment has enormous effects upon us as we become part of that very environment. In fact, what you experience as that environment you are creating using at least your brain, your mind and your body, and importantly how they unify. Using a film analogy, you are the film maker, the script writer, the star and the audience all rolled into one. Wow! How do we explain that? Using the very same unified processes to explain themselves! So, in becoming part of threat environment, the importance of choosing the right space is vital. Each day we should absorb ourselves in a nourishing place such as a park, by a river, in a forest or at least in a space where there is plenty of exactly that, space! And if you can’t do this on a particular day, then you can use imagery and visualisation and feel the resulting great feelings.

On a moment to moment basis, where we spend a lot of time, perhaps home and office, these spaces need to be nourishing and promote the feelings we want to feel — e.g./ at work to concentrate, focus, think, write, communicate; at home to feel comfortable, warm, safe etc. This may take some thought and some re-organising but it will be worth it — see here, a professional organiser: Cory Cook. Remember that the environment you choose to put yourself in impacts upon you enormously: the way you feel, the way you think, the way you interact. Something similar could be said for the people you spend time with.

So, when you are at work, at home, choosing a new job or accommodation, think carefully about the environment in which you will be living moment to moment experiences, because they will be shaped somewhat by that very environment. Get out into a big open space and move around in it, see it, smell it, feel it, using all your senses. And if you can’t, then take a deep breath, slowly let it go, do it again, close your eyes and take yourself to a space where you will feel great.

Pain Coach Programme for persistent pain | t. 07518 445493

07Jun/16

Depression and inflammation

Depression and inflammationFor some years there has been thinking about depression and inflammation being related in as much as when we are in the throes of inflammation, our mood changes. Think about when you feel unwell and how your mood drops, which is part of the well known sickness response. In some people, probably a large number, these sickness responses are the norm. In other words, they endure a level of this sickness response consistently that is underpinned to an extent by on-going inflammation.

Reports today about a study at Kings College London describe how inflammatory markers in the blood could identify a ‘type’ that would benefit from a certain antidepressant drug — read here. This would make the prescription specific for the person, so rather than trialing a drug, we would know which would be most likely to be effective for that person by identifying the blood markers.

Many people I see with persistent pain are low in mood and some have been diagnosed as being depressed. In my mind, it is entirely understandable why someone suffering on-going pain, who cannot see a way out, would be in such a state. In simple terms, the person with chronic pain may well be chronically inflamed. We know that people who perceive themselves to be under chronic stress will be inflamed as the body continues to protect itself via the immune system and other systems that have such a role. Typically and understandably, someone in a chronic pain state is stressed by their very circumstance and hence can be inflamed.

It is very common to suffer an enduring pain state and generally feel unwell; a sickness response. We all know what a sickness response feels like — we don’t feel ourselves, aches and pains, loss of appetite, irritability, emotional, sleepy, tiredness, poor concentration etc. This is underpinned by inflammation and how this drives a range of experiences and behaviours, all designed to create the conditions for recovery. In the short term this is adaptive but if prolonged, the symptoms are enormously impacting and potentially maintaining a cycle of stress and anxiety.

Like any problem, understanding its nature is the start point so that problem solving can be effective; i.e. think about it in the right way and take the right action, congruent with recovery and the desired outcome. Realising the links between health state, depression and inflammation helps to distance oneself from the lived experience, being less embroiled with that particular ‘film’, instead focusing on what needs to be done to overcome the problem.

A loss of the senses of self is often a part of a persisting condition such as chronic pain or dystonia. The overarching aim of a followed programme is for the individual to resume living their life with a sense of self worth which they can identify: I feel myself again. This self feels normal to that person, and only that person knows how that experience is lived. As best they can, I ask them to describe that experience, and this forms the desired outcome. The sense of self is at least a unification of body sense, interoception, exteroception, the inner dialogue and our past experiences. Improving body sense with exercises, some general and some specific, is a simple way of stepping towards that outcome. And of course there are all the other benefits of exercise to consider.

It will undoubtedly be very useful to identify who will benefit from which antidepressant drug, yet we must still consider each (whole) person. A comprehensive programme of treatment for pain for example, includes developing working knowledge of pain so that the person can independently make effective choices as well as eradicate fears, specific training, general activities, gradual progression of activity, and mindfulness to name but a few. However, it is not just the exercises that are important. The person also needs to be motivated, resilient and focused, all strengths that they have likely used before in other arenas but now need to employ here and now with their health — this is the strengths based coaching aspect of the Pain Coach Programme. In cases of depression, the chosen drug maybe more specific and hence more efficacious, yet there are other actions that are also important such as understanding the links as explained and consistent physical activity. Great work in the aforementioned study; it will be interesting to watch how this progresses.

Pain Coach Programme | t. 07518 445493

31May/16

Wrist injury for Nadal

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

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

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

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

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

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

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

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

Pain Coach Programme to overcome pain | t. 07518 445493

22May/16

Sports injuries brewing

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

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

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

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

What is happening?

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

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

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

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

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

09May/16

Get better

GB: Get Better

GB: Get Better

Regular readers will know that I firmly believe in getting better when it comes to pain and persisting pain. This should be our aim with each person. This thinking also needs to underpin research, policy making and clinical decision making across the board.

Recently I was asked to speak at an event that considered the question ‘how do tendons get better’, and my area of focus was the brain and pain. More on this shortly, but it was a pertinent question because for some time I have been pondering why people do get better (from persistent pain), what does getting better actually mean and who gets better?

To answer these questions experientially, I thought through many cases that I have seen to identify the common features. Not especially scientific, but a start point. People getting better meant that they would report that they felt more like themselves. A common phrase that we use, ‘I don’t feel myself today’, tells the world that all is not well, and equally saying ‘I feel myself again’ reports that what is happening in my world is what I expect to happen; a match up in other words. And who are these people who get better from a persisting pain state in the face of messages from society that chronic pain is here to stay and needs to be managed or coped with?

In short, these are people who take on board the true messages about pain and what it really is based on our modern understanding. Not only do they listen and put in into perspective within their lives, but they use the new information as working knowledge to be applied consistently, challenging previous thinking to drive new actions that are congruent with being healthy. With this working knowldge, moment by moment they are able to make clear decisions and groove new habits, pointing themselves via their perceptions and actions towards their desired outcome, as defined by themselves at the outset.

Everyone has experienced success in one or more arenas of their life, whether at home, at school, in work or playing sport. This success is achieved by focusing upon the desired outcome and then taking every opportunity to get there, even if things go wrong along the way. Distracting (unhelpful) thoughts and unforseen events are dealt with as learning experiences, and soon enough the person is back on the path towards their vision of success. Take a moment to recall a success and note how you did it. What strengths did you use? How could you bring them into this arena? The people that use their strengths and focus on their vision consistently, get better.

The tendon debate resulted in agreement that people needed to understand their problem and pain as a foundation from which different strategies could be used. The strategies chosen for the individual must reflect their needs and desired outcomes. I was asked if brain and pain could explain why a tendon gets better, and I argued that we are more than a brain, and in fact the construct of self is made up of a number of facets: my physical presence, how I experience that presence, the story I tell myself about me, the sense of the environment in which I reside in this moment, my past (perhaps unreliably retold to me by me) and my anticipation to name but a few. It is the person who gets better and not the tendon or the back or anywhere else in the body, because we are that body as much as we are the mind (the mind does not just exist in the head or brain, instead we are our mind, often using our body to think — embodied cognition). We are necessarily all of these things together: body-brain-mind-environment.

The overaching aim must be that the person gets better as defined by themselves as only they know what it is like to be better. And when the person is better, they feel themselves again, which in terms of pain emerging from me (felt in a body area), it exists less and less in the thin slice of awareness that is consciouness — most we are unaware of; externally and internally (the biology in the dark). When we are better, we don’t think so much, if at all, about our body until we have an itch or have sat too long and become uncomfortable. Then we scratch or move and resume a state of non-body awareness, just focusing on what it is that we need to in that moment.

Pain Coach Programme to get better: t. 07518 445493Get better

 

03May/16

Fear

This is a very brief treatise on fear. Fear is a unification of thoughts and feelings experienced by the individual as an attention grabber, motivating avoidance. We feel fear in our bodies in many ways, for example tension in the body, freezing on the spot, and a sharpening of visual acuity. It can pay well to experience a burst of fear as we become conscious of a threat that needs our attention in as much as we must face it or run away.

So whilst there can be an adaptive nature to short bursts of fear, prolonged or repeated fears to non-threatening or low-threat situations is a problem. Fear can in this way become hugely problematic as it grows to encompass the original ‘stimulus’ but then increasingly becomes a response to similar stimuli and then unrelated stimuli. The feelings and thoughts that are recognised and contributory to the lived experience that is fear become easily evoked and potentially destructive unless they are comprehensively addressed. And they can be by understanding what is happening — what comes together to be unified as the experience of fear — and gaining insight into the way in which one’s mind is working.

Fear is whole person — it is the person who fears. Yet it is the person who both creates the fear and experience the fear, which is why the person needs to be the focus of treatment.

RS

Here is some biology — Serotonin, Amygdala and Fear: Assembling the Puzzle:

Abstract: The fear circuitry orchestrates defense mechanisms in response to environmental threats. This circuitry is evolutionarily crucial for survival, but its dysregulation is thought to play a major role in the pathophysiology of psychiatric conditions in humans. The amygdala is a key player in the processing of fear. This brain area is prominently modulated by the neurotransmitter serotonin (5-hydroxytryptamine, 5-HT). The 5-HT input to the amygdala has drawn particular interest because genetic and pharmacological alterations of the 5-HT transporter (5-HTT) affect amygdala activation in response to emotional stimuli. Nonetheless, the impact of 5-HT on fear processing remains poorly understood.The aim of this review is to elucidate the physiological role of 5-HT in fear learning via its action on the neuronal circuits of the amygdala. Since 5-HT release increases in the basolateral amygdala (BLA) during both fear memory acquisition and expression, we examine whether and how 5-HT neurons encode aversive stimuli and aversive cues. Next, we describe pharmacological and genetic alterations of 5-HT neurotransmission that, in both rodents and humans, lead to altered fear learning. To explore the mechanisms through which 5-HT could modulate conditioned fear, we focus on the rodent BLA. We propose that a circuit-based approach taking into account the localization of specific 5-HT receptors on neurochemically-defined neurons in the BLA may be essential to decipher the role of 5-HT in emotional behavior. In keeping with a 5-HT control of fear learning, we review electrophysiological data suggesting that 5-HT regulates synaptic plasticity, spike synchrony and theta oscillations in the BLA via actions on different subcellular compartments of principal neurons and distinct GABAergic interneuron populations. Finally, we discuss how recently developed optogenetic tools combined with electrophysiological recordings and behavior could progress the knowledge of the mechanisms underlying 5-HT modulation of fear learning via action on amygdala circuits. Such advancement could pave the way for a deeper understanding of 5-HT in emotional behavior in both health and disease.

Full article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4820447/

 

11Apr/16

Hands-on treatment for pain

Hands-on treatment for pain should form part of the therapy programme for painful conditions including chronic or persisting pain. A line of thought exists that the hands-off approach for chronic pain is best yet there are some clear ways that clinicians can use their hands with great effect. It is also expected when a person goes to see a physiotherapist that they will receive manual treatments as a way to feel better, and indeed people often do feel better when such therapies are used wisely.

There is no certainty as to why hands-on treatment works but it is safe to assume that touch has an effect that is likely to be underpinned by a change in the interpretation of sensory input from the body. Modern concepts of brain function suggest that what we experience is the brain’s best guess about what the sensory information in that moment means, based on prior experience. This based upon probability that the sensory information infers something, i.e. something pleasant and hence the touch feels good, comforting, soothing etc., or something unpleasant and therefore the touch can feel painful or uncomfortable.

Touch is deemed important for healthy development and is certainly an act that is used commonly to communicate. In the same way then, touch can be used to communicate in the therapeutic setting as well as create an opportunity to change pain and sensitivity. We are changing constantly with each moment being fresh and new — in fact, this is one of only a few definites in life, is that we change. We are designed to change and hence the feeling we are feeling now is only temporary. The sense of ourselves, ‘me’, is something that we feel is constant yet it changes as time passes and we gather new experiences, learning and developing.

It is worth pointing out that the mention of brain does not mean that we are only a brain. I am a whole person made of my body, brain, mind and environment, none of which is any more important as it is the sum that makes me and who I feel I am at any given moment. The false division of mind and body certainly does not hold up. My mind is not in my head or my brain, I ma my mind, which is why when I think I use my body and my brain together as ‘me’ within a particular context (environment) in a particular moment (that has just passed). This may seem like play with words, yet it is fundamental to successfully addressing pain because this understanding gives both hope and a practical way forward as we use this knowledge to create a programme of treatment, training and movement to overcome pain so that it does not dominate but instead has its place as a survival mechanism. Briefly, pain is a motivator to take action on the basis that I am predicting the need for protection against a perceived threat. More threat, more protection, more pain — not more pain = more damage as was traditionally thought. Hence, the reduction of threat is our aim.

Now back to touch: how we can use it and how it plays a role in reducing pain. Preparing the recipient of the hands-on treatment is important, priming them with an explanation and positive expectations. This can be done by simply describing why it is useful, saying that it is usually a pleasant experience to ease symptoms whilst dropping in calming, soothing words into the conversation. Addressing concerns, especially if they have had a painful treatment beforehand, is also part of the preamble, in essence ploughing the field before sewing the seeds. Then the contact begins.

The clinician can do a few things to prepare him or herself so that the first contact is felt to be compassionate and soothing from the outset. This is of course the aim — to be soothing and to create calm, changing the way that the recipient’s brain is predicting what the sensory information means, i.e. it means safety. And safety in turn means less, or no need for protection, and no protection = no pain.

  • Prepare clean, warm hands
  • Take a breath or two and let muscles relax on the out-breath (we are not always aware of how much tension we are holding, especially if we have been using manual therapy often through the day)
  • Let go of any distracting thoughts and be entirely focused on the touch and responses of the person; again, the out-breath is good for focusing on the present moment

On starting the hands-on part of the session, having prepared the recipient and being present oneself, the first touch allows the therapist to note how guarded and protective the person is in respect of the body. The image of pushing a cork in a barrel of water is a useful visualisation of how to ease into, and respond to the person. It is worth considering that it is the person experiencing the touch and not the body part itself. It is the person who is conscious and gives meaning to the touch, and hence it is the person to keep in mind as you lay hands on. The treatment then becomes a dance or an art form as the hands and the body form an alliance that aims to transform sensory signals into the experience of relief; soothing, calming and peaceful. This would be the same whether the technique more soft tissue (the many forms of massage) or mobilising a joint.

  • Prepare the person
  • Prepare yourself
  • Apply the treatment
  • Conclude the treatment, making it obvious with the hands before uttering a few soothing words (consider tone, volume etc) that allows the person to realise the completion
  • Give a few moments for orientation and shift of state before inviting them to sit up or change position

Of course, hands-on forms only part of the programme with the other facets addressing the different dimensions of pain in an integrated manner: addressing the whole person. However, a key point made here is that in order to be as effective as we can, recognising our role as individual clinicians with our own characteristics and style, we must pay attention to the person, ourselves and the context in equal measure.

***

  • Pain Coach Programme — complete care for persistent pain
  • 1:1 Pain Coach — mentoring for clinicians
  • t. 07518 445493