Category Archives: Uncategorized

24Feb/16

Chronic fatigue syndrome

Chronic fatigue syndromeAn excellent article by Jo Marchant addressing chronic fatigue syndrome recently appeared in The Observer. Interestingly, the following question was posed, “Is it physical or mental – or a combination of the two?”, highlighting the on-going dichotomy that is seen to exist in both society and in healthcare.

I spend a fair amount of time helping people to understand their perceptions and experiences, usually involving pain and suffering. This is about giving a meaning to their pain, validating their lived experience before looking at the ways in which they can change direction towards a healthy and meaningful existence. Importantly, a vital part of this working knowledge is understanding that there is no body-mind separation. There is a general shift towards people’s acceptance of this fact, yet there is still some way to go before this could be seen as mainstream thinking across society. However, this is certainly not alternative thinking, as we have a significant amount of scientific and philosophical literature that is dedicated to this very question.

To answer the question quoted at the start of my blog, chronic fatigue syndrome is not physical, it is not mental and it is not a combination of both. Chronic fatigue sydrome is a whole person experience, much like pain, when the symptoms emerge in the person, in a location or in locations felt and described anatomically for convenience. Yet the biology of both CFS and pain exist well beyond where the feelings are felt. Similar to the notion of mind that does not only exist in the head, or the brain or behind the eyes as can be thought. There are no controllers pulling knobs and turning dials behind our eyes, although there can be the sense that we ‘see’ the world, the perceived world, through these eyes, creating the illusion that the thinker is in the cranium. Fascinating.

However, my mind exists in me, the whole person. I think and I am my whole body and my whole body is the thinker, hence there being no separation. As a simple example, anxiety is usually viewed as a psychological state of mind, yet where do we feel anxious? The stomach, the gut, the chest perhaps. Not in my head, that’s for sure. Same for pain — it is not in the head!!! I am sure many readers have either heard this about pain, either as a patient or a patient tells you that is what they have been told because no ’tissue’ or structure has been found to explain their pain. This is actually because structures do not explain pain as many now know.

Accepting the notion of a whole person opens a range of avenues for therapeutic purposes as we seek to give the person suffering symptoms the knowledge and skills to resume a meaningful and healthy life. The key principle and underlying thinking (with my whole person as the clinician or therapist) is that the individual in front of you is complete and the sum of parts that only exist as a whole — e.g./ as we are conversing or exploring movements (also known as tests, assessments etc.), seeing how the that person moves and experiences movement or expresses themselves with certain words and gestures that illustrate the meaning that they wish to convey.

The aim of a health-giving programme is to provide the individual with the knowledge and skills he or she need to overcome their problem and steer their change (we are designed to change; it is one of the very few definites) to a meaningful life. There maybe treatment within this programme, but in essence it is about giving the person the independence with regard to thought and action, which they understand are emergent from themselves as a whole person, enabling and empowering decisions that lead to action that is congruent with health. Understanding this means that the individual knows which levels they can use, combining movement and thought for best outcomes. This would include working knowledge of symptoms allowing for wise thought and selecting best action, specific techniques and strategies that promote the meeting of basic needs (i.e./ nutritional intake, fluid intake, security, movement, rest), movement and exercise for health and building tolerance for activity, resilience and motivation, and skills to deal with unhelpful and distracting thoughts (e.g./ practical mindfulness). These are some of the key elements of the Pain Coach Programme, when you become your own coach, conceptualised as a compass that one can use to determine current direction and motivate a shift in direction when needed, moment to moment. Essentially, with chronic fatigue and pain as lived experiences, it is the moment to moment thinking and actions that are vital in heading towards the healthy you.

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Contact us on 07518 445493 | Pain Coach Programme for Health & Living

 

 

13Feb/16

Tendon pain

40+60 Feet | Bark |https://flic.kr/p/7rvmbB

40+60 Feet | Bark |https://flic.kr/p/7rvmbB

Tendon pain has been a big topic for some years. The problem is seen commonly in the clinic and frequently poses a challenge because so often tendon pain persists. Local factors and nociception are typically blamed, yet when treatment is focused at the tissue level, the limitations are exposed. As an aside, tissue based strategies are cited, yet there is really no such thing as a tissue based treatment simply because the tissues are not separate from the person. They are the person, and of course the person knows that something is being done to them and hence emotions and thoughts are at play, affecting the outcome — consider the person who observes your hands whilst you mobilise or massage whilst remaining calm and curious versus the person who is anxious, guarded with their hand poised and ready to grasp your hand as you start treatment; the latter person demonstrating why it is vital that the threat value be diminished before starting any intervention.

Pete’s excellent blog about tendon pain acknowledges the person, perhaps for the first time in tendon literature, which is music to my ears. Having been heavily influenced by Oliver Sacks, my philosophy has always been to consider the person as much, if not more than the condition as it explains how a particular issue manifests uniquely in that person. Certainly in my mind, the ‘initial assessment’ for me is about getting to know the person, which then rolls into their own experience of pain.

I first started looking with interest at tendon pain some ten years ago as an example of a persistent condition in sport. With an interest in chronic pain, it appeared that the discussions about tendon pain remained within the boundaries of where the pain emerged, yet our understanding of pain had advanced to the higher centres and many body systems involved in the experience of pain. Even nociception was discovered as being an incomplete picture as this biological process can be afoot with or without pain. Detection of threat does not mean it has to hurt, and indeed nociception itself is not something we actually feel. However, when the brain (which is of course part of the person and not separate, although our language does sometimes suggest this) predicts the need for protection, pain emerges in the person in a location deemed under threat or potential threat. This complex activity, which includes consciousness and the mind (these are both small subjects……..), is a whole person experience that is lived moment to moment and hence a focus on what happens in the tendon is only part of the picture. There is still very little acknowledgement elsewhere within the hierarchy, so here are a few thoughts I would like to share.

Previously I have expressed the view that we treat, advise and educate a person; a whole person. The approach that I favour is one that delivers the (working) knowledge and skills for the individual so that they can overcome their pain problem and resume a meaningful life as defined by themselves. Fragmenting for convenience is common, breaking down a whole into parts, yet this can never give a full picture. Medicine and healthcare typically specialise and whilst this has value, in the case of a persisting pain that often means that people fall between the cracks. For example, a female with fibromyalgia, IBS, migraines and pelvic pain may be seeing a rheumatologist, a gastroenterologist, a neurologist and a gynaecologist, and whilst elimination of anything pathological is important, there is an understood common upstream biology. Interestingly, many of these cases also have tender tendons that can be a surprise to the person when the tendons are pressed, especially considering that they are not the primary reason for seeking help.

Nothing happens in isolation (is one of my favourite phrases), and hence the biological expressions in and around a tendon are not separate from the mechanisms that underpin how pain arises in our consciousness. We cannot explain how this happens — how do chemical reactions in our body become a lived experience? Despite the lack of an answer, it clearly involves more than the tissue or structure alone.

This is not to say that the brain and the mind alone are responsible. Where is the mind? Where is the seat of the mind? Again, we do not know. Yet surely the mind is not just in the brain, an argument put forward by supporters of embodied cognition. It is me that thinks, not my brain or my mind, but me. And I think with my whole person because I am a whole person, and indeed when I feel pain, it is me that feels pain and not the body part where I feel it. Because I am more than that body part, the experience of pain must involve the whole person in that moment in that context. It is also true to say that to be in pain, we must be thinking that we are in pain as much as experiencing the sensory qualities of pain. Thinking draws our attention to the said experience, otherwise it is subconscious and hence not occurring to me.

For tendon pain, practically speaking, we must of course consider the health of the tendon itself and surrounding tissues, but also the person’s general state (who are they, how are they), prior experiences relevant to the problem (e.g./ tendon pain, pain, general health), beliefs, expectations, vulnerabilities to developing persistent pain, their story of how the pain emerged, their movement patterns (and why they are moving in such a way; both at the planning stages of movement and actual movement), body sense and sense of self at the very minimum. This information is gathered within the first conversation, setting the scene as trust and rapport develops naturally from exploration of their story that validates and empathises.

This is a mere and brief overview of my thinking about tendon pain, which poses a significant clinical problem, often persisting for longer than is expected. Whilst the focus remains on the tendon and nociception, there will be limited results in my view as this only tells a part of the story of the person in pain. This is true for any pain, and not just tendon pain. Pain emerges in the person and all that that person means and embodies, hence we must address the person as much, if not more than the condition. As Oliver Sacks wrote on his father, a GP: ‘He knew the human, the inward side of his patients no less than their bodies and felt he could not treat one without the other’. So true and this has always been my abiding principle.

Pain Coach Programme | t. 07518 445493

07Dec/15

Pain Coach for vulvodynia

VulvodyniaPain Coach for vulvodynia and other persisting pains is an approach based on a blend of the latest thinking in pain science and strengths-based coaching. What does this mean?

Modern thinking about pain considers that the lived experience of pain is ‘whole person’, in other words, it is ‘me’ who is in pain and not the body part/area. By addressing the person, in effect steering thoughts, feelings and behaviours towards health, pain is overcome and a meaningful life is resumed, as defined by the individual themselves. Bearing this in mind, we can seek to achieve this with strategies that parallel the lived experience, becoming new habits that nurture change in a way that is healthy. Pain is embedded with the person, their life, their reality and how this is created by their whole self — body systems (including the brain, immune system), their body and the environment.

With pain being part of who we are at that moment, we need to be able to think clearly and logically about that moment, seeing it for what it is, and then respond in the best and wisest way. We are continually updating, with a fundamental design that means we change with every passing moment. The brain predicts what will happen next and the sum of the best guessed meaning to all sensory information is what we perceive in that moment. Each moment is of course in passing, with a new one on the way. Nothing is permanent, and this is also true for pain. Having a baseline understanding creates a new layer of thinking, which creates a new layer of lived experience each moment, and this is how we can overcome pain. You may ask why, if we are always changing, has my pain persisted; and this is a great question.

Why does pain persist? On one level, it is because there is on-going prediction of the need for protection against a perceived threat. The range of cues and triggers widens over time, as does vigilance and habits of thinking that underpin and flavour the lived experience. The sensory and sampling systems adapt and suggest threat, and the prediction goes on and on, until you take decisive action and create new thinking and behaviours to take the continual change in a new direction. To do this, as I said earlier, the new awareness and habits need to match the lived experience, and be employed moment to moment–in any given moment you need to be able to be witness to your thinking, emotional state and bodily sensations, then using this awareness to decide upon the best action (UBER-M is one of my self-coaching strategies that I have previously written about).

Putting this into practice for vulvodynia, we begin with the development of a working knowledge of the individual’s pain and what influences their pain (e.g. stress, anxiety, context, environment, anticipation, expectation, attentional bias, catastrophising, hypervigilance — to name but a few). Using this working knowledge, the person creates a sense of safety that is the foundation of the precise actions taken: specific exercises, training, general exercise, breathing/mindful techniques, re-charging (energy), movements that all form the healthy actions. This is becoming your own coach, so that at any given moment you can think and act to cultivate healthy habits, and in so doing, replace those that have been predictive of the need to protect.

The most frequently described pain experience is during intercourse with the clear impact upon the person and potentially affecting relationships and an ability to conceive. All are greatly emotive. There is often, rightly or wrongly, a sense of wanting to be healthy once again for their partner’s sake. Within this thinking, there can be a sense of guilt with the individual being hard upon themselves, the latter being a common characteristic, and one that needs to be addressed by developing kindness towards self.

UP | understand painAnticipation that a movement or activity will hurt sets up a cycle of protection — priming, expectant thoughts that drive tension and changes in perception, predictions of the need for protect then predominate and sure enough, the experience is painful and the cycle maintained through habit of thought and action. There are many points when new habits can be created from the moment of initiation of intercourse to during intercourse at different points (an anticipatory thought, a sensation of pain) and developing new thinking and reactions by practicing at other times — in essence reconfiguring the whole experience to resume the intimacy rather than fear of pain.

Pain Coach ProgrammeWe are designed to change, and we are changing continuously — it may not always seem like it, bit if you stop for a moment and note how your thoughts, feelings and body sensations shift and move like Constable’s skies, even within a minute or two, you will be aware of this in action. This awareness opens an opportunity to consciously decide to make changes in a direction of health, and in so doing, change your pain with new realisation and action. This all begins with the understanding of pain so that you can take wise action at every moment. The skills that you develop for overcoming vulvodynia you have probably noticed will be transferable to many areas of life because this is about your lived experience, moment to moment. Many women report feeling calmer, noticing more, responding and thinking with greater clarity and generally feeling well and healthy.

Pain Coach Programme to overcome persisting pain problems — t. 07518 445493

05Dec/15

Henderson’s heel

40+60 Feet | Bark |https://flic.kr/p/7rvmbB

40+60 Feet | Bark |https://flic.kr/p/7rvmbB

Henderson’s heel has captured the front page of the Guardian sports supplement today. The article claims that he has been told to play through pain as there is no cure for plantar fasciitis–the plantar fascia is a strip of tissue spanning from the heel to the forefoot.

In the general population this problem exists and is typified by first steps soreness on getting out of bed. The pain is often noted on walking, standing and running, in some cases being sore and stiff to begin with before easing and then building again.

The usual explanation is overload, but there is more to it than that. As with any persisting problem, it is not just about the blamed tissue, but much, much more. Similar to tendon problems, when the focus is merely on the structure, the outcomes are limited as are expectations:

“…with my heel there isn’t a timescale, there isn’t really a cure….”, said Jordan Henderson, continuing to describe how he feels, “There have been times when I’ve been pretty down because we couldn’t find the answers”.

Pain problems need to be addressed in line with our modern understanding of what pain really is, a protective device in the face of a perceived threat. The point in time when something hurts is not in isolation to what has been learned or believed beforehand, the meaning, the context and prediction of what may happen. Consider the footballer who attaches great importance to the state and health of their body and their legs and feet in particular. Also think about how these problems are discussed and viewed within the culture of football; all the views and opinions and what they are based upon. An injury deemed to be chronic or long-term has great consequences for the career of a footballer and hence the meaning of this pain is different to an amateur player or someone who does not play football. Much like the violinist who cuts their finger, this is more pertinent when they are about to play a concert — we know that pain threshold is lower in violinist due to the meaning and context. There is no reason to think this is different in footballers and their legs. What is the relevance?

Our pain experience is determined by the extent of threat and not the extent of tissue damage. How threatening to the footballer is the notion of a chronic foot problem? Very. Does this impact on the experience of pain, definitely. Pain tells us little about the tissue state, but much about how the brain is predicting what the sensory input (about the body and the environment) is meaning based on what is thought and believed. Already you should be seeing how the ‘treatment’ of such a problem needs more than local interventions to change the way in which the body-brain-environment interactions are manifesting as pain, in this case in Henderson’s heel.

We are designed to change and hence pain can and does change when you understand it and take the wisest and healthiest action. This action goes upstream of where the pain is felt.

Where do we feel pain? In our body, because this is where we perceive our actions, largely created by brain networks and body systems, yet none in isolation and none predominating. All are vital to have a sense of what is happening right now. And what is happening right now? Our reality in any given moment is created by the sum of all the activity in our body and brain within a certain context. This incorporates habits and associations that create the backdrop for prediction; e.g./ Henderson arrives at the training ground, and even at the thought of running around, the systems that protect us are engaging and priming in preparation so that when he begins to run, threat is assumed based on what is known, what has been and what could be. Result, pain in the heel.

Now, of course there can be an inflammatory response as well, and this may well have been detected on various scans. However, there are different inflammatory mechanisms, the one we know well from injury: think of a sprained ankle; and then neurogenic inflammation that is a feature of on-going sensitivity, when the peripheral nerves are stimulated from on high to release inflammatory chemicals into the tissues they supply, thereby maintaining the cycle. Again, predicting that healing is required, the higher centres trigger this response, and it needs addressing, but not just locally. This is the big problem with tendon treatments currently, the focus on the periphery. There must be an interpretation of what is happening in the tissues and concurrent thinking and feeling to make the experience of pain a conscious one. There is not always central sensitisation at play, but there are always higher centres involved with a conscious sensation.

There is much more to discuss and note in relation to the points raised, but for now we can look at the principles that are important for overcoming an on-going pain problem in relation to Henderson’s heel. Considering that pain is about threat value, the over-arching aim is to reduce the perception of threat and hence the prediction of required protection. This begins with understanding pain so that the individual’s thinking is based on the working knowledge that they are safe. Safe that is, to perform specific and general exercises to nourish the body and move for health. The specific desensitising techniques are tailored to the person who feels the pain, considering the existing associations and triggers. A sensorimotor training programme works to normalise movement from the planning level to the actual execution, thereby creating a new layer of experience that forms the basis for the next prediction; the prediction of safety. Building the tolerance gradually, allowing for adaptation is key. There are a number of ways to go about this, but in essence, the programme is to be lived through the day, moment-to-moment to match the lived experience that is pain.

It is the person who feels pain, not their foot or their tendon. Their tendon or fascia is not a separate entity seeking help. They are merely the place or space in the body where the pain is felt. The biology of the whole experience sits within that that creates who we feel we are, and the richness of that experience in that moment. Hence, we must always work with the person: their body tissues, their environment, their neuroimmune system and how the sum of all of this creates their lived experience. Within each dimension, there are a number of actions that influence the whole. This is how people overcome pain — not their foot; the person. And who are these people that overcome their pain? What do they look like?

They look like you and me. They have a working knowledge of their pain that allows them to exercise and re-train on a basis of the true meaning of their pain, a feeling of safety, diminished threat, the creation of safety in situations once deemed threatening, and they match their lived experience of pain with a programme that is likewise lived, health based, strengths-based and they have a clear vision of where they are going based on their values.

Pain can and does change, beginning with understanding it.

Pain Coach Programme for persisting pain — t. 07518 445493

 

23Sep/15

Repetitive strain injury (RSI)

r.nial bradshaw |https://flic.kr/p/fBm85W

r.nial bradshaw |https://flic.kr/p/fBm85W

Repetitive strain injury (RSI) is one of the office blights so it may seem. Of course you do not have to work in an office to suffer on-going arm or hand pain, or as some call it: WRULD (the rather clunky ‘work related upper limb disorder). You may have tennis elbow or golfer’s elbow, of course without playing either sport — then it should be lateral or medial epicondylalgia! Words aside, this is a big and costly problem for individuals who bear the brunt of the pain, symptoms and their consequential limitations, and for businesses that have employees on light duties or off sick. So how does typing cause an injury?

Well it may not. We are not really designed to be sat, hunched over a desk (as I am now I have just realised), poking away at small buttons, getting quicker and quicker so that we don’t even have to think about where our fingers are going in order to produce a document. The ‘noise’ created by all these small, precise movements of the fingers (signals flying up from the joints and muscles about movement, pressure, touch etc) can be difficult for the brain to gather into a tangible meaning. We start to develop different sensations, perhaps a change in temperature, some tingling, numbness or a sense of size difference (my hands are now warm and a bit tingly). If you interpret this as strange or mildly worrying because you have heard of RSI and you don’t want it because your job involves typing all day…..you can perhaps see how the worry and concern and vigilance and responses begin to amplify and amplify; this without any notable injury. However, the tension that builds, the stress responses that affect tissue health, the change in blood flow and nerve function when anxious, all impact and can create a threat value that is perceived as dangerous and hence the body systems that protect kick in — this may well mean some pain. And pain is useful and normal, even without a significant injury, because pain is a need state, motivating action: maybe I should take breaks? Perhaps I should type less at the moment? Maybe I need to work at changing my thinking about a  situation that is making me stressed? Maybe I should start exercising regularly? Maybe I should seek some help and advice?

On-going use without adequate recovery can lead to an imbalance between tissue breakdown and rebuild, the natural state of change that is constantly occuring to all of us. The inflammation that results can of course add to the level of sensitivity or activate it, leading to aches and pains that can begin in specific locations but with time expand up and down the limb and even be noted in the neck and shoulder. This is not the spread of a ‘disease’, but rather the volume switch being turned up, meaning that increasingly normal stimuli (touch and movement, thought of movement, particular environments) can result in pain. Associations build with stimuli, and we get better and better at certain habits of thought and action that can perpetuate the problem — e.g./ avoidance, expectation, changes in movement, extra muscle tension unbeknownst to us.

There comes a point when the symptoms can begin so quickly that it becomes difficult to type, text, hold light objects and even gesticulate. This makes work life and socialising very challenging as well as frequently occupying much of our thinking, planning and our mental resources from the emotional impact. A comprehensive approach is needed to change direction and begin recovering, from wherever your start point. Certainly if you are feeling a few aches and pains that are becoming more frequent, you would be wise to seek advice. Or if you are struggling, then the right treatment and training programme can help you to resume meaningful activities.

Due to the biology of RSI, like all persisting pains, being upstream in the main, i.e. away from where the pain is felt, any programme must address this as much as improving the health of the tissues locally with movement and use (gradually). Once you undertand your pain, you realise that pain is not an accurate indicator of tissue damage, and that there are many things you can do to take you towards a better life. Asking yourself why you want to get better gives you the answer as to where you want to be going; your direction. We need direction and then the know-how to get there, dealing with distractions on the way, so that we remain focused on the right thinking and actions.

You will have been successful before, using your strengths (e.g./ concentration, empathy, dedication, motivation) and values. Using these same strengths and values to perform the training and to think in the right way leads you to a better outcome. What are your strengths and values? The exercises, training and treatment are all straight-forward, but their effectiveness is impacted upon by the way you think about your pain and your life. There are many factors in your life that are affecting your pain: e.g. tiredness, stress, anxiety, people, places. Understanding these and your pain puts you in a position to make changes and groove healthy habits and in so doing take the focus away from pain and worrying about pain to the doing and enjoying and living. There is only so much you can attend to in a passing moment, so why not focus on the good stuff? And if you are in pain, you can learn how to create conditions for ‘pain-off’ over and over whilst you get healthier and fitter generally as well as specifically training to resume meaningful activities: common problems are typing, texting, carrying etc.

This is an insight into modern thinking about pain and how to overcome pain. We understand so much more and this knowledge is ever-expanding. Passing this knowledge to you with practical ways of using it to overcome pain is our role, and treating you with techniques that calm and ease symptoms whilst you get fitter and stronger. Together we can use your strengths to resume a meaningful life.

Call now to start your programme if you are suffering RSI or if you are a business wanting to reduce risks or develop a programme for your staff: 07518 445493

 

18Sep/15

Sports injuries that don’t go away

Jan-Joost Verhoef| https://flic.kr/p/6qqqCU

Jan-Joost Verhoef| https://flic.kr/p/6qqqCU

There are many cases of sports injuries that don’t go away. They linger on and on, becoming increasingly impacting as the sensitivity builds, often accompanied with varying patterns swelling and stiffness. Understanding what is happening is the key to deciding upon the right action to change course and recover. The way that your body and you respond is determined by the circumstances of the injury, prior experiences (injured the area before? previous injuries?), beliefs about pain and injury, genetics, the immediate thoughts and messages given by others and the action taken at that point, including pain relief. Here are some of the reasons:

  • The circumstances of the injury: how healthy you are, how you are feeling at the time, where you are, how the injury happened (your fault? Someone else’s fault? An accident? In fact, it is how you perceive it that is important, not the actual reality), your first automatic thoughts, the time of the game, the importance of the game — all of these factors come together, physical-emotional to create a memory of that moment, the pain intensity determined by the perceived level of threat, and not the extent of the tissue damage (consider the player who has a break but does not realise until later). The way you and your body respond to an injury will be very different if you are stressed vs relaxed for example.
  • Previous injuries leave their mark in terms of how you think about them and the associated pain. If you have injured the area before, then there is a greater likelihood that it will hurt because the body will protect more readily. If you have had a good or a bad experience before, this affects how your body systems that heal and protect will kick in.
  • Your beliefs about pain and injury that began to be sculpted in the early days of bumps and bruises and in particular how people around you reacted — too much mollycoddling by parents/teachers is perhaps not great for how we learn to deal effectively with injury; that’s both in the way we think but also how our biological systems work. What you are thinking will impact upon the pain (‘I must get up and play on in this cup final’ vs ‘it is the end of my career’ = very different biologies), and hence the early messages given by the clinicians and therapists must be accurate and calming.
  • It seems that we can have a genetic predisposition to over-responding to injury, with inflammation kicking in as it should but more vigorously. Some people are more inflammatory that others so it seems.
  • The early actions after an injury, including the messages as mentioned above, are really important to set up healing. It is normal for an injury to hurt, however in cases of severe pain, this needs to be addressed with the right analgesia. Early high levels of pain can affect the trajectory of the problem.

For these reasons and others, some injuries appear to persist or recur, which is highly frustrating for the individual, and for the therapists. Sometimes the factors mentioned above set into place a level of sensitivity and certain protective behaviours that mean protection is vigorous — this in terms of the way the person thinks, acts and their biology plays out. This needs to be identified as quickly as possible so that the right treatment can be administered alongside working with the player to developing his or her thinking. Whatever is playing out in their minds will be affecting their biological responses, in a positive or a negative way, so we must intervene or encourage depending on the predominant thought processes.

When an individual is experiencing an on-going issue there are a range of factors to consider and address, some relating to the points above. Hearing their complete story is a vital start point, including an understanding of their perception of the events to date, as well as prior experiences that will flavour what happened then and what is happening now.

Here are some examples of the common features:

  • Often the body continues to try and heal, squirting inflammatory chemicals into the area periodically or in response to movement. This is neurogenic inflammation and sensitises just like inflammation from a fresh injury and is part of the sensitised state, but co-ordinated by higher centres
  • Rarely does the person understand their pain, which creates worry and concern. Remember that chronic stress can make us more inflammatory — also consider other life stresses as these will impact; if the body/person is in survive mode (fright-flight), then resources for healing and recovery are limited.
  • Altered movement patterns, in part from fear/lack of confidence but also as part of protect mode. These must be re-trained from the right baseline (often people start too far down the line and fail)
  • A belief that there is a re-injury when in fact it is a flare up, or an increase in sensitivity, not an actual injury

In brief, we must ensure that the individual’s thinking is right — understand pain and injury, their pain and injury — and that they are taking the right actions towards recovery (a negative thought or over-training will not take you towards recovery); but they need to be able to think clearly about this themselves, because they are with themselves all the time whereas the therapist is with them periodically. They need to become their own coach, which is why I developed the Pain Coach Programme — not only are we coaching them, but also teaching them to become their own coach. When the understanding and thinking is in place, the training and exercises are all straightforward. I use no fancy tools or kit to coach and treat, except of course the most fancy piece of kit we all possess, our brains! But let’s not be all brain-centric; we are talking whole person. It is the person who is injured, not their leg or arm; it is the person who feels pain in the context of who they believe they are and in their life, not a leg or an arm. The person feels hungry, not their stomach. Remembering this when educating, coaching and treating creates the right thinking platform.

Pain Coach 1:1 Mentoring Programme for Clinicians — see here or call us 07518 445493

14Sep/15

Cervical dystonia

Keoni Cabral | https://flic.kr/p/9EVhyB

Keoni Cabral | https://flic.kr/p/9EVhyB

Cervical dystonia (CD) is a movement disorder that is characterised by unwanted and involuntary spasms of the muscles in the neck and shoulder region. It can also affect the facial muscles. There is a genetic aspect to cervical dystonia but frequently, people who come for the treatment and re-training programme will describe a period of stress when the problem really took off.

It is not uncommon to hear that the diagnosis eventually came some years after the problem began. Typically a neurologist will diagnose dystonia, although an informed GP or physiotherapist may also identify it from the twitching, pulling and sometimes writhing movements that are cleary involuntary.

Cervical dystonia can be a distressing condition for a number of reasons: the pain and discomfort from the constant tugging, the continuous battle between opposing muscles and attempted conscious corrections, the awareness of others looking, the way that the movement patterns and body sense affects how you feel and your sense of self, your self-esteem and confidence in social situations, perhaps hopelessness in the face of the persisting symptoms; all impact on the condiiton itself and your hopes and expectations.

In conversation with people with CD, we usually identify certain traits such as perfectionism, obsessiveness and a lack of compassion towards oneself (self-critical). In addition, there can be a heightened awareness towards the body, including aesthetically–how do I look? Combining the desire to look a certain way with the manifestations of CD and there is a great deal of angst created.

Modern treatment is often led medically, once diagnosed, 3 monthly injections of botulinum toxin are typical. With the right dose and careful placement of the injections, this creates a great opportunity for sensorimotor re-training. Whilst the training is the mainstay of improving movement, there are a number of other considerations, the so-called non-motor factors. These must be addressed within a treatment and training programme. Merely focusing on the senses and movements is simply not enough, and indeed when we purely attend to a problem at the expense of all else, it will increasingly dominate our thinking. So in a way, to treat a problem, we should not always treat the problem!

Sensorimotor training develops normal body sense and movement, the two being absolutely interrelated. Without good body sense, you cannot move with normal precision, and when we move abnormally, or what is deemed abnormal by the motor system, then our bodies can feel different. When our bodies feel different, the way in which we engage with the world changes and so on. Specific exercises and techniques are used on a ‘little and often’ basis, which are simple and do not require equipment except a mirror on occasion. They necessitate practice like any training that is designed to improve performance, in this case precise movements for everyday life.

Where there has been and is on-going tension from overactive muscles, these body tissues and the underlying joints that are limited in movement by the tension, require nourishment with easy and regular movements. This often works best after a period of relaxation from breathing exercises or mindfulness, both of which promote better blood flow and oxygen delivery. I call this ‘motion is lotion’, a term that I did not coin but use with everyone I see to encourage healthy movement, whether for chronic pain, dystonia or both.

The way we move and the way that our brains plan movement based on predicting what we may do in a given environment, is affected by many factors: e.g./ how you are feeling, what you are thinking, who you are with, what you have been doing, how tired you are, what you plan to do, what your brain predicts that you may do, what you have done before in that environment, to name but a few. You will not be aware of many of these, but you’ll be aware that your spasm or pulling worsens or eases depending on certain circusmstances. Identifying these circumstances and situations allows you to begin dissolving these associations and habits, creating new patterns of movement. Remember that we are designed to learn and change, with opportunities to do so existing at all times.

Spending some time doing something that is meaningful to you is a great way of focusing on something else. Many people with dystonia find that when they are in full flow, the spasm and pulling ease off. This can be when painting, speaking, reading or listening to music. Even if during a meaningful activity you notice the symptoms, you can practice and improve, acknowledging the symptoms and returning your attention to the favoured activity. The pleasure that you gain and the realisation that you can attend elsewhere is part of overcoming the problem.

Mindfulness practice and relaxation play a significant role in changing the brain state, immune state and dampen down other systems that work to protect us including the sensorimotor system. When we perceive a threat, the muscles tense up in readiness to fight or run away. This is a basic biological function that does not help the already overactive muscles of dystonia. Mindfulness is not a spiritual or religious practice but rather a practical way of looking your thinking rather than becoming embroiled in thoughts and living out the past or future in your head. The techniques are simple and can be practiced anywhere.

This is a brief insight into both the condition and some of the ways that we go about changing your experience with a training and treatment programme. As ever, it is the person who needs treatment as they are living the experience of dystonia (it is not the neck experiencing dystonia), much like it is the person who feels hunger, not their stomach that feels hunger. Thinking widely and individually is key to successfully changing the unwanted movement patterns and easing the symptoms, allowing for the resumption of a meaningful life.

For more information or to book an appointment, call 07518 445493

25Aug/15

I am in pain

We often say I am in pain but does this really describe what is happening. Knit-picking perhaps, but I think that what we say, the words we use and the way that we use them are fundamental to being human and who we are as individuals. The innumerable phrases that have been passed down the generations will have their origins in a time was very different. So how relevant are they now? And how useful?

Someone says to you, I am in pain and instinctvely you know what they mean. You cannot possibly know what they feel or how they are feeling it, but you know that they are feeling something unpleasant and want you to know about it. There is a point to telling others about your pain, perhaps to seek help or advice, to gain sympathy or to give reason for non-participation for example. These are all accepted reaons for sharing, and would typically be known as part of the social dimension of pain.

However, we cannot really be ‘in’ pain. We can feel pain, pain can emerge from our very being (this includes our body) and pain can hurt, but you cannot be in pain. You can be in a house, a car or tent. Being in something suggests that you can get out. If you say that you are in pain, it suggests that you can get out of pain. Now, pain changes and is transformed (we are not in a constant state of anything, hence pain comes and goes like any other state–pain is part of a protective state), but you cannot get out of pain because you cannot be in pain. There is no entrance or doorway to pain that once you have entered requires you to find an exit.

Should we change our terminology and what effect would that have? I don’t think it will really change anytime soon, however when clinicians are thinking about the pain being described by an individual, it is more accurate to  consider the whole person from where the pain emerges in a particular location, with the underpinning biology involving many systems upstream of the lived experience. A story book requires a reader, words on a page and the book to be bound together. The book is the body that is read yet the reader must take the words and create a meaning, a story that makes sense, lived in his or her whole person–a beautiful description is felt and lived through the whole person involving complex biology that is a blended mind-body; embodied cognition. Our body is a story book yet the story is our experience. Changing the terminology will occur with time and as the understanding of pain evolves.

The growth of pain understanding is vital as a basis for informed choices and treatment choices–one of the biggest reasons for chronic pain being the number one global health burden is the lack of understanding, whereby the medical model continues to predominate treatment choices; i.e./ target treatment at the place where pain is felt in the body. This misses the point of pain as part of the way in which a whole person protects himself/herself, and indeed much of our common language contributes to an old belief system that our generation has been brought up upon. Evolution takes time and of course a new and more complex explanation to replace one that is simple, will be threatening. Nonetheless, this is where we will go as people experience failed treatments or do not reach the expected outcomes alongside developments in pain science that become increasingly known in the public domain. This knowledge will demand that things continue to change, and as a result so will our language. As is common though, this is a two way street and if we take opportunites to change our language, then we are using the social dimensions of pain to create learning opportunities that lay the foundation for perceptual shifts. And there’s one thing that changes pain, and that’s a perceptual shift.

Richmond with Georgie Standage co-founded UP | Understand Pain, a campaign to raise awareness of the problem of pain and what we can do to overcome pain — we are no longer managing pain, we are changing pain and coaching people back to a meaningful life. The next UP event is in October when more than 1000 singers will be performing; even more than last time! 

The Pain Coach Programme is a comprehensive strengths based approach to overcoming pain. Call us on 07518 445493 to start your programme.

20Aug/15

Pain and compassion

puppy love by Porsche Brosseau https://flic.kr/p/cu9h5h

puppy love by Porsche Brosseau https://flic.kr/p/cu9h5h

Pain and compassion are being explored at a forthcoming British Pain Society Conference, so I thought that I would comment on a couple of important aspects.

Firstly, as clinicians compassion plays a role in our desire to guide and treat others in pain and most likely coloured our choice to become a health-carer in the first instance. Secondly, I find that the vast majority, if not all those I see are compassionate people to everyone (or most!) except themselves. Here are some brief thoughts.

Compassion is defined as ‘inclining one to help or be merciful’ (Oxford Dictionary). The Dalai Lama describes compassion from a Buddhist viewpoint: ‘Compassion is said to be the empathetic wish that aspires to see the object of compassion, the sentient being, free from suffering’. There must be an object of compassion that is another individual or of course the one that is often forgotten, oneself.

The feeling of compassion is often described as a warmth across the chest; the type of feeling associated with seeing a small, defenceless animal, or perhaps a newborn child. This feeling enhances our empathy, which drives actions of kindness towards that being. As a clinician there are clear benefits of cultivating a compassionate approach towards patients who suffer the consequences of pain, particularly on-going pain. Certainly compassionate listening and actions are skills to be nurtured as they envelope the therapeutic encounter with essential authenticity. Compassion also creates an environment and a context for effective and skilful communication; an openness that encourages the patient to express themselves as themselves, revealing the challenges that can be surmounted with a joint therapeutic effort. The importance of the clinician being kind to himself or herself is akin to that of the patient. Looking at ways to grow and flourish, to be a better clinician requires acknowledgement of the current standing, acceptance and a desire to improve, yet without self-criticism.

Frequently patients will illustrate their harshness towards themselves. This punishment and criticism fosters angst, frustration, anger and other negative emotions that are draining, damaging and ultimately wasteful as energies are put into everything but clear thought and action towards improvement. At any given time, one does his or her best based on their knowledge and skills — everyone makes mistakes, which the wise learn from and see the opportunity in errors, the opportunity to develop. Learning to be kind to oneself, often breaking a habit of some years (many people I see are perfectionists; but in some arenas this trait is very useful and a strength that enables high performance resulting in success; so let us learn how and when to utilise it), is a vital part of learning how to overcome pain, especially persisting pain.

Here are several videos that are useful to that end:

Learning about compassion towards oneself and others is part of the Pain Coach Programme for overcoming and transforming persisting and chronic pain. Call us to book your appointment: 07518 445493 | Clinics in London | Sessions available on Skype on request

09Jul/15

The habits of pain

When we have suffered pain for some time, the habits we create can become part of the problem, and part of the reason why we are not moving forward. Whilst certain actions that become habitual are useful in the early stages, they only have a role for a finite period of time. Subsequently, other strategies need to be used to develop, learn and move on to overcome pain. 

A simple example would be a limp that is useful after an ankle sprain, that is not helpful one year later. In different parts of the body we do different things according to the typical actions that body part would be actually used for as well as intended use. This latter point is relevant because we are continually predicting and planning actions mostly at a subconscious level. We are responding to ten environment we are in, the context of that environment and the tools within that environment that we may use, such as a cup or a pen that the brain plans to pick up on sight if relevant. We don’t always know about this, and interestingly, just the mere plan or intent of doing something can cause pain on the basis that we are in protect mode. The same is true for watching others actions that would be of a high threat value to us. Someone with pain in their back may experience a twinge on observing someone else bending. For clinicians, this offers clues as to the level of protection — bend in front of the patient to see how they feel. 

As well as movement based habits that are actually based upon our beliefs about pain, injury, ourselves and the world, we have habits of thought. We automatically think about a situation, someone’s comments and about something we may need to do. These thoughts, if identified with, will impact upon what we choose to do. If I believe that when I move it hurts because I am further injuring myself, I will either not move or will move in a guarded way. In part I will do this on purpose, in part my protective systems (nervous, immune, autonomic) will inlfuence my movement upstream by contacting the sensorimotor areas of my brain. Of course we are not just brain but whole person, so I say this for convenience of the description. We learn quickly at the outset that a particular movement hurts and we may then anticipate this and decide not to move to to tense up and move abnormally. Whilst this is again useful in the early stages when the tissues really need protecting (whilst healing), as time goes on we need to move to get fitter and back to normal life. 

These are just a few examples of what happens. In some cases there are cycles of inflammation that trigger an acute flare-up within a persisting problem. Initially it maybe useful to use some of these protective habits, but only in the short-term. Not allowing them to take hold and only using them wisely is key. I like the metaphor that describes a man who is walking through a forest and comes upon a fast moving river. To cross he builds a raft and successfully reaches the other side. Does he still have a need for the raft? Should he hoist the raft onto his shoulders and carry the cumbersome vessel thought the trees? I think not. At each moment we need to think clearly about what is the wisest action. 

As I said earlier, and often say, we must address the whole person including their habits of thought and action and how the two entwine. We must explore why protective habits are being used and then develop this thinking into a range of skills that take the person onwards to where it is they envision being. This vision is vital and I work hard with people to create a strong image of what it is they want and how it is they want to be. This becomes their steer and all their thinking, focus and actions are upon attaining this vision. We become what we focus upon and hence we must use our strengths. 

For further information about my Pain Coach Programme for overcoming persisting pain, please call 07518 445493