Category Archives: Understanding pain


A point in time…

A point in time….. some thoughts

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

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

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


Pain in Pregnancy

Pain in Pregnancy

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

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

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

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

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

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

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

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

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


Mindfulness for stress reduction

Mindfulness is becoming increasingly popular. This is good because of the benefits from regular practice that include improved concentration, focus, clarity of thought, reduction in negative thought streams and stress related problems. Pain falls into the last category as stress and pain often come hand in hand. In fact, pain is a stressor when it is perceived to be out of the control of the individual.

Stress refers to the body trying to restore balance physiologically. The bottom line is the perception of a situation. When our brains a working out what is going on inside of us and to us, if there is a perceived threat it will respond. We are then conscious of pain, discomfort, ‘butterflies’ and a host of other emotions with physical manifestations. Physical stress occurs when we exercise, sit too long and drink too much coffee to name but a few. Psychological stress happens in response to harassment, thinking negatively and ruminating on an argument for example.

The problem lies in the fact that the brain responds to perceived threats whether they really exist or not. If you play the tape of an argument with the boss, you experience the genuine feeling of rage and anger as very real chemicals are being released and giving you the same feelings. Therefroe an on going perception of threat leads to chronic stress as the brain and body try to restore balance. The persistent release of chemicals relating to stress can affect tissue health and maintain the cycle of sensitivity. We already know that thinking negatively has a measurable effect upon the immune system (catastrophising leads to an increase in IL-6 that impacts upon IL-1 and TNF that both have a role in inflammation), therefore for a number of reasons it is important to develop some skills in managing stress.

Mindfulness offers such an approach and if used well can be extremely beneficial in situations of stress and pain. At Specialist Pain Physio Clinics we use this technique and cover some basic skills to enable increased control, reduction in stress and anxiety and a stepping stone to deeper practice that has wide ranging healthy benefits.

NB/ The has been some confusion recently with comparisons of mindfulness to breathing. Mindfulness is mindfulness, breathing is breathing, they are not the same.

For more information read Matthieu Ricard’s Art of Meditation.


Practical Strategies for Pain

Having practical strategies for pain is one of the fundamental parts of the treatment programme for us. It is not enough to have an exercise programme that is completed twice a day for example, there has to be other aspects to the plan that promote change, learning and development that are felt to be pain relief and improved ability to work and play.

At Specialist Pain Physio Clinics we listen carefully to your experience of pain and injury and then look closely at the way your body is working. This ‘detective’ work leads to an understanding of where the treatment programme must intervene to give you relief. Attention to detail is vital.

The treatment programme therefore includes specific exercises to deal with the problems that we have identified (e.g. poor control of movement, tightness), general exercise advice plus a range of strategies that allow you to manage day to day activites effectively such as the work station, gradually returning to sport, socialising and taking part in family life.

As you progress with the exercise programme compnent it becomes increasingly challenging and it is so very important to have skills and knowledge to continue moving forwards. We will arms you with these skills that optimise your rehabilitation and hence the outcome.


Graded Motor Imagery

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

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

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

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

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

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

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


Is sitting a problem?

The following piece from Scientific American looks at the problem with sitting despite the fact that you may exercise regularly. A huge study in 2009 (17,000 participants) found that the time spent sitting was associated with increased risk of all-cause and cardiovascular disease mortality. It seems that the best way to manage this time, often at work, is to regularly break up the sitting periods. This is a strategy that we recommend to many clients, often to manage pain that gradually builds when you are in one position. However, it is clear that there are many other healthy benefits of taking on this approach. Read on for the article by Travis Saunders

We all know that physical activity is important for good health—regardless of your age, gender or body weight, living an active lifestyle can improve your quality of life and dramatically reduce your risk of death and disease. But even if you are meeting current physical activity guidelines by exercising for one hour per day (something few Americans manage on a consistent basis), that leaves 15 to 16 hours per day when you are not being active. Does it matter how you spend those hours, which account for more than 90% of your day? For example, does it matter whether you spend those 16 hours sitting on your butt, versus standing or walking at a leisurely pace? Fortunately or unfortunately, new evidence suggests that it does matter, and in a big way.

What is sedentary behavior?

Before we go any further, it’s important that we define the term “sedentary behavior”. Sedentary behavior is typically defined as any behavior with an exceedingly low energy expenditure (defined as <1.5 metabolic equivalents). In general, this means that almost any time you are sitting (e.g. working on a computer, watching TV, driving) or lying down, you are engaging in sedentary behavior. There are a few notable exceptions when you can be sitting or lying down but still expend high energy expenditure (e.g. riding a stationary bike), but in general if you are sitting down, you are being sedentary.

The above definition may seem rather intuitive, but this is not the way that the term sedentary has been used by exercise science researchers for the past 50 years. Up until very recently, referring to someone as sedentary meant simply that they were not meeting current guidelines for physical activity. In simple terms, if you were exercising for 60+ minutes/day, you were considered physically active. If you were exercising 10 minutes/day, you were sedentary. Case closed. But as we will discuss below, sedentary time is closely associated with health risk regardless of how much physical activity you perform on a daily basis. Further, it is entirely possible to meet current physical activity guidelines while still being incredibly sedentary. Thus, to quote researcher Marc Hamilton, sitting too much is not the same as exercising too little. (if you take only one thing from this post, let it be that quote from Dr Hamilton). Which is why it is so important that when we use the term “sedentary”, we are all on the same page about what that means.

Now that we know what sedentary behavior is, let’s look at its relationship with health risk.

Epidemiological Evidence

In 2009 Dr Peter Katzmarzyk and colleagues at the Pennington Biomedical Research Center published an influential longitudinal paper examining the links between time spent sitting and mortality in a sample of more than 17,000 Canadians. Not surprisingly, they report that time spent sitting was associated with increased risk of all-cause and cardiovascular disease mortality (there was no association between sitting and deaths due to cancer). But what is fascinating is that the relationship between sitting time and mortality was independent of physical activity levels. In fact, individuals who sat the most were roughly 50% more likely to die during the follow-up period than individuals who sat the least, even after controlling for age, smoking, and physical activity levels. Further analyses suggested that the relationship between sitting time and mortality was also independent of body weight. This suggests that all things being equal (body weight, physical activity levels, smoking, alcohol intake, age, and sex) the person who sits more is at a higher risk of death than the person who sits less.

The above findings linking excessive sitting with poor health are far from isolated. For example, a similar longitudinal study from Australia reports that each hour of daily television viewing (a proxy of sedentary time) is associated with an 11% increase in the risk of all-cause mortality regardless of age, sex, waist circumference, and physical activity level. And as my colleagues and I summarize in a recent review paper (PDF), numerous epidemiological studies have linked sedentary behavior with obesity, cardiometabolic risk, and even some cancers.

New evidence also suggests that in addition to the quantity of sedentary time, the quality of sedentary time may also have an important health impact. For example, Genevieve Healy and colleagues examined this issue in participants of the Australian Diabetes, Obesity and Lifestyle (AusDiab) Study. A total of 168 men and women aged 30-87 years wore an accelerometer (an objective measure of bodily movement) during all waking hours for 7 consecutive days, which allowed the researchers to quantify the amount of time that participants spent being sedentary, as well as how frequently they interrupted these sedentary activities (e.g. standing, walking to the washroom, etc).

What did they find?

The greater the number of breaks taken from sedentary behavior, the lower the waist circumference, body mass index, as well as blood lipids and glucose tolerance. This was true even if the total amount of sedentary time and physical activity time were equal between individuals—the one who took breaks more frequently during their time at the office or while watching television was less obese and had better metabolic health. Importantly, the breaks taken by the individuals in this study were of a brief duration (<5 min) and a low intensity (such as walking to the washroom, or simply standing).

Taken together, the epidemiological evidence strongly suggests that prolonged sitting is an important health risk factor. But what explains these relationships? Let’s now look at the multiple mechanisms linking sedentary time with increased health risk.


Reduced Energy Expenditure

Quite obviously (and by definition), when you are sedentary, you are not being physically active. And so one common assumption is that people who sit more are at increased health risk simply because they are getting less physical activity. However, somewhat surprisingly, sitting time and physical activity do not appear to be related for most people. For example a paper from the European Youth Heart Study published in PLoS Medicine reports no association between physical activity and TV watching in a sample of nearly 2000 children and teenagers, and other reports suggest that there is little evidence that sedentary behavior displaces moderate or vigorous physical activity. So while it makes intuitive sense that being sedentary reduces energy expenditure, it is likely through the reduction of very light intensity physical activity (e.g. standing, walking at a slow pace), rather than by reducing the volume of what we typically think of as exercise. This may also help explain why the relationship between sedentary behavior and health risk are often independent of moderate or vigorous physical activity.

Increased Food Intake

In addition to reducing our energy expenditure, sedentary behaviors may also promote excess food intake. For example, a recently published study in the American Journal of Public Health suggests that the amount of commercial television (e.g. television with advertisements) that children watch before the age of 6 is associated with increased body weight 5 years down the road, even after adjustment for other important variables including physical activity, socio-economic status and mother’s BMI. In contrast, watching non-commercial television (DVD’s or TV programs without commercials) showed no association with body weight. Similarly, it has also been reported that each hour of daily television watching in children is associated with an increased consumption of 167 calories per day (PDF), mainly through increased consumption of high calorie, low nutrient foods (e.g. the foods most commonly advertised on television). Much of this is likely just a learned behavior—watching TV exposes us to food ads promoting unhealthy fare, which is likely to have a disproportionate influence on younger viewers. Just as importantly, people may just really enjoy munching on food while relaxing on the couch. Either way, excess sitting (and TV watching in particular) seems to put us in situations where we choose to eat more than we would otherwise.

Physiological Adaptations

I don’t think the mechanisms described above—that sitting too much may lead to reduced energy expenditure and increased food intake—will come as much of a surprise. But what I find truly fascinating is that sedentary behavior also results in rapid and dramatic changes in skeletal muscle. For example, in rat models, it has been shown that just 1 day of complete rest results in dramatic reductions in muscle triglyceride uptake, as well as reductions in HDL cholesterol (the good cholesterol). And in healthy human subjects, just 5 days of bed rest has been shown to result in increased plasma triglycerides and LDL cholesterol, as well as increased insulin resistance—all very bad things. And these weren’t small changes—triglyceride levels increased by 35%, and insulin resistance by 50%!

These negative changes are likely related to reductions in the activity of lipoprotein lipase, an enzyme which allows muscle to uptake fat, thereby reducing the amount of fat circulating in the blood (it also strongly influences cholesterol levels—the details can be found here). Animal research has shown that lipoprotein lipase activity is reduced dramatically after just six hours of sedentary behavior—not unlike a typical day at work or school for many individuals. Sedentary behavior may also reduce glucose transporter protein content in the muscle, making it more difficult for glucose to be taken into the muscle and resulting in higher blood sugar levels. What is most interesting to me personally is that these physiological changes in skeletal muscle have little or nothing to do with the accumulation of body fat, and occur under extremely rapid time-frames. This means that both lean and obese individuals, and even those with otherwise active lifestyles, are at increased health risk when they spend excessive amounts of time sitting down.

Should we be concerned about the health impact of sedentary behavior?


Western society is built around sitting. We sit at work, we sit at school, we sit at home, and we sit in our cars as we commute back and forth. In fact, a recent survey reports that the average American accumulates more than 8 hours of sedentary behavior every day—roughly half of their waking hours. The situation in children is, unfortunately, no different. There is evidence that children in both Canada and the USA accumulate more than 6 hours of screen-time (time spent in front of the TV, computer, or other screen-based device) on a daily basis. Keep in mind that screen-time is almost exclusively sedentary (active video games excluded), and that all these hours of sedentary behavior are in addition to the hours and hours (and hours) that kids spend sitting at school. In fact, a recent study reports that roughly 70% of class time, including physical education class, is completely sedentary (while slightly better than class time, children were also sedentary for the majority of lunch and recess).

In short, given the consistent links between sedentary behavior and both death and disease, and the ubiquity of sedentary behavior in our society, we should be very concerned about the health impact of sedentary behavior.

What is the take-home message?

There is a rapidly accumulating body of evidence which suggests that prolonged sitting is very bad for our health, even for lean and otherwise physically active individuals. The good news? Animal research suggests that simply walking at a leisurely pace may be enough to rapidly undo the metabolic damage associated with prolonged sitting, a finding which is supported by epidemiological work in humans. So, while there are a lot of questions that remain unanswered (e.g. Is there a “safe” amount of daily sedentary time?), the evidence seems clear that we should strive to limit the amount of time we spend sitting. And when we do have to sit for extended periods of time (which, let’s face it, is pretty much every single day for many of us) we should take short breaks whenever possible.

Finally, if you take only one thing from this post, let it be this—sitting too much is not the same as exercising too little.


Repetitive strain injury (RSI)

Repetitive strain injury (RSI) is a common complaint that we see at Specialist Pain Physio Clinics as it is often reported as persisting or recurring. There is a spectrum from those suffering mild symptoms to those who have had to stop working due to pain and other signs and symptoms of RSI. The term describes what has happened in essence but we know more about how and why this problem occurs and continues therefore allowing for more effective treatment and management. The overall aim is to reduce symptoms and restore function, usually including a return to work.

Symptoms include

  • Pain: e.g./ sharp, dull, achy, spontaneous, shooting, throbbing
  • Altered sensation: pins & needles, numbness, crawling
  • Swelling
  • Altered perception of the limb, including size
  • Temperature change
  • Discolouration
  • Altered movement including being unable to grip, type, write, hold or perform fine motor skills (buttons, picking up small objects)
  • Altered joint position sense (unaware of where a body part is in space and where it is going, hence a loss of accuracy)
  • Fatigue

For normal tissue health the brain relies upon a regular flow of information about current status. There is a huge network of nerves performing this task. This information includes ‘online’ data about movement. However, with smaller movements such as typing, the brain does not register the movement as accurately. Essentially a mismatch can develop between what is expected and the information coming in. We know that this kind of sensorimotor mismatch can lead to the development of sensitivity. Subsequent to this sensitivity build up, the same nerve network can release chemicals into the tissues and provoke a host of symptoms. This is called neurogenic inflammation.

It is feasible that ‘overuse’ can lead to a breakdown of tissue via an imbalance that develops when the natural breakdown-rebuild process tips in the favour of the former. If an inflammatory process starts, the chemicals released cause sensitivity to develop. This can evolve into a greater problem over time if the tissues do not have the opportunity to heal adequately.

An inflammatory process that develops in the neck can cause a nerve to become sensitised with subsequent pain being felt in the tissues that the nerve supplies, in the hand for example. This is referred pain and can cause altered use of the limb that in itself leads to further problems of disuse and pain.

There are a range of conditions that can come under the repetitive strain banner:

  • Bursitis
  • Cubital tunnel syndrome
  • Carpal tunnel syndrome
  • DeQuervain’s syndrome
  • Diffuse RSI
  • Dupuytren’s contracture
  • Dystonia (writers cramp)
  • Epicondylitis
  • Gamekeeper’s thumb
  • Ganglion
  • Raynauds disease
  • Tendinitis
  • Tenosynovitis
  • Thoracic outlet syndrome

At Specialist Pain Physio we will ascertain the cause through the assessment along with the type(s) of pain so that we can provide the right treatment programme and advice. We work with you to restore function and relieve the symptoms.

Return to work

We provide return to work strategies that includes visiting your workplace and talking to your employer or occupational health department.

Useful resources: