Category Archives: Understanding pain


Persisting & recurring sports injuries: Specialist Clinics in London

Do you have a recurring sports injury? Do you continue to experience pain when engaging in exercise? Are you struggling to return to play after an injury or an operation?

This is one of the reasons why Specialist Pain Physio Clinics were set up in London and Surrey. The blight of on-going problems and pain after an injury or pain that has just crept up on you over time. In these situations, the tissue-based model of care does not suffice. In persisting states of pain, there are changes throughout the nervous system and other body systems at play to influence the processing of pain. Our movement changes, our thoughts about movement and exercise change and the pain changes with time. All of these changes require addressing and that is what we do.

Why does it persist?

There are some good reasons that we know of including continued change in movement, on-going guarding and protection, altered processing of sensation and psychosocial factors such as fear of movement, anxiety, negative emotions and beliefs. Addressing these and other issues is fundamental in handing back control, providing relief and moving forwards towards resumption of activities and sports.

What do we do?

Like Sherlock Holmes we look for the clues to your on-going experience and then design a treatment programme to target these mechanisms. We consider the type of pain(s) you are experiencing, the role of influential body systems, your lifestyle factors, your expectations and beliefs, the goals of the programme and other pertinent aspects of the experience. From here we use a range of strategies and therapies to facilitate your active participation in progressing towards your goals. Some of these therapies include mobilising muscles and joints if that is an issue (to guide normal movement and create normal sensation), specific exercises to restore control of movement with enhancements to create the best possible outcome, self-care strategies for day to day living and very modern approaches that facilitate learning and training in the brain (e.g. Motor imagery, sensory discrimination).

Overall we aim to create the right circumstances for your body, brain and mind to resolve the physical, psychological and social issues around persisting pain and injury.

So, if you are struggling with a persisting injury and/or pain, whatever your level of participation or sporting choice, get in touch and we can help you to achieve your goals.

T 07815 445493


Managing your flare-up

A flare-up is when the symptoms increase for a period of time. Sometimes it is clear why this happens such as after new activities or exercise, an increase in activity levels, when you are unwell, stressed or fatigued. In other cases there is no obvious reason as the routine has not changed and you cannot think of a reason why the pain has worsened.

Your brain will know why as it is responding to a potential threat. The brain is constantly monitoring the body and the environment through the senses and other body systems (e.g. endocrine, immune) and responds accordingly. Visual input has a significant effect and when we see others moving in a particular way or doing certain tasks, a threat value can be determined even though it is not ourselves doing it! For example, observing someone bend over and pick up a heavy box can evoke pain in our backs. The message is that our pain and perception of our body can change in response to things that we see.

So what do you do?

To manage a flare-up actively means that you can ride the storm more effectively and also learn about the process for greater effect if there is a further flare later on. In essence it is trying to remain active but tolerably.

1. Continue to break up sustained activities into chunks (pacing) as instructed by your therapist in terms of the timing. I would suggest as a ball park figure that 50% of the time it takes for the pain to enforce a change or cessation of activities should be a start point.
2. ‘Little & often': change position, move affected body part (avoid the area stiffening and provoking a worry about then moving) and other areas.
3. Use your prescribed exercises but in a calm way, i.e. Relaxed or meditative breathing before to ‘calm the seas’, think positively rather than dwelling on negative thoughts that can evoke other brain responses. Be flexible in the repetitions, for example, split the sets into shorter bouts but spread out over the day.
4. Before moving the affected area or undertaking the exercises, move regions that are remote or on the other side first. For example, if it is a foot problem, move the other knee and foot first, or the hip and knee on that side initially.
5. Pain relief as prescribed
6. If you are feeling unwell with a flare-up, manage as if you are sick. Your body is in a restorative mode and you must treat it as such, including rest periods.
7. Remember that this flare-up will pass.

Take the advice of your health professional in terms of the timings, repetitions and exercises. All activities should not be causing further increases in symptoms. It should be tolerable.

Little and often
Motion is lotion
Be consistent with your activities

For further information contact us on 07518 445493


Aches & pains, stresses & strains

Treatment Programme for life’s ailments

Aches and pains are a normal part of life, reminding us that we are doing too much, too little or something potentially injurious. Classically, sitting at the desk for hours, using a computer mouse repeatedly, texting and emailing on phones with small keypads, going from being sedentary all day to exercising furiously in the morning, at night or at the weekend, all can lead to aches and pains. Much of the time we expect this to be the case such as after a good workout, when re-starting at the gym or following an unusual bout of DIY. We can explain it, the pain has a meaning and often a short lifespan.

Whether we experience pain or not is not as simple as ‘we do some physical activity and then the tissues hurt’, but rather it comes down to the brain’s analysis of whether there is a threat to our tissues or not. So, we can do all sorts of activities, but it will only hurt when there is a perception of danger. The brain receives signals from the body tissues and organs, maintaining an ‘online’ monitoring system via a huge network of nerves that send messages to the spinal cord. These messages are then passed upwards to the brain for scrutiny. If, and that’s a big if, there is a sense of danger based on this information and past experience, the brain will protect the affected area and make it hurt. If there is no perceived danger, it simply won’t be painful. Good examples of this are phantom limb pain that is a sense of pain in a limb that is no longer present and battlefield stories of severe trauma yet no pain. The long and the short of it is that pain is not an accurate indicator of tissue damage as borne out in huge amounts of research that has been done over the years. This knowledge has advanced our ability to understand pain and treat it in a better way (for further information see our page dedicated to pain).

The aches and pains that we feel are influenced by a number of proven factors. These include stress, emotional state, fatigue, hormones, the immune system, past experience, culture, our beliefs about pain, gender and expectations to name but a few. Understanding this is very important for successful management and treatment as these factors need to be identified and dealt with appropriately. This approach is called the biopsychosocial model of care and deemed to be the best way of looking at and treating pain. We consider the biological mechanisms, the psychology and social impact. For example, a violin player cuts his index finger: biology includes inflammation that hurts, healing and changes in blood flow; psychology that would be thought about how this will affect his/her ability to play, ‘it’s a disaster’, anxiety about the future, I believe this will heal quickly; and social impact considers the fact that he/she cannot play and therefore there is no income this wee. Clearly there is more to it but this brief overview helps conceptualise the model and that the components are inter-related.

So the aches and pains of life are there and common and can become persistent, annoying, frustrating and affect ones ability to enjoy life. Our tolerance for the challenges we face may diminish and activity levels can drop and the downward spiral can begin. It could be that it is an old injury that recurs periodically or improved but never really resolved. Whatever the scenario, if the aches and pains, stresses and strains of life are too loud and bothersome or just there in the background nagging away, we have a programme for you that provides integrated treatment, strategies to develop resilience, relaxation and education so that you can understand what is happening to increase awareness allowing for change. The course is based on the latest understanding of pain, stress and health to offer informative, active, fun and effective ways of enjoying your body and life.

The basic programme consists of an assessment to determine the nature of the problem(s) followed by six 30 minute sessions. During these sessions you will receive an explanation of the problem including the causes and influences, treatment (this can include soft tissue massage, joint mobilisation, acupuncture), an exercise programme to focus upon stretching, mobilising or strengthening particular body regions, mindfulness techniques and breathing exercises. The programme parts create a synergy that targets body, brain and mind for better physical and psychological health.

Having completed the programme you are welcome to add sessions for ‘top ups’ on a individual or a single session basis.

To book, call now 07518 445493

Please note that if further investigations or a referral to see a consultant are required, a letter will be provided and recommendation made so that this can be actioned rapidly. Subsequently the programme or specific treatment can be started.

Hands of God & Adam

Complex Regional Pain Syndrome (CRPS/RSD)

Complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD), is undoubtedly a nasty condition in many cases. It can be hugely disruptive in the desire to lead a normal and fulfilling life due the experience of sheer pain and the difficulty in doing day to day activities.

I hear a huge range of stories of how the problem began and how it has been treated. Sometimes there is a significant injury, but often it is the type of event that one would associate with recovery such as an ankle sprain, a knocked elbow or a fracture. Unfortunately in a number of cases this simply does not happen. The injury is sustained, the area usually hurts as you would expect but then it continues to hurt and gets worse. There are associated signs and symptoms such as colour change, temperature change, altered sensation (pins and needles, numbness), an altered sense of position, a feeling of ‘largeness’, ‘thickened’ skin, huge sensitivity to light touch (allodynia), changes in skin, hair and nails. Fortunately we understand much more about the underlying mechanisms and can explain what and why this is happening, giving the problem a meaning which is so important in a condition that is troubling and causing great suffering.

CRPS in the foot and leg causes great difficulty in walking and standing in many cases. If the tissues are stiffened and the control of movement is poor, the ability to walk normally can be severely limited. Add the pain to this scenario and it becomes incredibly disabling at times as the sufferer simply cannot undertake normal activities. In CRPS in the upper limb it is writing, computer use, dressing, holding tools and self-care that are challenged.

Similar to any painful state, determining the pain mechanism(s) is important in deciding where to focus the treatment. Often there can be co-existing mechanisms such as inflammatory pain and neuropathic pain underpinned by different processes and manifesting in different ways. Neuropathic pain is often sharp, lancing, shooting and accompanied by a loss of sensation in the same area that can be confounding until you understand how it works. Inflammatory pain can be provoked by movement and touch with the mechanism being excited sensory nerves (nociceptors) as a result of the release of inflammatory molecules. Nerves themselves can release such chemicals into the tissues (neurogenic inflammation) and thereby keep the process going. There are many other aspects to the pain and the drivers and influences.

As well as elucidating the pain mechanisms, identifying the influences is also very important. This can include stress, fatigue, emotional state, past experience, culture, beliefs in addition to lifestyle factors and general health. Personally I look for risk factors for chronicity with all new assessments so that these can be fealty with swiftly. When a condition has been in existence for a longer period, adapting this to understand behaviours, choices and other factors that could be prolonging the problem is important.

Modern treatment of pain including CRPS should be within a biopsychosocial framework. That means looking at the biological mechanisms, psychology and social factors that are all part of the pain experience and mould the individual perception. In many cases the sufferer needs input from physiotherapy, pain medicine and psychology. Initially educating the patient to develop understanding, reduce fear of the pain and movement and enable effective coping and self-care is key. Desensitising the body with a range of techniques that blend the physical with the cognitive through the application of various stimuli is useful. This could be a paint brush or cotton wool for example. Tactile discrimination and two point discrimination are normal sensory functions that can be altered and according to recent studies are likely to need training. The graded motor imagery programme is part of the treatment, targeting brain changes that can occur. The three stages are laterality, imagined movement and mirror therapy. This is a newer intervention and is demonstrating good results in CRPS and with other nasty pains. The self-care aspects are fundamental. Teaching the patient to manage their activities and to develop consistency through their day is key. Sometimes activities are overdone and there is a trade off. For example standing at a party, but you really want to go and afterwards you know it will hurt but accept that this will be the case. Good flare-up management skills can play a huge role during these times. A further group of interventions I call perceptual exercises. Due to the plastic changes in the sensory and motor cortices, the sense of self, body and movement can feel different in many ways. Working with this through the use of imagery, mindfulness, awareness and other strategies can really help to get back in touch with the body alongside the other techniques. Finally, motor control exercise to normalise movement is very important but to be done at the right time in the right way.

The context of the treatment can affect the success of the strategy. Timing, environment, understanding and belief must all be considered when designing a programme. Newer ideas and research about neuroimmune responses to exercise, movement and thoughts suggest that we need to be mindful of these factors. This is the modern way of looking at the individual, their pain and circumstances to offer practical and effective strategies in improving outcomes and quality of life.

Subsequent blogs will look at the other symptoms, why and how they manifest and the effects of stress upon the body.


Mums in pain

Undoubtedly mums have many roles. From nurse maid to cook, from fashion designer to taxi driver, from swimming coach to chief bottom wiper, from peace keeper to play-mate, from goalkeeper to maths tutor and on and on… Of course ‘mums’ can be replaced with ‘dads’ who are the primary carers but as this blog is looking at women and pain from a particular angle I will be talking about mums from here onwards.

Having gone through a number of physical and physiological changes during preganacy, the female body returns to normal functioning. This is not always straightforwards and pains that occurred during
pregnancy can continue or recur. There are some reasons why this happens including the physical and mental demands of caring for little ones. Here is a list of examples, see if any are familiar:

1. Repetitive movements such as bending and lifting, pushing a pram at an awkward height (for miles)
2. Difficult positions for changing nappies and bathing
3. Trying to hold a baby and other implements (e.g./ hoover, kettle, brush, iron, another child)
4. Broken sleep and fatigue
5. Stress & anxiety
6. Feeding (position, length of time)

Thus is clearly not an exhaustive list but some examples of common activities that mums do regularly despite recovering from a huge physical and mental experience, child birth. This is both naturally and C-section with differing considerations afterwards.

The difficulty in trying to deal with a painful problem is that time for exercises and trying to alter the regime can be tricky. The demands of the child or children often take precedent and there can be little time for mum to follow her programme. By the end of the day there is enough time to eat and flop out on the couch. However, there are ways of integrating the necessary tasks for improvement. There maybe times when it is difficult, but with flexibility and undstanding set within the programme alongside realistic expectations, the necessary changes are possible and problems do get better.

Common examples of problems include back pain, hip pain (usually on the side and down the side of the thigh) and wrist pain (often tendons becoming sensitive). If there has been pain before, this can sometimes be re-ignited with the new carrying, lifting and postural changes that come as part of motherhood.

So, if you’re hurting seek advice. There’s usually a way to deal with the problem with the right understanding, treatment and effective self-management strategies to keep mums going with the pain eased.


Lorimer Moseley on the air…jazzy

My clinical work and huge interest in pain science has been influenced greatly by Lorimer’s work. The whole concept of really thinking about pain and it’s influences is key, and Lorimer’s delving into the mechanisms, the how’s and why’s has been hugely illuminating.

The clinician’s understanding of pain is vital in helping patients understand pain which is fundamental in coping and managing their problem(s) for a successful outcome. Really being able to explain pain and other symptoms and experiences is an art form. We can get better and better at explaining and communicating the details that help someone help themselves.

This recent interview on the radio with Lorimer is useful for clinicians but also patients. I’ve been asking patients to listen in as well as read Painful Yarns and other resources to develop undersanding to reduce fear, increase compliance, enhance learning and to get to the ‘aha’ moment. This is usually when there is a realisation that pain is not only influenced by physical means but a host of other factors including things that they don’t know that they know to coin a phrase. This moment (a point in time…!) is great because it means more control and meaning which is all so improtant in moving forwards.

Here’s the link:


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.

Richmond Stace MCSP MSc (Pain) BSc (Hons)
Specialist Pain Physiotherapist & Clinic Director
Specialist Pain Physio Clinics, London


London Marathon Training

At this time of year we see many people who are training for the London Marathon. This is an extraordinary commitment and achievement, often linked to raising money for a chosen charity. Naturally the training level gradually increases, which means a greater demand upon the body physically. Many people have not trained at such a level and they are reaching new realms. Consequently the niggles start causing problems beyond the expected pain of increased exercise.

Common problems other than blisters and exhaustion include knee pain, thigh pain, groin pain, hamstring pain, heel pain, foot and ankle pain. It can be highly frustrating when pain and injury prevent training and of course the concern turns to whether one can actually start the marathon.

A good training programme is of course important alongside some general strengthening work. However, despite this, pain and injuries do occur. If a problem starts, the best course of action is to seek help and advice. If this is done early, the problem can be solved more efficiently, returning you to the programme. Leaving the problem can lead to a worsening and development of further symptoms.


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.