Category Archives: Women and pain

24Oct/16

Women in pain

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

If society understood pain….

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

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

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

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

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

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

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

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

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

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

RS

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

 

 

 

23Mar/16

Women in pain

Women in painI see more women in pain than men in pain. Naturally, it depends upon the individual as to whether they seek help or not, yet as a general observation it appears that women in pain are more likely to take some action.

The most common presentation is a female aged between 30 and 55 years, who has suffered pain for some time, months or even years, which is now impacting upon her life in a number of ways. Typically the pain is affecting homelife, particulalrly looking after young children,  and worklife, or both in some cases as the pain pervades out into every nook and cranny. Sometimes this happens over a few months but often it is a slow-burner that is suddenly realised. When we have a conversation about the pain, cafe style*, it becomes apparent that there have been painful incidents punctuating a consistent level of sensitivity, building or kindling. The pains emerging in the person include back pain, neck pain, wrist pain, knee pain, foot pain — any joint pain — muscular pain; and can be accompanied by a range of pains known as functional pain syndromes: pelvic pain (dysmennorhoea, period pain, endometriosis, vulvodynia), irritable bowel syndrome, migraine, headache, fibromyalgia, jaw pain. The person, whilst unique and has a unique story to tell, is often hard on themselves by nature, a perfectionist, anxious and a worrier.

There are many, many women suffering a number of these problems that appear to be unrelated, but this is not usually the case. Upstream changes, or biological adaptations, play a role in the symptoms emerging, yet of course the way a condition manifests is dependent upon the individual themselves, with the uniqueness of each person, their tale, beliefs and life experiences.

Nothing happens in isolation. In other words, there is a point in time when we experience a sensation that we label and communicate, but this is not in isolation to what has been before. The story that the person tells me is vital because it reveals both the unfolding of how the individual comes to be sat in the room and allows me to begin giving some meaning to the experience; i.e. helping the person understand their pain and how it sits within their lifestyle and their reality. I say within because pain should not define who we are, yet it often appears to and hence needs to be put into perspective; the first step to overcoming the problem.

So, there are priming events that often begin much earlier in life than the pain that eventually brings the person along to the clinic. These priming events are biological responses to injuries, infections and other situations that are also learning situations. Learning how to respond at time point A then ‘primes’ for time point B as a response kicks in based on how our brains predict the best hypothesis for what ‘this all means’–what we are experiencing now is the brain’s best guess about what all the sensory information means based upon what has happened before, probability playing a role. One of the reasons for a good conversation is to identify the pattern of pain over the years, how it has gradually become more intrusive as the episodes intensify and become more frequent. The pattern can then be explained, given meaning and then provide a platform to create a way forward.

We are designed to change and each moment is unique. This gives us unending opportunities to steer ourselves towards a healthier existence and leading a meaningful life. To get there though, we must have a belief that we ‘can’ and be able to hold that vision. This vision of the healthy me is one that allows us to ask ourselves the question ‘am I heading towards the healthy me with these thoughts and actions, or not?’. If we are not heading in that direction, then we are being distracted and need to resume the healthy course, actively choosing to do so. How are you choosing to feel today? This is an interesting question to ask oneself.

We still have a certain amount of energy each day and a need for sleep and recuperation. Exceeding our capacity means that we are not meeting our basic needs — security, nutrition, hydration, rest. There is only a certain amount of time that we can keep drawing on our energy before we must refresh. Failing to attend to the basic needs leeds to on-going stress responses that are meant only for short bursts. Prolonged activation begins to play havoc in our body systems as we are in survive mode, not thrive mode. In particular, systems that slow down include the digestive system and the reproductive system. Many, many of the women I see have issues with both — e.g./ poor digestion, bloating, sensitivity, intolerances, fertility problems. The biology that underpins behaviours of protection (fright or flight) are preparing you to fight or run away. Having a meal or trying to conceive are low on the biological agenda when you are surviving.

Too much to do, too little time. Modern day living urges us to be busy being busy. Demands flying in from all quarters, yet it is the way we perceive a situation, the way we think about it that triggers the way we respond, not the situation itself. This gives us a very handy buffer. By gaining insight into the way we automatically think and perceive, this being learned over years (i.e. habits), we can become increasingly skilled at choosing different ways of thinking, letting thoughts go, and focusing on what enables us to grow. This very quickly changes our reality, our body, our environment and the sum of all, which is the lived experience.

With on-going pain we develop habits of thought and action, including the way we move that is integral to the way we sense our bodies. Our body sense and sense of self changes in pain, as does our perception of the environment (things can look further away when we have chronic pain or steeper when we are tired), all of which add up to provide evidence that we are under threat. More threat = more pain because the amount of pain we suffer is down to the level of perception of threat and not the amount of tissue damage. We have known this for years, yet mainstream healthcare and thinking remains steadfastly into structures and pathology. It is no mystery then, as to why chronic pain is one of the main global health burdens when the thinking is wrong! So what can we do?

If you are a woman suffering widespread aches and pains, tiredness and frequent bouts of anxiety, there is good news! As I said earlier, we are designed to change, and change is happening all the time. We need to decide which way we wish to change and then follow a plan, or programme, that takes you towards your vision of the healthy you. Pain is a lived experience and hence the programme must fit your life and unique needs as the techniques, strategies of thought and action interweave your life, moment to moment, taking every opportunity to create the right conditions. The blend of movements, gradually building exercises, mindful practice, sensorimotor training, recuperation, resilience, focus, motivation and more, together form a healthy bunch of habits that are all about you getting healthy again, which is the best way to get rid of this pain. No threat, no pain.

* the cafe style conversation is my chosen way of unfolding the person’s story. How do we chat in a cafe? It is relaxed and open, allowing for the full flow of conversation.

  • Pain Coach Programme t. 07518 445493
  • Pain Coach 1:1 Mentoring for clinicians and therapists t. 07518 445493
28Sep/14

Fibromyalgia in women | #fibromyalgia

I see many women suffering with fibromyalgia. I also see many women who have widespread aches and pains, frequently without an injury, but rather a gradual increase in pain across the body. This maybe fibromyalgia, but in essence we are talking about sensitisation that evolves if no action is taken.

The commonest profile is this: a woman with young children (may have had some problems conceiving), aches and pains across the body, disturbed sleep or too little sleep, always tired, emotions and mood vary, concentration and focus can wax and wane, irritable bowel syndrome (IBS — bloating, pain), migraines, headaches, jaw pain (perhaps grinding in her sleep), anxious, ‘stressy’, very little time to rest and recuperate, repeated bladder infections (often there is no actual infection, but the symptoms are the same) and poor recovery from illnesses. 

There is a common biological thread with these problems. On appearance it would be logical to assume that they are unrelated — many healthcare professionals also take this view. BUT, this is not the case. These functional pain syndromes are all manifest of adaptations in the nervous system, immune system, autonomic nervous system and endocrine system. The good news is that the changes are not set in stone because we are mouldable, or plastic. We learn and adapt according to our thinking, beliefs and actions.

Understanding your pain changes your thinking so this is the initial step. Thoughts are based on beliefs and evolve to ‘I can change my pain’ when you know the facts. First setting up your thinking, then creating a vision to aim for and finally making a definite plan to follow allows you to head towards sustainable change with healthy habits. It is a challenge, but one that is wholly worthwhile.

Women in Pain Clinic is based at 132 Harley Street in London — call now to start your programme and move forward 07932 689081

 

 

10Dec/13

Uncomfortably numb

Feeling numb can mean that the self has lost its physical presence, or in an emotional sense, feelings have become blunted. These are both different constructs of loss for which we are compelled to seek an answer, often causing great angst. To step out of the normal sense of self is profound, difficult to define and causes suffering, whereby one has lost his or her role.

Physical numbness, if we can say this, will usually be described in terms of a body region feeling different. Altered body sense is a common finding in persisting pain states and in post-traumatic stress disorder (PTSD). In extreme situations, an out of body experience can be described where the person views themselves from an outsider’s perspective, in the third person. Often though, one refers to numbness as an area with reduced or no sensation. This can be objective such as when a stimulus (eg/ a pin prick; a light brush) is applied to the body surface and the sensation is lacking; or subjective when an area is felt to be numb yet a stimulus can be felt normally.

Although numbness in the the body is not painful per se, it is often tarnished with an aversive element that is described as unpleasant. This seems to be a particular issue in the extremities; conditions that involve nerves such as Morton’s neuroma. The mismatch between what is physically present and can be seen yet not felt, is difficult to understand and compute until the construct is explained.

An explanation: the body is felt via its physical presence in space, interacting with the immediate environment, yet is ‘constructed’ by networks of neurons in the brain. These neurons or brain regions are integrated, working like superhighways in many cases, thereby enhancing certain experiences or responses. At any given moment, the feelings that we feel and the physical sensations that we experience are a set of responses that the brain judges to be meaningful and biologically useful. The precision with which we sense our physical self and move is determined by accurate brain (cortical) representations or maps of the body. These maps are genetically determined yet moulded with experience, for example the way the hand representation changes in a violinist. Similarly, when pain persists we know that the maps change and thereby contribute to the altered body sense that is frequently described. It is worth noting that patients can be reluctant to charge their altered body experiences for fear of disbelief when in fact they are a vital part of the picture.

Emotional numbness is consistent with physical numbness in the sense of a stunted experience, whereby the expected or normal feeling in response to a situation fails to emerge. Rather, something else happens thereby creating a mismatch between the expected feeling and that which occurs. This experience manifests as a negative and is not discriminatory, affecting a range of emotional responses. A sense of detachment from the world often accompanies the lack of feeling. One could argue that this is a form of protection against feelings of vulnerability where we can also use our physical body, our armour, to shield us from the threat. Of course the threat is down to our own perception of a situation, another example of a brain construct. A situation is a situation but we provide the meaning based upon our own belief system and respond accordingly, often automatically.

Cultivating a normal sense of self is, in my view, the primary aim of rehabilitation and this encompasses both the physical and emotional dimensions. Both are influenced by thoughts, the cognitive dimension, that emerge from our belief system that drives behaviours. Hence, a programme design must reflect the interaction as it presents in the individual, most of the clues residing in the patient’s narrative that we must attend to in great detail. Validating the story and creating meaning is the first step towards a normal sense of self, to be enhanced with specific sensorimotor training and cognitive techniques such as mindfulness based stress reduction and mindfulness per se.

Wider thinking and practice is desperately required in tackling the problem of persisting pain. One of many responses to threat, pain is part of the way in which we protect ourselves along with changes in movement and other drivers to create the conditions for recovery. Sadly, many people ignore or miss these cues in the early stages through being fed inaccurate information about pain and injury. Many common ailments that can become highly impacting and distressing such as irritable bowel syndrome, headaches, pelvic pain, widespread musculoskeletal pain, anxiety, fertility issues and low mood, gradually creep up on us as the sensitivity builds over a period of time; the slow-burners. An answer to these problems that are typically underpinned by central sensitisation and altered immune-endocrine functioning, is to create awareness and habits that do not continually provoke ‘fright or flight’ responses that essentially shut down many systems in readiness for the wild animal that is not present. Actually, the wild animal is the emotional brain that when untamed can and does create havoc through the body, affecting every system.

The ever-evolving science and consequent understanding now puts us in a great position to trigger change. Initially discussing numbness, I have purposely drifted toward a more comprehensive view looking down on the complexity of the problems that we are creating in modern existence, manifesting as common functional pains. As much as we are knowing more and more about these conditions, we are actually describing the workings of the different body systems in response to a perceived threat that may or may not exist. This is always multi-system: nervous, immune, endocrine etc. and all must be considered when we are thinking about a pain response. But let’s not just think about pain as this is one aspect of the problem, one part of the emergent experience for the individual — think movement, think language, think body language, think ‘how can we reduce the threat’ for this individual so as to change their experience of their body responses. It is at this point that we see a shift and it is possible in all of us. We are designed to change and grow and develop, so let’s create the conditions for that change physically, cognitively and emotionally.

13Aug/13

Endometriosis & Melatonin | Women and Pain Series

Chronic pelvic pain is a troubling condition for many women. The reason for pelvic pain varies but certainly includes endometriosis where the lesions impact upon nerve health and function (see here) with consequential sensitisation. The purported mechanisms of pain include inflammatory pain and neuropathic pain with subsequent central sensitisation that underpins the persistance and variance often described.

Pain is an output, a response to the brain’s perception of what is happening in the body. The sensation of pain emerges from that part of the body deemed in need of protection. The pain itself is modulated by a range of factors including stress, fatigue, anxiety and the environment. The actual feeling of pain is the end result of the brain’s analysis of what is going on ‘now’ on the basis of what it already knows and has learned. Hence, prior experience can flavour the pain. Changes in the spinal cord and higher centres can amplify danger signals, modulate normal signals (begin as normal and communicate with nociceptors, therefore the brain receives a danger signal despite the initiating impulse being one of touch; i.e./ allodynia) and are responsible for the varying patterns of pain such as when a treatment helps on one occasion yet seemingly worsens the pain on a subsequent occasion.

Alongside the painful experience there are other body and brain responses to the perceived threat. Altered control of movement that includes guarding and protective posturing that leads to patterns of on-going chronic tension. In the case of pelvic pain this emerges around the pelvic girdle, in the abdomen and in the spinal muscles and often across the body. It is not unusual to find that there are many tender and tight areas when the body has been protected for some time, demonstrating a more widespread pattern. Often there is sensitivity expressed via other body systems , for example the gastrointestinal system in IBS, headaches, migraine and recurring bladder infections to name but a few. General health can often be impacted upon, with levels of activity diminishing alongside a fear of moving and socialising (a gradual withdrawal from being out with friends and family). This typically leads to a downward spiral affecting mood, self-esteem and manifesting with anxiety in many situations. It is really a ‘hyper-protective’ state physically and mentally where many cues become threatening and hence we protect, sometimes consciously by making choices and frequently automatically or habitually. Breaking this pattern however, is entirely possible.

We are fundamentally designed to change, evolve and grow. When we set the right conditions physically and mentally (and it has to be both), then we can move forward and change our outlook and experience. I know that an individual is going to progress when they start changing their language, metaphor use and at the same time their appearance changes via posture, facial expression and general demeanour. The spark returns.

The optimal approach requires that we consider all the dimensions of pain: physical, cognitive and emotional. This must be integrated and a programme created to meet the unique needs of the person. Concomitant with a range of strategies and training techniques to retrain normal movement, tension patterns, ease pain, tackle stress and anxiety etc, medication can play a role. The efficacy of pain medication is varied and often there are side-effects to consider. A recent study looked at the use of melatonin for endometriosis-associated pain with some very interesting results.

The commentary of Timothy Ness in Pain 154 (2013) 775 summarises the study below: ‘The article by Schwertner et al..demonstrated efficacy of the hormone, melatonin, in the treatment of endometriosis-associated pain…..one of the few medications which have proven useful in the treatment of endometriosis-associated pelvic pain but it is also notable as an example of the back-and-forth translational process associated with preclinical models of pain/analgesia and the clinical demonstration of treatment efficacy.’ And, ‘In this particular example the information flow went in both directions from humans to non-humans and then back again’. He refers to the fact that the data produced in rats was also found in humans. Many studies use rodents as subjects with obvious limitations in terms of extrapolating data for humans.

Pain. 2013 Jun;154(6):874-81. doi: 10.1016/j.pain.2013.02.025. Epub 2013 Mar 5.

Efficacy of melatonin in the treatment of endometriosis: a phase II, randomized, double-blind, placebo-controlled trial.

Schwertner A, Conceição Dos Santos CC, Costa GD, Deitos A, de Souza A, de Souza IC, Torres IL, da Cunha Filho JS, Caumo W.

Source

Laboratory of Pain & Neuromodulation at Hospital de Clínicas de Porto Alegre (HCPA)/Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.

Abstract

Endometriosis-associated chronic pelvic pain (EACPP) presents with an intense inflammatory reaction. Melatonin has emerged as an important analgesic, antioxidant, and antiinflammatory agent. This trial investigates the effects of melatonin compared with a placebo on EACPP, brain-derived neurotrophic factor (BDNF) level, and sleep quality. Forty females, aged 18 to 45 years, were randomized into the placebo (n = 20) or melatonin (10 mg) (n = 20) treatment groups for a period of 8 weeks. There was a significant interaction (time vs group) regarding the main outcomes of the pain scores as indexed by the visual analogue scale on daily pain, dysmenorrhea, dysuria, and dyschezia (analysis of variance, P < 0.01 for all analyses). Post hoc analysis showed that compared with placebo, the treatment reduced daily pain scores by 39.80% (95% confidence interval [CI] 12.88-43.01%) and dysmenorrhea by 38.01% (95% CI 15.96-49.15%). Melatonin improved sleep quality, reduced the risk of using an analgesic by 80%, and reduced BNDF levels independently of its effect on pain. This study provides additional evidence regarding the analgesic effects of melatonin on EACPP and melatonin’s ability to improve sleep quality. Additionally, the study revealed that melatonin modulates the secretion of BDNF and pain through distinct mechanisms.

For further information about our proactive treatment, training and coaching programmes for chronic pain and injury, or to book an appointment please call us on 07932 689081 | Women in Pain Clinic in Harley Street

+++++++

J Pain Symptom Manage. 2012 Nov 27. 

Analgesic and Sedative Effects of Melatonin in Temporomandibular Disorders: A Double-Blind, Randomized, Parallel-Group, Placebo-Controlled Study.

Vidor LP, Torres IL, de Souza IC, Fregni F, Caumo W.

Source

Postgraduate Program in Medical Sciences, Faculty of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.

Abstract

CONTEXT:

The association between myofascial temporomandibular disorder (TMD) and nonrestorative sleep supports the investigation of therapies that can modulate the sleep/wake cycle. In this context, melatonin becomes an attractive treatment option for myofascial TMD pain.

OBJECTIVES:

To investigate the effects of melatonin on pain (primary aim) and sleep (secondary aim) as compared with placebo in a double-blind, randomized, parallel-group trial.

METHODS:

Thirty-two females, aged 20-40 years, with myofascial TMD pain were randomized into placebo or melatonin (5mg) treatment groups for a period of four weeks.

RESULTS:

There was a significant interaction (time vs. group) for the main outcomes of pain scores as indexed by the visual analogue scale and pressure pain threshold (analysis of variance; P<0.05 for these analyses). Post hoc analysis showed that the treatment reduced pain scores by -44% (95% CI -57%, -26%) compared with placebo, and it also increased the pressure pain threshold by 39% (95% CI 14%, 54%). The use of analgesic doses significantly decreased with time (P<0.01). The daily analgesic doses decreased by -66% (95% CI -94%, -41%) when comparing the two groups. Additionally, melatonin improved sleep quality, but its effect on pain was independent of the effect on sleep quality.

CONCLUSION:

This study provides additional evidence supporting the analgesic effects of melatonin on pain scores and analgesic consumption in patients with mild-to-moderate chronic myofascial TMD pain. Furthermore, melatonin improves sleep quality but its effect on pain appears to be independent of changes in sleep quality.

10Jul/13

Women and Pain Clinic @ 132 Harley Street

The Women and Pain clinic is dedicated to providing contemporary treatment, training and coaching for females who suffer persisting pain.

Common examples of on-going painful problems include:

  • pelvic pain: including pain from endometriosis, bladder problems, muscular spasm & guarding of the pelvis and abdominal area
  • back pain
  • joint pain (often multiple)
  • abdominal pain (irritable bowel syndrome or similar sensitivities)
  • migraine & headache
  • jaw pain & dysfunction
  • fibromyalgia

It is not uncommon for there to be several painful areas that are seemingly unrelated. However, with the advancing understanding of the neurobiology of pain, we know that there is a common thread that ties these problems together. This is termed central sensitisation and refers to adaptations within the nervous system that both amplify pain and reduce our natural ability to dampen sensitivity. The body areas that hurt can expand and involve a range of body systems, hence why the pain can manifest in different regions and organs. The pain is an expression of this underlying sensitivity that needs to be targeted at a nervous system-immune system-endocrine system level as well as addressing the health of the body tissues. We use a contemporary and neuroscience-based programme of treatment, training and coaching to tackle the problem of pain, focusing upon the inter-related dimensions of pain: physical-cognitive-emotional.

Working closely with leading gynaecologists and gastroenterologists in Harley Street, you will have a detailed assessment that includes diagnostics as indicated, a full explanation of the nature of the pain and symptoms (pain education) and a comprehensive treatment programme designed for you. 

How do we treat these problems?

A pathological or structural basis for pain only explains part of the problem or in some cases not at all. It is the adaptations within body systems that create the pain experience to which we respond in thought and action. Whilst acute pain serves a vital survival purpose, drawing our attention to a body region that needs protecting for healing, a persisting pain becomes increasingly about the neuroimmune system and endocrine system responses. Pain certainly emerges from the body yet there is an underpinning correlate of activity within a vast network of brain cells that actually drives the experience. This network monitors the activity in the body systems and responds according to need. The response can be protective when the brain perceives the body to be in potential danger and includes pain, changes in movement and a range of other actions. In the early stages of a condition this is useful and adaptive, however if these responses continue beyond a useful time they themselves must be targeted alongside body nourishing strategies.

How can we target these systems? In an integrated manner, these systems can be re-trained with a range of sensorimotor techniques, specific exercises designed to restore a normal sense of the body and movement, strategies to deal with stress and anxiety that both affect the body systems, techniques for the progression of day to day living (work, home, sports), and general activity and exercise with confidence. Interlaced with these strategies, pain education (reduce the threat by developing your understanding of pain and the body’s ability to change), mindfulness-based stress reduction, focused attention training, resilience, coping and motivational skills, are used to optimise outcomes that are based upon improving your quality of life, sense of wellness and performance.

For further information, to book an appointment or to refer a patient please call us on 07932 689081

23Jan/13

Women and pain 2 | Endometriosis

This is the second part in a series highlighting common painful problems that I see in women (Part 1 here). Endometriosis would not usually the reason for the referral, however this problem can often be mentioned as we talk about painful problems that are seemingly unrelated. To the individual, endometriosis can significantly affect quality of life, impacting upon day to day living in many ways. There are perhaps 2 million women with the problem.

What is endometriosis? The classic viewpoint

Endometriosis is a condition when the cells of the womb lining are found outside of their normal habitat. Commonly the cells are seen in the pelvic area and abdomen (ovaries, fallopian tubes, ligaments which hold the womb in place, the area between the rectum and the womb named the Pouch of Douglas) but occasionally in other locations in the body (bowel, bladder, intestines, vagina, rectum, on operation scars, in the muscular wall of the uterus and rarely in the skin, eyes, spine, lungs and the brain).

What are the symptoms?

There are a range of symptoms and problems that vary in their severity including:

  • Painful periods
  • Persistent pain in the pelvic area (chronic pain)
  • Bowel and bladder symptoms
  • Issues conceiving
  • Fatigue
  • Depression
  • Relationships difficulties
  • Limited or avoided socialising
  • Problems at work
The symptoms can often begin in adolescence (see article here), a time of great change and challenge in any case, complicated by this painful condition.

Reconceptualising pain – beyond the tissues

Although we feel pain in our bodies, the construction of the experience occurs within the brain via a widespread network of neurons. They are not specific for pain and have a large number of different functions including memory, concentration, movement, sensation, decision-making and fear to name but a few. In brief, we experience pain as an output or as the end result of the brain scrutinising the information from the body that is compared and analysed in the light of prior experience and the knowledge base. On concluding that there is danger or a threat to the body, the brain allocates the sensation of pain to the area deemed to require attention and protection.

Pain is a motivator, a need state that requires action to be taken to promote healing and survival. Pain emerges from the self and is hugely influenced by a range of factors beyond the ‘structure’ where the unpleasant experience resides.

Undoubtedly pain is complex and modulated by many factors, in particular emotional state, attention and lifestyle – see here. It is also useful to understand the pain mechanisms that can play a role in the maintenance of symptoms, including peripheral and central sensitisation that are not in isolation of immunological and endocrine activity that can hugely influence the perception of pain. The health of the tissues depends upon normal functioning of these body systems as well as movement to nourish both locally via blood flow and the representation of the body that exists in the brain. This representation relies upon regular updates from the body via signals about movement and chemical balance.

Recent neurobiology studies have identified mechanisms that may underpin pain and the process of sensitisation in endometriosis and other chronic pain problems – click here, here & here. There are many papers that help to explain the changes in the nervous system and other systems that contribute to a persisting pain problem. Basing one’s thinking purely around a structure as a cause for on-going pain is simply not encompassing enough to tackle the issue.

Researchers last year published a paper that described an imbalance between the sympathetic nervous system and the sensory nerves (click here) in peritoneal endometriosis, suggesting that this may underpin an on-going inflammation and consequential pain. The sympathetic nervous system (SNS) is a branch of the autonomic nervous system (ANS) and is responsible for the feelings one may experience when in danger, e.g. sweaty palms, increased heart rate, a feeling of anxiousness. The SNS is a direct link between our thinking and feeling self and the physical responses and therefore the way we perceive a painful problem can influence the pain we feel via this system but also the immune system that is responsive to our thinking and stress – click here and here. There are well established links between nerve and immune functions – click here.

The meaning or salience that is given to the pain and the context of the pain are both key considerations. Of course both can and do change, therefore affecting the pain perception at any given time. The meaning one ascribes will relate to beliefs about pain and its consequences upon health and lifestyle. The greater the perceived threat, the greater the chance that the brain will protect. Pain is part of that protection alongside other adaptations such as increased muscle tension that can cause further pain and discomfort.

Neuroscience confirms what people have been saying for years, that our thinking process affects our pain. The discovery of communication between different parts of the brain has helped us to understand this and actually target this mechanism with specific strategies. Changing our thinking really does change our pain. Interestingly, it was discovered that when we catastrophise about pain (cognitive and emotional factors) it can affect the immune system’s inflammatory profile. In other words, over-worrying about the meaning of our pain can potentially make us more inflammatory–see here. It does appear that some people are not able to turn off their inflammatory responses as effectively, thereby continuing to provoke sensitisation and pain. There is a genetic basis to this over or prolonged response.

How can we tackle pain in endometriosis?

Traditionally the pain of endometriosis is managed with analgesia, hormone based medication, surgery and complimentary therapies or a combination thereof. Considering the brief overview of the pain mechanisms above, although complex do provide a range of levels at which we can intervene to change the pain experience.

The contemporary way in which pain is considered is called the biopsychosocial approach. This means that the neurobiology, psychology and social aspects of pain are addressed in an integrated manner. We have said that pain is complex and multidimensional on the basis that the areas of the brain  responsible for the pain experience have a range of additional roles. They are not specific for pain and indeed there is no pain centre. Consequently, the need is for a wider lens and this is exactly what the biopsychosocial model offers.

Reasoning that there are different mechanisms, we can design and create programmes of treatment and training for each.

For example, we know that movement and muscular activity is different when we are in pain. These altered movement patterns feed back to the brain and are a mismatch for the expected patterns thereby maintaining protective measures. There are a number of ways that we can look at how the motor system has adapted and then seek to re-train normal movement and sense of the body that is often affected. Muscles that are overactive because we lose precise control can be the cause of local sensitivity, adding to the unpleasant picture.

Re-framing one’s thinking about pain with high quality education (informational medicine) actually changes pain perception and for good reason. Biologically the areas of the brain involved in thinking communicate with other regions that are part of the network we have been talking about, therefore negative thinking and anxiety can increase vigilance to pain, attention and focus towards pain, both of which can amplify the experience. Remember that a thought and an emotion is as much brain activity as a movement and both are potent ways of further sensitisation.

At our clinics we draw all this information together, blending with the individual’s narrative and experiences to develop a personalised care package that is as much about the person as the condition suffered. Several of the ways in which we look at and tackle pain are mentioned. These sit well with a range of strategies and treatment techniques that we employ to promote wellness and living. Interestingly, there are frequently other painful conditions that co-exist with endometriosis and the science demonstrates that there are usually similar mechanisms underpinning the seemingly unrelated problems (e.g. IBS, fibromyalgia, chronic fatigue syndrome, migraine, pelvic pain, bladder dysfunction). In targeting the peripheral and central mechanisms as outlined here, we often see a change in the other symptoms as well.

For further information about our clinics and treatment please contact us here or call 07932 689081

 

 

05Nov/12

Women and pain | Part 1

 

‘As many as 50 million American women live with one or more neglected and poorly understood chronic pain conditions’ 

Generally I see more female patients than male. This observation supports the view that chronic pain is more prevalent in women than in men for some conditions – see the International Association for the Study of Pain fact sheet here. There are some ideas as to why this may be, including the role of the sex hormones and psychosocial factors such as emotion, coping strategies and roles in life. Additionally, experimental studies have shown that women have lower pain thresholds (this is a physiological reading) and tolerance to a range of pain stimuli when compared to men although this does not clarify that women actually feel more pain – see here. Pain is a subjective experience of course, and modulated by many factors.

A campaign for women’s pain | Chronic pain in women (2010) report

It is not uncommon for a female patient to tell me about her back pain and continue the narrative towards other body areas that hurt and cause problems. This may include pelvic pain, migraine, headache, irritable bowel syndrome, chronic knee pain, widespread sensitivity and gynaecological problems (including dysmenorrhoea, endometriosis and difficulty conceiving). These seemingly varied conditions are typically looked after by a range of medical and surgical disciplines: gynaecology, neurology, rheumatology, gastroenterology and orthopaedics. More recent science and thinking has started to join the dots on these problems, offering new insight into the underpinning mechanisms and more importantly approaches that can affect all the conditions in a positive way. This is certainly my thinking on this hugely significant matter.

Reconceptualising pain

Undoubtedly pain is complex. This is particularly the case when pain persists, disrupting and impacting upon life. Reconceptualising pain according to modern neuroscience is making a real difference to how we think and treat pain – see this video. Briefly, thinking of pain as an output from the brain as a result of a complex interaction of circumstance, biology, thought, emotion and memory begins to give an insight into the workings of the brain and body. Pain is individual, it is in the ‘now’ but so coloured by the past and what it may mean to the individual. The context or situation in which the pain arises is so very important. We talk about pain from the brain but of course we really feel it in our physical bodies, but the location is where the brain is projecting the sensation – see this video.

Neuroscience has shown us that the danger signals from the body tissues are significantly modulated by the brain before the end output is experienced. Factors that influence the messages include attention, expectation and the circustance in which the individual finds herself. We have powerful mechanisms that can both facilitate and inhibit the flow of these signals and these reside within the brain and brain stem. For this reason we must consider the person’s situation, their expectations, hopes, goals, past experiences and current difficulties, and how these can affect their current pain.

Stress & emotion

Any hugely emotive issue within someone’s life can impact enormously upon pain and sensitivity. This can be the stress of a situation including caring for a relative, losing someone close, work related issues and divorce. The problem of conception certainly features in a number of cases that I see, causing stress and turmoil for both partners but clearly in different ways. Fertility receives a great deal of attention in the media and there are a many clinics offering treatment and therapies, in effect raising awareness and attention levels towards the problem. The pain caused by difficulties having children can manifest physically through the stress that is created by the situation. Thoughts, feeling and emotions are nerve impulses in the brain like any other and will trigger physical responses including tension. Stress physiology affects all body systems, for example the gastrointestinal system (e.g./ irritable bowel), nervous system (e.g. headaches, back pain) and the immune system (e.g. repeated infections).

Lifestyle

Lifestyle factors play a significant role in persisting pain. Modern technology and habits that we form easily may not be helpful when we have a sensitive nervous system. For example, sedentary work, the light from computer screens, pressures at work, limited exercise, poor diet, binge drinking and smoking to name but a few. All are toxic in some way as can be our own thinking about ourselves. When we have a thought, and we have thousands each day, and we pay attention, becoming absorbed in the process, the brain reacts as if we are actually in that situation. Consequently we have physical and emotional responses that can be repeated over and over when we dwell on the same thinking. This is rumination and is likely due to ‘hyper-connectivity’ between certain brain areas – see here. We can challenge this in several ways including by changing our thinking and using mindfulness, both of which will alter brain activity and dampen these responses. It does take practice but the benefits are attainable for everyone.

In summary, the underlying factors that must be addressed are individual and both physical and psychological. Pain is complex and personal, potentially affecting many different areas of life. How we live our lives, what we think and how we feel are all highly relevant in the problem of pain as borne out of sensible thinking and the neuroscience of pain. Understanding the pain, learning strategies to reduce the impact, receiving treatment that targets the underlying mechanisms, making healthy changes to lifestyle and developing good habits alongside the contemporary brain based therapies can make a huge difference and provide a route forwards.

For information on our ‘join the dots’ treatment programmes for chronic pain, contact us here or call 07932 689081