Tag Archives: back pain

28Oct/14
Low back pain specialist London

Top 5 back pain myths

Back pain myths

Back pain myths

Welcome to my top 5 back pain myths. What are these you may ask?

Around pain and in particular back pain, there are many phrases and explanations used to try to educate the patient. These have been handed down through the generations and can appear to be logical. Fortunately, the science has moved on and we know better.

Here are 5 common beliefs that have been challenged:

**I have not included the myths of core stability because this has been well documented previously. Pulling in your abs does not solve the complexity of back pain, especially chronic back pain.

1. Bending is dangerous

2. Discs slip

3. Nerves are trapped

4. Pain comes from facet joints, discs etc

5. Low back pain is in isolation to everything else in your life.

Comments below:-

———————————-

1. Bending is normal. Sure it can hurt when the back is being protected, and when we have back pain the muscles are guarding and this can reduce the amount of movement. In the acute phase, most positions and movements hurt, but this is protection and it is meant to be unpleasant in order to motivate action. Moving little and often, changing position and breathing all help to keep blood and oxygen flowing.

2. Discs are not actually discs and they do not go anywhere. Yes they can be injured like any other tissue. They can bulge and affect the local environment, and they can herniate, triggering a healing response — both can hurt because protection is initiated. The fact that there are so many nerve endings around the area mean that sensitivity can arise in a vigorous manner. Again, this is a normal if highly unpleasant experience. Remember that a 1/3 of the population have such changes in their spine but without any pain. The body as a whole must rate the situation as threatening for it to hurt.

3. Nerves do not get trapped. Local swelling and inflammation can sensitise the nerves meaning that they send danger signals. There is not too much room either, so if there is swelling or a bulge, this can affect blood flow to the nerve itself and cause sensitivity to movement and local chemical changes. Again, this can happen without pain as well, so it is down to the individual’s body systems and how they respond. Understanding, gradually moving and breathing can all help ease you through this phase.

4. Pain is whole person and involves many body systems that are protecting you. There is no pain system, pain centre or pain signalling. Pain is part of a protective response when the body deems itself to be under threat. We feel pain in the body but the underlying mechanisms are upstream of the body part that hurts. To successfully overcome pain we must go upstream as well as addressing the health of the body tissues.

5. Low back pain is embedded within your lifestyle. It is not separate to how you live — e.g. lack of exercise, postures, work, stress, emotional state, previous experiences, understanding of back pain, gender, genetics, just to name a few. This maybe more complex, but this provides many avenues for overcoming pain.

Suffering with persisting back pain? Have other seemingly different problems such as irritable bowel syndrome (IBS), headaches, migraines, other joint pains, muscular pains, pelvic pain, jaw pain, recurring bladder infections? Contact me today to learn how you can move forward and overcome your pain: 07518 445493

30Jul/14
20140730-225623-82583871.jpg

When is a door not a door? When it’s a jar – a perspective on back pain

This old joke springs to mind when I think about back pain. We can think simply about a doorBack pain and create an image of how it appears but in fact a door consists of at least some of the following: a piece of wood (or another material), a handle, some hinges, a lock and a frame. All of the physical components need to be made from raw materials and require the skills of an individual or a machine to make door. These skills must be learned or a machine need be designed for the specifics of making a part. In this sense, a door is not a door until all these come together. In fact, this can only make a door when the person looking at the door or using the door knows that it is a door and has the function of a door. Otherwise it is just a collection of abstract items. We can say the same for many things that we take for granted when we know what they are and their purpose.

Back pain is such a common problem that it seems as though we should experience this pain at some point in our lives. Certainly the way we live nowadays has a huge impact on the likelihood of suffering back pain. There are many simple habits that we can form to deal with the problem but all too often, we just don’t. Why? Because it is not at the top of our priority list. That said, when is back pain not back pain? When it’s understood. So this must be the start point. Understanding pain and back pain can make an enormous difference to the suffering that spans from mild discomfort to disabling agony.

Back pain is pain in the back — this may sound obvious and it is, yet there is much more to it, somewhat analogous to the door. What is the back? It is made of many components that together form the back. To know it is the back, we must have a construct of the back. We must know what is the back and what is ‘my’ back; the ‘mine-ness’. Similarly with pain, we must have a construct of pain that is learned. These are both the ‘what’, yet we need a ‘how’ to experience them. In the case of back pain, the way in which we are experiencing the back is with pain. Pain is how we feel the back at that moment.

Just as the back is constructed by physical ‘parts’ with a conscious aspect that is non-physical (the two create the whole), the ‘parts’ involve all the systems of the body as much as the self. Back pain is the end result of an enormous amount of multi-system activity, emerging in a body location that is felt. This is the ‘is-ness’ of the experience produced by the whole person that is the sum of every cell in the body. Pain as an emergent property of the whole person is a biological response to a perceived threat. This includes when the body is injured, pathologised and in anticipation that something could be dangerous. Consider a moment when you anticipate that it will hurt. What do you think? What do you do?

Practically, what does this all mean? It means that we cannot use a structural or component basis for treating back pain. The relationship between the body tissue state and the pain state is poor, perhaps even non-existent. Pain is emergent from a whole person who is embedded within a social setting, a culture and a context that all create a meaning for that individual who has a mind that needs a brain, yet the mind is unlikely to reside simply in that brain. The mind resides in that whole person much as the pain that emerges. Hence we must think about the whole if we are to be successful in treating pain.

If you are suffering with chronic pain, come and see us and discover what you can do to understand and change your pain

t. 07932 689081

Specialist Pain Physio Clinics, London

13Jan/14
Lumbar spine MRI scan

MRI for back pain – does the report content affect the management?

Lumbar spine MRI scan

Lumbar spine MRI scan

Lumbar MR Imaging and Reporting Epidemiology: Do Epidemiologic Data in Reports Affect Clinical Management? This is the question posed by the authors of this recent study, seeking to determine whether adding details about changes seen on an MRI scan in those without symptoms had any impact. The conclusion was: ‘Patients were less likely to receive narcotics prescriptions from primary care providers when epidemiologic information was included in their lumbar spine MR imaging reports’. 

Why may this be?

We can start by saying that jumping down the route of an MRI scan for back pain is not a given, but rather it requires wise thought. The American College of Physicians published a paper in 2011 stating: Diagnostic imaging is indicated for patients with low back pain only if they have severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition. In other patients, evidence indicates that routine imaging is not associated with clinically meaningful benefits but can lead to harms. Addressing inefficiencies in diagnostic testing could minimize potential harms to patients and have a large effect on use of resources by reducing both direct and downstream costs. In this area, more testing does not equate to better care. Implementing a selective approach to low back imaging, as suggested by the American College of Physicians and American Pain Society guideline on low back pain, would provide better care to patients, improve outcomes, and reduce costs’. 

One immediate issue is that an MRI scan can show structural changes that could be assumed to be the cause of the back pain. On making that assumption, both the clinician and the patient can be pulled down a route of thinking to somehow alter the structure, or remove the tissue will henceforth change the pain. Of course there are many cases of intervention, including surgery, that lead to pain relief. Is it simply because the structure has been removed? The same is true of joint replacement when relief is frequently obtained. However, there are many cases when this does not happen, with pain and other symptoms persisting. We know that this is because pain is not an accurate indicator of tissue damage — see Lorimer Moseley talking about this here. Phantom limb pain is the ultimate example of pain without body.

A scan does not show pain

A scan does not show pain

Including information about common scan findings in people without back pain appears to be a potent message that affects the patient journey. In essence that is what we are seeking to change, the trajectory of the condition and the patient experience, for the better. Cultivating the conditions for the body’s physiology to adapt and develop in such a way as to emerge with healthy function.

What are we doing with this message? Normalising. The key point is the fact that we can have certain changes in the body, in the spine, that do not cause problems. Clearly, the person sitting in the clinic does have a pain problem that needs to be solved, but not necessarily via an MRI scan. If a scan has been taken and shows no serious pathology, this is great news. Having said that, many people describe uncertainty and anxiousness at the lack of a structural explanation for their pain. This is entirely understandable as they have not had their pain explained to them at that time, hence there is no meaning. No meaning creates further worry and this most certainly affects pain.

So, the first point of action once all the information has been scrutinised, is to create a perspective based upon what we know about the body and pain. Describing the pain mechanisms, the underpinning biology that involves many body systems, and the influences upon pain such as fatigue, previous experience, self-analysis of the situation, stress, anxiety, movement and other factors that are all biological. Everything is biological — this is a key data point. A movement, a thought, an emotion; they are all underpinned by brain activity that often creates and colours sensations in the body. We can use the different yet inter-related dimensions of pain (physical – cognitive – emotional) to construct bespoke programmes to tackle both the sources of pain and the influencing factors.

The second point of action is to plan an individual programme that encompasses specific training to re-programme the way in which the body has been working. This sits alongside techniques to develop confidence and awareness of the body, both vital for normal functioning. The patient’s role in this training cannot be over-emphasised, hence why motivational factors, and barriers, must be considered and addressed.

The third point is the monitoring and progression of the training and treatment, sculpting the change in pain and function that is entirely possible once the right conditions have been set for both understanding and action.

The questions regarding MRI and other investigations will continue to be asked and rightly so. We must continually challenge our own thinking about the best route forward for each individual patient. Understandably, patients will continue to expect and hope for the fullest assessment including MRI, the gold standard, and from this we must use the information wisely and objectively, explaining the findings and creating a perspective that makes sense and propels the best possible treatment.

If you are suffering with back pain or persisting back pain, perhaps with leg pain — sciatica — come and see us to find out how to move forward 07932 689081

 

19Dec/13
A scan does not show pain

Low back pain & neck pain | a very common problem

Back pain and neck pain are very common

Most of us will experience low back pain and neck pain at some point in our lives. In fact, it is unusual not to have some aches and pains around the spine. With back and neck pain being so common in the modern world, you would assume that treatment is very effective. Sadly not.

There are different scenarios with back and neck pain, often either a nasty acute type pain or a lower level nagging pain that grinds on and on. A further common situation that I see is a persisting back pain that is part of an overall picture of widespread pain. Accompanying the pain is altered movement and muscle tension that adds to the unpleasantness. This is mainly due to the effects of overactive muscles that are being told to protect the area — acids released, reduced oxygen levels; both of which can excite local nerve endings (nociceptors) that send danger signals to the brain.

When a particular movement or action triggers the pain, we assume that this is dangerous and the cause of the pain. This is not quite the case. There is a lead up to the moment of pain when the nervous system is becoming sensitised, often slowly, over a period of time. This is called priming. Then, at a given moment, when the system is close to the threshold of becoming excited, a normally innocuous movement just tips the physiology over the line with a consequential range of protective responses that include pain, spasm and altered movement.

Sometimes there are changes in the tissues or ‘damage’. Again there is often an assumption that when the pain begins, this is the point of injury. This can be the case but equally the changes in the tissues may have been evolving over a period of time. The reality is that you will never really know, even with a scan. The scan may show a disc bulge or herniation but does this describe your pain? Or tell you when the problem began? No.

Unpleasant as the body responses are, they are normal, necessary and part of the way in which the body defends itself, largely organised by the brain. The pain draws our attention to the area that the brain wants us to protect. When the pain is severe of course our attentional bias will be towards the region most of the time — hypervigilance. How we think about the pain will determine the impact, level of suffering and influences the trajectory of the problem as our thoughts and beliefs about back pain will impact upon what action is taken. In the very acute stages, there may not be a great choice when the pain and spasm is strong, thereby limiting movement vigorously. It is good to know that this phase, as horrible as it can be, does not last too long in most cases if the right action is taken based on good knowledge.

It is always advisable to seek help and guidance: know that nature of the problem, how long it can go on, what is normal and what you need to do to ensure a good recovery. Generally, understanding that pain is not an accurate indicator of tissue damage — see video here — , controlling the pain with various measures in the early stages and trying to move as best you can starts off on the right footing. It can be scary when the pain is severe, so calming strategies really help to reduce the impact — anxiety is based on thinking catastrophically about the problem, thereby triggering more body defences in pain and tension. Mindful breathing and other relaxation skills should be practiced regularly.

In summary, back pain and neck pain are very common. The primary message here is that the acute stages are unpleasant and often distressing but they do not last long in most cases if the problem is managed well with understanding to reduce concerns and to minimise the threat value, good pain control, simple movement strategies and a little treatment to ease tension and change the sensory processing in the body so that it feels more comfortable.

If you have low back pain or neck pain, especially persisting pain or widespread pain, come and see us to find out how you can change your pain and get moving again: call 07932 689081

 

18Oct/13
Pain beliefs

The virus that is pain beliefs | A brief view on the ‘meme-osity’ of pain

Pain beliefsWe develop beliefs about pain very early in life through experience of injury, by the things we are told by significant others and via observation. These become ingrained and emerge later on when we experience a painful situation. This is part of how we decide what we should do when we are injured. At some point, we have learned that if we knock our elbow on the door frame, we should check it out by having a look, rub the area to make it feel better and move it to ensure that it still works.

Our culture plays a significant role in the development of our beliefs. This includes the meaning of pain and what is signifies and how you should respond; e.g./ ‘the stiff upper lip’. These messages like many others are passed down through the generations. In a sense, the beliefs spread much like a virus, or others such as Richard Dawkins describe the ‘meme’, which is a construct that is passed from person to person, and much like a gene can self-replicate and mutate.

The meme that is, “Don’t bend your back if it is painful” has become a widespread belief that I often hear in the clinic. If you have acute low back pain with accompanying spasm, the chances are it is going to be difficult to move, so bending may not be an option. We do condition very quickly as humans and construct a story from the facts, albeit the story may not be true, but it makes sense at the time. For example, on sending an email, the response does not come back immediately and therefore the receiver is rude, uncaring etc. That is the story whereas the fact is that you have merely sent an email. There is a significant difference, the former creating discomfort whereas the latter is easy to accept.

On bending if we experience acute pain we can quickly assume that bending is dangerous. This maybe confirmed by someone you go to see for some help and very soon this is a strong belief that guides our choices of how to move.

This message has spread across many cultures and could be termed a meme or even a virus. How can we change this? Through education and creating positive experiences for people to then inherently know that they are safe to move in particular ways. All of this takes time and perseverence as the message predominates. However, as we know that memes can mutate as can viruses, we should seek to culitvate accurate understanding of pain with the continuance of resaerch and translation into clincal practice. The idea of the meme then, can be a useful way of thinking about the reconceptualisation of pain for better treatment and care.

 

23Sep/13
Murray to have back surgery

A few thoughts on Andy Murray and his ‘minor back surgery’.

MurrayThe news that Andy Murray is to have a minor back operation hit the back pages last week. It is understood that he will undergo a microdiscectomy, a technique that minimises the tissue trauma in order to access the injured disc and the nerve that is being impacted upon by this structure.

Microdiscectomy – what is it?

For the decision to be made, it is likely that a disc has been seen on a scan to be affecting the health and physiology of a nerve root (where the nerve emerges between the vertebrae). In some people this will occur without causing pain but if pain and sensitivity does arise, then it is due to a gradual change in disc health over many months. Of course, it is very possible that repeated movements and in particular rotations with force will impact under certain circumstances. In fact, with any injury that is gradual, one has to consider the combination of circumstance (‘environment’) and genetics–termed epigenetics.

It seems that Murray has been experiencing back pain for several years. Many people who I see are in a similar situation having had pain for some time, often punctuated with more acute episodes. These acute bursts of pain are highly unpleasant and can make moving, working, sleeping and functioning very difficult for a few days and sometimes longer. When it comes to sports people, we can think about the injury or pain as threatening their career, however this is the same for others who plan to return to work following a back operation. Clearly the end point is different but the preparation and early rehabilitation need not be.

Preparing for surgery – see here

I make a point of encouraging a proactive approach to pre-op preparation both physically and mentally. Where possible, you want to be fit and healthy with ‘prehabilitation’, which is a structured programme of exercises to maximise tissue function. Picking up on the rehabilitation after surgery can be far easier if this is done in an orgainsed manner.

Equally, dealing with the mindset and fears that can encroach on one’s ability to train is as important. Understanding the pain, procedure, goals of the surgery and the recovery process will go a long way to reduce the stress and anxiety of an operation – or rather, the thought of an operation prior to the procedure. Using techniques such as mindfulness and relaxed breathing can be potently effective in reducing stress that occurs as a result of negative thinking. Certainly catastrophising about pain can lead to greater inflammation and thereby affect the healing process. We are seeking to optimise healing and therefore dealing with thinking that is overly worrisome can impact upon the immune system in the right way.

Early recovery

This will vary from person to person but in the initail stages it is all about allowing the tissues to go about their healing process, orchestrated by the neuroimmune system and certainly affected by other body systems. Beyond the gradual increases in movement, and tissues certainly need this for good healing, considering factors such as adequate rest, relaxation, good nutrition and a positive outlook are all key ingredients in creating the best possible conditions for moving forward. A range of strategies and techniques can be used including simple mobilisations but alongside motor imagery,  mindfulness, movement of other body areas, the use of music and motivational techniques and cognitive tools to fortify resilience and coping to name but a few.

Rehabilitation is not just about exercising. It is about understanding, learning, motivating, creating the right context for movement with confidence and many more factors that can lead to optimised outcomes.

* Naturally, you should take the advice of your health professional when it comes to your treatment and rehabilitation.

If you are about to have an operation or are recovering, contact us now to learn about our comprehensive treatment and training programmes: 07932 689081

23May/13

The Chelsea Flower Show, gardening and back pain

With the Chelsea Flower Show in full bloom the world of gardening is full of excitement and wonder as the designers exhibit their creations. Gardeners can relate to this sense of cultivation and creativity as they work hard to illustrate their vision through their plants, flowers, grasses and other garden features.

Gardening is often physically demanding. Carrying, lifting, holding sustained positions and repeated motions form the bulk of the activities and of course this challenges the body. Much like the writer or film viewer, becoming lost in the moment is wonderful yet the trade off can be a painful back.

Back pain and low back pain are very common. Most of us will experience such pain at some point in our lives and in the vast majority of cases the pain eases after a few weeks and we return to our normal activities and movements. In some this does not happen and they continue to experience pain that impacts upon quality of life. These are usually the individual whom I see and they all have a story to tell about their pain. We are wise to listen as this narrative is key – see Oliver Sacks talking about narrative here.

Many will describe how gardening upsets their back pain yet they love to be outside crafting their environment. Much like the sportsman who wishes to return to the field of play, the gardener wishes to be on the lawn or busy in the shrubs. Again, like the sportsman, this needs preparation and a degree of fitness that must be developed with exercise and functional tasks (movement that is the same as you would use in the activity).

If you have back pain, it can be fine to spend time working in the garden in most cases. It is how you go about it that is important. How many people warm-up and cool-down when they garden? Few I would imagine. But why not? This prepares the body for the demands. Planning and pacing activities is also very important. Taking breaks and changing positions consistently and regularly helps to nourish the tissues and develop tolerance for physical activity. There are a range of other techniques that we can use so that gardeners can garden safely, confidently and productively.

**Please note that if you are unsure you should always seek the advice of your GP or health professional.

For further information about gardening fitness and treatment of low back pain so that you can return to the garden (or return to sports and other activities), call us now 07932 689081

29Aug/12

Back pain in football and sport

Back pain is a common experience across society. Millions are spent each year on treatment yet we do not seem to be making any significant progress in tackling this vast problem. Undoubtedly footballers are also subject to spinal aches and pains, either from a direct injury or insidiously. Most people whom I see fall into the latter category, when the pain comes on gradually, the individual seeking help when the pain reaches a troubling level.

Frequently back pain is blamed upon a disc injury, a facet joint problem, arthritis or a ligament sprain. In the acute stages the muscles often tighten or spasm making it very difficult to move. The pain can be extremely intense and worrying, but in fact this is a normal body response to the problem, even if there is no significant damage to the tissues. It can sometimes take a few days for this to subside, with any movement triggering pain–when we move our arms and legs, because the trunk muscles are also being used it means that they can tighten and be painful.

Acute pain – seek help if you are unsure

The general advice with acute back pain is to remain active as possible. Usually your GP will suggest pain relief or anti-inflammatory medication to help ease the symptoms. Gentle and tolerable exercise maintains the tissue mobility meaning that movement becomes easier and easier. Typically the back will stiffen when we do not move, being painful and tight when we have to change position. Sometimes our posture is altered and we tilt forward or to one side, the muscles pulling the spine into a position of protection. Arguably pushing or pulling (manipulation) this into a straightened position is to force the body into a position and work against the natural protective mechanisms. It does seem that spinal manipulation can ease pain in the short term but does not necessarily offer a better long-term outcome. Consistent movement and positional change is a sensible option.

A study completed some years ago demonstrated that the best predictor of back pain was the ability to hold the back isometrically. With the individual lying face down on a table, his hips at the edge with the trunk being held straight out over the edge, they tested the endurance factor, i.e./ how long they could hold the position. Those with the ability to maintain the position were less likely to experience back pain over the next year.

Core stability encompasses a range of exercises that supposedly create a strong ‘middle’, thereby reducing the risk of back pain. This is based on research that was undertaken in Australia some years ago. Subsequent studies have found that to truly optimise the trunk muscles they need to be working as part of an overall movement strategy controlled by the brain. This requires subtle yet focused training with a strong cognitive element to ensure that the deeper muscles are working at the right level (very low) and with the right timing. This does not mean pulling the low abdomen in as tightly as possible. In fact, many whom I see who have practiced this end up with greater tension and pain as a result.

We simply cannot dissociate lifestyle factors from back pain. Our habits at home, work and during physical activity will have an effect upon the spinal tissues. At this point we have to consider the way in which we feel as stress plays a huge role in pain and how we use our body. The physiology of stress affects every system in the body including the musculoskeletal system where our movements and posturing are manifestations of our thinking. For example, many will tense their shoulders or clench their jaws on becoming stressed. Our thought processes therefore, have an enormous role to play in how we hold ourselves and move. In essence, movement is an expression of what we do and think about. When a pain has persisted for some time, dealing with stressors and emotions must be part of a comprehensive treatment programme. In the acute stage of back pain when fear and anxiety play a role in the protection, having a reassuring explanation is key to starting the process of recovery.

Many people with back pain demonstrate a fear of movement and avoid certain activities. The fear usually develops during the acute episode and is reinforced by further bouts of pain. This is one of the clearest demonstrations of how thinking affects our movement. Interestingly, the amygdala in the brain that deals with fear is connected with the motor centres thereby exerting an effect upon the planning and execution of movement. One of the primary roles of the healthcare professional is to thoroughly assess the patient and fully explain the symptoms and provide a meaning so as to reduce the fear factor and encourage positive engagement in tackling the problem proactively with physical and cognitive measures.

Spinal health in my view cannot be separated from our general health and lifestyle. Considering our physical activity levels, posturing, state of mind, life circumstances, past experiences, our beliefs about pain and injury, culture and the implications of injury are just some of the factors we must think about. No injury or pain happens in isolation. There is always a background to the initiation of pain whether it be acute or gradually building over a period of time. Our job is to look at the individual and their circumstances around the problem in order to find a route forward to recovery and health.

Many sports people will complain of back pain as it is such a common problem. With the right knowledge and strategies over a realistic timeline, the pain can change and we can adapt positively to lead fulfilling and active lives.

11Feb/12

Manual therapy, pain and the immune system

Pain relief

As a physiotherapist I frequently use my hands to treat the joints and tissues. It comes with the territory, everyone expects hands-on therapy and it does helps to reduce tension and pain. Most likely, the pain relief from joint mobilisation is due to descending mechanisms that include those that are powered by serotonin and noradrenaline (see here). This is very useful to know as it tells us about the effects of passively moving joints and importantly permits wise selection of techniques to target the pain mechanisms. Building on the knowledge base, two very recent studies have identified some extremely interesting results.

Firstly, Martins et al. (2011) found that ankle joint mobilisation reduced pain in a neuropathic pain model in rats along with seeing the regeneration of nerve tissue and inhibition of glial cell activation (a blog will be coming soon that discusses the immune system in pain states) in the dorsal horn of the spinal cord. Secondly, Crane et al. (2012) looked at how massage helps reduce the pain of exercise-induced muscle damage in young males. Taking muscle biopsies they found that massaged subjects demonstrated attenuation of proinflammatory cytokines, key players in sensitisation. It was also noted that massage had no effect upon metabolites such as lactate – see below.

More research into the mechanisms that underpin the effects of hands-on therapy is needed despite the advancements in our understanding. The ability to focus treatment upon this understanding can only develop our effectiveness in treating pain. I am very optimistic about the movement forwards in pain and basic science, and how this can be applied  in our thinking with individual patients. The language is changing with the words ‘treatment’ being used rather than ‘management’, the latter of which can imply that one has reached their limit of improvement. This is exciting and more importantly, realistic when one considers therapies such as the graded motor imagery. We do not have treatments that work for all pains but we do have brains and body systems that are flexible, dynamic and can change if given the opportunity, the right stimulation within the right context on the background of good understanding. It is our duty to keep this rolling onwards and thinking hard about how to best use the findings such as those highlighted in this blog.

Pain. 2011 Nov;152(11):2653-61. Epub 2011 Sep 8.

Ankle joint mobilization reduces axonotmesis-induced neuropathic pain and glial activation in the spinal cord and enhances nerve regeneration in rats.

Martins DF, Mazzardo-Martins L, Gadotti VM, Nascimento FP, Lima DA, Speckhann B, Favretto GA, Bobinski F, Cargnin-Ferreira E, Bressan E, Dutra RC, Calixto JB, Santos AR.

Source

Laboratório de Neurobiologia da Dor e Inflamação, Departamento de Ciências Fisiológicas, Centro de Ciências Biológicas, Universidade Federal de Santa Catarina, Campus Universitário, Trindade, Florianópolis, SC, Brazil.

Abstract

An important issue in physical rehabilitation is how to protect from or to reduce the effects of peripheral nerve injury. In the present study, we examined whether ankle joint mobilization (AJM) would reduce neuropathic pain and enhance motor functional recovery after nerve injury. In the axonotmesis model, AJM during 15 sessions every other day was conducted in rats. Mechanical and thermal hyperalgesia and motor performance deficit were measured for 5 weeks. After 5 weeks, we performed morphological analysis and quantified the immunoreactivity for CD11b/c and glial fibrillary acidic protein (GFAP), markers of glial activation, in the lumbar spinal cord. Mechanical and thermal hyperalgesia and motor performance deficit were found in the Crush+Anesthesia (Anes) group (P<0.001), which was significantly decreased after AJM (P<0.001). In the morphological analysis, the Crush+Anes group presented reduced myelin sheath thickness (P<0.05), but the AJM group presented enhanced myelin sheath thickness (P<0.05). Peripheral nerve injury increased the immunoreactivity for CD11b/c and GFAP in the spinal cord (P<0.05), and AJM markedly reduced CD11b/c and GFAP immunoreactivity (P<0.01). These results show that AJM in rats produces an antihyperalgesic effect and peripheral nerve regeneration through the inhibition of glial activation in the dorsal horn of the spinal cord. These findings suggest new approaches for physical rehabilitation to protect from or reduce the effects of nerve injury.

_____

Sci Transl Med. 2012 Feb 1;4(119):119ra13.

Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage.

Crane JD, Ogborn DI, Cupido C, Melov S, Hubbard A, Bourgeois JM, Tarnopolsky MA.

Source

Department of Kinesiology, McMaster University, Hamilton, Ontario L8S 4L8, Canada.

Abstract

Massage therapy is commonly used during physical rehabilitation of skeletal muscle to ameliorate pain and promote recovery from injury. Although there is evidence that massage may relieve pain in injured muscle, how massage affects cellular function remains unknown. To assess the effects of massage, we administered either massage therapy or no treatment to separate quadriceps of 11 young male participants after exercise-induced muscle damage. Muscle biopsies were acquired from the quadriceps (vastus lateralis) at baseline, immediately after 10 min of massage treatment, and after a 2.5-hour period of recovery. We found that massage activated the mechanotransduction signaling pathways focal adhesion kinase (FAK) and extracellular signal-regulated kinase 1/2 (ERK1/2), potentiated mitochondrial biogenesis signaling [nuclear peroxisome proliferator-activated receptor γ coactivator 1α (PGC-1α)], and mitigated the rise in nuclear factor κB (NFκB) (p65) nuclear accumulation caused by exercise-induced muscle trauma. Moreover, despite having no effect on muscle metabolites (glycogen, lactate), massage attenuated the production of the inflammatory cytokines tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) and reduced heat shock protein 27 (HSP27) phosphorylation, thereby mitigating cellular stress resulting from myofiber injury. In summary, when administered to skeletal muscle that has been acutely damaged through exercise, massage therapy appears to be clinically beneficial by reducing inflammation and promoting mitochondrial biogenesis.

21Jan/12

Central sensitisation is more common than you may think

Clifford Woolf recently said this about central sensitisation:

Nociceptor inputs can trigger a prolonged but reversible increase in the excitability and synaptic efficacy of neurons in central nociceptive pathways, the phenomenon of central sensitization. Central sensitization manifests as pain hypersensitivity, particularly dynamic tactile allodynia, secondary punctate or pressure hyperalgesia, aftersensations, and enhanced temporal summation. It can be readily and rapidly elicited in human volunteers by diverse experimental noxious conditioning stimuli to skin, muscles or viscera, and in addition to producing pain hypersensitivity, results in secondary changes in brain activity that can be detected by electrophysiological or imaging techniques. Studies in clinical cohorts reveal changes in pain sensitivity that have been interpreted as revealing an important contribution of central sensitization to the pain phenotype in patients with fibromyalgia, osteoarthritis, musculoskeletal disorders with generalized pain hypersensitivity, headache, temporomandibular joint disorders, dental pain, neuropathic pain, visceral pain hypersensitivity disorders and post-surgical pain. The comorbidity of those pain hypersensitivity syndromes that present in the absence of inflammation or a neural lesion, their similar pattern of clinical presentation and response to centrally acting analgesics, may reflect a commonality of central sensitization to their pathophysiology. An important question that still needs to be determined is whether there are individuals with a higher inherited propensity for developing central sensitization than others, and if so, whether this conveys an increased risk in both developing conditions with pain hypersensitivity, and their chronification. Diagnostic criteria to establish the presence of central sensitization in patients will greatly assist the phenotyping of patients for choosing treatments that produce analgesia by normalizing hyperexcitable central neural activity. We have certainly come a long way since the first discovery of activity-dependent synaptic plasticity in the spinal cord and the revelation that it occurs and produces pain hypersensitivity in patients. Nevertheless, discovering the genetic and environmental contributors to and objective biomarkers of central sensitization will be highly beneficial, as will additional treatment options to prevent or reduce this prevalent and promiscuous form of pain plasticity.

And Latremolier

Central sensitization represents an enhancement in the function of neurons and circuits in nociceptive pathways caused by increases in membrane excitability and synaptic efficacy as well as to reduced inhibition and is a manifestation of the remarkable plasticity of the somatosensory nervous system in response to activity, inflammation, and neural injury. The net effect of central sensitization is to recruit previously subthreshold synaptic inputs to nociceptive neurons, generating an increased or augmented action potential output: a state of facilitation, potentiation, augmentation, or amplification. Central sensitization is responsible for many of the temporal, spatial, and threshold changes in pain sensibility in acute and chronic clinical pain settings and exemplifies the fundamental contribution of the central nervous system to the generation of pain hypersensitivity. Because central sensitization results from changes in the properties of neurons in the central nervous system, the pain is no longer coupled, as acute nociceptive pain is, to the presence, intensity, or duration of noxious peripheral stimuli. Instead, central sensitization produces pain hypersensitivity by changing the sensory response elicited by normal inputs, including those that usually evoke innocuous sensations. PERSPECTIVE: In this article, we review the major triggers that initiate and maintain central sensitization in healthy individuals in response to nociceptor input and in patients with inflammatory and neuropathic pain, emphasizing the fundamental contribution and multiple mechanisms of synaptic plasticity caused by changes in the density, nature, and properties of ionotropic and metabotropic glutamate receptors.

In essence we are talking about changes within the central nervous system that underpin the widespread, unpredictable and varied nature of persisting pain.

When I am listening to a patient, observing their movements and performing a ‘multi-system’ examination, I am in part looking for the pain mechanisms at play, including central sensitisation. Several of my questions are: ‘what is going on here to create this experience for the person in front of me?’, ‘why are the nervous and other systems responding in such a way?’ and ‘what is influencing the behaviour of those systems?’. I really need to know what it is that is prolonging this protection and is it really worthwhile for the individual.

Suspecting that there is a component of central sensitisation at play in many cases of chronic pain that I see, it is pleasing to see a group looking at this closely and finding evidence to support this thinking:

J Bone Joint Surg Br. 2011 Apr;93(4):498-502.

Evidence that central sensitisation is present in patients with shoulder impingement syndrome and influences the outcome after surgery.

Gwilym SE, Oag HC, Tracey I, Carr AJ.

Source

Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7LD, UK. [email protected]

Abstract

Impingement syndrome in the shoulder has generally been considered to be a clinical condition of mechanical origin. However, anomalies exist between the pathology in the subacromial space and the degree of pain experienced. These may be explained by variations in the processing of nociceptive inputs between different patients. We investigated the evidence for augmented pain transmission (central sensitisation) in patients with impingement, and the relationship between pre-operative central sensitisation and the outcomes following arthroscopic subacromial decompression. We recruited 17 patients with unilateral impingement of the shoulder and 17 age- and gender-matched controls, all of whom underwent quantitative sensory testing to detect thresholds for mechanical stimuli, distinctions between sharp and blunt punctate stimuli, and heat pain. Additionally Oxford shoulder scores to assess pain and function, and PainDETECT questionnaires to identify ‘neuropathic’ and referred symptoms were completed. Patients completed these questionnaires pre-operatively and three months post-operatively. A significant proportion of patients awaiting subacromial decompression had referred pain radiating down the arm and had significant hyperalgesia to punctate stimulus of the skin compared with controls (unpaired t-test, p < 0.0001). These are felt to represent peripheral manifestations of augmented central pain processing (central sensitisation). The presence of either hyperalgesia or referred pain pre-operatively resulted in a significantly worse outcome from decompression three months after surgery (unpaired t-test, p = 0.04 and p = 0.005, respectively). These observations confirm the presence of central sensitisation in a proportion of patients with shoulder pain associated with impingement. Also, if patients had relatively high levels of central sensitisation pre-operatively, as indicated by higher levels of punctate hyperalgesia and/or referred pain, the outcome three months after subacromial decompression was significantly worse.

********

Treat the brain, treat the pain

Arthritis Rheum. 2009 Sep 15;61(9):1226-34.

Psychophysical and functional imaging evidence supporting the presence of central sensitization in a cohort of osteoarthritis patients.

Gwilym SE, Keltner JR, Warnaby CE, Carr AJ, Chizh B, Chessell I, Tracey I.

Source

University of Oxford, Oxford, UK. [email protected]

Abstract

OBJECTIVE:

The groin pain experienced by patients with hip osteoarthritis (OA) is often accompanied by areas of referred pain and changes in skin sensitivity. We aimed to identify the supraspinal influences that underlie these clinical manifestations that we consider indicative of possible central sensitization.

METHODS:

Twenty patients with hip OA awaiting joint replacement and displaying signs of referred pain were recruited into the study, together with age-matched controls. All subjects completed pain psychology questionnaires and underwent quantitative sensory testing (QST) in their area of referred pain. Twelve of 20 patients and their age- and sex-matched controls underwent functional magnetic resonance imaging (MRI) while the areas of referred pain were stimulated using cold stimuli (12 degrees C) and punctate stimuli (256 mN). The remaining 8 of 20 patients underwent punctate stimulation only.

RESULTS:

Patients were found to have significantly lower threshold perception to punctate stimuli and were hyperalgesic to the noxious punctate stimulus in their areas of referred pain. Functional brain imaging illustrated significantly greater activation in the brainstem of OA patients in response to punctate stimulation of their referred pain areas compared with healthy controls, and the magnitude of this activation positively correlated with the extent of neuropathic-like elements to the patient’s pain, as indicated by the PainDETECT score.

DISCUSSION:

Using psychophysical (QST) and brain imaging methods (functional MRI), we have identified increased activity with the periaqueductal grey matter associated with stimulation of the skin in referred pain areas of patients with hip OA. This offers a central target for analgesia aimed at improving the treatment of this largely peripheral disease.