Tag Archives: chronic injury

07Apr/12

Tackling chronic pain – it’s like learning a new language..and unlearning an old

Tackling chronic pain is a challenge. Undoubtedly our understanding of pain, the role of the nervous system and other body systems, has advanced to permit a reconceptualisation of the experience and how we can approach it. The knowledge that there is a form of conditioning and learning that goes on, means that we can switch our thinking to address these mechanisms. Clearly a change in reasoning was and continues to be required to be more effective in dealing with persisting pain.

I often use the analogy of learning a language with patients. Most people at some stage have had to go through this process, with some more natural than others at developing the skill. Equally, the thought of learning a musical instrument provokes a similar comparison. What is needed? Understanding, time, motivation and practice are certainly necessary ingredients. We also require adequate rest and sleep to cement the changes in brain function that occurs as a result of its plasticity.

So what has been learned in chronic pain?

We can divide this into biological responses and behaviours that we purposely adopt. The brain learns to produce pain and becomes very good in some cases, creating the experience even when it is not required–recalling that pain is an output from the brain in response to a perceived threat based upon the danger (nociceptive) signals received from the body via the spinal cord; the caveat being that nociceptive signals and the act of nociception is neither needed nor necessary for the brain to create pain. Equally, nociception can be ticking on but without the brain producing the conscious experience of pain. This means that as soon as the brain is sure we are under threat, it will protect us with pain and concurrent responses. These include changes in movement, activity in the endocrine system (hormones) and the immune system that pervades our body as a second nervous system.

‘..pain cannot exist out of consciousness. In contrast, but often erroneously considered analogous, nociception can exist outside of consciousness. In fact, nociception can occur without the brain–high-threshold peripheral afferents and their spinal projections can be activated in the absence of brain activity. Indeed, tactile perception, pain and other bodily feelings can be thought of as outputs of the brain that are based on an informed interpretation of the information coming from one’s body.’ Taken from Moseley & Flor (2012)

The way we respond to pain is individual and learned from previous experiences. Clearly it is both useful and vital to learn that an oven is hot and a pin is sharp. Acute pain is an incredible device and one of the body’s responses to perceived danger. In persisting pain states, arguably the pain is not useful or promoting adaptive behaviours. Although, when the tissues are not as healthy as they may be, the peripheral nervous system is sensitive and movement is not normal, perhaps some level of pain is useful as a motivator to develop healthier tissues. Undoubtedly though, in many cases of chronic pain, the intensity and impact far outweighs any benefit. The incredible sensitivity, robust and lengthy responses to normal activities cause utter havoc and enormous distress such as in the case of complex regional pain syndrome.

Approaching the problem of chronic pain requires a 360 view on the individual. Understanding pain mechanisms, limitations, social impact and influential factors are all important in the planning of a treatment programme. In addition, as argued here, considering chronic pain as a learned response on different levels is a useful way of conceptualising the problem in terms of understanding how the situation has evolved and how it must be tackled.

RS

01Feb/12

Can’t get over that skiing injury?

To the skier, the thought of watching friends and family clumping off in their boots towards the lift whilst sitting with a leg up, packed with ice and the daily paper, is intensely frustrating. Injuries happen. In many cases with the right early treatment, perhaps surgery and definitely a thorough rehabilitation programme, the symptoms resolve and the leg works again, good as new. However, there are a number of cases when this does not follow suit and the pain and limitations continue. There are reasons for this occurrence and they extend beyond the health of the tissues that almost always go through a healing process.

There are some complex mechanisms at play in the nervous and immune systems that are really useful when we first have an injury. This of course includes pain that is part of the way the brain defends the body when we damage ourselves. The way in which we go about protecting and treating ourselves is driven in part by the pain that motivates these actions: rest, seek advice or take analgesia. That is what pain really is, a motivator to take action to promote healing and survival. In the early stages of having injured tissues, often ligaments at the knee, this is really useful and important. Briefly, the damaged tissues release chemicals that sensitise the local nerve endings, stimulating a volley of danger signals to be sent to the spinal cord. Here, secondary neurons send this information to the brain for scrutiny. On deeming there to be a threat, the brain engages protective responses including pain, changes in movement and healing. Sometimes we can injure our tissues and the brain decides that something else is more important, perhaps escaping from the mountain, and will send signals down to the spinal cord to interfere with those coming from the tissues. The end result is the feeling of no pain and therefore you can take yourself to safety. Then it can start hurting. All in all, the responses will vary as will our ability to cope.

The early bombardment of the spinal cord and brain with danger signals that can also be influenced by the context of the injury, e.g. really scary, leads to changes in the properties of the neurons in the spinal cord. This means that subsequent signals can be amplified. It also means that normal signals (e.g. light touch) can start to provoke a painful response as can areas not directly involved. In the latter case one can find that the area of pain grows (click here). The on-going activity in the nervous system and other systems such as the immune system, endocrine system and autonomic system underpin the experience of persisting pain and protection, including altered movement that is so important to normalise.

In the case that the problem persists, the treatment is different. The tissues are addressed as one would expect with manual therapy, massage and other local treatments. However, alongside these traditional techniques are a range of strategies and treatments that are based upon the latest pain sciences that target the changes aforementioned and others. These strategies target the mechanisms at play and at source reduce the threat and hence the pain, normalise motor control and sensation of the affected area and restore function so that there can be a progression back to pre-injury activities.

For further information please contact the clinic: 07518 445493

19Dec/11

Back Pain and the BackCare Charity

Back pain is an enormous problem that impacts upon individuals and society. Most people will experience back pain at some point in their lifetime and a proportion will suffer continuing and recurring problems. Those who do continue to experience pain require effective treatment and strategies so that the impact and the distress that it can cause are diminished. Our understanding of pain science has moved forward significantly, meaning that there are contemporary therapies that target changes that we know occur in the brain and other body systems. For example, the graded motor imagery programme and cognitive techniques that impact upon pain threshold and movement.

The early management of a back pain as with other acute pains, will often determine the outcome. Full understanding of what has happened, why it hurts, what is normal about the pain response, how to cope effectively and the use of appropriate medication are all important at this point–see your GP or consultant for advice on medication.

Treat the brain, treat the pain

In persisting or complex cases, the assessment and treatment must be based upon the biopsychosocial model, considering the pain mechanism, influencing factors, beliefs & expectations, prior experiences of pain, the social impact (e.g./ work, family, sports) and fears in relation to movement and activity to name but a few. Pain is an output from the brain 100% of the time in response to an actual or perceived threat. Pain is always a normal response to the information that the brain receives from the spinal cord. In chronic conditions however, the way in which the nervous system changes means that danger signals can continue to be sent to the brain even when there is no actual threat. The brain must still respond by protecting the body by making the area hurt. The brain becomes very good at this, the analogy often used being an orchestra that learns to play one tune only. The pain tune–see Painful Yarns. To change the experience of pain in these cases requires a contemporary approach that is both ‘bottom up’ and ‘top down’. Bottom up refers to therapy that targets tissue health and movement, and top down pertains to training the brain and beliefs that are limiting recovery–see here for more details.

The BackCare Charity

BackCare is a national charity that aims to reduce the impact of back pain on society by providing information, support, promoting good practice and funding research. BackCare acts as a hub between patients, (healthcare) professionals, employers, policy makers, researchers and all others with an interest in back pain.

BackCare supply a number of resources including information packs, articles and a newsletter. A list of practitioners is available so that you can find a local therapist.

The BackCare App – Listed in The Sunday Times App List

If you are a back pain sufferer or you have a professional interest, you can join BackCare here

19Dec/11

Healthy tissues in 1-2-3

The simple fact is that our tissues need movement to be healthy. By tissues I am referring to muscles, tendons, ligaments, bones, fascia and skin. This does not need to be extreme movement but it must be regular and purposeful. Even without pathology, pain or an injury it is vital that the tissues are moved consistently throughout the day. It is likely that if you are recovering from a pain state, this movement will need to be ‘little and often’ to follow the principle of ‘motion is lotion’. I love this phrase. It was coined by the NOI Group guys and I use it frequently. At the moment I a considering some other phrases with similar meanings. If anyone has any suggestions please do comment below.

There are many types of movement from simple stretching to walking and more structured exercise such as yoga.  For convenience I talk to patients about the ‘themes’ of the treatment programme. In relation to movement there are three themes 1-2-3: specific exercises to re-train normal movement and control of movement, general exercise and the self-care strategies to be used throughout the day.

The specific exercises could include re-learning to walk normally, to re-establish normal control of the ankle or to concurrently develop confidence such as in bending forwards in cases of back pain. Normal control of movement is a fundamental part of recovery. When the information from the tissues to the brain is accurate, there is a clear view on what is happening, menaing that the next movement is efficient and so on.

General exercise is important for our health in body and mind. As well as reducing risk of a number of diseases, our brains benefit hugely from regular exercise. We release chemicals such as serotonin that make us feel good, endorphins that ease pain and BDNF that works like a miracle grow for brain cells. Gradually increasing exercise levels is a part of the treatment programme for all of these reasons.

Move from your seat, or buy one of these!

Regularly punctuating static positions with movement nourishes the tissues and the brain’s representation of the body. The tissues will tighten and stiffen when they remain in one position for a long period of time, and more so when there is pathology or pain. Often there is already overactivity in the muscular system when we are in pain as part of the way the brain defends the body. This overactivity leads to muscle soreness that can be eased with consistent movement.

These three simple measure are behaviours. Behaviours are based on our belief system and therefore we need to understand why it is so important to move and re-establish normal control of movement as part of recovering from an injury or pain state. This includes tackling any issues around fear of movement and hypervigilance towards painful stimuli from the body. Our treatment programmes address these factors comprehensively, employing the biopsychosocial model of care and the latest neuroscience based knowledge of pain.

Email [email protected] for more information about our treatment programmes or to book an appointment.

09Dec/11

Mindfulness

Mindfulness has grown in popularity over recent years, and for good reason. Those who regularly practice mindful meditation and mindfulness on a day-to-day basis will tell you about their clarity of thought, their sense of ease and their good physical health. The practice is recommended by NICE for depression as well as the frequent teaching of mindfulness as a way to deal with pain.

At the clinic, I encourage mindful practice to help the individual be released from the pull of negative and unhelpful thinking about pain. We all have thoughts. This is the action of the mind and is a normal process. Automatic thoughts pop into our head and trigger emotional and physical responses–think about a waxy, yellow lemon resting upon a plate; you take a knife and cut into the rind, releasing the citrus odour as you divide the lemon in two, the pieces rolling away from the blade; you further cut the two halves into quarter segments, each time triggering a small burst of juice into the air around; imagine taking one segment and gently placing it into the front of your mouth; what are you experiencing? Thoughts change our physiology because our brains respond to thinking or imagining, just as if we are present. This is why it can hurt when we watch someone else move their body in a way that would be painful for us.

Automatic thoughts are just that. How we respond next we can decide. By being observant of our thoughts we can avoid following an automatic thought with another thought and another that lead to persisting physiological responses and emotions that are unpleasant and unhelpful. In particular those thougths that often recur and create unease and anxiety. They are simply thoughts. They are not us and they are not reality. They are just thoughts. But, they can be powerful unless we can find a way to be observant, non-judgmental, aware and present. That ‘way’ can be mindfulness.

Here are some great people talking about mindfulness and meditation

 

There has been and continues to be a great deal of work looking at mindfulness and how it may work. The Oxford Mindfulness Centre (OMC) undertakes research and provides training.
‘The OMC Team does ground-breaking clinical and neuroscience research on mindfulness. It assesses the efficacy of different forms of mindfulness practice for different types of problem, and is building up a peer-reviewed body of knowledge about what forms of mindfulness intervention best suits which type of person.’
A list of the OMC publications is available here

For further information on our use of mindfulness for pain, please email [email protected]

21Oct/11

Using neuroscience to understand and treat pain

Neuroscience to treat pain and injury

I love neuroscience. It makes my job much easier despite being a hugely complex subject. Neuroscience research has cast light over some of the vast workings of our brains and helped to explain how we experience ourselves and the richness of life. An enormous topic, in this blog I am briefly going to outline the way in which I use contemporary neuroscience to understand pain and how we can use this knowledge to treat pain more effectively. This is not about the management of pain, it is the treatment of pain. Management of pain is old news.

Understanding pain is the first step towards changing the painful experience. Knowing how the brain and nervous system operate allows us to create therapies that target the biological mechanisms that underpin pain. Appreciation of the plastic ability of the nervous system from top to bottom–brain to periphery–provides us with the opportunity to ‘re-wire’, and therefore to alter the function of the system and make things feel better. Knowing the role of the other body systems when the brain is defending us, is equally important. The synergy of inputs from the immune system, endocrine system and autonomic nervous system provides the brain with infomration about our internal physiology that it must scrutinse and act upon in the most appropriate way. We call this action the brain’s ‘output’ which is the responses that it co-ordinates to promote health and survival.

Treat the brain and to reduce pain

Excellent data from contemporary research tells us that understanding pain increases the pain threshold (harder to trigger pain), reduces anxiety in relation to pain and enhances our ability to cope and deal with the pain. We know that movement can also improve after an education session. This is because the perceived threat is reduced by learning and understanding what is going on inside, and knowing what can be done. The vast majority of patients who come to the clinic do not know why their pain has persisted, what pain really is, how it is influenced and what they can do about it themselves. For me this is the start point. Explaining the neuroscience of pain. Facts that we know people can absorb, understand and apply to themselves in such a way that the brain changes and provides a different experience.

It is the brain that gives us our experience of ourselves and the world around us. This includes the sensory and emotional experience of pain. The brain receives information from the body via the peripheral nervous system that suggests there is a threat to the tissues (input). In response, the brain must decide whether this threat is genuine based upon what is happening at the time, the emotional state, past experience, the belief system, gender, genetics, health status, culture and other factors. In the case that the brain perceives a threat, the output will be pain. The Mature Organism Model developed by Louis Gifford describes this beautifully (see below).

Pain is a motivator. It grabs our attention in the area of the body that the brain feels is threatened based upon the danger signals it is receiving from the tissues via the spinal cord. The brain actually ascribes the location of the pain via the map of the body that exist in the sensory cortex. On feeling the pain, we take action. This is the reason for pain. It motivates us to move, seek help or rest. Pain is an incredible device that we have for survival and learning, necessary to navigate life and completely normal. The brain constructs the pain experience and associated symptoms in such a way that we have to take note and do something about it immediately.

When we injure tissue there is a local release of inflammatory chemicals. These chemicals excite local nerves in the tissues called nociceptors. Normally, nociceptors are quiet but when they are stimulated by inflammation, these nerves send danger signals to the spinal cord where they meet secondary neurons. The early bombardment of signals into the spinal cord causes the secondary neurons to become excited. These cells then send danger signals up to the brain where the information is scrutinised. On the basis of this scrutiny, if the brain perceives a threat, pain will be allocated in the area of the body that is deemed to be in danger. The area of pain is allocated via the representation of the body in the brain (see previous blog here) in the sensory cortex, first mapped by Wilder Penfield and published in 1951. Therefore we know that actually there is no ‘muscle pain’ or ‘knee pain’ but rather pain as a brain experience, and not in the mind I hasten to add, that is detected in a body part or region according to the brain’s perception of threat. These are the body maps that the brain uses to know where information is coming from and to control movement.

This information is part of the neuroscience knowledge that can be used to help people understand their pain and to create therapies that treat pain. Future blogs will look at how we can change and nourish the nervous system to promote healthy tissues at one end of the spectrum with the brain end being targeted by deeper education and Graded Motor Imagery (GMI) for example–click here. The brain and the tissues are not separate, they affect each other in many ways, as do other body systems such as the immune and endocrine systems. Looking at healthy movement and functioning in a truly holistic and biopsychosocial manner with neuroscience underpinnings, provides us with an exciting route forwards in dealing with pain problems.
29Sep/11

Mastering your rehabilitation – Part 1: why exercise & train?

When we sustain an injury or experience a painful condition, our movement changes. In the early stages this can be obvious, for example we would limp having sprained an ankle. Sometimes the limp, medically termed an ‘antalgic gait’, persists without the individual being aware. This is the same for other forms of guarding that is part of the body’s way of protecting itself. By tightening the affected area or posturing in a manner that withdraws, the body is changing the way that we work so that healing can proceed. Clearly this is very intelligent and useful. The problem lies with persisting guarding or protection that continues to operate.

Physiotherapy London

We know that when the brain is co-ordinating a response to a threat, a number of systems are active. This includes the nervous system, the motor system, the immune system and the endocrine system (hormones). This is all part of a defence in and around the location that is perceived to be under threat. It is important to be able to move away from danger and then to limit movement, firstly to escape from the threat (e.g. withdraw your hand from a hot plate) and then to facilitate the natural process of healing by keeping the area relatively immobilised. Interestingly, at this point our beliefs about the pain and injury will determine how we behave and what action we take. If we are concerned that there is a great deal of damage and that movement will cause further injury, we will tend to keep the area very still, looking out for anything or anyone who may harm us. Over-vigilance can lead to over-protection and potentially lengthen the recovery process. This is one reason why seeking early advice and understanding your pain and injury is important, so that you can optimise your potential for recovery.

We have established that we move differently when we are injured and in pain. In more chronic cases, the changes in movement and control of movement can be quite subtle. An experienced physiotherapist will be able to detect these and other protective measures that are being taken. These must be dealt with, because if we are not moving properly, this is a reason for the body to keep on protecting itself through feedback and feed-forward mechanisms. Re-training movement normalises the flow of information to and from the tissues to the brain. Often this process needs enhancement or enrichment as the sensory flow and position sense (proprioception) is not efficient. Movement is vital for tissue and brain health, nourishing the tissues with oxygen and chemicals that stimulate health and growth.

To train normal movement is to learn. The body is learning to move effectively and this process is the same as learning a golf shot, a tennis stroke, a language or a musical instrument. Mastery. You are asking yourself to master normal movement. What does this take? Consistency, discipline, practice (and then some more practice), time, dedication, awareness and more. The second part of this blog will look at mastery as a concept that can help you understand the way in which you can achieve success with your rehabilitation.

12Sep/11

Physiotherapy Clinic in Chelsea

Situated just off Sloane Square in Chelsea at 2, Lower Sloane Street, the physiotherapy clinic is in a convenient location close to the tube (Sloane Square) and bus stops. The Specialist Pain Physio Clinics are dedicated to treating pain and injury with modern strategies and therapies based upon the latest neuroscience to promote normal movement and healthy participation in an active lifestyle.

T 07518 445493

Physiotherapy in Chelsea for pain

Visit the profile on The Chelsea Consulting Room website that provides a brief outline of the clinic. The main Specialist Pain Physio website has details about the modern approach to the treatment of pain and chronic pain, the other clinic locations and links to useful sites.

Knowledge and healthy movement for normal self

Specialist Physiotherapy in Chelsea

Local residents, people from all parts of London, across the country and overseas visitors have come to the clinic for treatment of chronic conditions and pain.

Come and visit our blog for regular articles and information.

We see a range of complaints including back pain, neck pain, RSI, recurring and persisting sports injuries, complex regional pain syndrome (CRPS), tendinopathies (e.g./ Achilles, patella, shoulder, elbow & wrist), functional pain syndromes (e.g./ IBS, dysmenorrhoea, pelvic pain, fibromyalgia, chronic back pain), conditions that have failed to respond to treatment and medically unexplained symptoms.

T 07518 445493

21Jul/11

Treatment Update

Come and see the updated treatment programme page. We are regularly updating the site so do check back. This is when there is new knowledge or research that adds to our understanding of pain and how we can best treat on-going problems.

02May/11

Working with the team

Richmond Stace provides a specialist service for athletes and sportspeople who suffer on-going or recurring pain and injury that involves working with the existing medical and physiotherapy team. Either at one of the clinic locations or at the individual’s training facility, the detailed assessment elucidates the pain mechanism(s), factors that are influencing the pain and maintaining the current status, altered sensorimotor function and behaviours. Subsequently a treatment and rehabilitation programme is recommended. This may include the input of other specialists and health professionals depending upon the needs of the individual.

At the point of recommendation, Richmond can implement the programme or provide the structure for the existing team to follow and progress. Follow-ups in person and via telephone/email are standard to monitor and evaluate the programme.

Aims

  • Ease symptoms
  • Restore function & fitness
  • Optimise the outcomes through identification of influential factors (biopsychosocial)

The key points

  • The service is dedicated to the more persisting and complex problems that are affecting an athlete’s  ability to perform or return to sport
  • We work closely with the existing medical team
  • Detailed assessment to determine the nature of the problem and influencing factors
  • Bespoke treatment & rehabilitation programme
  • Regular follow-ups