Tag Archives: chronic pain in sport

05Feb/15

Today’s talk at QMUL | pain in sport

Today’s pain in sport talk at Queen Mary University of London (QMUL) for the MSc Sports & Exercise Medicine group focused on modern concepts of pain, in particular the problem of persisting pain. Using plenty of clinical examples and anecdotes, we explored a range of topics including:

  • The enormous (global) issue of pain
  • The dimensions of pain (physical – cognitive -emotional)
  • The importance of the whole person as much as the condition
  • The relevance of the meaning of pain to the individual and how this flavours the pain experience
  • The vital early messages when we talk to someone with pain, and how this can shape their thinking and actions
  • The importance of using the science of pain in dealing with sports injuries.

Richmond holds clinics for pain and chronic pain problems in Harley Street, Chelsea and New Malden

If you would like Richmond to come to your practice and talk about pain and chronic pain, please contact Jo on 07518 445493.

20Oct/14

Chelsea FC – ‘long, long’ injury list

Part of the role of being a manager is to juggle the team according to injuries. The list of injured players in The Premiership at the moment is significant. Jose Mourhino described his list as ‘long, long’, hence the Chelsea manager is being forced to consider his options for the forthcoming games. With the ever-growing costs involved in football, questions about players’ availability are now a routine focus for interviews.

Diego Costa is struggling with a persisting hamstring injury. Leg injuries and pain are the scourge of footballer’s careers, but with a change in thinking, many of the on-going problems can be eradicated.

Certainly players work hard on their conditioning to make sure that their bodies are prepared for the rigour and vigour of the modern game. Time away from running and kicking allows for the body to adapt — muscles and the systems that control the muscles. Active rest is vital and should include a techniques that create calm in the body via the mind. We know only too well the potent influence of the mind upon the body and vice versa. Allowing a negative thought about pain or injury to take hold will affect movement and performance. But, there are effective ways of dealing with this and should be routine for both players and managers.

There is a difference between hamstring pain and a hamstring injury. The latter involves damaged tissue whereas the former does not. Everyone needs to understand this and know how to discriminate — by everyone, I mean players, medical staff and managers. With everyone knowing the facts about pain and injury, communication is open and free, meaning that any stress created by worry and concern is eliminated. One thing that is not good for pain is stress. Why? Because the body will be in protect mode, and this is not compatible with recovery.

Understanding pain and injury is the start point. From here, recovery can be planned and implemented, working with all the body systems involved with injury and pain — and that includes body awareness, sensorimotor function, immune function, autonomic function; all involved with protection. Protection is vital in the initial stage of an actual injury, but as healing takes hold, the biology of protection may need a helping hand to switch off.

Struggling to get back to football? Have a player who is struggling? Get in touch and we can work together to return him or her to play — 07518 445493

 

 

18Oct/14

More Premiership injury woe

Headlines today in The Guardian sport section report that Daniel Sturridge is suffering from a further strain, this time in his calf. I do not know if this is the same leg as the thigh strain from which he has recently recovered, but if so, I would not be surprised. In addition, we learn that Raheem Stirling told Roy Hodgson that his legs were sore. Anyone who plays sports will know that feeling.

A second injury or pain on the same side — why?

When we injure a muscle or ligament, inflammatory chemicals are released locally. Danger-sensing nerves (nociceptors) are activated by these chemicals when their threshold of firing is lowered. Danger signals are sent to the spinal cord, where modulation takes place with signals being sent down from the brain — these are in response to thoughts, emotions, context, perceived danger etc. The danger signals are then sent up to the brain via a second neuron, where an analysis of what is happening takes place. On concluding that there is danger, pain emerges from the body in the place where it is thought the problem lies. The body uses cortical (brain) maps to allocate the pain in the body. Put simply, the biology of pain does not reside in the injured tissues but instead involves the protective functioning of many body systems working together.

Once protection kicks in, pain draws our attention to the area, our movement changes as does our thinking amongst other things. This does not involve only the injured body region, but widespread responses of body systems that protect us from actual and potential threat. The original injury goes through a healing process — we have incredibly potent healing abilities — yet the sensitivity and protection can persist. If, for example, the thigh is strained, it is all the ‘wiring’ that involves the leg that will be on alert. Without full resolution, and this includes confidence in the body, the systems are primed and hence during this period it is easier to ‘pick up’ another injury. Sometimes there is an actual injury and damage, but often there is nothing discernible yet it hurts in the same way. Differentiating an actual injury from the sensation of an injury is important. Players and coaches understanding these mechanisms (of pain) is vital in my view, so that these problems can be tackled efficiently. It would be straight-forward to deliver a mandatory, FA backed education package — contact me for details of an education programme.

In summary, why do pains appear on the same side? Because the initial sensitivity has not fully resolved in the case when no actual injury can be found. If there is a strain or sprain detected, there is a good chance that motor control, body sense and awareness and or confidence are not complete. Of course, there is always the possibility of just plain old bad luck, however I would suggest that it is more likely that the body remains in a degree of protection mode.

Aching legs and recovery

Briefly, the body needs time to recover from the demands of exercise. This can be all out rest for a short period but also active rest that would be a lower intensity of movement and activity; a skills based session for example. There are ways of enhancing recovery that include focused movements and body awareness exercises as well as the practice of mindfulness. We have a great ability to adapt, and in fact our body systems are continually changing and adapting to our lifestyles. This is one of the reasons for chronic health problems in a society that is ‘wired’ and ‘immediate’. Put simply, our bodies are not designed in this way.

Educating players about pain, injury, recovery and health empowers them to make good decisions. With coaches and managers also understanding these principles, it creates a positive culture with clear communication about injury and pain. A player should always feel that he can talk openly about how he is feeling, physically and mentally — although I would argue that these are one and the same because we are whole person: genes, character, personality, experience, knowledge, beliefs, mind, body etc., with no single feature standing above the others.

Contact me for information about pain seminars and training at your club — 07518 445493

 

12Oct/14

Athletes still on the bench?

Chronic pain exists in sport. It is a frustrating problem for players and coaches alike, and is accompanied by an expensive price tag in professional sport. Similar to non-sporting injuries, there is initial tissue damage (e.g. a ligament sprain) that triggers inflammation, a normal part of healing, which typically hurts. This is meant to happen as a motivator to take action: to protect the injured body and to change behaviour to allow healing to progress.

The focus of treatment is usually the injured body region. Reasonable, you may think. Indeed in the early stages, it is wise to think about creating the right environment for local healing. However, there are responses that go far beyond the muscles, ligaments and joints. It is worth pointing out here that we only ‘feel’ those structures because of how our brains create the experience, this merely touching the subject on how we really ‘feel’. This in mind, it is only logical to think further than the injured tissue in order to comprehensively rehabilitate an injury.

In persisting pain states that present as an on-going injury or an inability to return to the playing field, thinking beyond the body is essential. Why is this player not recovering? The ligament has healed, the bone has healed, there is little or no inflammation on the scan etc, etc. What is going on? Going upstream of these tissues provides the answers. In fact, going upstream will explain persisting inflammation in many cases, and help to break the cycle.

Pain is multi-system, pain is emergent, pain is whole-person. A range of body systems kick-in when we injure ourselves, and sometimes they do not switch off as you may expect. There are indicators at the time of injury that suggest the route forward will be an issue. These need to be addressed rapidly.

I read and hear about treatment and rehabilitation programmes that focus on movement, proprioception, strength, core and the like. All important, but what happens when these fail to get the sports person back to play? What is the reason? The answers lie in the adaptations of the body systems and the beliefs and expectations of the healthcare professionals and the athletes.

Different thinking is needed for persisting, complex and chronic pain.

If you are struggling to return to sport or you are working with a player who is stuck, get in touch and we can work together to identify the problems and how to solve them: call now 07518 445493 

24Jul/14

It’s time to bring what we know about chronic pain into sport

I recall a time when a consultant told me that chronic pain does not exist in private medicine. I was somewhat dumbfounded that an intelligent person could have such a thought. As a far as I was (and am) concerned, pain is classless. This was some years ago, however I am reminded of this when I think about the lack of recognition of chronic pain in sport.

Injury and pain are part of sport and we all know this well. Healthy people engaging in regular physical activity gain the physical and psychological benefits of exercising, but there is a risk of injury. And whilst many people who are injured will heal and recover, resuming their sport, there are a cohort who do not return to full participation and suffer on-going pain. Persisting pain affects one’s ability to perform, self-confidence, self-efficacy and in the professional case, a career. This is no different to the situation with a non-athlete with chronic pain.

There are a number of reasons why an athlete fails to recover including the context of the injury, early management, the development of fear, the understanding of the pain and injury, and the intensity of the pain at the outset. When lecturing on this subject, I tell the story of Messi who believed that his career was over because of the pain he experienced in his knee having collided with a goalkeeper. He was immediately taken for an MRI scan that revealed no injury. Recovery was swift when Messi knew he had not damaged his body. The pain he experienced on the field when he thought his footballing days were over was intense with a meaning that drove into the heart of his emotions, and that of the silenced crowd.

The reasons that pain persist are no different in the non-sporting person: the context of the injury, the state of health at the time, prior pain and injury and how they were dealt with, initial management etc. This being the case, we can bring the modern thinking about chronic pain into the sports arena for two reasons. One is to look at how injuries are dealt with in the early stages, and the other to take a broad perspective in tacking the on-going or recurring injury.

The early management of sports injuries is well known. The aspect to which I refer is the communication about injury and pain. In fact, even before an injury, providing education for players and athletes would impact upon those first vital moments that can prime and set up the recovery. At the point of injury, a whole body, all-system response kicks in, and recognising these processes in their entirety will maximise the recovery potential from the outset. All the necessary processes for recovery are in the human body. The main proponents of disruption are over-zealous treaters, fearful potential recoverers and those who ignore what the body is orchestrating. A careful explanation of the injury, pain and what will happen to aid recovery goes a long way to calming excited protective body systems.

Changing a pain state is entirely possible. Understanding that pain emerges in the body but involves the whole body is vital when considering all the factors necessary to set up recovery. When pain persists there are many habits and behaviours that become part of the problem. These need identification and re-training as much as the altered body sense, altered movement patterns, altered thinking, altered emotional state, altered immune responses, altered endocrine responses, altered autonomic responses, altered self-awareness, altered perception of the environment — we are altered in this state and it involves a host of responses, not set in stone but instead, adapting and surviving. On spraining a knee ligament, it’s not the ligament as much as how the body is responding to the detection of chemicals released by the injured tissue, the perception of threat and how the individual responds to the conscious feelings created by the whole body that drive thoughts and behaviours.

In the light of this knowledge (that has existed for many years), far more comprehensive treatment and training measures have been devised in small quarters. This approach delivers vastly improved outcomes because the problem is being addressed in a way that recognises that pain emerges from the whole. This notion was crafted from the merging of neuroscience and philosophy and is now taking our thinking forward (thanks to Mick Thacker and Lorimer Moseley for bringing this mode of thinking to physical therapy and beyond). I no longer refer to ‘pain management’ as this implies we are not trying to change pain, and I believe that we can and do change pain.

Pain is changing all the time as is every conscious experience. What patients believe is what they will achieve: “Whether you think you can, or think you can’t, you’re right”, Henry Ford. Let us draw upon the psychology of success, create a clear vision and go for it. Every action and thought can be challenged with the question, “Will this take me towards my vision?”. This is the same in sport as it is in the general population and we can use exactly the same principles, just with different end points — everyone has a different end point, hence my push for recognition that chronic pain exists in sport and remains a huge and costly problem for individuals and clubs.

How can we go about this? Initially we must create awareness of the extent of the problem, recognising that a wider approach is needed and subsequently implementing contemporary treatment and training methods that work with the whole person. Understanding the pain mechanisms, the pain influences and the context of the pain for the individual orientates thinking that creates a route forward toward the identified vision. Blending specific training (e.g./ body awareness, sensorimotor control) with techniques that boost self-efficacy and maintain motivation for the necessary steps towards recovery. The recovery is part of the vision and is determined by prioritising the programme and working consistently.

Using comprehensive measures and thinking, we can create the conditions that allow for pain to change in the whole person by allowing body systems to do their work. Our role is to facilitate this biology by what we say, do and advise. Drawing upon the contemporary way persisting pain is approached in the general population, sportsmen and women can access the same benefits, optimise their potential to return to exercise and reduce the risks of recurrence.

Richmond specialises in creating the conditions for people with chronic pain and injury to recover and move forward. When he is not seeing patients, Richmond spends his time writing and talking about pain with the aim of bringing the modern understanding of pain into the public domain for better treatment

Specialist Pain Physio Clinics, London

10Aug/13

Shoulder injuries: rotator cuff | Our new article in press

Rotator cuff tendinopathy & CNS considerations | our new paper in press here ow.ly/20Tpy3

Authors: Chris Littlewood (@PhysioChris), Peter Malliaras, Marcus Bateman, Richmond Stace, Stephen May, Stephen Walters.

Similar to any injury that persists we must ask ‘why?’ and seek the mechanisms that underpin the on-going experience of pain and altered movement that come hand in hand. One mechanism that has been identified is central sensitisation – see here. In this paper (in press), we consider the role of the central nervous system in rotator cuff injuries, a problem that is often painful and can persist.

Rotator cuff injuries & shoulder pain are common persisting injuries

Chronic injuries require a different approach to treatment and training. As well as improving the health and mobility of the tissues, we must look at the reasons why the body and brain continue to protect the area. Modern pain science has revealed a range of reasons why pain continues including sensorimotor incongruence, central sensitisation, changes in specific cell activity in the brainstem, mechanisms as a result of nerve injury and inflammation, neurogenic inflammation, beliefs about pain, fear of movement and stress to name but a few. These factors are revealed in a detailed assessment with the subsequent creation of a tailored treatment and training programme to tackle the problems at source.

For more details or to book an appointment call 07932 689081

Specialist physiotherapy in London for chronic pain, persisting pain and injuries: clinics in Chelsea | Harley Street | Temple | New Malden

28Mar/13

Chronic pain in sport | painphysio article in SportEX journal

In the April edition of the SportEX journal you can read my article on chronic pain in sport – click here

Chronic pain and recurring injuries in sport are a huge problem. The modern approach uses the latest neuroscience to tackle the pain and restore normal function required for the particular sport.

Call us for details on 07932 689081 or read more about our treatment programmes here

03Feb/12

Chronic pain in sport – Specialist Clinic in London

Chronic pain is a real problem in the sporting world. The effects of not being able to participate are far reaching, especially when sport is your profession. There are a huge numbers of clinics offering treatments to deal with pain and injury and in many cases the problem improves. However, there are those who do not progress successfully, resulting in on-going pain, failed attempts to return to playing and varied responses to tissue-based treatment (manual therapy, injections, surgery etc). Understanding more about pain and how your body (brain) continues to protect itself is a really useful start point in moving forwards if you have become stuck. We know that gaining knowledge about the problem can actually improve a clinical test and the pain threshold.

When we injure ourselves playing sport the healing process begins immediately. Chemicals released by the tissues and the immune system are active locally, sealing off the area, dealing with the damaged tissue and setting the stage for rebuilding and repair. The pain asscociated with this phase is expected, normal and unpleasant. It is the unpleasantness that drives you to behave in a protective manner, for example limp, seek advice and treatment. Again, that is normal. Sometimes we can injure ourselves and not know that we have damaged the tissues. There are many stories of this happening when survival or something else is more important. This is because pain is a brain (not mind or ‘in the head’) experience 100% of the time. The brain perceives a threat and then protects the body. If no threat is perceived or it is more important to escape or finish the cup final, the brain is quite capable of releasing chemicals (perhaps 30 times more powerful than morphine) to provide natural pain relief. We know that pain is a brain experience because of phantom limb pain, a terrible situation when pain is felt in a limb that no longer exists. The reason is that we actually ‘feel’ or ‘sense’ our bodies via our virtual body that is mapped out in the brain. This has been mapped out by some clever scientists and in more recent years studies intensely using functional MRI scans of the brain.

Unfortunately, the brain can continue to protect the body with pain and altered movement beyond the time that is really useful. Changes in the properties of the neurons in the central nervous system (central sensitisation) mean that stimuli that are normally innocuous now trigger a painful response as can those outside of the affected area. One way to think about this functionality is that the gain or volume has been turned up, and we know that much of this amplification occurs in the spinal cord, involving both neurons and the immune system. Neurogenic inflammation can also be a feature, where the C-fibres release inflammatory chemicals into the tissues that they supply. On the basis that the brain is really interested in inflammation, even a small inflammatory response can evoke protective measures. Changes in the responsiveness of the ‘danger’ system as briefly described, underpin much of the persisting sensitivity. Altered perception is a further common description, either in the sense that the area is not controlled well or feels somewhat different – see here.

As the problem persists, so thinking and beliefs about the pain and injury can become increasingly negative. Unfortunately this can lead to behaviours that do not promote progression. Avoidance of activities, fear of movement, hypervigilance to signals from the body and catastrophising about the pain are all common features, all of which require addressing with both pain education and positive experiences to develop confidence and deeper understanding. An improvement in the pain level is a great way of starting this process, hence the importance of a tool box of therapies and strategies that target the pain mechanism(s) identified in the assessment.

Experience and plenty of scientific data describe the integration of body, brain and mind. This can no longer be ignored. It is fact. The contemporary biobehavioural approach to chronic and complex pain addresses the pain mechanisms, issues around the problem and the influencing factors in a biopsychosocial sense:

  • Biology: e.g./ physiology of pain, body systems involved in protection, tissue health
  • Psychology: e.g./ fears, anxiety, beliefs about the pain, thinking processes, outlook, coping, past experiences
  • Social: e.g./ work effects, effect upon the family, socialising, role of significant others (spouse, family), financial considerations

Specialist Clinic in London and Surrey for chronic pain and injury in sport – call 07518 445493

Chronic pain and injury requires an all-encompassing biobehavioural approach. Although the end aims can be different, the structure and themes within the treatment programme are similar to those that tackle any chronic pain issue. Bringing these principles into the sports arena, we can incorporate traditional models of care and advance beyond the tissue-based strategies to a way of working that addresses the source of the problem alongside the influencing factors that are slowing or even preventing recovery.

If you as a player are struggling to move forwards or have a player on your team who is not recovering or failing to respond as expected to treatment, we would be very pleased to help you. Call 07518 445 493 or email [email protected] for further infomartion about the clinics:

The Specialist Pain Physio Clinics work closely with the very best Consultants and can organise investigations such as MRI scans and x-rays with reports rapidly, an on-site at the New Malden Diagnostic Centre, 9 Harley Street and in Chelsea.