Tag Archives: chronic pain

03Mar/15
Treatment of pain and injury

Joe’s pain story

Up LogoJoe’s pain story told by his mum Jenny as part of the UP | Understanding Pain Campaign that launches this Saturday with 700+ singers performing at Heathrow – follow us on Twitter @upandsing to show your support

It was the morning of Tuesday 27th November 2012 and the usual school morning rush was well underway when my son, aged 11, lent forward and picked up his school bag. Straight away he complained of back pain, he was unable to fully stand up straight but by no means was in agony. I explained to my son that I felt his muscles were in spasm and the best thing for him to do was to keep moving. I work in a sports injuries clinic and said that I would book him in after school for a massage. I’d only been in work 10 minutes when the school called to say that Joe had ‘got stuck’ bending down at this locker and could I come and collect him. Joe shuffled out to the car in a manner that I had seen many patients at work walk and knew he must be in a fair amount of pain. On the subject of pain I would like to point out that Joe was no stranger to pain, he’s broken bones in his foot and not even muttered anything about it until I noticed the lovely purple bruise. He’s been a keen cyclist since the age of 5 and has had crashes resulting in loss of skin and friction burns; crashing at around 30 mph dressed in lycra is always going to hurt! Thinking back over Joe’s life he had never complained of pain and he was always one of those people who would rather get on with it.

Joe’s muscles where indeed in spasm and the physio treated Joe as much as he could but he recommended further investigations at our local hospital. The local hospital listened to what had happened and sent us home with paracetamol. That evening Joe’s pain became worse. He was only comfortable lying on his side and struggled to walk, I started rotating paracetamol and ibuprofen every two hours but nothing was touching the pain. We tried every distraction technique we could think of, hoping that once Joe slept he would feel better in the morning. Joe was literally screaming with pain by midnight, we had no way of moving him to the car so we called an ambulance.

To cut a very long story short this first hospital visit was the first of many. Joe would be screaming in pain day in day out. It was the most heartbreaking thing to witness as I had no way of controlling his pain. Our local hospital had no way of controlling Joe’s pain either, they had tried everything they could think of but where unable to pinpoint why Joe was in so much pain. Our experience at the hospital soon became very stressful, we became in a loop of ambulances and ward stays. One day they sent us home and within two hours of being at home Joe started screaming, ‘blacking out’ and screaming again, it was relentless and we had no option but to call for another ambulance. Thankfully by now they were used to seeing Joe so started the morphine and we thought it would just be a matter of time before the pain was under control. Three hours later Joe was still screaming non stop and my husband and myself were at breaking point. Consultant after consultant came in to see Joe, they all did the exactly the same leg lift test and left. No one except the A&E nurses seemed to care that Joe was still screaming and that nothing was helping him. Eventually one of the nurses said she had had enough. He had enough morphine to knock out a rugby player and she was moving Joe round to adult A&E as she said they couldn’t ignore him there. Within five minutes we were surrounded by consultants who decided that Joe needed to be put under so that they could perform a lumbar puncture. The relief when he fell asleep was overwhelming. I cannot begin to describe what it feels like to see your child in so much unbearable pain. Every time Joe ‘blacked out’ for a few seconds it was a relief only for him to wake again and continue screaming.

Joe was awake when we next saw him and surprisingly in no pain. The consultant said that maybe his brain had forgotten to turn his ‘pain switch’ off and going under had ‘reset him’. At the time I didn’t care why the pain had stopped I was just so glad it had! Joe was admitted and over the next day his pain started to return. His results had come back negative so the hospital decided to refer him to Great Ormond Street Hospital (GOSH). After spending a very surreal New Year’s Eve in hospital we were transferred on New Years Day. GOSH started him on a different mix of medication that started to work within a coupe of days. Their physio’s worked with Joe several times a day with his first goal being able to sit up for 10 seconds. They re-ran loads of tests on Joe but they were also unable to come up with a definite answer. They explained that unfortunately as it was 5 weeks since the Joe had injured himself, the injury could have already healed. They felt that the best course of action was to continue with the medication, pain killers and tens machine and to go to our local hospital to continue the physiotherapy.

We returned home after a week in GOSH with Joe’s pain under control with medication and plenty of telephone help from the Pain Team. After our experience with the local hospital I felt that attending physio with them would be a waste of time. I started searching on the internet for private physio’s and Richmond Stace came up again and again. I spoke with the GOSH Pain Team and they were happy for us to attend a private physio. I contacted Richmond and briefly explained our story and asked if he could help, ‘Of course’ was his reply. I remember putting the phone down half smiling and half in shock. Had I just heard right? He knew how he could help Joe. I was so shocked as apart from the staff on Koala ward at GOSH no one, I repeat no one had any idea what was going on with and how to deal with it.

Our first meeting with Richmond was such a positive experience, he listened and understood Joe’s pain. He explained that Joe was not the first person he had seen with that level of pain and it was something he could help us with. Joe started to improve over the weeks that we saw Richmond and we started to lower his medication. He was also managing more school that ever before and I could finally see a glimpse of the future and Joe being well. Richmond has this amazing ability to calm you, take the stress and worry out of the situation and just help you focus on the here and now. We learnt that our surroundings, state of mind, belief in what is wrong etc all have such a major impact on how we perceive pain and how we deal with it. For me, as Joe’s mum, I felt in control for the first time in months and I have no doubt that the feeling of being in control rubbed off on Joe. Listening to Richmond speak to Joe made me realise there was hope. I had truly started to question whether Joe would ever be pain free, how can no one know what caused the pain? How can they not know how to stop it? If we didn’t know what caused the pain could it happen again?

After everything that Joe had been through it had changed him. No longer was Joe my fearless boy, he was now cautious, carried himself differently and seemed different from his peers. In my opinion there is no doubt that pain changes you, makes you aware of your immortality and causes you to protect yourself when, most of the time that protection isn’t actually needed. Maybe our brains are too clever for their own good! Richmond helped Joe realise he was ok. In fact his was better than ok he was Joe again. Not Joe who screams in pain, not Joe who is fragile and unable to do much more than lie in bed but old Joe — Joe who loves school, riding his bike, playing football, going out with friends and playing his guitar. Richmond helped Joe see that and he helped him see that he can control his pain, giving Joe the belief in himself again, proving that he was not at the mercy of a painful back, destined to take painkillers and other medication for the rest of his life. The belief and the tools Richmond gave Joe changed his thought processes, enabling him to progress through his physio, lower and eventually stop his medication.

If anyone reading this is suffering with pain please, please see Richmond. Your life doesn’t have to be ruled by pain. Pain is exhausting and all consuming and it doesn’t have to be that way.

18Nov/14
Caring for our carers

Caring for our carers

help concept, special toned photo f/x, focus point selectiveMy simple message with this blog is that we need to care for the carers. Undoubtedly the individual with pain or ill-health is suffering, but so are the carers who may be partners, family members and friends. They may also be professional carers who are not immune to the stress of looking after someone.

In brief, here are some of the reasons why carers will suffer:

  • Seeing a loved one in pain
  • Feeling helpless
  • Mirroring pain — it is not uncommon for someone to feel pain in their body having observed another person in pain. Biologically this may be quite useful as a learning tool, similar to learning that touching the oven causes a burn injury; ‘I won’t do that again’.
  • Becoming absorbed in negative thought patterns
  • The physical demands, including the number of hours dedicated to caring and what it involves; e.g./ helping to move the patient, household chores — this often in addition to their own needs
  • Disturbed nights
  • A lack of respite
  • Feeling a lack of support
  • Financial worries
  • Own relationship issues

There are many other reasons, however the key point is that the demands upon carers are immense. One of the biological consequences is inflammatory activity in the body due to chronic stress. This inflammation underpins and affects the widespread aches and pains, the compromised health (feeling under the weather), limited resilience and motivation, varied and unpredictable emotional responses and difficulty thinking with clarity — see the interesting study below.

Carers are vital for both the person in pain but also for society at large. There are not enough resources to provide for all those with chronic pain and health issues on a day to day basis and hence we need to care for our carers.

For this reason, I offer treatment, training and mentoring sessions for carers. Ranging from the treatment of aches and pains to creating ways of constructively adding to the therapy for their charge, we also work upon resilience, problem solving and motivational techniques. These strategies are for that person to cultivate their own wellbeing, but also that of the person they are caring for at home. Partners commonly ask how they can be involved in helping the patient move forward, and I gladly reach them about pain, health and what they can do to contribute in a potent way.

If you are a carer, or would like your carer to be more involved, contact me to book the initial session: 07518 445493

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Greater inflammatory activity and blunted glucocorticoid signaling in monocytes of chronically stressed caregivers. Miller et al (2014).

Abstract
Chronic stress is associated with morbidity and mortality from numerous conditions, many of whose pathogenesis involves persistent inflammation. Here, we examine how chronic stress influences signaling pathways that regulate inflammation in monocytes. The sample consisted of 33 adults caring for a family member with glioblastoma and 47 controls whose lives were free of major stressors. The subjects were assessed four times over eight months. Relative to controls, caregivers’ monocytes showed increased expression of genes bearing response elements for nuclear-factor kappa B, a key pro-inflammatory transcription factor. Simultaneously, caregivers showed reduced expression of genes with response elements for the glucocorticoid receptor, a transcription factor that conveys cortisol’s anti-inflammatory signals to monocytes. Transcript origin analyses revealed that CD14+/CD16- cells, a population of immature monocytes, were the predominate source of inflammatory gene expression among caregivers. We considered hormonal, molecular, and functional explanations for caregivers’ decreased glucocorticoid-mediated transcription. Across twelve days, the groups displayed similar diurnal cortisol profiles, suggesting that differential adrenocortical activity was not involved. Moreover, the groups’ monocytes expressed similar amounts of glucocorticoid receptor protein, suggesting that differential receptor availability was not involved. In ex vivo studies, subjects’ monocytes were stimulated with lipopolysaccharide, and caregivers showed greater production of the inflammatory cytokine interleukin-6 relative to controls. However, no group differences in functional glucocorticoid sensitivity were apparent; hydrocortisone was equally effective at inhibiting cytokine production in caregivers and controls. These findings may help shed light on the mechanisms through which caregiving increases vulnerability to inflammation-related diseases

14Nov/14
CRPS Clinics | London & New Malden

5 facts about complex regional pain syndrome | CRPS

 

CRPS Clinics | London & New MaldenThanks to modern pain science we know a huge amount about complex regional pain syndrome (CRPS). Of course there is much more to know, and the way in which we think and take action to tackle the problem will evolve accordingly.

 

Here are 5 facts that I believe to be important:

1. The pain is not directly related to the extent of the injury or damage — the pain in CRPS can be unimaginably horrendous without any great change in the tissue health. Remember that pain is part of the way that the body protects itself, and not an indicator of tissue damage.

2. The affected limb can feel very different to the way it looks; size and temperature included.It can even feel like it does not belong, being described as detached or ‘not mine’. The loss of sense of ownership is because the brain provides this sense, but can also modulate it.

3. The symptoms can change according to your mood and the way you feel — stress can often make the pain worse. This is due to the perceived threat to the whole person triggering protection.

4. Seeing someone else move their corresponding body part can hurt. The brain starts to plan the same movement and will also protect at this stage, causing actual pain.

5. The limb changes colour because of blood flow changes. The autonomic nervous system (ANS) controls blood flow. This is the system that responds to perceived threat — ‘freeze, flight or fright’. In essence it is a system that responds to how and what we think. When we are embarrassed, we turn red (blood flow). This is because of the way in which we think about the situation:’ I have said something that I now think is silly’, ‘Is he looking at me?’ The ANS can also become sensitive, and is very involved with CRPS — colour change, altered sense of size, sweaty palms etc.

Suffering complex regional pain syndrome? Visit my specialist CRPS clinic in London to start your programme: call 07518 445493

09Nov/14
Pain specialist clinic in London

My top 5 pain myths

In my view, it is the lack of understanding that causes so many problems with pain in terms of how pain is viewed, treated and conceived as being changeable. Pain can and does change when you understand it and think about it in accordance with the modern (neuroscience-based) viePain specialist clinic in Londonw and have a definite plan that is followed with big action towards a vision of where the you want to be. Having seen many individuals put this into practice, I am confident that the start point is always how we think because this is from where the action emerges. The right thinking begins with understanding your pain.

In the light of this, here are my top 5 pain myths:

1. Pain comes from a ‘structure’ in the body — e.g./ a disc, a joint, a muscle.

2. The amount of pain suffered is related to the amount of damage or the extent of the injury.

3. Pain is in your mind if there is no obvious cause in the body — i.e./ via scans, xrays etc.

4. There are pain signals from the body to the brain.

5. Pain is separate from how you feel or think.

There are many others.

Now, this all sounds rather negative and I like to turn this on its head and look at how we can positively influence health in order to change pain. The programmes that I create with individuals for them to follow are all about creating the right conditions in the body systems, all beginning with the right thinking that often challenges existing ideas and notions about pain.

Struggling with pain? Persisting pain? Call me 07518 445493 | Specialist clinics for pain and persisting pain in London

26Oct/14
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Pelvic pain in men

Pain is a whole person experience

Pain is a whole person experience

Many men experience chronic pelvic pain that significantly affects their lives. When we talk of pelvic pain, we often think about women and their suffering, however, this problem is one that besets both sexes and hence we must encourage all who endure such pain to seek help. As with any persisting pain state, pelvic pain impacts upon the way we think, the way we act and the decisions we make, thereby intruding on quality of life.

There are many reasons why men can suffer pelvic pain. To identify all the causes is not the purpose of this blog, but rather to highlight the problem and provide an insight into how the body becomes stuck in a protective mode. This is the experiential dimension, the story that is told and the narrative that provides all the clues. For the pelvic pain itself is downstream, and with chronic pain we must also go upstream to look at the context within which the pain is happening.

Most people who come to see me do not have pathology or ‘damage’ that justifies the pain response that they suffer. Some have nothing of note at all as shown by scans and other tests. Understanding that you can be in pain without an injury is an important step towards changing pain — for those new to this notion, consider phantom limb pain for a moment. Often there is a start point that involves inflammation, which shifts the body into protect mode. Protect mode involves many body systems, conscious and unconscious behaviours (the latter being habits and conditioned responses). When the body is protecting itself, the area needing attention and defending will hurt, but we also move differently and think differently — if you have a painful ankle, you may think twice about ‘popping’ out to the shop for a paper.

In many cases, these protective responses die down as healing progresses. However, this does not always happen, and with statistics suggesting that 20% of the population suffer chronic pain, many continue to experience protection despite the tissues healing — pain, tension, a different sense of the body (there are many other feelings and sensations described to me, and I encourage this narrative so that I can fully appreciate the story). My thinking about this on-going protection is that the body senses all is not as well as it should be. In other words, the individual is not fully fit, the tissues (muscles, joints etc) are not entirely healthy, behaviours are not orientated towards health, and lifestyle factors in which pain is embedded have not been addressed satisfactorily. This is a huge topic to address at another time, but suffice to say, as much as pain is multi-factoral, so is recovery, which is why a programme to change pain must address the biology of pain and all the influences upon this biology (they are also biology!).

Back to the pelvis, an area full of muscles, nerves, blood vessels, ligaments and other soft tissues. From the pelvis ‘hang’ the legs, and on top sits the trunk. And let’s not forget the genitals, and both their importance and necessary sensitivity. The deep tension and pain that one feels in this region is truly visceral, radiating out into the groin and abdomen, accompanied by an awful tension and pulling in the muscles and testicles. Once the pelvis is grabbing your attention, it can be hard to distract yourself without learning how to change body tension.

Tim Parks - Teach us to sit stillIn this very personal tale of pelvic pain, Tim Parks describes his own journey via the book he wrote, “Teach us to sit still”. It’s a wonderful read for so many reasons, and I frequently encourage patients to tuck in. For me though, the bottom line is that Tim has validated a problem that needs addressing in a comprehensive manner, because so often there is no serious pathology despite the significance of the suffering. Getting to grips with this is part of moving forward and should be embraced. We do not need pathology to hurt. There are other reasons, one of which includes, as Tim says, sitting on your pelvis for 20 years and being stressed — this is by far enough to cause nasty pelvic pain!

What do you do when you are stressed? Tense muscles. This has an energy cost and impacts on the way oxygen is delivered to those very muscles. Consider exercising a muscle over and over. It hurts. It is exactly the same in the pelvis that you may be parked (no pun intended Tim!) on for extended periods of time. “I don’t get stressed” you may say. First of all, I don’t believe you (sorry!), because we all stress out at times and secondly, most of the time we are unaware of what our body is doing in response to our thoughts, environment and what we are doing; that is until it is too late — ooh, my ____ hurts because I haven’t moved for ____ hours (fill in the gaps).

So, what can we do. What do we need to do. Here are a few things that I believe are fundamental to changing what your body is doing:

  • Understand your pain and condition — that’s your clinician’s job, to help you.
  • Create awareness of how your body is responding rather than being on autopilot and then fire-fighting when it gets too much.
  • Think about what the body needs — oxygen to the tissues, especially nerves that become very grumpy when the supply drops (numb bum from being sat too long) — and make sure you do enough to nourish the muscles: move and breathe!
  • Go upstream of the pelvic pain, and look long and hard at your lifestyle and environments — e.g. How are you doing things? Where are you doing things? What habits can you release and change?

Chronic pain is a huge and costly global problem. The main reason why this is true is because of misunderstandings and the low expectations of successfully overcoming the condition (patients and clinicians) because the focus is upon treating ‘structures’ deemed to cause pain. Pain is not a structure, hence why this approach fails. The science of pain has moved forward hugely over the past 10 years and continues to deliver a new understanding. This new understanding challenges existing thinking, and it needs to. Pioneers of pain are hard at work and are finding ways to reduce suffering, and we can. It starts with a change of thinking based on new knowledge. Your knowledge that is translated into effective action.

If you are suffering pelvic pain, get in touch and start your programme to overcome your pain — call us now 07518 445493 — Specialist clinic in London and Surrey for chronic pain & persisting pain

 

22Oct/14
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Girls, stress and pain

Stress and painI have seen a number of teenage girls over the past year who are affected by chronic pain. They are often referred because of recurring headaches or migraines but we discover that there is widespread sensitive at play. How does this happen? Why does it happen?

Headaches and migraines can be functional pains. When these pains are part of a picture of sensitivity, often accompanied by anxiety, there are often other problems such as irritable bowel syndrome, pelvic pain and jaw pain. Whilst these problems all appear to be different, they have a common biology. Typically I work with women aged between 30 and 55 who suffer these aches and pains, but increasingly this is an issue of the younger female. Having said that, when I explore the story of an adult, we often find reasons for sensitivity that begin in childhood. This priming sets the scene for later events.

As adults we face many challenges. We have body systems that are trigged by these challenges, especially if we think they are threatening to us. In particular the autonomic nervous system (ANS) is quite brilliant at preparing us to fight or run away, which is very useful…..if you are facing a wild animal. On a day to day basis, it is in fact useful for the ANS to kick in and create some feelings in the body that alert us to danger — the caveat being, nothing is dangerous until it is interpreted as so, and hence we need a construct of ‘danger’ and of the thing that is perceived to be dangerous. For example, a baby may not have the construct of a lion and hence sees this big, cuddly, moving….thingy…like my teddy (may not have a construct for any of these either!), and essentially detects no threat. As the baby detects no threat, he or she behaves in a way that may not threaten the lion and hence the lion may feel safe. Both feeling safe, they become friends. Perhaps — these things have happened apparently. Please do not try this at home, but hopefully you get the idea. Back to day to day….

London Fibromyalgia ClinicsIn the modern world we often feel anxious. This is the body warning us that something is threatening. In many cases that I see, there is a strong reaction to banal events and non-threatening cues. Or if the cue is worthy of attention, the response is well out of proportion — e.g. utter panic and defensive thinking-behaviours. To what do we respond most frequently? Definitely not lions. Muggers? Gunmen? Earthquakes? Tidal waves? These are all inherently dangerous situations, that we simply do not often face. Sadly some people do have such encounters but the majority of us do not. The answer is our own thinking. The thoughts that are evoked — seemingly appearing form nowhere at times — are not the actual problem but instead the interpretation of the thought (metacognotion; our thinking about our thinking). The meaning that we give to a thought, often automatically, will determine the body response as our thoughts are embodied. And just to complicate things further in relation to thinking, there’s a world of difference between the experiencing-self and the memory-self. The former refers to what is happening right now, the latter to what we remember, or think we remember. In terms of pain, if our memory of a painful event concludes with a high level of pain, this will flavour the memory-self and we will report as such. The story, which is a snapshot within our lives, and how it turns out has a huge impact upon the subsequent memory of what happened.

The adult within an environment that becomes threatening, the workplace for example, can become very responsive to different cues that once were innocuous. Now they pose a potential danger and each time that happens and we respond with protective thinking and behaviours, the relationship becomes stronger — conditioning. There is no reason any this cannot be the same for younger people who are consistently within an environment and context that begins to pose a threat; a demanding school environment with high expectations plus the child’s own expectations and perfectionist traits. Place this context within a changing period of life and minimal time for rest and there is the risk of burn out or development of problems that involve many body systems. We cannot, no matter what age we are, continue to work at a level that is all about survival.

I focus on girls and women because females outnumber the males coming to the clinic. Many are perfectionist, many are hypermobile, many are anxious, many are in pain and many are suffering. This is a situation that needs addressing worldwide, and starts with understanding what is happening, why it is happens and how it happens. Over the past 10 years this understanding has evolved enormously, providing tangible ways forward. This does not mean that we need to change perfectionism, but rather recognise it and use it wisely; this does not mean that anxiety is abnormal, but rather recognise it as a normal emotion that motivates learning and action; this does not mean that feeling pain is a problem to fear, but rather know it can change when we take the right action; and it does not mean that we will not suffer, but rather accept that part of living involves suffering that we can overcome and move on.

We have created an incredible, fast moving world. The body does not work at such a pace. It needs time to refresh and renew so that we can think with clarity and perform to a high level, achieve and be successful. We are humans. We are a whole-person with no division between body and mind; instead one thinking, feeling, sensing, creating, moving and living entity responding to the experience of the now and to memory of what we think happened. Gaining control over this with understanding and awareness provides a route forward to wellbeing, no matter where the start point.

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If you are suffering with persisting pains — body pain, joint pain, irritable bowel syndrome (IBS), headache, migraine, pelvic pain, jaw pain + feeling anxious, unwell, tired — call now and start moving forward 07518 445493 | Clinics in Harley Street, Chelsea and New Malden

12Oct/14
Still on the bench?

Athletes still on the bench?

Still on the bench?

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 

02Oct/14
Pain is a whole person experience

CRPS Research Update | October 2014 #CRPS

Physiotherapy LondonWelcome to the Complex Regional Pain Syndrome Research Update for October, a summary of the latest studies. 

If you are suffering with CRPS, I am here to show you how you can move forward — come and visit the CRPS clinic page here.

Spinal cord stimulation for complex regional pain syndrome type 1 with dystonia: a case report and discussion of the literature.
Voet C1, le Polain de Waroux B2, Forget P2, Deumens R3, Masquelier E4.

Abstract
BACKGROUND:
Complex Regional Pain Syndrome type 1 (CRPS-1) is a debilitating chronic pain disorder, the physiopathology of which can lead to dystonia associated with changes in the autonomic, central and peripheral nervous system. An interdisciplinary approach (pharmacological, interventional and psychological therapies in conjunction with a rehabilitation pathway) is central to progress towards pain reduction and restoration of function.
AIM:
This case report aims to stimulate reflection and development of mechanism-based therapeutic strategies concerning CRPS associated with dystonia.
CASE DESCRIPTION:
A 31 year old female CRPS-1 patient presented with dystonia of the right foot following ligamentoplasty for chronic ankle instability. She did not have a satisfactory response to the usual therapies. Multiple anesthetic blocks (popliteal, epidural and intrathecal) were not associated with significant anesthesia and analgesia. Mobilization of the foot by a physiotherapist was not possible. A multidisciplinary approach with psychological support, physiotherapy and spinal cord stimulation (SCS) brought pain relief, rehabilitation and improvement in the quality of life.
CONCLUSION:
The present case report demonstrates the occurrence of multilevel (peripheral and central) pathological modifications in the nervous system of a CRPS-1 patient with dystonia. This conclusion is based on the patient’s pain being resistant to anesthetic blocks at different levels and the favourable, at least initially, response to SCS. The importance of the bio-psycho-social model is also suggested, permitting behavioural change

RS: With CRPS we absolutely need to consider ‘multilevel’ modifications and adaptations within the nervous system but also how all the other systems that have a role in protecting us are functioning. This often manifests as habitual thinking and activities that maintain protection. Realising these habits, automatic by the nature of being a habit, and making changes with specific training creates new patterns of activity that head towards health.

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Longstanding Complex Regional Pain Syndrome is associated with activating autoantibodies against α-1a adrenoceptors.
Dubuis E1, Thompson V2, Leite MI3, Blaes F4, Maihöfner C5, Greensmith D6, Vincent A7, Shenker N8, Kuttikat A9, Leuwer M10, Goebel A11.

Abstract
Complex Regional Pain Syndrome (CRPS) is a limb-confined post-traumatic pain syndrome with sympathetic features. The cause is unknown, but the results of a randomized crossover trial on low-dose IVIG treatment point to a possible autoimmune mechanism. We tested purified serum immunoglobulin G (IgG) from patients with longstanding CRPS for evidence of antibodies interacting with autonomic receptors on adult primary cardiomyocytes, comparing with control IgG from healthy and disease controls, and related the results to the clinical response to treatment with low-dose intravenous immunoglobulins (IvIG). We simultaneously recorded both single cell contractions and intracellular calcium handling in an electrical field. Ten of 18 CRPS preparations and only 1/57 control preparations (p<0.0001) increased the sensitivity of the myocytes to the electric field and this effect was abrogated by pre-incubation with alpha1a receptor blockers. By contrast, effects on baseline calcium were blocked by pre-incubation with atropine. Interestingly, serum-IgG preparations from all four CRPS patients who had responded to low-dose IVIG with meaningful pain relief were effective in these assays, although 4/8 of the non-responders were also active. To see if there were antibodies to the alpha1a receptor, CRPS-IgG was applied to alpha 1a receptor transfected rat1-fibroblast cells. The CRPS serum IgG induced calcium flux, and FACS showed that there was serum IgG binding to the cells. The results suggest that patients with longstanding CRPS have serum antibodies to alpha 1a receptors, and that measurement of these antibodies may be useful in the diagnosis and management of the patients.

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A CRPS-IgG-transfer-trauma model reproducing inflammatory and positive sensory signs associated with complex regional pain syndrome.
Tékus V1, Hajna Z1, Borbély É1, Markovics A1, Bagoly T1, Szolcsányi J2, Thompson V3, Kemény Á1, Helyes Z2, Goebel A4.

Abstract
The aetiology of complex regional pain syndrome (CRPS), a highly painful, usually post-traumatic condition affecting the limbs, is unknown, but recent results have suggested an autoimmune contribution. To confirm a role for pathogenic autoantibodies, we established a passive-transfer trauma model. Prior to undergoing incision of hind limb plantar skin and muscle, mice were injected either with serum IgG obtained from chronic CRPS patients or matched healthy volunteers, or with saline. Unilateral hind limb plantar skin and muscle incision was performed to induce typical, mild tissue injury. Mechanical hyperalgesia, paw swelling, heat and cold sensitivity, weight-bearing ability, locomotor activity, motor coordination, paw temperature, and body weight were investigated for 8days. After sacrifice, proinflammatory sensory neuropeptides and cytokines were measured in paw tissues. CRPS patient IgG treatment significantly increased hind limb mechanical hyperalgesia and oedema in the incised paw compared with IgG from healthy subjects or saline. Plantar incision induced a remarkable elevation of substance P immunoreactivity on day 8, which was significantly increased by CRPS-IgG. In this IgG-transfer-trauma model for CRPS, serum IgG from chronic CRPS patients induced clinical and laboratory features resembling the human disease. These results support the hypothesis that autoantibodies may contribute to the pathophysiology of CRPS, and that autoantibody-removing therapies may be effective treatments for long-standing CRPS.

RS – as ever we must consider the role of the immune system but in the light of other systems as no system works in isolation to the others. There is vast interaction between the immune system, nervous system, endocrine system and autonomic nervous system to the point where I believe we are a single system interpreting and responding. One response maybe pain as part of protection and our systems become very good at protecting us — this is not to suggest that our systems and ‘me’ are separate entities. Whole person is the only way we can sensibly think about this.

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Local Anesthetic Sympathectomy Restores fMRI Cortical Maps in CRPS I after Upper Extremity Stellate Blockade: A Prospective Case Study.
Stude P, Enax-Krumova EK1, Lenz M, Lissek S, Nicolas V, Peters S, Westermann A, Tegenthoff M, Maier C.

Abstract
BACKGROUND:
Patients with complex regional pain syndrome type I (CRPS I) show a cortical reorganization with contralateral shrinkage of cortical maps in S1. The relevance of pain and disuse for the development and the maintenance of this shrinkage is unclear.
OBJECTIVE:
Aim of the study was to assess whether short-term pain relief induces changes in the cortical representation of the affected hand in patients with CRPS type I.
STUDY DESIGN:
Case series analysis of prospectively collected data.
METHODS:
We enrolled a case series of 5 consecutive patients with CRPS type I (disease duration 3 – 36 months) of the non-dominant upper-limb and previously diagnosed sympathetically maintained pain (SMP) by reduction of the pain intensity of more than > 30% after prior diagnostic sympathetic block. We performed fMRI for analysis of the cortical representation of the affected hand immediately before as well as one hour after isolated sympathetic block of the stellate ganglion on the affected side.
STATISTICS:
Wilcoxon-Test, paired t-test, P < 0.05.
RESULTS:
Pain decrease after isolated sympathetic block (pain intensity on the numerical rating scale (0 – 10) before block: 6.8 ± 1.9, afterwards: 3.8 ± 1.3) was accompanied by an increase in the blood oxygenation level dependent (BOLD) response of cortical representational maps only of the affected hand which had been reduced before the block, despite the fact that clinical and neurophysiological assessment revealed no changes in the sensorimotor function.
LIMITATIONS:
The interpretation of the present results is partly limited due to the small number of included patients and the missing control group with placebo injection.
CONCLUSIONS:
The association between recovery of the cortical representation and pain relief supports the hypothesis that pain could be a relevant factor for changes of somatosensory cortical maps in CRPS, and that these are rapidly reversible

RS – we are either in pain or not in pain. If our focus is elsewhere and we are not experiencing pain, then we are not in pain. Whilst this may sound obvious, many people tell me that they are in pain all of the time. When I ask about times that they feel no pain, an oft given answer is that the pain is hidden at times when they do not feel it. Pain cannot hide. It is on-off, binary. At any given moment, we are either in pain or not in pain. Every moment changes and hence pain can change in a moment — referring to the rapidly reversible change in maps in this article; and why wouldn’t we have the ability to rapidly adapt? I believe we can change and it happens in a moment — our thinking, actions and experiences. Consider how we can be happy in a moment, and sad in a moment. Happiness is a feeling, pain is a feeling. Both have a purpose, to motivate us to do something or think in a particular way. There is a desperate need to change the globe’s thinking on pain, this being my main purpose. In doing so, we can alleviate a vast amount of suffering from pain, narrowing it down the pain that we need for survival and eliminating the pain that persists for no good reason.

28Sep/14
London Fibromyalgia Clinics

Fibromyalgia in women | #fibromyalgia

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

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

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

Irritable Bowel Syndrome

Irritable Bowel Syndrome

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

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

 

 

29Aug/14
Conditions

There is no pain system

Pain is whole person

Pain is whole person

Many writers in health journals and magazines continue to refer to pain systems, pain pathways, pain signals, pain messages and pain receptors. There is no pain system, there are no pain pathways, there are no pain messages and there are no pain receptors.

Pain emerges from the body (or a space that has a representation in the brain in the case of phantom limb pain) and involves many body systems and the self. Where does pain come from? Well, it comes from the person describing the pain. Does it come from the back or the knee or the head? That is where you could feel it, but in order to feel it in a location we need our body systems to be in a protective mode and to be responding to a potential threat.

Pain is allocated a space where the body requires attention, and whilst this is a vital survival device when we have an injury, it is less useful when the injury has healed or there is no injury. This is the case in chronic pain, although there are reasons why the body continues to protect based on the fact that the perception of threat exists.

Pain is part of a protective response. Many other systems are also working to protect us: the immune system, the endocrine system, the autonomic nervous system, the sensorimotor system etc. — and all the systems that these impact upon, such as the gastroenterological system (how many people suffer problems with their gut at the same time as having persisting pain?).

So, in chronic pain we need different thinking because tissue or structurally based therapies do not provide a sustained answer. Instead we need to address the fact that persisting pain is as a result of the body’s on-going perception of threat. It is this that requires re-training alongside any altered movement patterns and a shift in body sense in order to successfully deal with pain and move on.

Specialist Pain Physio Clinics – transforming a life of pain to a life of possibility 

Call us to start now: 07932 689081 or email [email protected]