Tag Archives: Functional pain syndromes

24Oct/16

Women in pain

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

If society understood pain….

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

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

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

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

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

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

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

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

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

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

RS

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

 

 

 

22Oct/14

Girls, stress and pain

I 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….

In 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

06May/14

London Fibromyalgia Clinics | London FMS Clinics

London Fibromyalgia Clinics — I think differently about fibromyalgia, functional pain syndromes and chronic pain. Believing that there is a need to challenge the way these problems are addressed, I created a specialist clinic that draws upon neuroscience, philosophy and other disciplines to create innovative and effective ways for individuals to move forward in their lives.

Fibromyalgia is known as a functional pain syndrome, sharing a common biology with other problems such as migraine, irritable bowel syndrome (IBS), pelvic pain, musculoskeletal pain and painful bladder syndrome. This common biology is an adaptation in the central nervous system called central sensitisation with changes in the excitability of the nervous system alongside on-going responses of the immune system. The way that the body systems and the brain adapt and learn means that it has become persistently protective, igniting painful and other responses to a range of normal cues and situations. The sensitivity results in on-going pain and general sickness responses (e.g./ aches and pains, tiredness, fatigue, appetite changes, mood changes, anxiety, loss of concentration, brain fog, altered body sense); the latter just like a feeling of the flu.

Stress often plays a role. Stress is a response to a perceived threat, the meaning of which we give to the situation as an individual. The physiology that follows is designed to protect us from wild animals — either to run away or fight. Whilst this is useful when danger presents itself and in the short-term, if these responses continue, they impact upon the immune system, switch off the digestive system and reproductive system (neither eating or digesting a meal are useful in the face of danger; reproduction is not useful in the face of danger — resulting in a sensitive and/or sluggish gut, and fertility problems), prepare the motor system and mobilise energy in preparation for flight or fight.

It is a combination of genetics and experience that results in the condition. Our genes are moulded by these experiences and to what we are exposed: stress, injury, pathology. Protection is triggered but not turned off, the responses continuing as if there is a problem, even when it is resolved. These on-going responses then create further changes, for example chronic inflammation, and a continued loop that maintains the condition. That is until the circumstances are changed and the conditions created to move out of the loop and onto a route of wellbeing.

Believing that pain can and does change via neuroplasticity, I create bespoke treatment and training programmes for individuals who visit the clinic from all over the UK. The programmes ensure that you fully understand the problems and comprehensively target the biological mechanisms addressing the physical, cognitive and emotional dimensions. I help you to develop the knowledge and skills that you need to move forward in your life with a range of proactive strategies, techniques and treatments grounded in neuroscience.

Call now for more information or to book an appointment: 07518 445493

10Dec/13

Uncomfortably numb

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

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

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

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

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

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

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

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

05Nov/12

Women and pain | Part 1

 

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

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

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

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

Reconceptualising pain

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

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

Stress & emotion

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

Lifestyle

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

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

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