Tag Archives: Low back pain

11Jun/15

Stiff low back. Why?

Have you got a stiff low back? Stiffness is often part of the picture of low back pain. Why is this?

Stiffness is a conscious experience–a feeling that we sense, interpret and then label as ‘stiff’, usually describing difficulty moving a body part. And just like any other conscious experience, there are the embodied dimensions as well as cognitive and emotional elements: how does it feel? What does it mean for me? Hence to think about stiffness is to think about the body-body systems that create the feeling and meaning.

Stiff low back: there are three common types of stiffness that are addressed in different ways.

  1. Stiffness from actual shortening of the muscles and their compounding tissues
  2. Stiffness from muscles being told to be ‘on’
  3. Stiffness from changes at the joint

Stiffness from actual shortening occurs due to sustained positions or repeated positions being held so that the tissues change in their length. In so doing, there is less freedom of movement at the joints. This tends to gradually worsen as time progresses, with less and less movement at the joint causing further shortening. Regular movement, nudging into the limitation is key in overcoming this aspect of stiffness along with manual treatment that gives you the experience of movement into that part of the range. The manual treatment must sit alongside your understanding of what is happening and why this therapy is being applied, otherwise ‘top-down’ influences can interfere with success (see next section).

Stiffness from muscles instructed to be ‘on’ by the brain is part of the way that the body protects. Otherwise called guarding, the body-brain’s continual planning, expectation, anticipation and desire are embodied, responding to the environment and the context of the situation at that moment. Within our consciousness, different experiences seemingly appear and then fade away as others emerge. Stiffness and pain are no different in this respect, however they may emerge repeatedly in response to normal situations that pose no actual threat. But, due to the sensitive state and vigilance to the environment, non- or low threat stimuli are now interpreted as potentially dangerous and therefore the body responds. The first we know about this is the pain or tightening — the stiff low back. The pain and stiffness are motivators for us to take action, both in thought and behaviour. These thoughts and behaviours seek to reduce the threat and therefore reduce the pain (pain emerges in the person as a result of a perceived threat) and how the body is responding with it’s natural armour, the muscular system. As the need for defence diminishes, so the muscle tension eases and movement improves.

What reduces the threat and muscle tension?

  • Relaxation–this is a skill to learn
  • Mindfulness
  • Understanding pain and knowing that you are ‘safe’
  • Motor imagery

Changes at the joints can, but not always, affect the quality of movement. It is not a given that if your joints show arthritic change, movement will be problematic. Many people have arthritis but suffer no pain or stiffness. Whether you feel pain and stiffness or not is determined by many inter-related factors: e.g./ genetics, gender, past experience, beliefs, expectations, the environment; also known as pain vulnerabilities that all have an underpinning neurobiology that is becoming increasingly understood.

If you enjoyed this blog, please visit my Facebook page here and ‘like’ and/or my Twitter page here and retweet — thanks!

* Visit my home page here for details for appointments.

 

 

 

09Jun/15

Do you have persisting low back pain?

Persisting low back pain is common. It is the number one global health burden (Vos et al. 2012) and hence is the cause of much suffering,  and personal and societal cost. We need a re-think, because the misunderstanding of pain is at the root of this vast problem, especially when it comes to chronic low back pain: persisting or recurring.

I see people every day with chronic low back pain. It is one of the main vehicles that brings patients to my clinic. In many cases, chronic low back pain is part of the presentation with other complaints and problems including widespread pain, anxiety, irritable bowel syndrome, headaches, migraines, pelvic pain, disturbed sleep, poor concentration and performance at work, relationship disharmony and fertility issues. Is there a connection between these seemingly disparate issues? Yes. And by focusing on the whole-person, as suggested by the latest thinking in pain neuroscience, neuroscience and philosophy, we can create a tangible way forward.

So what can we think about? Here are some ideas with examples:

1. What is pain all about in this person?

  • Protection

2. How is the persisting back pain emerging in the individual?

  • Where in the body is the protection emerging?
  • Which (protective) body systems are interacting?
  • What is the context for the pain?
  • What features of the individual’s narrative suggest a vulnerability to persisting pain?
  • What habits of thought and action (the two being utterly entwined) exist?

3. What are the person’s beliefs about pain?

  • Pain = damage?

4. Why is the pain persisting?

  • Vulnerabilities to chronic pain
  • Is there a good reason for the pain to persist? Is it useful somehow, indicating a need for more action?

5. What needs to be done?

  • Understanding — the right thinking, pain can change
  • Create the opportunity for change
  • What action is required on a moment to moment basis?
  • Development of motivational skills and resilience
  • Persistence, courage, focus, determination

This is merely an insight, and conveniently broken into sections. There is no prescription, just facts about pain that we must work with and employ within a whole-person centred approach to overcoming persisting low back pain and other persisting pain problems.

For further information about treatment and coaching programmes to overcome pain, call now: 07518 445493

* Specialist Pain Physio Clinics: Harley Street | Chelsea | New Malden

 

23Mar/15

I used thirst to help someone understand pain

I used thirst to help someone understand pain. He had been given the structural explanation for recurring low back pain (trapped nerve that runs all the way to the toes), which naturally leads to a tissue based focus on ways to get better. Whilst this is a common way to describe pain, it is wrong. Pain is a protective response to a perceived threat.

Yes, if a nerve is sensitised by inflammation or injury, it will transmit danger signals to the spinal cord and then the brain. All the while, signals are being sent down from the brain to mingle with these ascending signals, the sum of which will be scrutinised by brain networks to determine whether a threat exists. If there is a threat deemed tangible, then the body will protect itself with pain, altered movement, altered thinking and altered behaviours:

  • it hurts in a location
  • you limp or limit how far you move the painful area
  • you consider how bad it is and whether you can go to the party, game, work etc
  • you don’t go to the party, the game, work etc

This is all very useful at the outset, but becomes less so as time goes on and the body is healing.

Often there is a kindling or priming effect. The first acute painful episode calms down but then recurring bouts of pain become more intense and with less and less time between–familiar? In the first instance, the systems that protect do so effectively, slowing you down and enforcing action to allow healing. This would usually be in response to inflammation, and is all entirely normal whilst being an unpleasant experience. Not nice, but nothing to worry about. Of course, you would be wise to take heed and do everything that you can to fully recover, which means that the tissues heal and the protective systems switch back to normal modus operandi. There is a chance that you will need some guidance.

It appears that there are some people who maybe vulnerable to developing on-going pain, which is on-going protection. There is likely to be a genetic aspect to this, and certainly a prior experience that may have primed the systems so that they kick in more vigorously, or simply do not turn off when they need to. An over-protect or sensitivity. The priming event(s) may happen much earlier in life so that when the body perceives a threat some years later, there is recognition of the need to protect based upon what has been learned before. Detecting this potential vulnerability is really important in the assessment so that the right action can be taken to counter on-going pain.

Back to thirst.

Where do you feel thirst? Think about it for a minute. Where in your body is thirst? It is not a dry mouth; so it is not your mouth (a dry mouth is a dry mouth and that is all). Is it in your stomach or chest? We have a sense of discomfort that can include a dry mouth, and when we note that sense we give it a meaning. That meaning is “I am thirsty’. The point of this is to motivate us to take action and seek water to quench the thirst.

The same happens in pain. We have a feeling or sensation in our body that grabs our attention. This sensation is given a meaning: this hurts, and then we look for a cause, why does this hurt? What have I done? What is going on? What are the implications, now and in the future? Naturally this happens very quickly, in a split second. The pain then motivates us to take action, like thirst. We rub, cry out, seek help.

In both thirst and pain it is the meaning that defines the experience, and whilst we feel things in certain places, it is how we think about them that gives the richness and implication. We therefore have these experiences with our whole body and self. We feel and experience thirst with our whole body, the sensation not distinct from how we then think and act. The same in pain. To se the whole creates marvellous opportunity for change, growth and moving forward. In most cases thirst is easily overcome, chronic pain being far more challenging.

Chronic pain is about on-going perception of threat as body systems adapt, we adapt and the world around us adapts. We are on a continuous timeline of development that we can influence by our knowledge, understanding and use of skills. Understanding your pain is the first step, creating a foundation for overcoming pain.

Pain Coach

Pain Coach courses for clinicians and therapists: a practical way to coach chronic pain sufferers how to overcome their pain; small group learning and 1:1 mentoring. Call us on 07518 445493

28Mar/14

Relieving low back pain — keeping it simple but effective

Back pain is very common and most people will experience it. Many reasons are given for back pain, usually blaming the discs (they are not discs but rather amazing structures that work with the vertebrae to allow movement and force transduction — they are also very robust), joints, muscles and posture.

The simple fact is that the pain we feel in our body is not because of a structure. It is because our brain thinks we are in danger, or the tissues in the area of pain are in danger or potential danger, a warning. Pain is an output from the brain that is detected in the body, driving and motivating protective behaviours. This can be helpful in the acute stages of pain, but as time moves forward and the tissues heal (if they have been injured), these learned strategies become part of the problem. The pain persists, the alarm bells go off during normal activities (e.g. sitting, standing, walking) and we continue to behave as if we need to protect healing tissue. This on-going guarding, change in movement and adapted activities causes many problems including pain and fear.

Breaking the habits of protection and guarding are essential. The increased and inappropriate use of muscles in the back means that they work hard, too hard. Similar to a challenging workout, there is post-exercise soreness and pain, except this is happening on a day to day basis. Re-training the way the brain is activating muscles is vital but to do this, firstly you must understand that you are safe. The movements that re-educate normal movement are simple and can be done at home, at work, in the garden, in the park, anywhere that promotes safe and varied actions. This safety comes from an individual’s understanding of pain. So, this is the first step, making sure that pain is understood in the context of the patient’s narrative.

Understanding pain plus simple movements to develop body sense, nourishment for tissues (‘motion is lotion’) on a consistent basis (again very simple moves with feedback and a sense of safety) and skills to calm systems that are on alert to protect such as mindfulness or relaxed breathing. A basic movement can be primed and used in many different ways to represent the variance we experience every day. The brain loves variety and if it feels safe, you will be able to gradually build your activities back up to recover and get back to having fun.

Here are my formulae:

Understand pain + simple movements + confidence + feedback = reduced threat

Reduced threat + gradual increase in activities + mindfulness = pain relief and resolution of normal activities

13Jan/14

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

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

Why may this be?

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

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

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

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

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

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

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

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

 

23Sep/13

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

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

Microdiscectomy – what is it?

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

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

Preparing for surgery – see here

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

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

Early recovery

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

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

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

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

08Aug/13

Suffering surfer

Spending time in the West Country you cannot help but be drawn into the culture of surfing. Whether it be watching the action from the beach, taking a lesson, going shopping in one of the vast array of surf outlets or sitting in a cafe watching footage of surf champs (the most intriguing are those that illustrate the 60s and 70s surfers in sepia without the modern day equipment). So, taking in a healthy infusion of the lifestyle so removed from the metropolis, I asked a local instructor Pete from @KingsurfNewquay (King Surf, Mawgan Porth) about the types of pain and injuries that surfers suffer.

Like most outdoor adventurers, these guys and girls are robust. They don’t moan but rather get on with their pursuit and deal with aches and pains at the end of the season. Of course this may not be the best course of action, however there is a way or perhaps a code that is unwritten but known and communicated with expressions and colloquialisms such as the ‘sea ulcer’. This is not something you find on a rock but rather a breakdown of flesh that struggles to heal despite the fitness of the surfer. Simply due to the repeated friction with certain parts of the board and the hours spent in the sea water, the healing process struggles to keep up with the repeated damage.

Pete tells me that the commonest pains are in the back and knees. Another instructor Nick, adds in shoulders. Both agree that in fact you can experiences aches and pains in different places across the body that seemingly pop up randomly. Of course the reality is that these aches and pains are not random at all, but part of the body’s incredible protective device in action, responding to perceived threats.

Briefly, why would these areas predominate? The paddling action requires a great deal of shoulder use, the back is often held in extension and there is a fair amount of twisting force about the knees. That could be an explanation that would make sense to most people however, we have to ask about those who make the same actions yet feel no pain. We must also consider the fact that any sports or physical activity is accompanied by the pain of exertion that is entirely normal. Most people are familiar with the pain that follows a new exercise regime or an unaccustomed activity that lasts for a few days. This type of pain usually settles, however if you do not allow the body to adapt to the demand, you could further wind-up the sensitivity and see a more persisting pain develop.

Pain is a response to a perceived threat. Who does the perceiving? Actually it is the brain that works out the threat value of what is going on, even if we know the activity is not really dangerous. The problem is that the ‘output’ from the brain when it perceives threat to the body is pain in most cases, and this really feels like you have injured something, even if you haven’t. This is often the situation when we have a persisting problem. In an acute injury, the pain is a vital attention grabber so that we take a course of action to promote survival and healing. It hurts when we move or touch the area which is very useful and adaptive in the first days as the inflammation takes hold and kick starts the process of repair. Other responses include changes in motor control, blood flow and sometimes we are aware the we feel and think differently, more protectively. We guard and make decisions based on how the body feels. This is all entirely normal. As the healing process rolls on, the sensitivity often reduces and movement becomes easier, and we resume activities as before. Often to encourage the right conditions and to ensure that we restore normal control of movement and sense of the body, we follow a rehabilitation programme that may be accompanied by treatment. This is typically effective when we fully understand the injury, the mechanisms and our role in proactively rehabilitating the problem both physically and mentally.

In some cases, and these are the cases that I specifically see, the pain and sensitivity persist or recur. Why is this?

Scientists continue to research why people continue to suffer pain. Approximately 1:5 people have an on-going pain and although many are able to continue with their normal lives, there are those who are unable to work or play. Clearly there is a spectrum and between these ends are individuals who suffer but persevere with their activities. This often includes sportsmen and women who ‘patch’ themselves up and keep going. Admirable though this is, it may not be doing them any favours in the longer term. One major issue is that often it is these individuals who rely upon their body and an ability to be active for their income. This will clearly change the context and as regular readers will know, context in pain is a key factor for the meaning of the pain and consequently the on-going response.

What we do know is that in the early stages of an injury, if the sensitivity builds and causes changes in the central nervous system (central sensitisation) this mechanism will underpin persisting pain. This will typically occur when a nerve is injured. Nerve tissue in the periphery (body) can be damaged like any other soft tissue except that the injury causes changes in the spinal cord and higher centres manifesting as a widened area of pain, changing locations and a reduced ability of the nervous system to inhibit the sensitivity. Altered function of specific cells in the brain stem also affect both the facilitation and inhibition of the flow of danger signals thereby amplifying the sensitivity under certain circumstances. Inflammation can also cause persisting sensitivity from the periphery as the molecules bathe the nerve endings, ramping up their excitability.

The key point to remember is that pain is not an accurate indicator of tissue damage. Phantom limb pain is the classic example with their being no tissue (limb) yet the sensation of pain exists. This is because the brain perceives a threat in a limb that despite not being present, still has a representation in the brain. The body is mapped out in the brain, allowing the brain to know where sensory information is coming from with accuracy and to control precise movement. Motor and sensory function is integrated to create the ‘concrete’ sense of self that we experience. The feeling of our body is constructed by the brain as is the visual field we experience. Both vision and pain share common features in that the brain receives information and creates a reality that we feel and sense to be true. As we know from the great illusionists and many other life situations, our experience of ‘reality’ is hugely variable and often suggestible—how scary is a dark corridor after watching a horror movie? How quickly do we move after repeating a train of words pertaining to youth?

Knowing pain helps us to rationalise fears that we may have and thereby create the right conditions to move forward. To change a state of persisting pain we must be proactive but this requires the understanding of pain, the development of confidence in using the body self-sustaining tissue nourishing techniques and strategies that re-train the way in which the brain is protecting the body on the basis that the real threat is diminishing.

For the surfer who has to keep going for competition or livelihood, gathering knowledge as described above, and integrating a range of strategies into the day will be important in re-learning normal movement patterns rather than guarded postures. Pain has physical, cognitive (what we think) and emotional (how we feel) dimensions, and all must be addressed in an on-going pain state as they are entirely interdependent. For example, regular simple movements of the affected body areas that are tolerable and develop confidence as well as nourish tissues that have often become tense with a consequential poorer oxygen supply, neurodynamic movements to mobilise the nervous system and the interfacing tissues, pacing activities and mindfulness practice. With any exercise routine, it is not enough just to consider the movement itself but also the mindset, any known factors that could prime the neuroimmune system (eg/ fear of movement, stress, fatigue, previous activities) and the timing. I consider a good analogy to be taking a prescribed drug that seeks to alter physiology in the body as does exercise. Except exercise and movement when performed with confidence has a wider positive effect physically and mentally. It is the best drug we know!

Suffering persisting pain is more common than most people realise. With perhaps 20% of the population experiencing on-going pain, we need a wider shift in understanding and knowing our own pain so that we can create the right conditions for change. We are fundamentally designed to change, learn and grow with the neuroplastic characteristics of the neuroimmune system, it is just knowing how to access these mechanisms proactively and in a self-sustaining manner in order to attain the freedom we desire.

If you suffer persisting pain or injury, contact us to learn how you can creat the conditions to move forward: 07932 689081

20130808-124326.jpg

23May/13

The Chelsea Flower Show, gardening and back pain

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

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

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

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

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

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

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

13May/13

Posture | Embodiment of what we are doing and thinking

Back pain and neck pain are very common and costly problems, both personally and economically. Many people suffer bouts of such pain and some continue to suffer on-going pain and consequences.

Posture is often quoted as being a causative factor although this is really too simple to explain back pain and neck pain. Of course, when we are suffering pain, the way in which we sit and stand has a bearing upon the pain with some positions making the pain worse and some offering relief. In very acute episodes or during a flare-up, an unfortunate individual may find it very difficult to find any comfortable position although this is usually short lived – if you are currently experiencing such pain you should seek the advice of your doctor or healthcare professional as early pain relief, perhaps by medication, is very important for early coping.

When we are sitting in a particular form, we embody what we are doing and thinking about. This means that the effects of maintaining a position are not purely a consequence of the posture but rather a combination of the body’s configuration and what is going on physiologically. In particular, I am referring to the effects of stress when we perceive a situation to be out of our control. This in combination with the particular posture is what leads to pain and discomfort in the ‘end organ’, the musculoskeletal tissues of the body.

What emerges when we sit for long periods at the desk is a consequence of how we are sitting, what we are thinking and how we are feeling

There are some fundamental factors to address when treating low back pain and neck pain. These include education about the pain mechanisms and the problem to reduce the threat and empower the individual to be proactive and the maintenance of activity levels. Around this can be a range of therapies and strategies that should all point the compass towards the restoration of healthy movement and healthy metaphor, both emergent from the individual.

A significant consideration for developing healthy tissues and movement is posture as a construct of the aforementioned factors: position + cognitive/emotional state. Addressing this in detail is vital, especially for those who spend time at a desk, as this is a large chunk of their time. It is not simply a case of suggesting an ‘ideal’ posture but rather an active, nourishing approach to the physical, cognitive and emotional dimensions of pain.

For more details on our proactive postural programme for individuals and businesses call us now: 07932 689081 or email: [email protected]

 

 

28Feb/13

Fibromyalgia and the autonomic nervous system

Several recent papers have looked at the autonomic nervous system in fibromyalgia – see below

Clin Physiol Funct Imaging. 2013 Mar;33(2):83-91. doi: 10.1111/cpf.12000. Epub 2012 Nov 4.

Autonomic nervous system profile in fibromyalgia patients and its modulation by exercise: a mini review.

Kulshreshtha P, Deepak KK.

This review imparts an impressionistic tone to our current understanding of autonomic nervous system abnormalities in fibromyalgia. In the wake of symptoms present in patients with fibromyalgia (FM), autonomic dysfunction seems plausible in fibromyalgia. A popular notion is that of a relentless sympathetic hyperactivity and hyporeactivity based on heart rate variability (HRV) analyses and responses to various physiological stimuli. However, some exactly opposite findings suggesting normal/hypersympathetic reactivity in patients with fibromyalgia do exist. This heterogeneous picture along with multiple comorbidities accounts for the quantitative and qualitative differences in the degree of dysautonomia present in patients with FM. We contend that HRV changes in fibromyalgia may not actually represent increased cardiac sympathetic tone. Normal muscle sympathetic nerve activity (MSNA) and normal autonomic reactivity tests in patients with fibromyalgia suggest defective vascular end organ in fibromyalgia. Previously, we proposed a model linking deconditioning with physical inactivity resulting from widespread pain in patients with fibromyalgia. Deconditioning also modulates the autonomic nervous system (high sympathetic tone and a low parasympathetic tone). A high peripheral sympathetic tone causes regional ischaemia, which in turn results in widespread pain. Thus, vascular dysregulation and hypoperfusion in patients with FM give rise to ischaemic pain leading to physical inactivity. Microvascular abnormalities are also found in patients with FM. Therapeutic interventions (e.g. exercise) that result in vasodilatation and favourable autonomic alterations have proven to be effective. In this review, we focus on the vascular end organ in patients with fibromyalgia in particular and its modulation by exercise in general.

++++++++

Clin Auton Res. 2012 Jun;22(3):117-22. doi: 10.1007/s10286-011-0150-6. Epub 2011 Oct 25.

A comprehensive study of autonomic dysfunction in the fibromyalgia patients.

Kulshreshtha P, Gupta R, Yadav RK, Bijlani RL, Deepak KK.

Abstract

OBJECTIVES:

The hypothesis of autonomic nervous system involvement in pathophysiology in the patients with fibromyalgia has been addressed and tested time and again but the existing reports are both contradictory and inconclusive. A complete knowledge of the degree of autonomic dysfunction in fibromyalgia patients would be more substantial. We conducted a comprehensive non-invasive study to investigate the complete autonomic profile of female patients with fibromyalgia.

METHOD:

An autonomic function test using a standard battery and heart rate variability analysis in the 42 fibromyalgia patients as well as 42 age matched healthy controls was performed. Both autonomic activity (tone) and reactivity were measured. Autonomic tone (both time and frequency domain parameters) was measured using heart rate variability (HRV) analysis. Autonomic reactivity was measured using a standard battery of autonomic function tests.

RESULTS:

Resting blood pressure (both systolic and diastolic) was significantly higher in the fibromyalgia patients than controls. The time domain variables and HF% as recorded by HRV were significantly lower in the patients than the controls. The autonomic reactivity for sympathetic and parasympathetic nervous system was found to be within normal limits.

INTERPRETATION:

The cardiac autonomic function is normal and the autonomic reflex arc seems to be intact in the patients with fibromyalgia.

++++++++

It seems that ANS function may be normal in fibromyalgia. Of course there are many other factors to consider including the role of the immune system, central sensitisation, the endocrine system and the effects of stress.

In common with other persisting pain problems, fibromyalgia is a multidimensional and multisystem condition and must be addressed as such. Exercise has a role in that we need movement and exertion at an appropriate level for normal health. Of course any physical activity must be organised, planned and be titrated to the individual, similar to a drug. There must also be confidence in the activity and coping skills for the effects of exercise to deal with hypervigilance and catastrophising that often feature.

Fibromyalgia is a functional pain syndrome. Often in the clinic we see individual’s with more that one functional pain, for example pelvic pain, dysmennorhoea, IBS, migraine, bladder dysfunction and TMJ pain. We address these problems at source by using strategies that target the pain mechanisms and address the physical-cognitive-emotional factors that are integral to fibromyalgia and other enduring pain states.

RS – Specialist Pain Physio Clinics, London