Tag Archives: pain

09Dec/11

Top 3 recommended books

These three titles I frequently recommend to patients to help develop the necessary deeper understanding of pain, stress and the role of the mind in physical health. They are all extremely well written and designed to educate to promote change towards more healthy behaviours. This sits exactly with my approach to physiotherapy for painful conditions that are complex, chronic or often both.

Painful Yarns by Lorimer Moseley

‘Moseley is pain management’s answer to James Herriot. This book capture that illusive ability to both educate and entertain’. Dr Micheal Thacker, Pain Sciences Program, Kings College London

‘I love a good story…..but the best thing was that when the stories were compared to how pain works, it made sense’. Dimos, lorry driver with chronic back pain

Available from NOIgroup 01904 737919

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Why zebras don’t get ulcers by Robert Sapolsky


Now in a third edition, Robert M. Sapolsky’s acclaimed and successful Why Zebras Don’t Get Ulcers features new chapters on how stress affects sleep and addiction, as well as new insights into anxiety and personality disorder and the impact of spirituality on managing stress. As Sapolsky explains, most of us do not lie awake at night worrying about whether we have leprosy or malaria. Instead, the diseases we fear – and the ones that plague us now – are illnesses brought on by the slow accumulation of damage, such as heart disease and cancer. When we worry or experience stress, our body turns on the same physiological responses that an animal’s does, but we do not resolve conflict in the same way – through fighting or fleeing. Over time, this activation of a stress response makes us literally sick. Combining cutting-edge research with a healthy dose of good humour and practical advice, Why Zebras Don’t Get Ulcers explains how prolonged stress causes or intensifies a range of physical and mental afflictions, including depression, ulcers, colitis, heart disease, and more. It also provides essential guidance to controlling our stress responses. This new edition promises to be the most comprehensive and engaging one yet.

Available from Amazon here

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Mindfulness by Mark Williams & Danny Penman

‘If you want to free yourself from anxiety and stress, and feel truly at ease with yourself, then read this book.’ –Ruby Wax

‘You would do well to put yourself in the experienced hands of Mark Williams and Danny Penman, and give yourself over to their guidance and to the programme that they map out.’ –Jon Kabat-Zinn

‘Want a happier, more content life? I highly recommend the down-to-earth methods you*ll find in ‘Mindfulness’. Professor Mark Williams and Dr. Danny Penman have teamed up to give us scientifically grounded techniques we can apply in the midst of our everyday challenges and catastrophes’ –Daniel Goleman, Author of ‘Emotional Intelligence’

‘Peace can’t be achieved in the outside world unless we have peace on the inside. Mark Williams and Danny Penman’s book gives us this peace’ –Goldie Hawn

‘Want a happier, more content life? I highly recommend the down-to-earth methods you’ll find in ‘Mindfulness’. Professor Mark Williams and Dr. Danny Penman have teamed up to give us scientifically grounded techniques we can apply in the midst of our everyday challenges and catastrophes’ –Daniel Goleman, Author of ‘Emotional Intelligence’

Available from Amazon here

21Oct/11

Using neuroscience to understand and treat pain

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

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

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

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

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

29Sep/11

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

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

 

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

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

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

26Sep/11

Dysmenorrhoea and Pain

Dysmenorrhoea and pain — You may wonder why I am writing about dysmenorrhoea. It is because in a number of cases that I see, there is co-existing dysmenorrhea and other functional pain syndromes. These include irritable bowel syndrome (IBS), migraine, chronic low back pain, pelvic pain, bladder pain and fibromyalgia. Traditionally all of these problems are managed by different specialists with their particular end-organ in mind—e.g./ IBS = gastroenterologist; migraine = neurologist; fibromyalgia = rheumatologist. The science however, tells us that these seemingly unrelated conditions can be underpinned by a common factor, central sensitisation. This is not a blog about dysmenorrhoea per se, but considers the problem in the light of recent scientific findings and how it co-exists with other conditions.

 

Central sensitisation is a state of the central nervous system (CNS)—the spinal cord and the brain. This state develops when the CNS is bombarded with danger signals from the tissues and organs.  It means that when information from the body tissues, organs and systems reaches the spinal cord, it is modified before heading up to the brain. The brain scrutinises this information and responds appropriately by telling the body to respond. If there is sensitisation, these responses are protective and that includes pain. Pain is part of a protective mechanism along with changes in movement, activity in the endocrine system, the autonomic nervous system and the immune system. Pain itself is a motivator. It motivates action because it is unpleasant, and provides an opportunity to learn—e.g./ do not touch because it is hot. This is very useful with a new injury but less helpful when the injury has healed or there is no sign of persisting pathology.

Understanding that central sensitisation plays a part in these conditions creates an opportunity to target the underlying mechanisms. This can be with medication that acts upon the CNS and with contemporary non-medical approaches that focus upon the spinal cord and brain such as imagery, sensorimotor training, mindfulness and relaxation. In this way, dysmenorrhoea can be treated in a similar fashion to a chronic pain condition although traditionally it is not considered to be such a problem. The recent work by Vincent et al. (2011) observed activity in the brains of women with dysmenorrhoea and found it to be similar to women with chronic pain, highlighting the importance of early and appropriate management.

The aforementioned study joins an increasing amount of research looking at the commonality of functional pain syndromes. We must therefore, be vigilant when we are assessing pain states and consider that the presenting problem maybe just part of the bigger picture. Recognising that central processing of signals from the body is altered in a number of conditions that appear to be diverse allows us to offer better care and hence improve quality of life.

* If you are suffering with undiagnosed pain, you should consult with your GP or a health professional.

12Sep/11

Physiotherapy in Chelsea

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

T 07518 445493

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

Knowledge and healthy movement for normal self

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

Come and visit our blog for regular articles and information.

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

T 07518 445493

09Jun/11

Complex Regional Pain Syndrome – ‘it feels weird’

Complex Regional Pain Syndrome (CRPS) often presents with a number of signs and symptoms. The main complaints are usually pain, colour change (minute to minute sometimes), temperature change, swelling, sweating changes, skin/nail/hair changes (trophic) and an altered perception of the affected part. It is this last sense that I am going to focus upon in this blog.

I hear many different descriptions of the symptoms of CRPS and actually encourage the use of a wide range of words. This is so that I can develop a really good picture and insight into the individual’s experience which is exactly that, individual. One aspect that I am particularly interested in is the perception of the affected area. In the vast majority, if not all, cases there is an altered sense of the region. For example, in the case of the hand it can feel bigger (sausage fingers often a good description of the feel), swollen, distorted, out of place, detached, like it belongs to someone else, like it is not there unless looked at (visual input to confirm presence) or denial that it is there at all (denial – similar to those who suffer strokes).

This variety of descriptions paint the picture of a ‘stranger’ aspect of the condition, often claimed to be ‘weird feelings’ as they are so abstract and like nothing before. Clearly this can be worrying and sometimes I hear that when the descriptions are given to others there maybe disbelief. Any aspect of a problem that creates fear or anxiety can affect pain and must be addressed.

So what is going on? When we have an on-going painful problem and we are not moving normally, changes occur within the central nervous system to give us this different experience. In the brain we have maps, virtual maps, that the brain uses to work out where sensory information is coming from and control movement. These maps are well defined under normal circumstances with a genetic blueprint that is moulded by experiences. This precise definition relies on a constant stream of information coming in from the tissues. In the case that this flow is altered or stopped, the map changes. We know this from fMRI studies that demonstrate reorganisation of the brain in certain areas. Certain representations of body parts are found to be in different locations in pain states. In fact, many brain changes have been found in chronic pain, these changes underpinning our different experiences of the body. The good news is that with effective treatment of the pain, these changes are reversed. Effective treatment will be the subject of another blog, but this includes such therapies as graded motor imagery and others that seek to ‘redefine the maps’.

In summary, chronic pain states, including CRPS and back pain, we know that the cortical (brain) maps change and that this is the reason why the affected area can feel ‘weird’, out of place and just not right. The map is ‘smudged’. In a sense this is useful as it draws our attention to something that needs dealing with imminently. The focus of treatment for this is upon ‘redefining’ the maps, the same for a range of conditions. In fact, my view is that this is what modern rehabilitation is really about in essence, via normalisation of sensation, motor control and the congruence of these factors, alongside the traditional strength gains and tissue changes. Our understanding of smudging and cortical reorganisation has triggered a change in thinking for rehabilitation, targeting the brain, training the brain and offering science based solutions for chronic pain.

 

05May/11

Managing your flare-up

A flare-up is when the symptoms increase for a period of time. Sometimes it is clear why this happens such as after new activities or exercise, an increase in activity levels, when you are unwell, stressed or fatigued. In other cases there is no obvious reason as the routine has not changed and you cannot think of a reason why the pain has worsened.

Your brain will know why as it is responding to a potential threat. The brain is constantly monitoring the body and the environment through the senses and other body systems (e.g. endocrine, immune) and responds accordingly. Visual input has a significant effect and when we see others moving in a particular way or doing certain tasks, a threat value can be determined even though it is not ourselves doing it! For example, observing someone bend over and pick up a heavy box can evoke pain in our backs. The message is that our pain and perception of our body can change in response to things that we see.

So what do you do?

To manage a flare-up actively means that you can ride the storm more effectively and also learn about the process for greater effect if there is a further flare later on. In essence it is trying to remain active but tolerably.

1. Continue to break up sustained activities into chunks (pacing) as instructed by your therapist in terms of the timing. I would suggest as a ball park figure that 50% of the time it takes for the pain to enforce a change or cessation of activities should be a start point.
2. ‘Little & often’: change position, move affected body part (avoid the area stiffening and provoking a worry about then moving) and other areas.
3. Use your prescribed exercises but in a calm way, i.e. Relaxed or meditative breathing before to ‘calm the seas’, think positively rather than dwelling on negative thoughts that can evoke other brain responses. Be flexible in the repetitions, for example, split the sets into shorter bouts but spread out over the day.
4. Before moving the affected area or undertaking the exercises, move regions that are remote or on the other side first. For example, if it is a foot problem, move the other knee and foot first, or the hip and knee on that side initially.
5. Pain relief as prescribed
6. If you are feeling unwell with a flare-up, manage as if you are sick. Your body is in a restorative mode and you must treat it as such, including rest periods.
7. Remember that this flare-up will pass.

Take the advice of your health professional in terms of the timings, repetitions and exercises. All activities should not be causing further increases in symptoms. It should be tolerable.

Little and often
Motion is lotion
Be consistent with your activities

For further information contact us on 07518 445493

21Apr/11

Aches & pains, stresses & strains

 

Treatment Programme for life’s ailments

Aches and pains are a normal part of life, reminding us that we are doing too much, too little or something potentially injurious. Classically, sitting at the desk for hours, using a computer mouse repeatedly, texting and emailing on phones with small keypads, going from being sedentary all day to exercising furiously in the morning, at night or at the weekend, all can lead to aches and pains. Much of the time we expect this to be the case such as after a good workout, when re-starting at the gym or following an unusual bout of DIY. We can explain it, the pain has a meaning and often a short lifespan.

Whether we experience pain or not is not as simple as ‘we do some physical activity and then the tissues hurt’, but rather it comes down to the brain’s analysis of whether there is a threat to our tissues or not. So, we can do all sorts of activities, but it will only hurt when there is a perception of danger. The brain receives signals from the body tissues and organs, maintaining an ‘online’ monitoring system via a huge network of nerves that send messages to the spinal cord. These messages are then passed upwards to the brain for scrutiny. If, and that’s a big if, there is a sense of danger based on this information and past experience, the brain will protect the affected area and make it hurt. If there is no perceived danger, it simply won’t be painful. Good examples of this are phantom limb pain that is a sense of pain in a limb that is no longer present and battlefield stories of severe trauma yet no pain. The long and the short of it is that pain is not an accurate indicator of tissue damage as borne out in huge amounts of research that has been done over the years. This knowledge has advanced our ability to understand pain and treat it in a better way (for further information see our page dedicated to pain).

The aches and pains that we feel are influenced by a number of proven factors. These include stress, emotional state, fatigue, hormones, the immune system, past experience, culture, our beliefs about pain, gender and expectations to name but a few. Understanding this is very important for successful management and treatment as these factors need to be identified and dealt with appropriately. This approach is called the biopsychosocial model of care and deemed to be the best way of looking at and treating pain. We consider the biological mechanisms, the psychology and social impact. For example, a violin player cuts his index finger: biology includes inflammation that hurts, healing and changes in blood flow; psychology that would be thought about how this will affect his/her ability to play, ‘it’s a disaster’, anxiety about the future, I believe this will heal quickly; and social impact considers the fact that he/she cannot play and therefore there is no income this wee. Clearly there is more to it but this brief overview helps conceptualise the model and that the components are inter-related.

So the aches and pains of life are there and common and can become persistent, annoying, frustrating and affect ones ability to enjoy life. Our tolerance for the challenges we face may diminish and activity levels can drop and the downward spiral can begin. It could be that it is an old injury that recurs periodically or improved but never really resolved. Whatever the scenario, if the aches and pains, stresses and strains of life are too loud and bothersome or just there in the background nagging away, we have a programme for you that provides integrated treatment, strategies to develop resilience, relaxation and education so that you can understand what is happening to increase awareness allowing for change. The course is based on the latest understanding of pain, stress and health to offer informative, active, fun and effective ways of enjoying your body and life.

The basic programme consists of an assessment to determine the nature of the problem(s) followed by six 30 minute sessions. During these sessions you will receive an explanation of the problem including the causes and influences, treatment (this can include soft tissue massage, joint mobilisation, acupuncture), an exercise programme to focus upon stretching, mobilising or strengthening particular body regions, mindfulness techniques and breathing exercises. The programme parts create a synergy that targets body, brain and mind for better physical and psychological health.

Having completed the programme you are welcome to add sessions for ‘top ups’ on a individual or a single session basis.

To book, call now 07518 445493

Please note that if further investigations or a referral to see a consultant are required, a letter will be provided and recommendation made so that this can be actioned rapidly. Subsequently the programme or specific treatment can be started.

19Apr/11

Complex Regional Pain Syndrome (CRPS/RSD)

Complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD), is undoubtedly a nasty condition in many cases. It can be hugely disruptive in the desire to lead a normal and fulfilling life due the experience of sheer pain and the difficulty in doing day to day activities.

I hear a huge range of stories of how the problem began and how it has been treated. Sometimes there is a significant injury, but often it is the type of event that one would associate with recovery such as an ankle sprain, a knocked elbow or a fracture. Unfortunately in a number of cases this simply does not happen. The injury is sustained, the area usually hurts as you would expect but then it continues to hurt and gets worse. There are associated signs and symptoms such as colour change, temperature change, altered sensation (pins and needles, numbness), an altered sense of position, a feeling of ‘largeness’, ‘thickened’ skin, huge sensitivity to light touch (allodynia), changes in skin, hair and nails. Fortunately we understand much more about the underlying mechanisms and can explain what and why this is happening, giving the problem a meaning which is so important in a condition that is troubling and causing great suffering.

CRPS in the foot and leg causes great difficulty in walking and standing in many cases. If the tissues are stiffened and the control of movement is poor, the ability to walk normally can be severely limited. Add the pain to this scenario and it becomes incredibly disabling at times as the sufferer simply cannot undertake normal activities. In CRPS in the upper limb it is writing, computer use, dressing, holding tools and self-care that are challenged.

Similar to any painful state, determining the pain mechanism(s) is important in deciding where to focus the treatment. Often there can be co-existing mechanisms such as inflammatory pain and neuropathic pain underpinned by different processes and manifesting in different ways. Neuropathic pain is often sharp, lancing, shooting and accompanied by a loss of sensation in the same area that can be confounding until you understand how it works. Inflammatory pain can be provoked by movement and touch with the mechanism being excited sensory nerves (nociceptors) as a result of the release of inflammatory molecules. Nerves themselves can release such chemicals into the tissues (neurogenic inflammation) and thereby keep the process going. There are many other aspects to the pain and the drivers and influences.

As well as elucidating the pain mechanisms, identifying the influences is also very important. This can include stress, fatigue, emotional state, past experience, culture, beliefs in addition to lifestyle factors and general health. Personally I look for risk factors for chronicity with all new assessments so that these can be fealty with swiftly. When a condition has been in existence for a longer period, adapting this to understand behaviours, choices and other factors that could be prolonging the problem is important.

Modern treatment of pain including CRPS should be within a biopsychosocial framework. That means looking at the biological mechanisms, psychology and social factors that are all part of the pain experience and mould the individual perception. In many cases the sufferer needs input from physiotherapy, pain medicine and psychology. Initially educating the patient to develop understanding, reduce fear of the pain and movement and enable effective coping and self-care is key. Desensitising the body with a range of techniques that blend the physical with the cognitive through the application of various stimuli is useful. This could be a paint brush or cotton wool for example. Tactile discrimination and two point discrimination are normal sensory functions that can be altered and according to recent studies are likely to need training. The graded motor imagery programme is part of the treatment, targeting brain changes that can occur. The three stages are laterality, imagined movement and mirror therapy. This is a newer intervention and is demonstrating good results in CRPS and with other nasty pains. The self-care aspects are fundamental. Teaching the patient to manage their activities and to develop consistency through their day is key. Sometimes activities are overdone and there is a trade off. For example standing at a party, but you really want to go and afterwards you know it will hurt but accept that this will be the case. Good flare-up management skills can play a huge role during these times. A further group of interventions I call perceptual exercises. Due to the plastic changes in the sensory and motor cortices, the sense of self, body and movement can feel different in many ways. Working with this through the use of imagery, mindfulness, awareness and other strategies can really help to get back in touch with the body alongside the other techniques. Finally, motor control exercise to normalise movement is very important but to be done at the right time in the right way.

The context of the treatment can affect the success of the strategy. Timing, environment, understanding and belief must all be considered when designing a programme. Newer ideas and research about neuroimmune responses to exercise, movement and thoughts suggest that we need to be mindful of these factors. This is the modern way of looking at the individual, their pain and circumstances to offer practical and effective strategies in improving outcomes and quality of life.

Subsequent blogs will look at the other symptoms, why and how they manifest and the effects of stress upon the body.

09Jan/11

Tips for effective rehabilitation

Tips for effective rehabilitation

 

Rehabilitation is absolutely essential in restoring normal activity after an injury or painful event, as part of chronic pain management, improving one’s ability to be active and following an operation or other medical procedure. The programme should be individualised, progressive and be appropriate for the goals of the individual, i.e. functional for work, sport and other activities. The following tips are ways of really enhancing the process of rehabilitation, drawing upon some of the most recent understanding in neuroscience and cognitive science.

Tips

In no particular order:

1. Ensure that you have set goals related to your objectives. Follow the SMART procedure.

2. Keep a rehabilitation or training diary so that you can tick off your exercises and feel good about it as well as mark off goals when they have been achieved.

3. The programme should start at a baseline determined with the help of your health professional. This is the start point from where you move forwards.

4. The programme should be progressive, fitting with your goals, looking to challenge and move forwards but without causing unnecessary flare-ups.

5. Flare-up management should involve understanding what it is, how it can be managed effectively and used as a learning experience.

6. Rehabilitation should include components of education, motor control, proprioception, functional exercise, strength, endurance and posture. Other aspects can be power, speed, agility, work and sports specific tasks.

7. Understand realistic time lines that includes the healing process so that you know what to expect and where you are along the line of recovery. You should ask your health professional to keep you updated on this point.

8. Vary the tasks when you can. By the nature of rehabilitation you have to repeat the exercises, in some cases very often. This is because in essence there is a learning process going on and it takes time, just like learning a language or musical instrument. Changing the context can help to keep the interest.

9. Gaining feedback is really important. This can come from an observer or a mirror. Mirrors are brilliant rehabilitation tools as the brain uses visual feedback over sensory feedback and therefore can help to correct movement patterns. Mirror therapy is a different approach that can be used in certain conditions with good effect when used appropriately by a trained practitioner, for example in stroke victims, phantom limb pain, complex regional pain syndrome and other painful conditions.

10. Using cognitive and motivational techniques has a huge effect and can make a really significant difference to the outcomes. Again this requires an appropriately trained and knowledgeable practitioner who can integrate these methods into the programme. Targeting the brain is a very powerful way of maximising potential. Techniques include awareness, assessing beliefs, education, goal setting and mindfulness.

11. Set up the environment to promote concentration, focus and awareness

These factors and others are fundamental to a successful rehabilitation programme. Enhanced programmes make a difference as they draw upon not just the physical parameters such as altered movement, pain, the healing process and altered neurodynamics, but also the integration of senses, past experience, cognition, immune function, stress, anxieties and other psychological states, personality, culture, understanding and a host of other human characteristics. Looking at rehabilitation in a wider sense is complicated, takes time and understanding, however by drawing upon the knowledge of brain and nervous system function, immune activity, tissue healing and other bodily systems, we can create bespoke, challenging, progressive and fun programmes that maximise potential.

Rehabilitation programmes at Specialist Pain Physio Clinics are thought out based on your experience, presentation and the requirements that you identify. We constantly strive to update our methods by keeping abreast of research and science. Follow the blog and our Twitter page to learn more.