Tag Archives: pain education

03Mar/15
Treatment of pain and injury

Joe’s pain story

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

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

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

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

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

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

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

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

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

02Oct/14
Pain is a whole person experience

CRPS Research Update | October 2014 #CRPS

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

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

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

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

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

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

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

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

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

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

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

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

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

25Aug/14

Greatness, smoothness & injury

In response to @simonrbriggs excellent article in the Telegraph (see here) contrasting Federer and Nadal in respect of their physical longevity on the court, I wanted to agree with Simon’s subsequent tweet about the many factors involved with an injury — the line I frequently quote being: ‘no injury happens in isolation’. Whilst I am no tennis expert, I understand that these two masters have very different approaches on the court that define their games. The wicket is more familiar territory, and I would equate this observation to the games of Tendulkar versus Gilchrist. Both masters of the willow, yet styles that illustrate very different means and modes of dominating the ball. 

Sport enthusiasts and pundits alike gush with awe at the ease with which a stroke player caresses the ball. The expert appears to have all the time in the world to position themselves in perfect balance, to be able to effortlessly time the touch, and send the ball at a speed that is vastly out of proportion to the effort applied. Federer fits this mould, and whilst he undoubtedly trains to be fit and strong, he has a technique that is so efficient and so thoughtless that he can focus entirely upon the whole game as if viewing from a point up above. And to take nothing away from the skill of Nadal, his explosive force delivers excitement as he thunderously strides across the court in Zeus-like fashion. As Simon points out, if Nadal were to maintain a physical wellness, his dominance would surely prevail. Who you would most like to be conqueror would then be down to a preferred style, and we love to talk about style.

Returning to the construct of injury that is always embedded within a context and never in isolation to a range of factors that create a situation — no injury happens in isolation. The meaning of an injury is tantamount, and certainly impacts upon the intensity of pain. Cast your memory back to Messi believing that his career was over after he collided with the goalkeeper. He had merely bruised his knee yet the pain was so intense he had to be carried from the field of play in hushed silence.  A violinist who cuts his left index finger will suffer more pain than if I slice the skin on my same digit. There is a different meaning attached to his finger, even with a paper cut. 

Whilst both Federer and Nadal will be accustomed to the pain of hard training and playing, the pain of injury is different. The way we think about the pain at the time of injury sets up the on-going responses and how we chose to behave — it is not the injury itself, but the way we think that counts. Spraining an ankle usually means limping, and this is a sensible behaviour as partial weight-bearing reduces the strain through healing tissues, and is more comfortable. When we know that all is well, in other words that the injury is healing normally (and this is meant to hurt, however unpleasant or inconvenient), there is an acceptance of the necessary steps back to normal movement and activities. The early messages after an injury then, are vital to set up a positive route forward. Excessive fear, anxiety and incorrect messages at the start can set up a pathway of obstacles to recovery. 

Drawing together the smoothness of action that interweaves with other characteristics that construe the greatness of Federer: the technical self-efficacy, rehearsed movements that require no conscious processing and a baseline of fitness and mobility, all of which create a context that minimises the risk of injury. The sublime control, gliding easily across the surface and a ‘oneness’ with the occasion offers only the smallest opportunity for breakdown that most can only dream of, including Nadal whose vigorous assault upon ball and opponents opens the door for stress and strain to emerge, persist and potentially dominate.

Whilst we can swoon over the masters of any game, the vast majority of us play amateur sport. At the level of the masses, I always feel that the risks of injury are outweighed by the benefits of participation — physical fitness, the offsetting of cardiovascular disease, the cathartic outlay against stress and of course the social element (after the game: the 19th, the clubhouse, the curry house…). Equally, whilst the professionals are honing their skills and prowess, amateurs spend a great deal of time around their occupations and families to improve on the fields and courts, imagining achievements on the great meadows of Lords and Wimbledon. I too dream and envision, but returning to diminishing the risk of injury, as the principle is the same whether pro or amateur. And there is no reason why the latter should not acquire the same knowledge and receive the same principled care.

One of the first actions I take is to ensure that the injured person’s knowledge and thinking are in alignment with what we know about pain and healing, and that their choices of behaviour always take them toward and not away from recovery, no matter the start point.  My fundamental belief in our ability to change pain drives my over-arching mission to deliver pain education to all. Understanding pain will inform positive and healthy actions across the board from professional athletes to children to stakeholders (more on this in subsequent blogs). 

Recovering from an injury is straight forward. Most of the problems arise from the wrong early messages and a desire to move on faster than the healing process, thereby disrupting mechanisms that have inherent intelligence. We literally get in the way of our own recovery. We are the problem, yet the injury is blamed. Know the injury, know the pain, know the time line and know the action to take. Simple. One of the issues that Nadal may suffer, as do many professionals, is the rapid return after injury without full recovery, or a lack of time for the body to adapt. This latter problem disrupts the balance of breakdown and rebuild that is constant in the body. Tipping towards breakdown, inflammation persists and causes persistent sensitivity, even at a low level. This manifests as the on-going niggles, gradually becoming more widespread as time progresses and often without an obvious injury. Familiar? Perfectly solvable when you know how and respect the time lines of healing and recovery. Time is money some may argue, but then stepping back and thinking about the longevity of a career provides a different perspective. Deal with this bout of aches and pains completely and create the opportunity for more years of competing as opposed to the stop-start, partial recovery that affects performance and confidence, the two being utterly related. Over-thinking movement and lacking confidence both affect quality of movement — manifesting as the yips in some cases. Is Nadal smashing his way through because he fears that one day he will finally breakdown? Only he knows. Feeder on the other hand as we have seen, has a smooth style that glides him across the courts of the world. 

In summary, to look at the differing styles of play that define Federer and Nadal, it is clear that the smooth approach taken by the former has played a role in his longevity in terms of fitness (lack of injury) and success, the two being related. Simply, the more games you are able to play without a physical hinderance or even the thought that you may have a physical hinderance, for mere thinking affects the way we move, the greater the opportunity for winning titles. So surely, the planning of any athlete’s training and career must consider the ways in which maximum participation can be balanced with time required to adapt and recover. This is the same for both the professional and the amateur athlete, beginning by understanding pain and injury. 

25Apr/14

When do we seek help for our pain?

When do we seek help?

I am interested in the point at which an individual decides that they need help. The timeline varies enormously from the initial feeling of pain to years of discomfort that finally become intolerable or limiting. Each person will have their own view that is grooved by prior experiences, culture, beliefs about health and pain, access to healthcare, the impact that the problem is having upon lifestyle and tolerance of the pain at any given moment. These factors blend to create the individual’s experience of pain that contains their own personal meaning, or lack of, the sensory and emotional dimensions.

The initial meeting presents the opportunity to explore the story of the problem. It is not just about the pain but how it affects the person, those around him or her and the interactions with their environments. The brain, the body and the environment are co-dependent and influence each other, described by Nobel Prize winner Gerald Edelman as the econiche. Each must be explored within the context of the narrative to gain an insight into the reasons for seeking help.

Over the desk I hear people tell me that they have had enough, previous treatment hasn’t worked, surgery has failed, their spouse is sick of the moaning, they cannot play with the kids, work or play sports. They have reached their coping threshold and now want change.

In most cases, the story extends into the past, sometime before the patient arrives. The problem may have been ignored or attempts have been made to ease the symptoms. The majority whom I see will have had numerous attempts to get better via medical or surgical routes but with limited or no success. This leads to frustration, anger, lowered expectations, all of which can be understood. We must also acknowledge that the body and the brain have really tried to deal with the problem but require increasing conscious involvement to move forward. The lack of progress usually means that the biology of pain has not been fully targeted, along with the vast array of individual influences upon the pain. The need for a comprehensive approach is tantamount to success in changing pain and one’s ability to engage with life once more.

The first meeting is a point in time. This is not in isolation to the complete story, similarly for the physical assessment that is a snapshot of what is going on at that particular moment. With pain and body physiology changing from moment to moment as the systems respond to the internal and external environments. The interactions of brain-body-environment are fundamental to the expression of how we feel and experience the world around us. The brain is constructing all that we experience, hence the significance of this organ when addressing pain.

So when do we seek help? This is individual and based upon our beliefs about ourselves, the world and our health. These are not separate entities but rather consistently interacting modules. Thinking in these terms helps us to devise a route forward and a way of creating the right conditions for the body systems to change in the way they are functioning. We are designed to evolve, change, grow and develop. Comprehensively addressing pain and the influences upon pain provides a tangible, measurable and effective way forward, whenever the patient decides it is the right time to engage.

For further information about our comprehensive treatment and training programmes for chronic pain, please call us now on 07932 689081 and discover how you can change and move on.

17Dec/13
Brain~Body

A quick note on brain~body — body~brain

Brain~BodyThe brain is where it’s at. Or so it seems if you read the press or look at the bookshelves. The notion that brain is everything has been challenged recently and so it should — see here. We need enquiry at every point, challenging the comfort of thinking that we know.

Despite this, it seems logical to think that the brain is involved with much of our existence. The ‘hows’ and ‘whys’ need continued clarification. In a crude sense, on the end of our brain lies a body. This body is where we feel life whether that be the experience of an external stimulus such as touch or the result of a thought that always triggers a physical and emotional response once we engage with that thought.

The term ‘body-mind’ has been used countless times by both mainstream practitioners of medicine and health and alternative or complimentary therapists. Most people understand the concept although many still try to deny the links. Can a thought really change the physiology in my body? Of course it can. It happens all the time. In fact, I would argue that our body functioning is the emergent physical manifestation of all the processing going on in the mind.

The way in which we move, posture, position ourselves is dependent upon the task at hand but also the task that we may engage with at some point in the near future. The brain is the greatest predictor and will continually analyse the environment, the situation and compare this to what it knows to create the actions necessary. In cases of chronic pain or stress, the brain becomes hypervigilant and responsive to a range of cues that would not normally evoke a protective response but now does via the the autonomic nervous system (‘fright or flight’), the nervous and immune systems.

Much of the activity in our body systems we are unaware of as the brain and reflexive activity takes care so we can attend to the necessary survival tasks. Filtering out the millions of stimuli, the brain draws our attention to what is deemed to be salient for that moment.

In a state of anxiety, this is usually felt in the body — churning stomach, tension, sweaty palms etc. We use the body as a yardstick as to how we are feeling although the thoughts evoking these bodily and physiological responses are not always immediately apparent. The thoughts will eventually pop in there, or emerge, this from an unspecified network of neurons in the brain.

In essence, we can think about the body~brain or brain~body relationship as a needy one; they need each other for full function. To separate makes no sense bit neither does to blame one or the other. Thinking about the emergent features of the synchrony appears to provide a better way of considering problems such as pain, stress and other conditions.

RS — Specialist Pain Physio Clinics, London 

26Dec/12

Top 5 tips I’ve given to patients this year

There are a number of key messages that I deliver to patients during their programme

I see this as ‘drip feeding’ vital information that changes the perception of threat and hence alters the way in which pain is experienced. We know that understanding pain has a very real benefit by changing the meaning of the pain, i.e. informational medicine. We also know that negative messages can have a detrimental effect upon pain and also the way in which behaviours are constructed subsequent to such messages, e.g. ‘You’re always going to have this pain’ or ‘you’ve slipped a disc’. Unfortunately if such language is used, it can be so potent as to change the way in which the listener perceives their problem and hence chooses to move. This, often at a subconscious level (most of our thinking that influences our behaviours).

Lets get accurate in our understanding and reconceptualise pain so that we can know that it is changeable.

Here are common pieces of information that I pass onto and re-emphasise during treatment & training programmes.

1. Pain is constructed by the brain and felt in the area of the body that is perceived to be in danger. Think of phantom limb pain.

2. Pain is not an accurate indicator of tissue damage. Think of the discomfort of a paper cut and battlefield tales of significant trauma that is painless at the time.

3. Regular and consistent movement & positional change throughout the day from the start to nourish the tissues and representation of the body in the brain.

4. Exercise doesn’t have to mean the gym or going running. There is always some form of activity that can be started with the right baseline & instruction to develop confidence and healthy notions of movement.

5. There are a range of influences upon the pain: stress, fatigue, emotional state, expectation, attention, physical activity changes (new activity or more intensity).

RS

07Sep/12

A quick word on…the flare up

When pain flares up we need ways of dealing with the increase in symptoms, the distress that this can cause and the impact upon day to day living. If we could look inside our brains when a flare up is in full swing we would see a storm of activity in many areas, especially the sensory and emotional regions. These parts of the brain let us know where the pain is in our body and try to make sense of the situation – the meaning of the pain.

To deal with a flare up takes knowledge and understanding of pain so that best choices can be made. Undoubtedly a flare up can be influenced heavily by worry and anxiety that is often underpinned by a fear of what the pain means. In the early stages of a treatment programme, pain and its influences must be explained and be understood, creating fertile ground and context for exercise and other strategies to be employed most effectively.

Flare-ups are common and not to be feared but to be dealt with. Anyone who has increased their exercising or re-started a gym programme is familiar with the feeling of increased pain and stiffness subsequently. This is a normal body response to a physical demand. A flare up can be an amplified version of this response to a new activity, an increase in activity, to a stressor, change in health, fatigue or sometimes it is not obvious.

Nothing happens in isolation, inlcuding flare-ups or sharp, sudden pains – there is a build-up with the moment of awareness being the point when the threshold of sensitivity is reached. The questions to ask are what have I been doing and how have I been feeling?

How can we calm the storm? Remembering that there are many parts of the brain involved in the pain state, including the sensory regions, emotional centres, areas that play a role in homeostasis and the motor centres, we can seek to change the activity with a range of strategies. This can include activity modification (e.g. changing the training parameters, altering the time of day, even the room and other contexts), active rest periods (breaking up activities into sections including having rest breaks), relaxation (e.g./ breathing, music, gentle stretches), mindfulness based stress reduction and distraction*. Clearly each individual will find that a different blend of the techniques that work for them at different times. Some flare-ups last for a day or two and sometimes longer with a more aggressive response to what may seem to have been an innocuous activity. This can of course be frustrating and indeed worrying but it is important to remember that flare-ups do come to an end (even if you have to keep reminding yourself) and that more angst often triggers further physical responses and pain.

If you are unsure about your flare-up or symptoms, contact us here or speak with your GP.

* Examples of strategies that we teach on the treatment programmes – learn more here

Disclaimer

The resources on this site should not be used as a substitute for professional medical care or advice. Users seeking information about pain should consult with a qualified healthcare professional

05Sep/12

Working with consultants & GPs for better care

Dimensions of pain: Affective, Sensory, Emotional

Our aims for patients are to ease their pain, increase their activity levels and significantly improve their quality of life with the development of heathy habits. These aims are achieved with comprehensive treatment programmes that tackle the pain source(s) and the influencing factors.

Specialist Pain Physio Clinics – London & Surrey

Teaming with the referring consultant or GP means that the care and treatment is multidimensional, just as the pain experience is multidimensional. We aim to work closely with consultants and other healthcare professionals who refer to the clinic or when we refer for concurrent input, for example psychology. GPs are often key players in the co-ordination of the relevant services, and indeed we communicate regularly to ensure that the information is up-to-date.

Specialising in pain means that we work closely with a range of specialists including those in orthopaedics (e.g. sports injuries, repetitive strain injury, tendinopathy, arthritis, back pain), rheumatology (e.g. arthritis, osteoporosis, rheumatoid arthritis, fibromyalgia), neurology (e.g. migraines, headaches, back and neck pain, dystonia), gynaecology (e.g. pelvic pain, back pain), gastroenterology (e.g. IBS) and pain medicine (a range of painful conditions often including complex regional pain syndrome, back and neck pain).

We are always keen to develop effective working relationships with specialists and GPs, seeking to create an avenue for struggling patients. If you are interested in this, lunchtime seminars and other training events, please do make contact by emailing [email protected]

* Our clinics are based in Harley Street, Chelsea, Temple and New Malden

21Aug/12

Rehabilitation of thinking – A key element in maximising performance

The rehabilitation journey following an injury must be traveled with full commitment and completed. Usually when we talk about rehabilitation, it is the exercises that are focused upon: the movement, the task, the goal and how much to do. Nothing wrong with this of course as the training parameters are important to understand the effects of the exercise and how to subsequently progress. An aspect that is vital, yet less frequently mentioned, is the thinking both behind the activity and that of the individual undertaking the training.

Each exercise must have a meaning that needs to be explained. Full understanding of how, when and why the particular task is being undertaken is vital for full engagement, both physically and cognitively. In addition we have to consider the context of the exercise including the time of the day, the environment, the mood of the participant, level of discomfort, general health factors and other variables. Being aware of these influences and how they affect performance permits accurate assessment of the outcomes and where to focus upon for future improvement. In essence it is a learning process similar to that of learning a language or a musical instrument. Feedback plays a key role via the trainer correcting movement verbally and physically, and other means including exercising in front of a mirror.

The thinking of the participant before engaging in the exercise, during and afterwards will have an impact on success and hence learning. We can call this his or her mindset. Carol Dweck talks about a fixed mindset which describes a thought pattern underpinned by inflexible beliefs: it is how it is, this is my lot, change does not happen etc. Clearly this thinking can limit success and progression. A growth mindset on the other hand, is characterised by a belief that we can learn, change and grow. This mindset is one I encourage and seek to nurture as part of moving forwards following an injury or in progressing with a painful condition. In essence we are designed to change and adapt to our environment and circumstances. Given the right opportunity, input, motivation and timeline, we can evolve and develop healthier notions and actions for life both physically and in thought.

In summary, rehabilitation is not about simply going through the motions of certain exercises. It is about taking the opportunity to grow and develop physically and cognitively. In many cases we have to address thinking that is affecting the rehabilitation process, for example, thoughts that would be of a fixed mindset. Working upon these with strategies can and often are as important as the physical activities for optimum outcome. Our comprehensive rehabilitation programmes encompass these details so that you can progress from pain to performance.

20Jul/12

Pudendal Neuralgia & Pudendal Neuropathy

Pudendal Neuralgia & Pudendal Neuropathy

From Hopkins Medicine

Also termed pudendal nerve entrapment, this problem afflicts both men and women having immense effects upon quality of life. The pudendal nerve is a sensory, autonomic, and motor nerve that carries signals to and from the genitals, anal area, and urethra. There are three branches of the nerve on each side of the body: rectal, perineal and clitoral/penile. Pudendal neuropathy occurs when the nerve or one of its branches is damaged, inflamed, or becomes entrapped.

The symptoms can be on one side or bilateral, starting acutely or developing over time. They include:

  • Pain in the areas innervated by the pudendal nerve or one of its branches
  • Burning
  • Reduced or loss of sensation
  • Electric shock-like pain, stabbing pain, knife-like or aching pain
  • The sense of a lump or foreign body – increased sense of size of the affected area
  • Altered sense of temperature
  • Constipation with pain on straining with bowel movements
  • Urination causes a burning pain
  • Painful intercourse
  • Sexual dysfunction

Once diagnosed, treatment often involves a combination of medication, procedures such as a pudendal nerve block, and physical therapy to address the pelvic floor muscles.

A contemporary approach to pain

Similar to other persisting pain states, to think about the suffering individual as much as the condition is fundamental. The wide ranging affects of the pain, associated symptoms and subsequent limitations have to be carefully considered within the treatment programme. The underpinning neurobiology is the basis for the problem but the responses of the body and brain and the individual are key determinants upon the impact. Initially developing a good understanding of the pain and the problem through high quality education creates a strong platform for effective coping and engagement in the rehabilitation and training programme.

The neuroimmune system is designed to adapt and change. This is how we learn. On the basis of the plasticity characteristic of neurons and how they fire together, we believe that change is possible with the right strategies based upon the right understanding within a realistic time-frame. See here

When we are in pain we move differently. The brain and body changes the way that the muscles are used including increased tension to protect the affected area. This is called guarding. The fact that the muscles are overworking creates its own issues including soreness, tightness, difficulty moving and often pain. Trigger points can develop that refer pain into other areas. Tackling changes in the motor system, especially those in response to nerve injury, needs an approach that considers the top-end, the brain (motor cortices and the areas of the brain that communicate with the motor centres, e.g. visual areas, emotional areas). It is important to understand that the associated thoughts about pain and the situation affect the way in which we move. If our belief is that the pain is a sign of damage and danger, we are going to be more protective and hence feed back into guarded posturing and movement. This is how understanding pain and the influences upon pain can really help. Changing our thinking through deeper understanding uses the frontal cortex to change our perception of pain. This is because the frontal cortex is part of the matrix of brain cells (neurons) that underpins the experience of pain. Directly targeting the areas of the brain involved in pain is a logical and now scientifically demonstrated way of dealing with pain.

Certainly local treatment of the the superficial muscles about the lumbar spine and pelvis can be useful to ease tension. In fact, anything that relaxes the individual will help to ease tension. For example, watching a favourite film, laughing with a friend, listening to music or taking a bath. Going beyond the tissues is vital though in dealing with nerve related pain (neuropathy) because of the adaptations that occur in the neuroimmune system. In recent years the use of Graded Motor Imagery for pain and movement problems has provided us with a way of working with the higher centres (‘top-down’) alongside approaches that nourish and mobilise the tissues gradually and safely. Together with development of understanding and often mindfulness, this combined approach offers a tangible and effective way of bringing about change to reduce the impact factor, distress level, increase function and improve quality of life.

For further information upon our approach to pain please contact us here or call 07518 445493

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Research

Pain Med. 2012 Apr;13(4):596-603. doi: 10.1111/j.1526-4637.2012.01343.x. Epub 2012 Mar 5.

Response to pudendal nerve block in women with pudendal neuralgia.

School of Women and Children, University of New South Wales, Sydney, Australia. [email protected]

OBJECTIVE:

To examine the evolution of pain and the duration of numbness after neural blockade of the pudendal nerve in women with pudendal neuralgia and correlate with clinical and historical data.

DESIGN:

Prospective, single arm, open label study.

SETTING:

University hospital and outpatient clinic.

SUBJECTS:

Eighty-two adult female patients were recruited from November 8, 2008 to February 14, 2010. Patients were selected based on the presence of spontaneous or provoked pain in the distribution of the pudendal nerve.

INTERVENTIONS:

Subjects underwent a standardized pudendal nerve block.

OUTCOME MEASURES:

Visual analog pain scores and the presence of numbness were recorded before and for 64 hours after the pudendal nerve block. A complete clinical history and examination were documented.

RESULTS:

Sixty-six patients completed the study. About 86.9% had a reduction in one or more pain symptom, while 44.3% found that more than one of their pain symptoms did not return. About 69.7% of patients reported numbness lasting up to 16 hours or longer. Previous gynecological surgery was recorded in 75.8%, previous traumatic obstetric events in 47.0% of cases. Prolonged history of pain correlated with a reduced chance of positive outcome of the pudendal nerve block.

CONCLUSION:

In patients with pudendal neuralgia, the pudendal nerve block has a variable response, but may have a beneficial effect in a subset of women. Surgical and obstetrical trauma are common historical antecedents

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World J Gastroenterol. 2011 Oct 28;17(40):4447-55.

Chronic proctalgia and chronic pelvic pain syndromes: new etiologic insights and treatment options.

This systematic review addresses the pathophysiology, diagnostic evaluation, and treatment of several chronic pain syndromes affecting the pelvic organs: chronic proctalgia, coccygodynia, pudendal neuralgia, and chronic pelvic pain. Chronic or recurrent pain in the anal canal, rectum, or other pelvic organs occurs in 7% to 24% of the population and is associated with impaired quality of life and high health care costs. However, these pain syndromes are poorly understood, with little research evidence available to guide their diagnosis and treatment. This situation appears to be changing: a recently published large randomized, controlled trial by our group comparing biofeedback, electrogalvanic stimulation, and massage for the treatment of chronic proctalgia has shown success rates of 85% for biofeedback when patients are selected based on physical examination evidence of tenderness in response to traction on the levator ani muscle–a physical sign suggestive of striated muscle tension. Excessive tension (spasm) in the striated muscles of the pelvic floor appears to be common to most of the pelvic pain syndromes. This suggests the possibility that similar approaches to diagnostic assessment and treatment may improve outcomes in other pelvic pain disorders

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Neurourol Urodyn. 2008;27(4):306-10.

Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria).

Service d’Urologie, CHU Hôtel-Dieu, Nantes, France.

AIMS:

The diagnosis of pudendal neuralgia by pudendal nerve entrapment syndrome is essentially clinical. There are no pathognomonic criteria, but various clinical features can be suggestive of the diagnosis. We defined criteria that can help to the diagnosis.

MATERIALS AND METHODS:

A working party has validated a set of simple diagnostic criteria (Nantes criteria).

RESULTS:

The five essentials diagnostic criteria are: (1) Pain in the anatomical territory of the pudendal nerve. (2) Worsened by sitting. (3) The patient is not woken at night by the pain. (4) No objective sensory loss on clinical examination. (5) Positive anesthetic pudendal nerve block. Other clinical criteria can provide additional arguments in favor of the diagnosis of pudendal neuralgia. Exclusion criteria are also proposed: purely coccygeal, gluteal, or hypogastric pain, exclusively paroxysmal pain, exclusive pruritus, presence of imaging abnormalities able to explain the symptoms.

CONCLUSION:

The diagnosis of pudendal neuralgia by pudendal nerve entrapment syndrome is essentially clinical. There are no specific clinical signs or complementary test results of this disease. However, a combination of criteria can be suggestive of the diagnosis

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Neurourol Urodyn. 2007;26(6):820-7.

Pudendal entrapment as an etiology of chronic perineal pain: Diagnosis and treatment.

Fort Bend Neurology, Sugar Land, Texas 77479, USA. [email protected]

AIMS:

This study was conducted to evaluate pudendal entrapment as an etiology of chronic pain, a diagnostic protocol for pudendal entrapment, and clinical response to surgical decompression.

METHODS:

A case series of 58 consecutive patients with a diagnosis of pudendal entrapment, based on clinical factors, neurophysiologic studies, and response to pudendal nerve infiltrations, is described. All patients were refractory to other treatment modalities. Patients were assessed before and after surgical decompression: degree of pain was assessed by visual analog scale (VAS) score, percent global overall improvement, and improved function and quality of life before surgery and 12 months or longer after surgery.

RESULTS:

The primary presenting feature was progressive, chronic, intractable neuropathic pain in the perineum (ano-rectal and/or urogenital) that worsened with sitting. Other symptoms included urinary hesitancy, frequency, urgency, constipation/painful bowel movements, and sexual dysfunction. After surgical decompression, 35 (60%) patients were classified as responders, based on one of the following three criteria: a greater than 50% reduction in VAS score, a greater than 50% improvement in global assessment of pain, or a greater than 50% improvement in function and quality of life.

CONCLUSIONS:

Pudendal entrapment can be a cause of chronic, disabling perineal pain in both men and women. Since symptomatic patients seek medical care from many different medical specialists, a reliable diagnostic protocol should be established. For patients refractory to conventional interventions, surgical decompression of the pudendal nerve can improve pain-related symptoms and disability. With ongoing work on this subject, which is a difficult disorder to accurately diagnose and treat, a better awareness of pudendal entrapment across specialties will emerge

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J Minim Invasive Gynecol. 2010 Mar-Apr;17(2):148-53. Epub 2010 Jan 12.

Pudendal neuralgia.

Department of Obstetrics and Gynecology, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona 85013, USA. [email protected]

Pudendal neuralgia is a painful, neuropathic condition involving the dermatome of the pudendal nerve. This condition is not widely known and often unrecognized by many practitioners. The International Pudendal Neuropathy Association (tipna.org) estimates the incidence of this condition to be 1/100,000; however, most practitioners treating patients with this condition feel the actual rate of incidence may be significantly higher. Currently, there is fair paucity of medical literature and scientific evidence in the diagnosis and treatment of pudendal neuralgia. Diagnosis of this condition is based on the utilization of Nantes Criteria, in conjunction with clinical history and physical findings. CT-scan guided nerve blocks are also employed, by this author, to provide additional information. Subsequent treatment of pudendal neuralgia is medical and well as surgical, with Physical Therapy a key component to all aspects of treatment. The goal of this paper is to present evidence based information, as well as personal clinical experience, in treating approximately 200 patients with pudendal neuralgia.

Useful links

http://www.pudendalhope.info/ (please note that on the home page is a video demonstrating a surgical procedure. If you are particulalry sensitised it maybe advisable to avoid watching the film currently although with graded exposure this could become a goal. Seek the advice of your health professional)

http://www.instituteforwomeninpain.com/