Tag Archives: pain London


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.


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.