Tag Archives: pain specialist

Richmond M. Stace MCSP MSc (Pain) BSc (Hons)

Richmond Stace | Specialist Pain Physiotherapist

Richmond Stace | Specialist Pain Physiotherapist

Richmond Stace | Specialist Pain Physiotherapist

About Specialist Pain Physio Clinics

In 2006, I started the Specialist Pain Physio Clinic concept in London and Surrey to provide contemporary and innovative physiotherapy for chronic pain and injury.

I believe and know that pain can and does change when the right conditions are created in both thought and action. Blending the latest neuroscience of pain with tried and tested mentoring techniques, together we comprehensively address the biology of your pain and the influences upon your pain.

Let’s aim high and target success with the right thinking, a vision of where you want to be and a definite plan of how to achieve your success.

Effective treatment, training and mentoring for health and performance — it is time to change..
My physiotherapy treatment, proactive training and mentoring programmes are based upon the latest sciences and understanding of pain. The biopsychosocial approach that I use is the contemporary way of addressing enduring pain and suffering — considering the biology, psychology and social impact.

Richmond Stace MCSP MSc (Pain) BSc (Hons)

I am a Chartered Physiotherapist and registered with the Health Professions Council. Originally training as a Registered General Nurse, I developed an interest in pain whilst observing the varying responses in recovery after operations. I continued to train as a physiotherapist, I have a further degree in Sport Rehabilitation and a Masters Degree in Pain Science. My passion is in providing the best journey for you by using the latest therapies for chronic and complex pain. Seeing and hearing about your relief from symptoms, your development of healthy habits and sustained change is my aim for you.

Outside of the clinic, I write and talk about how we can globally change pain by understanding it, communicating about pain accurately, creating a definite plan and how to implement the plan in the most effective way.

I am on the editorial team for the Physiotherapy Pain Association (PPA), a member of the International Association for the Study of Pain (IASP), The Royal Society of Medicine and the Acupuncture Association of Chartered Physiotherapists.


Fibromyalgia — creating conditions for change

Pain and symptoms can and do change. They can change moment to moment and day to day, but if you suffer persisting symptoms, all of the variations can blend into a long physical and mental struggle. Striving for change needs understanding, motivation, resilience and a plan of how to reach your goals.

Fibromyalgia is biology in action. An integrated response of the nervous system, immune system, autonomic system and endocrine system, all of the manifestations of fibromyalgia are the outputs, the end result of how those systems operate together. Unpleasant and troubling as the pain and symptoms are, this is the body trying to recover and making the individual aware. Most of the processes happen beneath our conscious level, but those that don’t cause suffering, whereby suffering is a loss of a sense of self.

Together the sensations that we feel, the thoughts that we have and the environment around us are the experience. Edelman calls this the econiche, the interaction and end result of this interaction being the individual’s reality. The reality has to be unique: what I see and what you see in the same scene can be different based upon what we know, what we expect, current mood and attention to name a few variables. The same could be said for pain that will be influenced by similar variables. There is a biology of pain and the biology of the influences upon the pain.

My farming analogy that is based upon my belief that pain can change (neuroplasticity — the ability of the nervous system to adapt and learn; it is always changing….there it goes again, it’s just changed. And again), is a useful way of explaining to patients how we think about these systems and interactions, how we have to create the right conditions for change. Much as a farmer will prepare his field and cultivate the best soil for his crops to grow, the individual must take conscious action for the body systems to work towards wellbeing. This is the ‘why?’, with the ‘how?’ being a comprehensive approach that targets the physical, cognitive and emotional dimensions of pain.

Come and see us to find out how you can create the right conditions for changing your pain and symptoms: call 07932 689081

London Marathon - Tower Bridge

Training for the marathon – developing pain & injury

London Marathon - Tower Bridge

At this time of year, as the London Marathon nears, runners reaching new levels of training can start to develop aches and pains. Usually the pains are in the legs or feet and often begin as an annoyance but develop into a problem that means training has to stop.

The tissues are constantly breaking down and rebuilding. This is a carefully orchestrated process that is impacted upon by exercise. This is how we develop muscle bulk. However, we do need a period of adaptation that can be disrupted if there is inadequate rest. The balance tips towards tissue breakdown and inflammation triggers the development of sensitivity that if ignored can progress and become amplified. A good training programme should account for both rest periods and gradual progression of intensity.

A second issue is that of control of movement. On a day to day basis we can walk around, undertake normal activities, play sports and even run for certain distances with minor motor control issues. Motor control refers to the way in which our body is controlled by the brain with a feedback-feedforward system. The tissues send information to the brain so that there is a sense of position and awareness, allowing for the next movement to be made and corrected if necessary. The problem lies in the increasing distances, often never reached before, that can highlight these usually minor issues. Compensation and extra strain upon muscles and tendons that are trying to do the job of another can lead to tissue breakdown as explained previously. The sensitivity builds and training becomes difficult.

A full assessment of the affected area, body sense and the way in which movement is controlled will reveal factors that need addressing with treatment and specific exercises. This fits alongside a likely modification in the training programme that allows for the sensitivity to reduce before progressing once more. In some cases a scan or other investigations are recommend to determine the tissue nature of the problem.

If you are starting to develop consistent twinges that are worsening, pain that is affecting training or you are concerned, you should seek advice.

For appointments at one of the clinics please call 07518 445493

  • 9 Harley Street
  • The Chelsea Consulting Rooms
  • Temple
  • New Malden Diagnostic Centre

Back Pain and the BackCare Charity

Back pain is an enormous problem that impacts upon individuals and society. Most people will experience back pain at some point in their lifetime and a proportion will suffer continuing and recurring problems. Those who do continue to experience pain require effective treatment and strategies so that the impact and the distress that it can cause are diminished. Our understanding of pain science has moved forward significantly, meaning that there are contemporary therapies that target changes that we know occur in the brain and other body systems. For example, the graded motor imagery programme and cognitive techniques that impact upon pain threshold and movement.

The early management of a back pain as with other acute pains, will often determine the outcome. Full understanding of what has happened, why it hurts, what is normal about the pain response, how to cope effectively and the use of appropriate medication are all important at this point–see your GP or consultant for advice on medication.

Treat the brain, treat the pain

In persisting or complex cases, the assessment and treatment must be based upon the biopsychosocial model, considering the pain mechanism, influencing factors, beliefs & expectations, prior experiences of pain, the social impact (e.g./ work, family, sports) and fears in relation to movement and activity to name but a few. Pain is an output from the brain 100% of the time in response to an actual or perceived threat. Pain is always a normal response to the information that the brain receives from the spinal cord. In chronic conditions however, the way in which the nervous system changes means that danger signals can continue to be sent to the brain even when there is no actual threat. The brain must still respond by protecting the body by making the area hurt. The brain becomes very good at this, the analogy often used being an orchestra that learns to play one tune only. The pain tune–see Painful Yarns. To change the experience of pain in these cases requires a contemporary approach that is both ‘bottom up’ and ‘top down’. Bottom up refers to therapy that targets tissue health and movement, and top down pertains to training the brain and beliefs that are limiting recovery–see here for more details.

The BackCare Charity

BackCare is a national charity that aims to reduce the impact of back pain on society by providing information, support, promoting good practice and funding research. BackCare acts as a hub between patients, (healthcare) professionals, employers, policy makers, researchers and all others with an interest in back pain.

BackCare supply a number of resources including information packs, articles and a newsletter. A list of practitioners is available so that you can find a local therapist.

The BackCare App – Listed in The Sunday Times App List

If you are a back pain sufferer or you have a professional interest, you can join BackCare here


Using neuroscience to understand and treat pain

Neuroscience to treat pain and injury

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.

Treat the brain and to reduce pain

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.

When we injure tissue there is a local release of inflammatory chemicals. These chemicals excite local nerves in the tissues called nociceptors. Normally, nociceptors are quiet but when they are stimulated by inflammation, these nerves send danger signals to the spinal cord where they meet secondary neurons. The early bombardment of signals into the spinal cord causes the secondary neurons to become excited. These cells then send danger signals up to the brain where the information is scrutinised. On the basis of this scrutiny, if the brain perceives a threat, pain will be allocated in the area of the body that is deemed to be in danger. The area of pain is allocated via the representation of the body in the brain (see previous blog here) in the sensory cortex, first mapped by Wilder Penfield and published in 1951. Therefore we know that actually there is no ‘muscle pain’ or ‘knee pain’ but rather pain as a brain experience, and not in the mind I hasten to add, that is detected in a body part or region according to the brain’s perception of threat. These are the body maps that the brain uses to know where information is coming from and to control movement.

This information is part of the neuroscience knowledge that can be used to help people understand their pain and to create therapies that treat pain. Future blogs will look at how we can change and nourish the nervous system to promote healthy tissues at one end of the spectrum with the brain end being targeted by deeper education and Graded Motor Imagery (GMI) for example–click here. The brain and the tissues are not separate, they affect each other in many ways, as do other body systems such as the immune and endocrine systems. Looking at healthy movement and functioning in a truly holistic and biopsychosocial manner with neuroscience underpinnings, provides us with an exciting route forwards in dealing with pain problems.

Mastery (2): practice, practice and then….practice

Mastery is defined in the Oxford dictionary as:

  • comprehensive knowledge or skill in a particular subject or activity
  • control or superiority over someone or something

The concept of mastery is often applied to a musical instrument, golf, martial arts or a language. The word is rarely used in conjunction with the rehabilitation of an injury or a painful condition. It occurred to me that there are vast similarities between the principles and experience of training for a sport or a skill and the participation in a rehabilitation programme. The difference will be the end goals and the specific reason for the training. In the case of mastering a sport, it is about performance enhancement with greater skill and efficiency to achieve fewer shots or more accuracy for example. In rehabilitation the goal are pain relief, normal mobility, control of movement, restoration of strength, power and a return to daily activities (work, home, exercise).

End-stage rehabilitation

Undoubtedly the body has incredible mechanisms that heal injured tissue. Unfortunately there are many people who despite the healing process do continue to suffer painful symptoms. We see many cases of enduring and problematic pain at the clinic and set about the problem with a contemporary approach. This involves a range of treatment techniques and strategies including active rehabilitation or training. This training requires instruction, understanding, dedication, awareness, consistency, intention and practice. Just like learning a golf shot or the piano.

Setting up the principles of training (I will refer to the rehabilitation now as training) creates the right context and mindset. This includes pain/condition specific education so that the programme makes sense, the aims of the exercises, when to do them, how often and how to progress or moderate the intensity. In laying out the way forwards, the concept of mastery is introduced. What is it that needs mastery?

Mastering the mind

When we are in pain we change the way that we move. The longer the condition has been existing, the more the body and brain will have adapted alongside your thoughts and beliefs about the problem. The meaning that you give to the pain can also change with time and this is important. If the ‘meaning’ of the problem is significant, negative in nature and threatening to you as an organism (evolution speaking), the brain is more likely to protect you. This protection includes pain and altered movement, therefore perpetuating the cycle. This subject is for another day, important though it is, but dealing with negative thought patterns and unhelpful beliefs is fundamental, and requires restructuring. Returning to altered movement, this needs to be re-trained to reduce the guarding and protection. Of course this is one aspect of a treatment programme, but it is a great example to use when thinking about how you are going to master normal movement.

Mastering normal movement as mastering a language takes instruction, practice and dedication as mentioned. Often along the road we meet challenges and resistance both physically and mentally. One of those challenges is the plateau when it appears that nothing is happening or changing. The performance still seems to be the same, the outcomes like before. It is during this time that there is change occurring but it has not yet clearly manifest. Understanding that the plateau is an important part of the process and using the time as a chance to learn and an opportunity to create change. The nervous system is very plastic and adaptable according to the stimuli that it receives. In rehabilitation, the repeated stimulus of the right movements, in the right setting and mind set create such an opportunity.

To be good at any skill we must fully engage and spend the time with ourselves practice for the sake of practicing. Applying similar principles to rehabilitation in re-training normal movement, thoughts about movement and exercise and the functional skills of your chosen activity, provides a framework and a well trodden philosophical pathway to success. You will have your chosen goals that you will seek to achieve and on reaching them you will have further targets to attain. This is the journey.


Dysmenorrhoea & 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.


Problematic Sports Injuries

Sustaining an injury is a common problem for athletes. Unfortunately, a number of these injuries become enduring and the player struggles to regain fitness and cannot return to play. There are known reasons why this can happen, including the effectiveness of the early management, accurate diagnosis of the problem and how the player initially responds to the injury. All of these factors are important and often accounted for within the medical team’s preparation and planning. It is within the screening process that the medical team can gather such player information. This usually includes the usual fitness parameters, a history of previous problems and how they were managed and past medical history. Beyond these considerations I am interested in certain behavioural and physiological characteristics of the player that will give me an insight into how they will respond to pain and injury.

The problem has usually been persisting for some time when the player comes to the clinic. Beliefs, expectations and concerns will already be flying around his or her head. These emotions can be stoked by failed treatments and a lack of a diagnosis. Certain fundamental adaptations will have occurred as a result of the injury, such as changes in control of movement, altered perception of the affected area, pain felt with innocuous activities and other physiological goings-on that are not consciously observable. These vital functions involve the immune system, endocrine system and autonomic nervous system, all of which have a wide range of effects across body systems and play a significant role in healing, recovery and protection.

Protection is a key point. When you are in pain the body is protecting itself. You may also be aware of spasm or tightness and these are also part of a survival strategy that is orchestrated by the brain. When we are injured or have a problem we usually focus on the pain–and so we should. Pain is a motivator for us to take action to promote recovery. It grabs our attention to the area at risk so that we can attend to the injury. This is an amazing device that means we can learn and adapt. However, when this device adapts and creates sensitivity that is prolonged, it becomes difficult to progress and return to play.

The device is really a network of nerves that communicates information about the health of the tissues to the brain via the spinal cord. These nerves also play a role in maintaining tissue health by releasing certain factors into the tissues. On receiving information from the tissues via the spinal cord, the brain then scrutinises this data and responds appropriately. On perceiving there to be a threat to the tissues, the brain creates pain via a widespread network of neurons becoming active. It is this widespread network of neurons with a range of roles that is the reason for the many influences upon the pain including past experience, emotional state, fear, anxiety, vision, sound, genetics, gender and significance of the perceived danger to name but a few.

Returning to the enduring sports injury, these processes are underpinning the persisting sensitivity that is evoked with normal activities and amplified when pushed harder, altered motor control and perception, sensorimotor mismatch and continued tightness. These are common reasons for non-progression and require addressing with a modern rehabilitation programme that addresses the tissues, the aforementioned body systems and the brain with specific techniques and strategies that are based on the latest neurosciences.

If you would like any further information please do contact us here or call 07518 445493. Click here for our programme details.


Treatment Update

Come and see the updated treatment programme page. We are regularly updating the site so do check back. This is when there is new knowledge or research that adds to our understanding of pain and how we can best treat on-going problems.


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.