Tag Archives: pain treatment

20Feb/17

Pain is whole person

Pain is whole person

There is only one way to approach the problem of chronic pain as it emerges in the individual, and that is by addressing the whole person. This way demonstrates a true understanding of pain: the lack of any pain system, pain signals or pain centres and that the vast majority of the biology of pain is not where we actually feel it in the body or body space in the case of phantom limb pain. Much like when you watch a film in the cinema, most of what you need is not on the screen.

With pain being absolutely individual, coloured by the context, the environment in which it is being phenomenologically experienced, prior experience and beliefs (about pain, health, danger, ‘me’, the world etc.), the action we are motivated and compelled to take, existing health and level of threat perception to name but a few. In short, this includes activity in the brain and central nervous system, immune system, endocrine system, sensorimotor system, visual system, and the autonomic nervous system. Most of this is not where the pain is felt.

Pain and injury are notorious for being poorly related. There are countless stories of people suffering great trauma (tissue damage) and reporting minimal or no pain, some sustaining minor injuries and describing agonising pain and a huge variation in between. Considering the factors in the previous paragraph, one can start to understand why. In essence it is due to pain being a better indicator of the level of perception of threat; i.e./ more threat, or existence of threat = pain.

Bearing this in mind, and this is the current understanding of pain, you can see why the whole person approach is necessary. It is as much about the person as the condition, as Oliver Sacks wrote and practiced, and indeed this is a vital principle to work to. Understand the person and their circumstances and you go some way to seeing a way forward. Listening deeply in the first instance creates the opportunity to gain insight into the reasons for the person’s suffering — the reasons for pain and what is influencing that experience. From this foundation, one develops a rapport, not just as a clinician or therapist but as a trusted advisor, giving the person the knowledge and skills to overcome their pain and live a meaningful life.

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Pain Coach Programme to overcome chronic pain ~ t. 07518 445493 or email: [email protected]

 

05Aug/15

Messages about pain

Important Message by Patrick Denker | https://flic.kr/p/a9iUAG

Important Message by Patrick Denker | https://flic.kr/p/a9iUAG

When someone seeks help for their pain and injury, they will be given messages about pain that are potent. They are told a, b and c, and hence often take these messages and become them via their own thinking and actions. This is the reason why the early messages about pain need to be accurately based on what we really know about pain and that they motivate people to focus on what they must do to recover. The way in which we think about and hence perceive our pain has tremendous impact on the extent of suffering and how we actually experience the pain itself. Put simply, a lack of understanding that can create concern, worry and anxiety, will raise the threat value of the whole situation, and therefore the body (you) protects further, including an increase in the intensity of the pain itself. All these experiences of thought and action are chemically based — depending on which chemicals are working with which receptors determines how the body systems are functioning and underpinning what we live out.

So what should the messages contain?

1. Facts about pain and the injury, including the poor relationship between the two, that pain is part of a protective response that includes other protective means such as altered movement (e.g. limping) and that the way we think and feel influence both the amount of suffering we endure as well as the actual intensity of the pain itself.

2. The person has an active role in overcoming pain — based on (new perhaps) understanding of pain and person, what is happening, why it is happening and what action needs to be taken.

3. Other relevant information to develop the person’s understanding, and in so doing, gain their trust, respect to follow a programme that motivates through positive thinking and experience towards their vision of how they want to be and live their life.

Undoubtedly, as with any problem we must understand it before we can deal with it. In the case of chronic pain, explanations incorporate the biological changes, behavioural changes and cognitive-emotional changes afoot and how to address these comprehensively–whole person.

The whole person approach recognises that there are many inter-related dimensions of that person, and that we must consider the individual as a whole rather than a back or a knee or any other structure or pathology. The experience of pain and other symptoms is a conscious leap from the underpinning biology, and no-one fully understands how our bodies, our ‘selves’, make that leap from biology to the lived experience. However, listening carefully and compassionately to the individual provides many clues as to why they are in protect and survive mode, emerging as pain and other symptoms, behaviours, thought processes and ultimate actions. This becomes the start point for designing a bespoke, proactive programme, beginning with the right messages.

Whilst the first meeting may identify where the actions taken by the individual are incongruent with recovery, it is worth remembering that this person is doing their very best with the knowledge and skills that they possess at that moment. Everyone has strengths with which they attained success in a range of arenas. Elucidating these strengths creates a start point and also allows that person to know and start feeling that they have the tools to overcome pain, but need guidance on how to best use them. That is our job.

This approach is part of The Pain Coach Programme for individuals to overcome their pain problem and for clinicians seeking to learn the Pain Coach approach for chronic pain. Contact us for more details if you are suffering chronic pain or a therapist wanting to advance yourself in the field of chronic pain: 07518 445493

11Apr/15

50 strokes

Ajahn Brahm tells the story of a monk who thought he deserved punishment for breaking a monastic rule. He had knowingly done wrong and expected reprimand, yet this was not the way. The monk insisted, so Ajahn Brahm prescribed 50 strokes. The thought of this ancient punishment undoubtedly filled the monk with fear yet he knew this was his fate. However, no whip was produced but instead a cat, which the monk was ordered to stroke—50 times. After the 50 strokes of the cat there was peace and calm and the passing of a learning experience. Change was afoot.

In physiotherapy we use our hands to treat and create calm in a body that is protecting itself, perceiving a range of cues to be threatening. It has been thought that moving joints, muscles and nerves bring about the desired changes (or not if unwisely applied) because of a change in the structures. Science has since taught us otherwise, and that in fact what we are really doing is changing the processing in the body systems and then the recipient has a different and better experience—pain eased and movement more natural and thoughtless.

Touch is very human. Touch is a part of the way we develop in the early years, a lack of touch being detrimental to normal development. So potent when the meaning is aligned with a sense of creating wellbeing and soothing woes both physical and emotional, touch should be part of therapy for any pain condition. Interweaving hands-on treatments during sessions, teaching patients how to use touch themselves, teaching carers and partners how they can use touch, all create the conditions for healthy change.

Touch send signals from the nerves in the skin and muscles to the spinal cord and then onwards to the brain. In this way, the body is an extension of the brain and the brain an extension of the body, demonstrating  how we are  a whole person with no system or structure being in isolation to any other. Using touch is literally sculpting the representation of the body that exists in the brain, like moulding clay into a humanly shape. And of course, a shape has a function and the two are not distinct. The more precise the shape, the better the function. The manifestation of this being a normal sense of self in how we think and feel and a move. Normalising, desensitising, to me are one and the same.

— 50 strokes of the area of the body being protected, much like stroking the cat then, sculpts our ever changing brain and sense of physical body. The physical body exists and occupies space with the ever-potential of action, yet this does not exists without thought—it is my thought, the meaning that I give to my body that creates what it is in any given moment. When the strokes feel pleasant, or at least not painful, then this is your body and brain perceiving the action as being non-threatening and learning that the area is safe. The more of this the better. The same applies with movement: any action that is tolerable or feels good is the body (your whole self) saying ‘yes, that’s ok’. And that’s what we practice and practice.

To overcome and change pain is to normalise and to alter one’s relationship with pain and overall perception. We have much more say in this than most people realise but once they understand their pain, what pain really is and what they can do, change occurs in the desired direction.

Puuurrrrrrrrrrrrrrrrrrr.

29Aug/14

There is no pain system

Many writers in health journals and magazines continue to refer to pain systems, pain pathways, pain signals, pain messages and pain receptors. There is no pain system, there are no pain pathways, there are no pain messages and there are no pain receptors.

Pain emerges from the body (or a space that has a representation in the brain in the case of phantom limb pain) and involves many body systems and the self. Where does pain come from? Well, it comes from the person describing the pain. Does it come from the back or the knee or the head? That is where you could feel it, but in order to feel it in a location we need our body systems to be in a protective mode and to be responding to a potential threat.

Pain is allocated a space where the body requires attention, and whilst this is a vital survival device when we have an injury, it is less useful when the injury has healed or there is no injury. This is the case in chronic pain, although there are reasons why the body continues to protect based on the fact that the perception of threat exists.

Pain is part of a protective response. Many other systems are also working to protect us: the immune system, the endocrine system, the autonomic nervous system, the sensorimotor system etc. — and all the systems that these impact upon, such as the gastroenterological system (how many people suffer problems with their gut at the same time as having persisting pain?).

So, in chronic pain we need different thinking because tissue or structurally based therapies do not provide a sustained answer. Instead we need to address the fact that persisting pain is as a result of the body’s on-going perception of threat. It is this that requires re-training alongside any altered movement patterns and a shift in body sense in order to successfully deal with pain and move on.

Specialist Pain Physio Clinics – transforming a life of pain to a life of possibility 

Call us to start now: 07932 689081 or email [email protected]

 

 

01Aug/14

When in pain, the World looks different

When in pain, the world looks different — We are familiar with the notion that the World is always changing. In fact, change is one of the few certainties in life that we can rely upon. However, change is only possible if there is someone present to experience how things are evolving, and that person is also changing. No two moments are the same.

To experience change we need to know what has happened previously and to recognise the difference in the now. As humans we have complex systems that work together as a whole (the ‘me’) to make sense of what is going on within us and around us, and in so doing, create a perception of the World and where we are within that World. When these pieces fit well, we feel good.

For those suffering chronic pain the World changes in a way that makes it appear threatening, distant, disjointed and sometimes intolerable. We know that places appear to be further away when we have persisting pain, and that stairs look steeper when we are tired. Both of these altered perceptions are protective as they motivate defensive behaviours that can manifest as avoidance. Whilst this is an important strategy in the early stages of an injury, as time passes, this way of operating becomes a problem in itself as engagement with life diminishes. This choice, sometimes conscious and sometimes subconscious, becomes conditioned quickly. Often the decisions about whether to approach or avoid are based upon a belief that pain equates to tissue damage. Understanding pain counters this problem.

I as an individual, with a set of beliefs about myself and the World construct the perception that I have of that World. The reality that I experience is mine, and only mine. This reality can be suggestible and is certainly influenced by many factors, including how I am thinking right now. Is a sunset the same experience when I am happy compared to when I am sad?

Pain is part of the perception of the World, my World. The pain I feel is the ‘how’ I am experiencing the present moment, and I am feeling the pain in a part of my body. This is ‘how’ I am feeling my body, and often the painful area to which I am drawn is the only part of my body that I am feeling. The pain is not separate from the World I perceive, instead it is embedded within the context of my perceived World. Pain is changeable and is a different experience when I am at home compared to when I am at work. Pain is moulded by the environment as much as the perception of my environment is moulded by my pain. We are not, and cannot be separate from the environment in which we reside.

We can use this understanding to our advantage when designing rehabilitation, training and treatment programmes. Considering the environment from where the patient has come, and certainly the environment created for face to face therapy sessions. This is both the space in which the treatment is happening and that cultivated by the therapist through language and posturing. Treatment is embedded within the place where it happens and therefore, creating a place of positive meaning can empower recovery.

28Mar/14

Relieving low back pain — keeping it simple but effective

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

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

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

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

Here are my formulae:

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

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

04Mar/14

Pain – the unseen force

“Do we see the hundred-thousandth part of what exists? Look, here is the wind, which is the strongest force in nature, which knocks men down, destroys buildings, uproots trees, whips the sea up into mountains of water, destroys cliffs, and throws great ships onto the shoals; here is the wind that kills, whistles, groans, howls–have you ever seen it, and can you see it? Yet it exists.” Guy De Maupassant – the monk talking to the author at Mont Saint-Michel.

Pain, have you ever seen it, and can you see it? The unseen power of pain that is the cause of suffering is one of our greatest enigmas. We are understanding where pain comes from with greater precision but with every painful experience being unique, the pattern of activity in the brain is rightly different on each occasion. The widespread networks of neurons that are active when we are in pain are not specific to hurting, there is no pain centre. It is fascinating that we can see similar brain activity during a pain that results from nociceptive stimulation of the body and from social isolation. Neither pain can be seen from the outside, only the facial expression and verbalisation with the hundreds of words that can describe the feeling.

Is this the reason why people are disbelieved? Because pain cannot be seen. How can anyone truly measure the pain of another? Hurting is subjective. I know and only I know how much it hurts and how it affects me. All too often a patient describes returning to work and feeling a sense that colleagues do not believe or understand their suffering. This can only increase the threat and elucidate further protective responses that feed into the cycle of thoughts–physical responses–emotions–thoughts.

Thoughts cannot be seen but they are real as they play in the mind, each one creating a body response: “I am hungry,”, the stomach rumbles; “I don’t know my lines,” the stomach tightens and tingles; “I have pain, what does it mean?” the body tightens, the pain intensifies. None of these can be seen but they exist as much as the wind that can bend a tree.

Pain is embodied. We feel pain in a location in the body, even if the body part no longer exists such is the case in phantom limb pain. The brain networks ensure that we attend to the body region deemed in need of protection, creating the unpleasant experience that is pain so that action is taken to resolve the issue. In the early stages of an injury we actively protect the area by reducing movement, guarding with increased tension, warning others away with bandages and crutches. If you are travelling in London on the tube, this may even afford you a seat in rush hour. Persisting pain is not related to the extent of tissue damage, if it ever really is–for pain is not an accurate indicator of tissue damage. Chronic pain can feel like a fresh injury and drives the same behaviours: attention towards the painful area, guarding with the musculoskeletal system by tightening up the muscles–our natural armour, and avoidance. These behaviours feed back into the body systems that tell the brain something is up and the brain responds by continuing to protect. The cycle continues until there is a good reason for it to stop because a safe state has been achieved.

The challenge of tackling chronic pain means that we must look beyond the tissues. Exploring the brain, the immune system, the endocrine system, the motor system and how they interact to create our moment to moment experiences, the interface with life and how we respond at any given time. Nothing is permanent. Pain can come and pain can go. Cultivating the conditions for pain to change is the contemporary way of thinking and each person requires a unique approach based on sound scientific principles. So, much like we can harness the wind to create power, we can harness our biology to create a meaningful life.

RS

To book an appointment or for information about our bespoke treatment and training programmes for pain and chronic pain, contact us today: 07932 689081

 

 

11Feb/14

20 years in healthcare — what have I learned?

Reflecting back on over 20 years of time spent in healthcare there are a few things that stand out as being important. Much of what is learned has been pruned and will continue to be sculpted as knowledge emerges from the research.

Here are my top three:

1. Harnessed from the great writing of Oliver Sacks: it is as much about the person as it is the condition.

2. The effects of any intervention are affected by the patient’s perception and expectation, moulded by prior experiences and their belief system.

3. Communication sits at the heart of successful therapy, both verbal (this includes body language) and written.

RS

The Specialist Pain Physio Clinics in London deliver the very latest in treatment and training for chronic pain, persisting and recurring injuries 

Call us for information or to book an appointment: 07932 689081

31Jan/14

5 reasons why I use manual therapy for cases of persisting pain

Some will argue that manual therapy — joint and/or soft tissue techniques — has no role in chronic pain. I disagree. Why?

(In no particular order)

1. Touch is normal and it is something that we do when we care.
2. Hands on treatment is expected when you visit a physiotherapist or physical therapist.
3. Stimulation in the area of the body that hurts can feel good. If it causes little or no pain, the brain is happy and interpreting the stimulus (touch, pressure, movement) as being safe. More of that please! A great way to desensitise and for the experience of pleasure in the affected area.
4. Change the brain’s output by addressing the area with therapy that feels good — that’s the output feeling good, along with reflexive reduction in protection.
5. What do you do if you bang your elbow? Rub it. In chronic pain, you may need to think about how and when to rub it, but nonetheless, rubbing it needs. Combine rubbing with visual feedback and there you have a pain relieving strategy.

27Jan/14

Where do we tackle pain?

When someone tells you that they have a painful knee, it makes sense to have a look at the joint to see what has gone wrong. Perhaps an x-ray or a scan would help to determine the state of the cartilage, bone and surrounding soft tissue. An assessment of the range of motion, motor control and the responses to sensory testing reveal any functional limitations and adaptations. Is this enough to truly understand where pain really sits? Is it enough to decide where to intervene? In some cases yes is the answer, but not always!

Important that this kind of evaluation maybe, we must consider the significant pile of literature that points out pain is not an accurate indicator of tissue damage, as so eloquently concluded by Lorimer Moseley. One has only to think about phantom limb pain to realise that there is no need to have an arm, or a leg, or indeed any body part, for there to be pain in that location.

Phantom limb pain is the condition that illustrates the concept that pain is allocated a space. This space could be the knee as in our example above, any other body region or regions, or even outside of the body. A study by Lorimer Moseley also suggested that pain is felt in a space and not within the tissues. Subjects were asked to cross their arms, placing the affected hand into the space usually occupied by the unaffected hand. The effect? Pain relief. This is of course one study, however there was an impact that needs to be further investigated. Assuming that pain is allocated a space, this would explain why, when you position the hand in that of the non-painful side, both the pain and movement quality improve.

This is easily tested in the clinic with both hands and feet. The demonstration is a potent one for the individual as their limb experience can change. Seemingly there is an ease of the tension and guarding as well as the sensitivity. It can be profound, especially when someone has been suffering with a nasty pain such as in complex regional pain syndrome (CRPS) or neuropathic pain. The caveat is that this is not a cure, and it does not work every time, however in those that the effect is apparent, the ability to move more normally promotes healthy tissue and perception by the brain, especially if you are looking at the movement — extra sensory feedback via the visual system.

In summary, as best we know, pain is allocated a space. This can be a space that is occupied by a body region that why we feel pain in the tissues, the place where the pain emerges. The actual location of the pain is determined by the brain as it decides where we need to attend for protection. Recall that pain is a protective device involving a widespread network of neurons within the brain. There is no higher pain centre, but rather a network that monitors the sensory situation and responds as needed. On the basis that the sensory feedback suggests something dangerous is happening, the network will create an output that we experience in the body via a space that is deemed to need protection. Unfortunately, this output can occur without sensory input in some cases of persisting pain as the neuroimmune system becomes very sensitised and responsive to a range of stimuli including those that are not actually dangerous, hence why normal activities can hurt.

On this basis, when considering where to treat pain, we have to consider the space where the brain feels we need protecting. With the emergent property that is pain, the sensation is at the end of a process and it is therefore wise to target the entire biology from top to bottom and bottom to top. This means we need to address the higher centres, for example developing the individual’s understanding of their pain, reducing fears and using strategies for the brain maps of the body concurrent with using techniques within the space, i.e. the body area where the pain is felt.

For more about our comprehensive treatment and training programmes for persisting pain and injury, call us on 07932 689081 to make an appointment. Clinics in London & Surrey.