Tag Archives: physiotherapy Chelsea

09Dec/11

Mindfulness

Mindfulness, Neuroscience, Pain, Pain Education, Stress, Treatments, , , , , , , , , , ,

Mindfulness has grown in popularity over recent years, and for good reason. Those who regularly practice mindful meditation and mindfulness on a day-to-day basis will tell you about their clarity of thought, their sense of ease and their good physical health. The practice is recommended by NICE for depression as well as the frequent teaching of mindfulness as a way to deal with pain.

At the clinic, I encourage mindful practice to help the individual be released from the pull of negative and unhelpful thinking about pain. We all have thoughts. This is the action of the mind and is a normal process. Automatic thoughts pop into our head and trigger emotional and physical responses–think about a waxy, yellow lemon resting upon a plate; you take a knife and cut into the rind, releasing the citrus odour as you divide the lemon in two, the pieces rolling away from the blade; you further cut the two halves into quarter segments, each time triggering a small burst of juice into the air around; imagine taking one segment and gently placing it into the front of your mouth; what are you experiencing? Thoughts change our physiology because our brains respond to thinking or imagining, just as if we are present. This is why it can hurt when we watch someone else move their body in a way that would be painful for us.

Automatic thoughts are just that. How we respond next we can decide. By being observant of our thoughts we can avoid following an automatic thought with another thought and another that lead to persisting physiological responses and emotions that are unpleasant and unhelpful. In particular those thougths that often recur and create unease and anxiety. They are simply thoughts. They are not us and they are not reality. They are just thoughts. But, they can be powerful unless we can find a way to be observant, non-judgmental, aware and present. That ‘way’ can be mindfulness.

Here are some great people talking about mindfulness and meditation

 

There has been and continues to be a great deal of work looking at mindfulness and how it may work. The Oxford Mindfulness Centre (OMC) undertakes research and provides training.
‘The OMC Team does ground-breaking clinical and neuroscience research on mindfulness. It assesses the efficacy of different forms of mindfulness practice for different types of problem, and is building up a peer-reviewed body of knowledge about what forms of mindfulness intervention best suits which type of person.’
A list of the OMC publications is available here

For further information on our use of mindfulness for pain, please email richmond@specialistpainphysio.com

21Oct/11

Using neuroscience to understand and treat pain

Chronic low back pain, Chronic pain, Complex regional pain syndrome, Functional Pain Syndromes, Low back pain, Neck pain, Neuropathic pain, Neuroscience, Pain, Pain Education, Pain Psychology, Problematic sports injuries, Rehabilitation, Treatments, Understanding pain, , , , , , , , , , , , ,

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

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

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

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

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

09Oct/11

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

Chronic pain, Exercise, Pain Education, Pain Psychology, Psychology, Rehabilitation, Treatments, Uncategorized, Understanding pain, , , , , ,

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).

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?

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.

26Sep/11

Dysmenorrhoea and Pain

Chronic low back pain, Chronic pain, Dysmenorrhoea, Fibromyalgia, Functional Pain Syndromes, Headache, Low back pain, Migraine, Pain, Pain Education, Understanding pain, , , , , , , , , , , ,

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

 

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

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

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

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

20Sep/11

Problematic Sports Injuries

Problematic sports injuries, Rehabilitation, 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.

12Sep/11

Physiotherapy in Chelsea

Chelsea, Clinic News, London, , , , , , , , , , , , ,

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

T 07518 445493

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

Knowledge and healthy movement for normal self

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

Come and visit our blog for regular articles and information.

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

T 07518 445493

21Jul/11

Treatment Update

Clinic News, Pain, Pain Education, Treatments, , , , , , , , , , ,

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.

19Apr/11

Complex Regional Pain Syndrome (CRPS/RSD)

Complex regional pain syndrome, CRPS, New treatments, Pain, Pain Education, Rehabilitation, Uncategorized, Understanding pain, , , , , , , ,

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.