Tag Archives: Tendon pain

26Apr/16

Why tendons get better or not…

Why tendons get betterWhy tendons get better or not… was the question posed. Six of us were lined up to look at potential answers, the areas including isometrics, movement, injections, brain and pain. I was asked to consider brain and pain. Here are my thoughts.

To feel, to think, we need a brain but we are not just a brain. We are of course much, much more. We are a whole person and hence the brain is not the answer to the question why tendons get better, or worse. My main clinical focus is upon those that have not got better, looking at why (the back story, the primers and vulnerabilities) and then what thinking and action is needed now to change course. So most people I see are those who have got worse and in fact, we need to know as much about getting better as we do getting worse. Both are complex but then I argue, we have a greater opportunity to intervene.

The emphasis in my 10-minute talk, a format that is increasingly popular, was upon the fact that it is the person who gets better and not the tendon. What is getting better? What does this mean? I asked myself this question some time ago and followed up with asking ‘who gets better?’ for a talk at a CRPS conference. It has to be the person because it is the person who is conscious and ‘rating’ themselves as being better. The tendon cannot do this — a tendon does not know if it is better or not. Semantics you may think, but important I would say on the basis that we ‘treat’ a person.

A sense of being better results in a person being able to fully engage in their lives as they wish — meaningful living. However, much of our day to day existence is unremarkable, punctuated by situations we remember unreliably. However, we tell ourselves a story about ourselves over and over, with the ‘self’ as the main part in the film. It is strongly argued that the ‘self’ is an illusion: ask yourself where your ‘self’ exists? When you have finished pondering on that small questions, consider again getting better — ‘I’ must rate myself as getting better, meaning that I am able to focus on the task at hand and not be regularly drawn to unpleasant sensations in the space where my tendon (and other tissues) lie or be thinking about the implications of the pain — I can’t do this or I can’t do that etc. So, I concluded that the person gets better when they judge it so and hence the person being more than a brain, but certainly needs a brain, then we have to think wider.

On brain, I also briefly cleared up the seeming confusion between talking about the brain and central sensitisation. Because I argue that we need to address the person (a brain, a body, a context, an environment — unified) to address pain, and that this includes the brain, this does not mean we are saying it is central sensitisation. Without a thought that I have a tendon pain, there is no tendon pain, and hence we must address the top down processing (e.g. thoughts that are underpinned by beliefs, because of what we have been told or learned) because they impact upon the prediction as to what the sensory information means in this moment; the brain’s best guess, which is what you and I are feeling right now. Changing this prediction by minimising the prediction error by taking action is most likely how we are going about getting better.

In terms of pain, this is usually the driver that takes the person to seek help. The pain is stopping the person performing and motivating or compelling action because it hurts. The pain itself is flavoured by thoughts, sensations, thoughts about sensations as a unified experience involving many body systems that have a role in protecting us. Pain is about protection yet is part of the way we protect ourselves with other adaptations including changes in sense of self via altered body sense, altered movement, altered thinking and perception of the environment. With these adaptations occurring over and over, adapting to adaptations and onward, we need a programme that matches pain as a lived experience. What do I think and do now in this moment? The person needs to become their own coach to think and act in a way that takes them towards their vision of getting better, over and over. This means creating new habits, and that is the training programme aspect.

There is much more that can be said on this area, which has many common features with other persistent pain states. We can summarise by agreeing, as we did on the night, that there is no single answer but instead we must draw upon different areas of science and philosophy to ask the right questions and create the wisest programme that addresses pain as the unified experience that it is — physical, cognitive and emotional — but in that person with their story.

 

 

13Feb/16

Tendon pain

40+60 Feet | Bark |https://flic.kr/p/7rvmbB

40+60 Feet | Bark |https://flic.kr/p/7rvmbB

Tendon pain has been a big topic for some years. The problem is seen commonly in the clinic and frequently poses a challenge because so often tendon pain persists. Local factors and nociception are typically blamed, yet when treatment is focused at the tissue level, the limitations are exposed. As an aside, tissue based strategies are cited, yet there is really no such thing as a tissue based treatment simply because the tissues are not separate from the person. They are the person, and of course the person knows that something is being done to them and hence emotions and thoughts are at play, affecting the outcome — consider the person who observes your hands whilst you mobilise or massage whilst remaining calm and curious versus the person who is anxious, guarded with their hand poised and ready to grasp your hand as you start treatment; the latter person demonstrating why it is vital that the threat value be diminished before starting any intervention.

Pete’s excellent blog about tendon pain acknowledges the person, perhaps for the first time in tendon literature, which is music to my ears. Having been heavily influenced by Oliver Sacks, my philosophy has always been to consider the person as much, if not more than the condition as it explains how a particular issue manifests uniquely in that person. Certainly in my mind, the ‘initial assessment’ for me is about getting to know the person, which then rolls into their own experience of pain.

I first started looking with interest at tendon pain some ten years ago as an example of a persistent condition in sport. With an interest in chronic pain, it appeared that the discussions about tendon pain remained within the boundaries of where the pain emerged, yet our understanding of pain had advanced to the higher centres and many body systems involved in the experience of pain. Even nociception was discovered as being an incomplete picture as this biological process can be afoot with or without pain. Detection of threat does not mean it has to hurt, and indeed nociception itself is not something we actually feel. However, when the brain (which is of course part of the person and not separate, although our language does sometimes suggest this) predicts the need for protection, pain emerges in the person in a location deemed under threat or potential threat. This complex activity, which includes consciousness and the mind (these are both small subjects……..), is a whole person experience that is lived moment to moment and hence a focus on what happens in the tendon is only part of the picture. There is still very little acknowledgement elsewhere within the hierarchy, so here are a few thoughts I would like to share.

Previously I have expressed the view that we treat, advise and educate a person; a whole person. The approach that I favour is one that delivers the (working) knowledge and skills for the individual so that they can overcome their pain problem and resume a meaningful life as defined by themselves. Fragmenting for convenience is common, breaking down a whole into parts, yet this can never give a full picture. Medicine and healthcare typically specialise and whilst this has value, in the case of a persisting pain that often means that people fall between the cracks. For example, a female with fibromyalgia, IBS, migraines and pelvic pain may be seeing a rheumatologist, a gastroenterologist, a neurologist and a gynaecologist, and whilst elimination of anything pathological is important, there is an understood common upstream biology. Interestingly, many of these cases also have tender tendons that can be a surprise to the person when the tendons are pressed, especially considering that they are not the primary reason for seeking help.

Nothing happens in isolation (is one of my favourite phrases), and hence the biological expressions in and around a tendon are not separate from the mechanisms that underpin how pain arises in our consciousness. We cannot explain how this happens — how do chemical reactions in our body become a lived experience? Despite the lack of an answer, it clearly involves more than the tissue or structure alone.

This is not to say that the brain and the mind alone are responsible. Where is the mind? Where is the seat of the mind? Again, we do not know. Yet surely the mind is not just in the brain, an argument put forward by supporters of embodied cognition. It is me that thinks, not my brain or my mind, but me. And I think with my whole person because I am a whole person, and indeed when I feel pain, it is me that feels pain and not the body part where I feel it. Because I am more than that body part, the experience of pain must involve the whole person in that moment in that context. It is also true to say that to be in pain, we must be thinking that we are in pain as much as experiencing the sensory qualities of pain. Thinking draws our attention to the said experience, otherwise it is subconscious and hence not occurring to me.

For tendon pain, practically speaking, we must of course consider the health of the tendon itself and surrounding tissues, but also the person’s general state (who are they, how are they), prior experiences relevant to the problem (e.g./ tendon pain, pain, general health), beliefs, expectations, vulnerabilities to developing persistent pain, their story of how the pain emerged, their movement patterns (and why they are moving in such a way; both at the planning stages of movement and actual movement), body sense and sense of self at the very minimum. This information is gathered within the first conversation, setting the scene as trust and rapport develops naturally from exploration of their story that validates and empathises.

This is a mere and brief overview of my thinking about tendon pain, which poses a significant clinical problem, often persisting for longer than is expected. Whilst the focus remains on the tendon and nociception, there will be limited results in my view as this only tells a part of the story of the person in pain. This is true for any pain, and not just tendon pain. Pain emerges in the person and all that that person means and embodies, hence we must address the person as much, if not more than the condition. As Oliver Sacks wrote on his father, a GP: ‘He knew the human, the inward side of his patients no less than their bodies and felt he could not treat one without the other’. So true and this has always been my abiding principle.

Pain Coach Programme | t. 07518 445493

13Apr/13

Tendinopathy & Tendon Pain | Guest Blog by Dr Peter Malliaras

Thanks to my friend and colleague Dr Peter Malliaras for this blog on tendinopathy – here is his bio

Painful tendon injury or tendinopathy is common and often difficult to manage. Previously this type of injury was known as tendinits, and the suffix ‘it is’ suggesting an inflammatory pathology. For over three decades now researchers have known that longstanding tendon pain may not be inflammatory, so now the popular term is tendinopathy. The pathology that is seen in laboratory studies is effectively a failed response of the tendon to adapt to forces places upon it with daily activities and sport. This is largely because tendon responds very slowly and sluggishly to changes because its infrastructure of cells and blood flow are not as extensive as some other tissues.

It is generally accepted that the key treatment for tendinopathy is exercise. Exercise is the only intervention that can restore a painful tendons ability to take the loads that it needs to in everyday function and sport. A simple formula that I use in clinical practice is to consider the loads that a patient needs to endure in their day to day function and then design an exercise program that progressively allows them to endure these loads without the tendon becoming painful. The key is to make sure that exercise is commenced at a level that will not cause the tendon to become irritable and that it is progressed at a rate that the tendon can tolerate. Every patient that I see is different and how they progress with their rehabilitation and this depends on many complex individual factors, including musculoskeletal, systemic, motivational, psychological factors, etc.

Over the last 15 years the most popular form of exercise that clinicians prescribe is eccentric exercise. This is where the muscle is loaded whilst it is lengthening (e.g. the downwards phase of a biceps curl) and is in contrast to concentric exercise where the muscle shortens whilst under load (e.g. the upwards phase of a biceps curl). An international research group I am involved with, including two physiotherapist PhD clinician-scientists (Dr Peter Malliaras, Dr Christian Barton), a Senior Human Movement Research Fellow (Dr Neil Reeves) and a Public Health Professor (Prof Henning Langberg) recently published a review questioning eccentric exercise treatment for Achilles and patellar tendon injury.

There were four studies that compared loading programs in the Achilles and six in the patellar tendon. Only two studies were rated as high quality. The most surprising finding was that very few studies have actually compared eccentric training to other forms of exercise. For example, only one study had compared eccentric training in the Achilles tendon. Overall, there was no evidence that eccentric training is better than other exercise in treating these injuries. In fact, there was equivalent (Achilles tendon) or more evidence (patellar tendon) to support exercise that involved both eccentric and concentric contractions in combination. So combined eccentric-concentric contractions may be useful in tendinopathy. Clinically, I see mainly second opinion tendinopathy cases and one of the most common reasons they have not improved with eccentric loading is that they have marked weakness of their concentric function. Due to a very well established principle of known as ‘specificity in exercise’, people will tend to get better at the type of exercise they do. So, I always give eccentric-concentric combined loading to patients with concentric weakness. Another important point is that no studies to date have investigated isometric loading in Achilles and patellar tendinopathy rehabilitation. Isometric exercise enables muscle-tendon unit load at a constant joint angle. Clinically, I use this to exercise people at a painfree joint angle that limits compression whilst still loading the tendon. Tendon compression is associated with pathology. It is very effective in the very painful or very compressive tendon presentations, and our review has highlighted that we need more research in this area.

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