Tag Archives: Women in pain

24Oct/16

Women in pain

Women in painRecently I gave a talk to a group of female health professionals at the Inspiring Women in Medicine meeting entitled ‘Women in pain’. I spoke about the significant societal problem of women suffering persistent pain, which is one of the issues that comes under the banner of women’s health. Society needs women to be healthy and hence the problem of women in pain must be addressed. Fundamentally at present, society does not understand pain sufficiently to address this enormous public health matter effectively, which is where I believe we must begin: understanding pain.

If society understood pain….

  • individuals would know what to do and think in order to orientate themselves towards getting better
  • it would not be feared; instead the focus would be on overcoming pain
  • healthcare would deliver the right messages early on so that the right actions are informed by correct beliefs about pain
  • the right treatment appraoches would be employed from the outset
  • there would not be the same level of suffering — the figures say: 100 milliion Americans suffer persistent pain; 20% of the population; 1:5 children

Chronic pain is a huge global health burden that costs both individuals and society enormously in terms of finances and suffering. Of course, this pervades out into family and social networks and hence those around the individual can also be suffering through their on-going provision of care. Pain is a strain on society, literally. If it were understood, this can change.

Women in painWomen are reported to suffer more pain and visit their doctor more often about pain than men. Females are more likely to suffer functional pain syndromes. There are still many people, including healthcare professionals, who do not know what functional pain syndromes are or have insight into the basic biology that emerges as a range of painful problems that are very common. They include irritable bowel syndrome (IBS), migraine and headache, back pain, fibromyalgia, pelvic pain (e.g. vulvodynia, painful bladder syndrome, dysmennorhoea) and temporomadibular dysfunction. Other regular features include anxiety, depression, a history of early life events (and later in life when a challenging situation brings about pain and suffering), perfectionism, a person who is very hard on themselves and hypermobility.

This being the case, one would expect that research into how females experience pain and why they feel more pain would be stacking up. Unfortunately this is not the case with most research done in males and male rats. Clearly that has to change alongside the overall attitudes to women in pain.

Women in painRecently the press ran with stories about how women in pain receive different care and approaches to men. Women waited longer for treatment, were less likely to receive opiates for pain (opiates are effective for acute pain — there are big issues with the use of opiates for chronic pain) and were deemed to be more emotional and hence somehow their pain was different in the sense of how it should be treated. Of course this is wrong on every level. Each person has a unique pain experience that is flavoured by a perception of threat within a certain context and enviornment, based on prior experience and beliefs of that person. Therefore, each person needs to be addressed as such and treated according to this principle, man or woman.

There arWomen in paine some ideas as to why men and women should experience pain differently. The most obvious is that of gender biology based primarily around hormones and the menstrual cycle. In particular there maybe an important time at the onset of menarche when sensitisation could emerge in some individuals, thereby priming them for future events such as injuries, viruses and illnesses when the systems that protect us (immune, nervous, sensorimotor, autonomic, endocrine — they work together as opposed to being in isolation) are active in the face of a perceived threat and increasingly vigorously. What the person lives are the symptoms of thee systems working including fever, pain, altered perceptions of the world, altered thinking and emotions. It can sound like these are all separate ‘reactions’ when in fact they are part of an on-going cyclical process: we think, perceive and act as a unified lived experience.

Another observation relates to empathy and how women maybe more empathetic for the purposes of caring for their children. A truly empathetic person is a caring person yet they must be careful and skilled so as not to embody their own versions of observed others’ suffering. As an example, it is not uncommon for me to feel a pain in the same place that a patient is describing their pain to me. Understanding the mechanism, I can rationalise the feeling and it will pass as I actvely change my perception — this is likely the same mechanism that underpins the change from being in pain to not being in pain in all people. I know that others I have spoken to also have this experience, which one could argue is deeply helpful as a healthcare practitioner as we seek to understand the causes of the other person’s suffering.

A described emotion that often appears within conversations about pain, particularly women in pain, is that of guilt. The reasons for expressing guilt are based around the conflict between work, home, partner and children — trying to please all but rarely pleasing or looking after oneself. Being kind to self is important in the sense that being hard on oneself can be the cause of great suffering. This is common and will almost certainly be taking the woman closer to her biological protect line, the point at which threat is perceived and enacted as a pain experience. Learning how to foster the existing compassion towards oneself then, is a typical part of a comprehensive programme for getting better. With many whom I see displaying and admitting perfectionist traits, it is not a surprise that harsh inner dialogue results in repeated negative emotions. Strung together frequently, this forms the basis for chronic stress, which in turn is the means for a pro-inflammatory state, which emerges as aches and pains, troubled tummies, headaches, mood changes, sleep issues, fertility problems and more. The reason is simply that in the pro-inflammatory state, the body is in survive mode that is great when there is a real threat. However, most of the time there is no threat, it is just something we are thinking about that triggers the same response via a prediction taht one exists.

Now, there is nothing wrong in experiencing negative emotions. We need them as much as the others. It is really about the apporpiateness of the emotions: when we feel them, how long we feel them for, how often etc etc. If we consistently think that something bad will happen or ruminate on things that have happened rather than seeing things for what they really are in this moment, then this basic survival biology will keep going. This is where mindful practice is so beneficial, cultivating awareness of existing habits that allows for a reappraisal, a space to see things for what they are and gain insight into the causes of your own suffering and others, from which you can choose a new and healthy way onward. Clearly there is much more to say about mindfulness and its benefits, in particular in the face of mcuh exciting data from studies across the world.

Whilst this blog scratches the surface, it hopefully provides some food for thought. This is a significant public health issue that we can tackle by understanding pain and applying simple and sensible compassion-driven care, which will make a huge difference. Coaching the individual woman to coach herself in a direction that is toward her desired outcome is out role as we empower individuals and allow them to realise their sense of agency in getting better. There are simple measures such as movement, exercise and mindfulness that work in synergy to create a meaningful life to be engaging and enjoyed so that when challenges arrive, they are overcome and used as learning experiences. Science, compassion and sense are at the heart of the Pain Coach approach, one that we can all adopt to change for the better. Ourselves and our patients.

RS

The Pain Coach 1:1 Mentoring programme is for busy clinicians who wish to develop their working knowledge and to be effective in coaching people suffering chronic pain to lead meaningful and fulfilled lives. Contact us on the form below or call Jo for further information t. 07518 445493

 

 

 

18Jun/16

Biology of pelvic pain

Pain nowMost of the biology of pelvic pain does not exist in the pelvis. The same is true for any pain — back pain, knee pain, neck pain etc. Much like the screen turning blank in the cinema, the problem itself is not the screen but instead the projector or the power source. In other words, to think about pain requires us to go well beyond the place where it is experienced.

Pain is of course lived and whilst it must have a location, the relationship between pain and injury is unreliable. With a huge number of factors influencing the chances of feeling pain in any given circumstance, there is a requirement for a perception of threat that is salient and exceeds other predictions in terms of a hierarchy. Once felt, pain compels action much like thirst and hunger. Again, like thirst and hunger, context and meaning we give to the sensations influence that very experience, which clarifies to a greater extent the difference between on-going (chronic) pain and that of labour.

To feel pain we need a concept of the body, which itself is constructed elsewhere as the sensory information flowing from the body systems is predicted to mean something based upon what is already known and has been experienced, we need a nervous system, an immune system, a sensorimotor system, a sense of self and consciousness to name but a few. Where in the pelvis do these reside?

This is not to ignore where we may feel pain as this is an ‘access’ to the pain experience that should be used in terms of movement and touch. However, it is the person who is in pain and not the body part. My pelvis is not in pain, I am. My pelvis does not go and seek help, I do. My pelvis does not ease its pain, I do. So when ‘treating’ a person, we must go beyond the place where the pain is felt to be successful. And it is vital that the person is considered a whole; there is no separation of mind-body. The notion of physiological, body, psychological division etc. etc., just does not fit with the lived experience; I think, and I do so with my whole person — embodied cognition.

Locally one will usually find evidence of protection and guarding, which themselves manifest as the tightness, spasm, painful responses to touch and movement. This is all manifest of an overall state of protection, co-ordinated largely unconsciously accompanied by a range of behaviours and thinking that quickly become habitual — they are certainly learned from priors, our reference point. This is simply why delving gently into the story is important, as we can identify vulnerabilities to persisting pain such as previous experiences of pain, functional pain syndromes, stressful episodes in life; all those things that put us on alert when the range of cues and triggers gradually expand so now I am vigilant and responding to all sorts of normal situations with fear.

The start point is always developing the person’s working knowledge of their pain, which also validates their story. So many people still report that they feel that they have not been believed, which I find incredible. How can someone work in healthCARE and not believe what a person says? Baffling. Once the working knowledge is being utilised and is generating a new backstory, new reference points emerge. We create opportunities for good experiences over and over, moment to moment, day after day, in line with their desired outcome, the healthy ‘me’ that is envisioned from word go. This strong foundation that opens choices once more then permits exploration of normal and desired activities supported by sensorimotor training and other nourishing movements, alongside techniques in focus, relisience and motivation. Realising and actualising change in a desired direction must be acknowledged as the person lives this change knowing that they can.

Pain can and does change when you understand it, know where you want to go and how to get there, quickly getting back to wise, healthy action when distracted (i.e./ flare ups, mood variance, loss of focus etc). The biology of the pain is one aspect, hidden in the dark within us, and the lived experience is another. The two are drawn together to give meaning and to develop an understanding of the thinking and action that sculpt a new perception of self and pain, resuming the sense of who I am, as only known and lived by that person.

23Mar/16

Women in pain

Women in painI see more women in pain than men in pain. Naturally, it depends upon the individual as to whether they seek help or not, yet as a general observation it appears that women in pain are more likely to take some action.

The most common presentation is a female aged between 30 and 55 years, who has suffered pain for some time, months or even years, which is now impacting upon her life in a number of ways. Typically the pain is affecting homelife, particulalrly looking after young children,  and worklife, or both in some cases as the pain pervades out into every nook and cranny. Sometimes this happens over a few months but often it is a slow-burner that is suddenly realised. When we have a conversation about the pain, cafe style*, it becomes apparent that there have been painful incidents punctuating a consistent level of sensitivity, building or kindling. The pains emerging in the person include back pain, neck pain, wrist pain, knee pain, foot pain — any joint pain — muscular pain; and can be accompanied by a range of pains known as functional pain syndromes: pelvic pain (dysmennorhoea, period pain, endometriosis, vulvodynia), irritable bowel syndrome, migraine, headache, fibromyalgia, jaw pain. The person, whilst unique and has a unique story to tell, is often hard on themselves by nature, a perfectionist, anxious and a worrier.

There are many, many women suffering a number of these problems that appear to be unrelated, but this is not usually the case. Upstream changes, or biological adaptations, play a role in the symptoms emerging, yet of course the way a condition manifests is dependent upon the individual themselves, with the uniqueness of each person, their tale, beliefs and life experiences.

Nothing happens in isolation. In other words, there is a point in time when we experience a sensation that we label and communicate, but this is not in isolation to what has been before. The story that the person tells me is vital because it reveals both the unfolding of how the individual comes to be sat in the room and allows me to begin giving some meaning to the experience; i.e. helping the person understand their pain and how it sits within their lifestyle and their reality. I say within because pain should not define who we are, yet it often appears to and hence needs to be put into perspective; the first step to overcoming the problem.

So, there are priming events that often begin much earlier in life than the pain that eventually brings the person along to the clinic. These priming events are biological responses to injuries, infections and other situations that are also learning situations. Learning how to respond at time point A then ‘primes’ for time point B as a response kicks in based on how our brains predict the best hypothesis for what ‘this all means’–what we are experiencing now is the brain’s best guess about what all the sensory information means based upon what has happened before, probability playing a role. One of the reasons for a good conversation is to identify the pattern of pain over the years, how it has gradually become more intrusive as the episodes intensify and become more frequent. The pattern can then be explained, given meaning and then provide a platform to create a way forward.

We are designed to change and each moment is unique. This gives us unending opportunities to steer ourselves towards a healthier existence and leading a meaningful life. To get there though, we must have a belief that we ‘can’ and be able to hold that vision. This vision of the healthy me is one that allows us to ask ourselves the question ‘am I heading towards the healthy me with these thoughts and actions, or not?’. If we are not heading in that direction, then we are being distracted and need to resume the healthy course, actively choosing to do so. How are you choosing to feel today? This is an interesting question to ask oneself.

We still have a certain amount of energy each day and a need for sleep and recuperation. Exceeding our capacity means that we are not meeting our basic needs — security, nutrition, hydration, rest. There is only a certain amount of time that we can keep drawing on our energy before we must refresh. Failing to attend to the basic needs leeds to on-going stress responses that are meant only for short bursts. Prolonged activation begins to play havoc in our body systems as we are in survive mode, not thrive mode. In particular, systems that slow down include the digestive system and the reproductive system. Many, many of the women I see have issues with both — e.g./ poor digestion, bloating, sensitivity, intolerances, fertility problems. The biology that underpins behaviours of protection (fright or flight) are preparing you to fight or run away. Having a meal or trying to conceive are low on the biological agenda when you are surviving.

Too much to do, too little time. Modern day living urges us to be busy being busy. Demands flying in from all quarters, yet it is the way we perceive a situation, the way we think about it that triggers the way we respond, not the situation itself. This gives us a very handy buffer. By gaining insight into the way we automatically think and perceive, this being learned over years (i.e. habits), we can become increasingly skilled at choosing different ways of thinking, letting thoughts go, and focusing on what enables us to grow. This very quickly changes our reality, our body, our environment and the sum of all, which is the lived experience.

With on-going pain we develop habits of thought and action, including the way we move that is integral to the way we sense our bodies. Our body sense and sense of self changes in pain, as does our perception of the environment (things can look further away when we have chronic pain or steeper when we are tired), all of which add up to provide evidence that we are under threat. More threat = more pain because the amount of pain we suffer is down to the level of perception of threat and not the amount of tissue damage. We have known this for years, yet mainstream healthcare and thinking remains steadfastly into structures and pathology. It is no mystery then, as to why chronic pain is one of the main global health burdens when the thinking is wrong! So what can we do?

If you are a woman suffering widespread aches and pains, tiredness and frequent bouts of anxiety, there is good news! As I said earlier, we are designed to change, and change is happening all the time. We need to decide which way we wish to change and then follow a plan, or programme, that takes you towards your vision of the healthy you. Pain is a lived experience and hence the programme must fit your life and unique needs as the techniques, strategies of thought and action interweave your life, moment to moment, taking every opportunity to create the right conditions. The blend of movements, gradually building exercises, mindful practice, sensorimotor training, recuperation, resilience, focus, motivation and more, together form a healthy bunch of habits that are all about you getting healthy again, which is the best way to get rid of this pain. No threat, no pain.

* the cafe style conversation is my chosen way of unfolding the person’s story. How do we chat in a cafe? It is relaxed and open, allowing for the full flow of conversation.

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23Jan/13

Women and pain 2 | Endometriosis

This is the second part in a series highlighting common painful problems that I see in women (Part 1 here). Endometriosis would not usually the reason for the referral, however this problem can often be mentioned as we talk about painful problems that are seemingly unrelated. To the individual, endometriosis can significantly affect quality of life, impacting upon day to day living in many ways. There are perhaps 2 million women with the problem.

What is endometriosis? The classic viewpoint

Endometriosis is a condition when the cells of the womb lining are found outside of their normal habitat. Commonly the cells are seen in the pelvic area and abdomen (ovaries, fallopian tubes, ligaments which hold the womb in place, the area between the rectum and the womb named the Pouch of Douglas) but occasionally in other locations in the body (bowel, bladder, intestines, vagina, rectum, on operation scars, in the muscular wall of the uterus and rarely in the skin, eyes, spine, lungs and the brain).

What are the symptoms?

There are a range of symptoms and problems that vary in their severity including:

  • Painful periods
  • Persistent pain in the pelvic area (chronic pain)
  • Bowel and bladder symptoms
  • Issues conceiving
  • Fatigue
  • Depression
  • Relationships difficulties
  • Limited or avoided socialising
  • Problems at work
The symptoms can often begin in adolescence (see article here), a time of great change and challenge in any case, complicated by this painful condition.

Reconceptualising pain – beyond the tissues

Although we feel pain in our bodies, the construction of the experience occurs within the brain via a widespread network of neurons. They are not specific for pain and have a large number of different functions including memory, concentration, movement, sensation, decision-making and fear to name but a few. In brief, we experience pain as an output or as the end result of the brain scrutinising the information from the body that is compared and analysed in the light of prior experience and the knowledge base. On concluding that there is danger or a threat to the body, the brain allocates the sensation of pain to the area deemed to require attention and protection.

Pain is a motivator, a need state that requires action to be taken to promote healing and survival. Pain emerges from the self and is hugely influenced by a range of factors beyond the ‘structure’ where the unpleasant experience resides.

Undoubtedly pain is complex and modulated by many factors, in particular emotional state, attention and lifestyle – see here. It is also useful to understand the pain mechanisms that can play a role in the maintenance of symptoms, including peripheral and central sensitisation that are not in isolation of immunological and endocrine activity that can hugely influence the perception of pain. The health of the tissues depends upon normal functioning of these body systems as well as movement to nourish both locally via blood flow and the representation of the body that exists in the brain. This representation relies upon regular updates from the body via signals about movement and chemical balance.

Recent neurobiology studies have identified mechanisms that may underpin pain and the process of sensitisation in endometriosis and other chronic pain problems – click here, here & here. There are many papers that help to explain the changes in the nervous system and other systems that contribute to a persisting pain problem. Basing one’s thinking purely around a structure as a cause for on-going pain is simply not encompassing enough to tackle the issue.

Researchers last year published a paper that described an imbalance between the sympathetic nervous system and the sensory nerves (click here) in peritoneal endometriosis, suggesting that this may underpin an on-going inflammation and consequential pain. The sympathetic nervous system (SNS) is a branch of the autonomic nervous system (ANS) and is responsible for the feelings one may experience when in danger, e.g. sweaty palms, increased heart rate, a feeling of anxiousness. The SNS is a direct link between our thinking and feeling self and the physical responses and therefore the way we perceive a painful problem can influence the pain we feel via this system but also the immune system that is responsive to our thinking and stress – click here and here. There are well established links between nerve and immune functions – click here.

The meaning or salience that is given to the pain and the context of the pain are both key considerations. Of course both can and do change, therefore affecting the pain perception at any given time. The meaning one ascribes will relate to beliefs about pain and its consequences upon health and lifestyle. The greater the perceived threat, the greater the chance that the brain will protect. Pain is part of that protection alongside other adaptations such as increased muscle tension that can cause further pain and discomfort.

Neuroscience confirms what people have been saying for years, that our thinking process affects our pain. The discovery of communication between different parts of the brain has helped us to understand this and actually target this mechanism with specific strategies. Changing our thinking really does change our pain. Interestingly, it was discovered that when we catastrophise about pain (cognitive and emotional factors) it can affect the immune system’s inflammatory profile. In other words, over-worrying about the meaning of our pain can potentially make us more inflammatory–see here. It does appear that some people are not able to turn off their inflammatory responses as effectively, thereby continuing to provoke sensitisation and pain. There is a genetic basis to this over or prolonged response.

How can we tackle pain in endometriosis?

Traditionally the pain of endometriosis is managed with analgesia, hormone based medication, surgery and complimentary therapies or a combination thereof. Considering the brief overview of the pain mechanisms above, although complex do provide a range of levels at which we can intervene to change the pain experience.

The contemporary way in which pain is considered is called the biopsychosocial approach. This means that the neurobiology, psychology and social aspects of pain are addressed in an integrated manner. We have said that pain is complex and multidimensional on the basis that the areas of the brain  responsible for the pain experience have a range of additional roles. They are not specific for pain and indeed there is no pain centre. Consequently, the need is for a wider lens and this is exactly what the biopsychosocial model offers.

Reasoning that there are different mechanisms, we can design and create programmes of treatment and training for each.

For example, we know that movement and muscular activity is different when we are in pain. These altered movement patterns feed back to the brain and are a mismatch for the expected patterns thereby maintaining protective measures. There are a number of ways that we can look at how the motor system has adapted and then seek to re-train normal movement and sense of the body that is often affected. Muscles that are overactive because we lose precise control can be the cause of local sensitivity, adding to the unpleasant picture.

Re-framing one’s thinking about pain with high quality education (informational medicine) actually changes pain perception and for good reason. Biologically the areas of the brain involved in thinking communicate with other regions that are part of the network we have been talking about, therefore negative thinking and anxiety can increase vigilance to pain, attention and focus towards pain, both of which can amplify the experience. Remember that a thought and an emotion is as much brain activity as a movement and both are potent ways of further sensitisation.

At our clinics we draw all this information together, blending with the individual’s narrative and experiences to develop a personalised care package that is as much about the person as the condition suffered. Several of the ways in which we look at and tackle pain are mentioned. These sit well with a range of strategies and treatment techniques that we employ to promote wellness and living. Interestingly, there are frequently other painful conditions that co-exist with endometriosis and the science demonstrates that there are usually similar mechanisms underpinning the seemingly unrelated problems (e.g. IBS, fibromyalgia, chronic fatigue syndrome, migraine, pelvic pain, bladder dysfunction). In targeting the peripheral and central mechanisms as outlined here, we often see a change in the other symptoms as well.

For further information about our clinics and treatment please contact us here or call 07932 689081