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Look after yourself this Christmas!

Every year around Christmas time I have a number of people come in to see me with lowerfather-christmas-7 back and neck spasms. When I ask these people how their pain came on, they reply that ‘they can’t really think of a reason, it just went into spasm’. This is a pattern I have observed for a number of years now and in my early years as a physiotherapist I was left scratching my head as to why these people had high levels of pain and intense spasms, without a clear mechanical reason for it.

 

Since I have transitioned to using a neuro-physiological approach and now use the SIRPA approach it is now obvious why I see this pattern. Christmas is one of the most busy and stressful times of the year! On top of your usual amount of stress, there are presents to buy and the stress of finding the right present for people. There is the food to buy in and the added pressure of making sure everything goes well on the day. There are more social events to attend and if you’re more of an introvert that may not be something you looking forward to. There is the prospect of spending time with your family and if you don’t get along with your family this can be difficult. You may also have work that needs to be finished before the holiday, so you are front loading to get that finished. All this is on top the stress that you already have in your life!

 

In previous blogs I have already explained how changes in lifestyle can cause stress. I have also explained how stress can make the central nervous system more sensitive and it makes muscles more hyperactive. If you’re not getting enough downtime, which can often happen in the lead up to Christmas, the pain and muscle spasm can come on to make you slow down.

 

During this period, try to take care of yourself and make sure you still have time for yourself. If you can, try and take ten minutes out of every day when you sit and do nothing at all. This will allow your nervous system to switch off. There is also lots of other good advice on the clinic’s facebook page: BPRC Facebook page

 

Look after yourself and have a Great Christmas!

Breaking the Pain Habit

It was previously thought that the brain doesn’t change much after childhood and because of this certain habits or behaviours we developed in this period cannot be changed. It was believed that this could cause us to get stuck in later life continually acting out certain behaviours we have learnt during this period. Likewise there are also people who believe that once pain has lasted for longer than 3 months (the medical definition for chronic pain) then it is unlikely it will resolve and will become permanent. We now understand that this is wrong on both counts.

 
What I have found when working with people who have chronic pain is that there are certainly behaviour and thought patterns that can have a negative effect and even cause pain. Often these patterns are learnt in childhood, but they are not permanent and can be changed. Yes the brain can get stuck repeating the same thought pattern, which causes you to act in a certain way, but you can retrain it to think differently. Likewise the adaptive changes that occur in the brain and central nervous system that cause the majority of chronic pain are also not permanent. So by changing the negative thought and behaviour patterns you can in turn stop them from driving the pain cycle.

 
Here is a great video that explains neuroplasticity (Patterns of activity in the brain and nervous system). It shows how the brain like the nervous system is adaptable and constantly changing. Because of this it is possible to rewire your brain to a new way of thinking:

 

 

Negative self-talk that may have started when we were young can continue in later life and become a habit. Often when people with a low self-esteem can reinforce this with negative self-talk. This also prevents people from doing things that are good for them because they don’t feel they are worthy. It may mean you stop socialising with friends, stop exercising due to a negative image of yourself or don’t take time out to do things you enjoy. If you don’t do things that are good for you and you are regularly feeding negative information into the system, it will have a negative impact and is likely to cause pain.

 
As the video explains you can change your thought patterns, which in turn can help change your behaviours, which in turn can make you do activities that are positive for your pain. By doing this it helps to switch of the pathways in the brain that are causing the pain and helps to create new pathways that switch the pain off.

 
Now just because you can do this it doesn’t mean it is easy. It requires will power and perseverance to break the negative habits. Imagine you are golfer who has swung his club in a particular way for years. You go to see a coach who tells you that they could improve your game by changing your swing pattern. To begin with the new swing will feel very strange and you may not play as well for a few weeks as you adjust to the different way of playing. After a while though when you have repeated the new swing enough it will start to feel natural. You get used to it and actually find that your game improves and you are a better player than before.

 
Breaking habits can work in the same way but with perseverance and repetition you can create more positive habits instead! This switches off the old habits and pathways that were leading to the pain.

 
For some great advice on creating new positive habits have a read of this blog written by Georgie Oldfield on the SIRPA website:

http://www.sirpauk.com/blog/using-willpower-to-break-the-pain-cycle/

How we feel pain Part 3 – The impact of stress

Imagine that you’re sitting in a room with a group of people. You’re all sitting on an identical chair and talking to each other. After about half an hour of sitting some of the people in the room may start shifting around in their seat and look a bit uncomfortable. After an hour or so, more people will feel uncomfortable and people will begin to move about and change position. As time passes people start shifting around more and some people may even have to stand up due to the discomfort.

 

What is happening here and what has this got to do with stress and pain?

 

Whilst you are sitting, your brain is collecting information from all over your body; from your muscles, skin, joints and organs and it makes decisions about the information it’s receiving. If it doesn’t like the information it’s receiving, it may do something about it. This is how we avoid danger and protect ourselves. In this instance, if the brain feels like too much tension is building up in the muscles or that your cardiovascular system needs to work a bit harder, it will do something to make that happen. So what can it do? Well it could cause some discomfort to make you move around and to get the cardio-vascular system working and to stretch out your muscles. The pain is switched on to motivate you to move, it’s not happy with the information and feels you need protecting. This is part of the homeostatic mechanism, in a similar way to when we feel thirsty it feels uncomfortable or if you sit somewhere cold you may feel uncomfortable. The pain is there to make you act.

 

So what has stress got to do with it? Well the brain can respond to stress in the same way. If there is a build-up of stress in your life or you are causing yourself a lot of stress, the brain can trigger pain to try and protect you. This pain makes you slow down and take things a little easier than maybe you have been doing.

 

During an acutely stressful event, like being attacked by a tiger (not a common scenario in the UK I know), the brain will release cortisol to activate the fight and flight response. Muscle activation and heart rate will increase to get you ready to run for fight (The fight orPicture1 flight response). Once the attack is over and you have survived, the brain and nervous system will deactivate the release of cortisol. Otherwise you would be kept in a hyperactive state where you would find it difficult to relax and slow down your heart rate.

 

So the release of cortisol is good for a short period but if it carries on for too long it will overload the system and cause increased activity in the nervous system. It causes hyperactivity in the central nervous system that causes normal nerve pathways to change how they perceive information so that normal information now becomes painful. As I explained in a previous blog, our brain and nervous system are adapting and changing all the time. When you feel stressed your nervous system naturally becomes more protective of you. These adaptions have been shown in numerous studies on humans and in animals that have been put under continuous stress. They become more sensitive to pressure and temperature and can tolerate less than they previously could.

 

The tiger scenario is not one we encounter frequently, we generally do not encounter too many acutely stressful situations, instead in modern life, 99% of the tigers we run from are in our heads. That is to say that we produce most of our own stress and often this stress continues over longer periods. For example, pressures that we place on ourselves to
do well, difficulty finding a work life balance, feeling the need to be liked all the time, putting others before ourselves, relationship problems and financial pressures all lead to stress. There may also be external stress like caring for an elderly relative or the death of someone close to you. All these lead to an over-active nervous system, difficulties relaxing and can lead to pain.

If we don’t slow down or look after ourselves the unconscious parts of your brain might take matters into it’s own hands and decide that enough is enough and that it needs to do something to protect you. In the same way that it causes discomfort to make you move from the chair, it may cause pain to protect you from stressful situations or the pressure you are putting on yourself. If you think about it, pain is a great way of making you slow down and take time out.

 

Next time you feel some pain have a think about what is happening in your life or how you have been feeling recently. It may be that your brain is trying to tell you something. You might need to slow down or stop putting yourself under so much pressure. There are ways to help reduce stress and stop it from causing pain and health problems. Get in touch if you want to learn how.

Running a marathon can be stressful!

 

It’s one month before the marathon, training’s been going well, you’ve stuck to the plan and you’re on course to do a PB. Then out of nowhere disaster strikes; at the end of a training run you feel a twinge in your calf and have to pull up. You think I’ll leave it a couple of days and try again, but next time the pain comes on and after only a mile! You try to work out what you have done wrong, but nothing comes to mind. You’ve been stretching regularly, keeping hydrated, had your trainers checked, biomechanics are good and you’ve stuck to the training plan to the letter. So what has triggered this pain now and at such an inopportune moment?

 

This situation is one I see regularly in clinical practice especially in the build-up to the London Marathon. People get themselves in the perfect shape physically and feel they’ve taken everything they can into consideration, good trainers, stretching regularly, diet, regular massage etc. The one thing that people often overlook is the stress and pressure that running a marathon can create, both physically and mentally. It can be incredibly time consuming fitting the training in for a marathon, particularly if you have a full time job and a family, which can create extra pressure. Often people get back from work, get their trainers on and head straight out, giving themselves no time to relax before going into intensive exercise. If you’ve had a difficult day at work, you can spend the whole run recycling the problems you’ve had. There may also be the added pressure of trying to raise money for the charity and not wanting to let down the charity and the friends and family who have given you money. There may also be pressure that you’re putting on yourself to do a good time or a PB. All of these factors can lead to increased stress and pressure and this will lead to more tension in your muscles and more activity in the central nervous system increasing the risk of pain and injury.

 

Another common problem with runners that I see, is the curse of a previous injury. I see a lot of runners who have had an injury in their calf, ITB or hamstring, who then fixate on the problem whilst they are doing subsequent runs. By checking in on that area to see if it is tight or painful it will actually make the area tight and could lead to pain. If you go for a run and only focus on that area, one you will probably make it worse and two you won’t enjoy the run.

 

runnersSo what can you do to reduce stress and help to prevent pain and injuries? Well first of all ask yourself ‘are you running stressed?’ If you are getting back from work and heading straight out for a run, your muscles may be tighter than they need to be. Instead, try taking an extra 10-15 minutes to switch off before heading out. During this time you could also try some breathing techniques to help relax. Mindfulness breathing exercises are a great way to focus your attention and to help relax muscles. You could do this before or during a run.

 

If you are putting pressure on yourself to get a good time and are constantly checking your watch during a run, this may be making you more tense when running. Likewise if you are constantly checking your calf or ITB, it will also make you more tense and may lead to pain. Instead before you go for a run, try telling yourself that you are just going to enjoy the run. Maybe pay attention to the scenery as you run rather than focusing on your time or on your body.

 

Next time you go for a run just acknowledge what you are thinking about and see if it could be causing you added pressure. If so, try some of the techniques suggested.

 

Good luck for the Marathon and happy running!

How we feel pain – Part 2 Our adaptive nervous system and central sensitisation

In my last blog I explained the process of ‘nociception’ and how we feel pain. In this blog I’m going to explain how the nervous system adapts in response to pain and a process known as central sensitisation. It’s important to remember here that you don’t need tissue damage to cause pain. You only need a signal that is strong enough to be deemed as dangerous by the brain to trigger the protective mechanism of pain.

 

To recap when the brain receives information or a signal from peripheral tissues like muscles, joints, nerves and ligaments it makes a decision on what to do with that information. If it decides the information is too strong or dangerous it is likely to produce pain to protect the area. Once it has received this information it then has the capability to enhance the signal from the periphery, pay more attention to it and increase pain or inhibit the signal, pay less attention to it and decrease the pain. If there is extensive tissue damage it will probably pay more attention to it and increase the pain response. This makes you more protective of the area and reduces the chance of further injury, a very good survival mechanism.

 

Overtime, if these signals continue to be received from the periphery, adaptions start to occur in the central nervous system and in the brain. The brain begins to pay more attention to the signals and wants to know what’s going on in that area. In essence it starts allowing more signals to come through. The pathway from the painful area to the brain opens up. Before the area was painful, the pathway may have been a quiet country lane, but as signals continue and the brain pays more attention to it more lanes open up until the pathway becomes a motorway.

 

Overvi3

As the brain pays more attention to the affected area as well as opening up the pathway, the brain may also change the signals coming from the periphery. Signals that were weaker non-dangerous signals can become enhanced to strong dangerous signals or ‘nociceptive’ signals. This process is known as central sensitisation and occurs in an area of the spinal cord called the dorsal horn. The dorsal horn acts like a switchboard for information going from the periphery up to the brain.

 

An example of central sensitisation is feeling pain when an injury has healed or there is no 7496406-young-man-having-pain-in-his-elbowinjury in the first place. Let’s say for instance that you have injured your arm and signals have been sent in from the periphery to let the brain know about the injury. The brain has also been enhancing the signals and now the cells in the dorsal horn (the switchboard) are receiving lots of information and have become overstimulated. The injury in the arm heals up, but these cells remain overstimulated and continue to be protective of the arm by perceiving information in the wrong way. So that if someone lightly brushes against your arm it feels painful, even though the healing has taken place and the light brush hasn’t caused any damage.

 

Overtime the pain system can get stuck, with too many strong signals coming from the periphery and the brain enhancing these signals. If this carries on it will lead to chronic pain. There is evidence to show that central sensitisation is involved with lots of chronic pain conditions including chronic lower back and neck pain, temporomandibular joint disorder, Irritable bowel syndrome and fibromyalgia (Kindler et al., 2011). It is often why people have more than one painful condition at the same time and if the whole system is sensitised and hyperactive you are more likely to feel more pain generally.

 

So the big question, I think, is why does this happen? What is the point of making things more painful than they should be? And what is the benefit to someone of this enhanced painful response? In my next blog I will explain why I think this happens, how psychological stress and negative thinking can lead to central sensitisation and an overactive pain system and why it can be of benefit to have this response. The good news is that this is reversible and by understanding how and why the adaptations occur and changing how we think about pain we can switch this response off.

 

Matt Kinal

How we feel and the causes of pain – Part 1 ‘Nociception’

This blog is part of a series of blogs I’m writing explaining how we feel pain and the causes of pain. In this first part I will give an explanation of what is known as ‘nociceptive’ pain. This is the type of pain you feel if you stub your toe, cut yourself or anything else that causes an initial quick sharp pain. It’s your brain and body’s initial alarm system, to protect you from damage, potential damage or the perception of damage. That is right if you get pain it doesn’t always mean you’ve damaged yourself, I’ll explain why.

 

It is now commonly accepted that all pain is produced by the brain. It was previously thought that we have ‘pain receptors’ in the body’s tissue that would send pain signals to the brain to let it know something had been damaged. We now know that we don’t have ‘pain receptors’ and what we do have is receptors for mechanical load, chemical stimulation and temperature.   What usually happens when we feel pain is that there is sufficient input into these receptors, to trigger a fast acting signal from the periphery (Muscles, joints, ligaments etc), into the central nervous system, up to the brain to let it big toeknow there is potential danger in that area of the body. The input needs to be strong enough to stimulate receptors beyond there threshold to activate a signal into the central nervous system, for instance if you put your hand on a hot pan or drop a heavy weight on your toe. This is known as a ‘nociceptive signal’. These receptors won’t be activated unless there is sufficient input i.e. high mechanical load (banging your thumb with a hammer), high or low temperatures or chemical irritation.

 

When the brain receives this information it then has to decide whether to cause pain. Most of the time if the brain receives nociceptive information it will cause pain. This is where it becomes interesting, because there are times when it may decide that it is not advantageous to cause pain at that moment, even if there is actual tissue damage. There are also times when there may not be any damage, but the brain perceives things to be worse than they really are and causes pain anyway. I will go on to explain situations where this can happen in later blogs. So, this strong ‘nociceptive’ information is received by a certain part of the brain, what happens next is that this area of the brain then communicates very quickly with other parts of the brain. It will communicate with the visual cortex to see if it has noticed the danger; it may communicate with the amygdala or insula, where we store our fear memories to see if they think this situation is dangerous or the auditory cortex to see if it heard anything dangerous. Your brain very quickly collates all this information and then decides whether to cause pain or not.

 

Why would the brain decide not to cause pain? Well it maybe something simple, like it was distracted at the time an injury occurred and not enough danger information was received. Have you ever cut yourself or had a bruise that you didn’t notice, but only became painful once you did see it? Your brain may have been distracted by something more important at the time the injury occurred and didn’t register the injury, so it didn’t see the need to cause pain. It’s only when it gets the visual input that it realises it needs to protect this area, so that is when it causes pain.

 

There are also times when even though the brain recognises there is damage it still decides not to cause pain, for instance when you are playing sport or if you are a soldier in battle.

 

crossing the finish lineIf you are trying to win a match and you get injured your brain may decide it does not want to cause pain, as the pain will prevent you from playing well and winning the match. A lot of elite athletes often compete with injuries, but the motivation of winning overrides the pain. Likewise, if you are a soldier in a war zone and have just been shot, you may still be in danger and there may still be a risk of further injury or fatality. Again the brain may decide not to cause pain at this time as there is still a greater risk and you may lose your life, so pain at that time may distract you from survival and would be disadvantageous.

 

In the same way that the brain can decide not to cause pain even when there is severe tissue damage, pain can be triggered when there is no tissue damage at all. Over the next series of blogs I’ll explain how and why this occurs and how the brain and nervous system can adapt to continue causing pain long term, even without tissue damage and how a build-up of stress and negative thinking can cause pain and lead to these adaptive changes in the nervous system being maintained.

 

Matt Kinal

Anticipation of pain can lead to pain!

As a physiotherapist working with people in chronic pain, I often find that people are very uncertain about doing certain movements and activities. In a lot of cases it goes even further and people avoid doing certain movements or activities altogether for fear that they will damage themselves. When this happens, I ask people what they think would happen if they went to do this movement? and I get an array of answers, including:, ‘I’m worried my disc will pop out’, ‘It feels like something is going to snap!’, ‘if I do this movement I’ll pay for it the next day’ and ‘I can’t do that because my physio/doctor, told me it is dangerous’. Well imagine that you are about to do a certain movement and you are telling yourself ‘this is going to be dangerous!’ what do you think will happen in your body?

 

What happens is your brain quickly sends a signal down to the central nervous system to put it on high alert. It tells the receptors in that area of the body that danger is imminent and that they should be careful. Once the central nervous system becomes more hyperactive it also tells the muscles to be more protective. So, if you did go to do the movement, it becomes more guarded and more awkward. By thinking something is going to cause you damage you have automatically triggered the body’s protective mechanisms and pain is a protective mechanism. By telling yourself it could cause you damage you are more likely to feel pain when you go to do the movement. Then, if you continue to avoid certain movements it maintains the central nervous system in a hyperactive state, it maintains muscle over-activity and maintains a restricted range of movement. All caused by how you are thinking!

 

An interesting study was conducted recently at the University of Manchester into anticipation of pain (Brown, El-Deredy & Jones, 2014). In the study they found that in people with chronic fibromyalgia and chronic osteoarthritis pain their brains anticipated pain in a different way to people who didn’t have pain. There was more activity in an area called the insula and less activity in an area called the dorsolateral prefrontal cortex (DLPFC). The insula is part of the brain that is involved with negative conditioning, ie telling yourself to avoid certain activities because they may be harmful. If this part of the brain becomes more over-active, you are more likely to stop doing certain activities. The DLPFC has also been shown to reduce the unpleasantness of pain (Lorenz, Minoshima & Casey, 2003), so if this area is less active you are more likely to attribute unpleasantness to painful stimulation, which may further enhance the avoidance behaviour.

 

So, what can you do to help stop thinking yourself into pain? Well one technique I use regularly with people is visualisation. If someone has been told that a prolapsed disc is the cause of their pain, it’s quite common that people avoid bending forwards. They may have been told by their physiotherapist or doctor that this movement is dangerous because it will increase the bulge in the disc. Once you start thinking this, each time you go to bend forwards at the back of your mind you may imagine that the disc is bulging even more and if you do, you’ll trigger the protective mechanism. What I do, is to get people to visualise that there back is nice and healthy, their disc is healthy and the muscles are nice and relaxed. This way it helps to switch off, rather than switch on the protective mechanism. This then helps people to start doing activities they may not have done for a while.

 

If you would like any help in understanding how your thought processes affect pain and other physiological processes, feel free to get in touch.

 

Matt Kinal

Neck pain or RSI? It might not be the chair that’s the problem

Neck and back pain and repetitive strain injuries (RSI) are a common cause of pain at work and can account for a lot of missed days from work. Often the cause of the symptoms is attributed to poor posture, the chair you use at work, the height of your computer or the position of your keyboard. There are now masses of ergonomic devices that are available to use at work or in your car to adjust your position and some of these ergonomic devises available are incredibly expensive. Yet despite all of these devises the incidence of neck and back pain and RSI are on the increase, so why is this?

 

The thing with posture is that there are two different ways of thinking about posture, that is structurally ie the bones and joints and posture affected by muscles. Structural posture doesn’t change dramatically it takes years to change, whereas posture affected by muscles can change within the space of a few days.  So, if you have a specific type of structural posture, that’s just the way you are, your body will adapt to it. For instance people get labelled with a ‘kyphotic’ posture and told this is the reason for their pain, but the pain that gets attributed to posture often comes on very quickly within hours or a day. So it is unlikely that this pain is caused by poor structural posture.

 

Muscular posture can change more quickly and it isn’t always linked to how we are sitting. It has been shown in some studies that a high mental workload and increased stress at work will lead to increased muscle activity, particularly in the muscles that will cause what’s known as ‘poor posture’. In this study they found that there was increased muscle activity when subjects were criticised compared to when they were praised during a lifting task. See the link:

 

http://www.ncbi.nlm.nih.gov/pubmed/11145816

 

Another study found that subjects’ muscles had less relaxation time when they were under higher metal work load compared to a lower mental workload, when they were sitting in exactly the same position. If your muscles are constantly active then you are more likely to get muscle spasms. You can follow the link for this article:

 

http://www.ncbi.nlm.nih.gov/pubmed/18282206

 

This over-activity in the muscles is usually a consequence of over-activity in the central nervous system, usually as a consequence of stress. Once the nervous system and muscular system are over-active then you are more likely to get pain and muscle spasms. Have a think about times when you’re more stress out can you straighten up as easily? Do you feel like standing tall or do you feel like slumping forward?

 

So, before you order that new ergonomic chair, it might be worth taking a few more breaks at work and getting away from the computer. If you let your brain relax then the nervous system and muscles will follow suit. This will help to relax whichever muscles are affected, be it the neck muscles or the muscles in the forearm. It might also be worth trying to make time to relax a bit more generally, as this will help with pain. There are also good exercises to do to help relax overactive muscles.

 

If you would like any advice on how we can help with persistent neck and back pain or RSI, then get in touch.

People with chronic pain see greater improvements when there is psychological input

Chronic pain is a huge problem and now affects millions of people worldwide. Pretty much everyone now agrees that a purely medical model is not enough to effectively treat chronic pain. Recent evidence shows that there are many different factors that lead to the onset of pain and the maintenance of pain. It can be influenced by emotions, thought processes, pressure or stress at work, lack of sleep, traumatic events in our life and our general behaviour patterns. All of these psychological factors have been shown to affect people’s pain thresholds and tolerance. New research has shown that physiological changes occur within the central nervous system and the brain as a consequence of these psychological processes. A response known as central sensitisation, which is hyperactivity and hypersensitivity of the central nervous system, occurs with the psychological factors mentioned above and in lots of different chronic pain states. When this happens it means that something that previously wouldn’t have felt painful now feels painful.

 

With all of these things being able to influence pain, it is easy to see why medication alone is not effective in treating chronic pain. That’s why at the BPRC, we feel that by acknowledging that psychological processes influence pain, helping people to gain perspective on this and giving them support and useful tools to help improve how they feel, we can help improve their pain. As a physiotherapist I help people to become aware of how stress, be that external or internal, affects pain and through using the Sirpa approach I help people to reduce stress and improve pain. Tania is a psychotherapist, who is very experienced in helping people with anxiety, stress and depression and by helping people with these problems it also helps reduce their pain.  Don as an experienced GP understands that by making people aware that psychology can influence pain works alongside medication and other targeted treatments.

 

There is a lot of emerging evidence that psychological interventions do have a positive influence on pain. There is now a growing body of evidence to support the use of mindfulness and meditation as a technique to help with pain. Recent research has shown that mindfulness and meditation can reverse the physiological changes that cause pain. It has been known for a while that CBT can have a positive effect on pain and evidence is also growing for Acceptance and commitment therapy (ACT), a similar approach to CBT. Emerging techniques such as private emotional disclosure or therapeutic journaling are also beginning to gain support in the literature. In time I’m sure we will see much more evidence and support in the medical literature for these treatments.

 

There is an interesting article on the American Psychology Associations website, which reviews the influence of psychological intervention on chronic pain. The evidence suggests that treatment is more effective when psychological science is involved. Here is a link to the article:

 

https://www.apa.org/news/press/releases/2014/02/pain-relief-science.aspx

 

At the BPRC our therapists have experience of using these techniques and we regularly implement them to help people with chronic pain. One type of technique may be more beneficial for one person than it is for someone else and some people need more than one approach.  This is why we do an in-depth assessment and take the time to see what the best approach is for the individual. This way you get the most effective treatment from the start!