Women and Pain | Part 3

Posted on by under Pain, Chronic pain, Explain Pain, Chronic disease, Women and pain, Functional pain

Women and pain 3

A number of women who come to the clinic with a musculoskeletal complaint will describe other painful syndromes that involve other body systems (see Women and Pain blogs Part 1 & Part 2). These include irritable bowel syndrome (IBS), pelvic pain, dysmennorhoea, endometriosis, bladder dysfunction, jaw pain (TMJ), migraines and widespread musculoskeletal pain. Often hypermobility is also a feature (see blogs here and here) . These are termed functional pain syndromes and require a comprehensive approach to tackle the physical, cognitive and emotional dimensions of the pain and associated problems that impact upon quality of life.

This recent study looked at a cohort of women in Australia and showed that the presence of one condition is associated with the development of another. Certainly in functional pain syndromes we know about the underpinning central sensitisation that is a common theme that manifests in different end-organs or body systems to create the aforementioned conditions. Using strategies to cultivate health within the systems is important, but so is using therapies to target the central mechanisms and driving systems, i.e. the nervous system, the immune system and the endocrine system (including stress physiology).

Only through a detailed assessment and the creation of an environment that permits the patient’s narrative will this vital piece of the puzzle emerge (see Oliver Sack talk about narrative here).

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Clin J Pain. 2013 Mar 12. [Epub ahead of print]

The Relationship Between Incontinence, Breathing Disorders, Gastrointestinal Symptoms, and Back Pain in Women: A Longitudinal Cohort Study.

Smith MD, Russell A, Hodges PW.

Abstract

OBJECTIVES:: Recent studies suggest a relationship between incontinence, respiratory disorders, gastrointestinal (GI) symptoms, and back pain (BP). However, causality is difficult to infer. This longitudinal study aimed to determine whether the presence or development of one disorder increases risk for the development of another. METHODS:: Women from the Australian Longitudinal Study on Women’s Health were divided into subgroups; those with no BP (n=7259), no incontinence (n=18,480), no breathing problems (including allergy) (n=15,096), and no GI symptoms (n=17,623). Each subgroup was analyzed to determine the relationship between the development of the absent condition and the presence or development of the other conditions. Factors with a previously identified relationship with BP were included in analysis.

RESULTS:: Women with pre-existing and/or newly developed incontinence [prevalence ratios (PR): 1.26 to 2.12] and breathing problems (PR: 1.38 to 2.11) had an increased risk for the development of BP, and women with pre-existing and newly developed BP were more likely to develop incontinence and breathing problems (PR: 1.18 to 2.44 and 1.53 to 2.62, respectively). The presence of GI symptoms was also identified as a risk factor for the development of these conditions.

DISCUSSION:: This study provides evidence of a relationship between BP, incontinence, respiratory problems, and GI symptoms in which the presence of one symptom is associated with the development of another. This suggests that common factors may contribute to the development of symptoms across this range of conditions.

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If you suffer functional pains, please call us on 07932 689081 for further information or to book an appointment. See our clinic website here: Specialist Pain Physio Clinics

Oliver Sacks talks about ‘narrative & medicine’

Posted on by under Case Histories, Narrative, Oliver Sacks

I am an avid follower of Oliver Sacks’ writings and an admirer of his approach to neurological conditions and human-beings. Here is a talk given recently on ‘narrative and medicine’ emphasising the story that must be told by the patients. All too often there is a lack of time in healthcare for the individual to tell their tale, using their own language and metaphor, or a concern for expressing such language for fear of disbelief.

When talking to a patient and listening to their narrative, I like to create an environment and space for self-expression so that we can understand the heart of the problem

Of course we need the objective information and data but we also must hear the case history and try to bring the two together. One is objective and the other subjective. An excellent paper was recently written on this by Mick Thacker & Lorimer Moseley, both whom have influenced my work and approach greatly – here is the article. Interestingly, Sacks refers to such concepts in his well known book ‘The Man Who Mistook His Wife For A Hat’.

See our main site here: Specialist Pain Physio Clinics, London

Persisting pain after surgery

Posted on by under Chronic pain, Post-operative pain

Post-surgery pain

Cochrane Review: Chronic Pain Can Persist After Major Surgery

Miami Beach, Fla.—Administration of local or regional anesthesia before some major surgeries can prevent long-term pain for patients at five to six months postoperatively, according to a recent meta-analysis.

“A large percentage of people have pain at six months, especially after thoracotomy, breast cancer surgery and cesarean section” Michael H. Andreae, MD, said in an interview at the Annual Fall Meeting of the American Society of Regional Anesthesia and Pain Medicine.

Dr. Andreae and his associate, Doerthe A. Andreae, MD, identified 23 double-blind, randomized controlled trials in the literature that compared local or regional anesthesia technology (epidural, spinal or local blocks) with conventional treatment of pain (nonsteroidal anti-inflammatory drugs [NSAIDS] or morphine) and grouped them according to the surgical intervention. Many studies showed that local or regional anesthesia can prevent chronic pain after different surgical interventions, but a meta-analysis could only be performed if there was more than one study in a surgical subgroup.

See the remainder of the article here

RS Comments:

Pain control after surgery is a very important part of the recovery process. This may sounds obvious but the trajectory of the recovery can be affected by early severe pain. Pre-surgical assessment of pain, the condition and the person is vital in planning how the symptoms are going to be controlled, allowing for adaptive and positive behaviours, thinking and actions to begin swiftly after the operation.

 

2nd Report from the 2nd International Congress on Treatment of Dystonia

Posted on by under Dystonia, Focal Hand Dystonia, Musician's Cramp, Sensorimotor training

2nd International Congress on Treatment of Dystonia

Of the many interesting topics covered at the congress, the talk by Laurent Boullet stood out. He is a Belgian concert painist who experienced focal hand dystonia himself. Now Laurent works with muscians who also suffer focal hand dystonia, using a programme to retain normal control of movement. He follows the principles of rehabilitation, gradually building the challenge of movement and precision required for playing the piano.

A graph that Laurent displayed showed how there is extra and early activity in the muscular system, a feature that is most significant with dystonia – too much activity and at the wrong time. The training seeks to change this patterning and restore the more discrete control.

Laurent has noticed that children often display similar movement patterns to those who have focal hand dystonia. I found this point to be highly relevant as I use the analogy that when there is an issue with movement, we lose precision and perform actions much like a young child, grasping rather than the refined movements of an adult with skill (although we do not often think about our movements as ‘skill’, this is indeed what they must be for success). Of course, precision must be learned by children and re-learned by adults with dystonia.

Recognising that there are changes in the brain functioning that underpin dystonia, there was a focus upon targeting these adaptations. Of course, any learning is a brain-based activity, whether it be a language or a musical instrument.

Two further observations by Laurent were the fact that muscle fibre switching may take place (fast & slow twitch fibres) and that the overall patterning of movement changes including the postural muscles. In respect of the latter, he referred to the work of Hodges et al. (click here), ‘Experimental muscle pain changes feedforward postural responses of the trunk muscles’ that shows how the feedforward system changes postural activity, relating that to dystonia.

In summary, although the problem manifests about the hand we are really thinking about a whole body strategy to move the arm to a certain place where the hand can perform intricate and timed activity. The automatic nature of movement changes and becomes increasingly conscious and therefore where our attention lies is important. The classic example is the yips (a later blog on this fascinating area). In focal hand dystonia we must consider this overall patterning but also the cognitive and emotional dimensions, similar to pain, addressing how these aspects of being human affect movement.

For further information about our Dystonia Clinic in London please call us on 07932 689081 | Clinic locations

Neuro……

Posted on by under Flourish, Neuroleadership, Neuroscience, Neuroscience and business, Pain Education

Neuroleadership in business and self

There is a growing trend to ‘neuroscience-up’ as a way of powering information and concepts. This is no bad thing as it means that current research is being applied to enhance our understanding of who we are, what we do, why we do it and how we can best go about it. Certainly in the world of business the concept of neuroleadership has emerged as a force. The notion can also be used to optimise the self and achieve healthy aims.

Neuroscience for leadership, decision making, performance & health

Employing the notion of neuroscience in health means that we can understand the functioning and interaction between the body systems (nervous, immune, endocrine, autonomic etc), cognitions and emotions. From there, healthy strategies evolve, pointing our natural compass towards wellness. This of course can include how we function as work, developing clarity of thought and resilience in the face of problems that emerge.

Understanding how we can use the body as a yardstick of wellness, for example noting the sensations as a way of detecting a threat, in one of many ways of ‘neuro-self-regulation’ (I just made that term up – it shows how easy it is to ne neuro). We can feel ‘tingling’ in the stomach which is noted as anxiety. Then we need to work out why we are anxious and this may be obvious or may require some thought. This is ironic as anxiety stems from thinking about something that is potentially threatening, albeit on many occasions it emerges from subconscious activity, becoming conscious when we need to attend to the matter. This is ‘self neuroleadership’ – the development of your own toolbox, facilitating a flourishing and flowing lifestyle at home, work and play.

Learn about the science of stress and how to tackle it

Good quality education that is delivered in a way that brains can absorb, process and apply is a further example. Creating the right environment, atmosphere, delivery approach and range of tasks will impact upon the outcomes.

In summary, the neuro-revolution is an important step forward. The science is moving on and we can follow the developments to employ in health and business, and where the two meet. Of course we must look at the science with a critical eye and check the robustness of the data, ensuring we understand the messages before imparting them in an education arena.

Exciting times. Neuro times! (and immune, endocrine, autonomic….)

For further information about the use of neuro in health and business, call us now: 07932 689081 or email: richmond@specialistpainphysio.com

Surgical Sadness

Posted on by under Uncategorized

Reblogged from noijam:

The invitation

I was kindly invited to the recent Royal Australian and New Zealand College of Surgeons meeting last week in Auckland to speak about pain related to surgery. My session was concurrent and the other talks in my session included a superb one on central sensitisation by a rheumatologist and one by a psychologist on anxiety and wound healing.

Read more… 329 more words

Indeed sad. Two thoughts: 1. The well known phenomena that change is threatening, avoid, avoid, avoid. 2. Each person will have their priority and work out the 'line-up' that they will follow at a conference, much like a music festival. It may not come on to the radar of importance, or perhaps they feel that this is someone else's role in the team to deal with pain. I once gave a lecture to a group of mixed doctors and physiotherapists about pain. One piece of feedback always stuck in my head: 'why did we have to have a lecture on pain?'. Not only sad, but very worrying. We will persevere!

Treatment is not in a vacuum

Posted on by under Anxiety, Brain, Stress, The Patient Experience, Treatment philosophy

How can we create the best environment for treatment?

A phrase I often use with patients is ‘nothing happens in isolation’. This concept is about priming and how the neuroimmune system is set at the time of an intervention as this will affect the outcome. The question to ask is ‘how is this system likely to respond to the treatment I am about to employ based on what I hear from the patient and what I can see?’

How will this system respond to the treatment I am about to give?

This is the same for any healthcare practitioner whether it be a physiotherapist about to mobilise a joint or ask a patient to perform a movement, a doctor prescribing a drug or administering an injection.

The key factors that are somewhat controllable are the environment in which the treatment is taking place and the approach of the practitioner. Both of these can be created to optimise the patient experience and hence the effect of the therapy. Here are two scenarios to illustrate.

1. A patient arrives at the clinic and discovers that there is a delay. There is no explanation given when they are directed to their seat. Naturally the patient is a little anxious about the forthcoming injection. They sit in a waiting room that is plastered with posters and leaflets about various health matters. And there is a pile of old magazines. Dogeared. Twenty minutes later the patient is called to Room 5 by an electric sign. They tap on the door and a gruff response permits entrance. There is no eye contact, no smile and no invitation to sit down because the practitioner is looking at the computer.

How would this prime a neuroimmune system? What would an aroused and threatened system do? Will it be readily acceptant of a needle? May the musculoskeletal tighten in response?

2. A patient arrives at the clinic and is greeted warmly by the reception team. On taking a seat the patient notices the artwork on the wall. The healthcare professional emerges smiling from his room and invites the patient to enter, welcoming them to take a seat and be comfortable.

What might this do to a threatened neuroimmune system (threatened because the patient has been thinking about the injection and is slightly anxious)?

Whilst it is always easy in theory to create scenarios, it is quite feasible to employ an approach that considers the influential factors upon the patient experience. In essence they do not want to be there, they do not want to have to have treatment but they must for the sake of their health. The neuroimmune system is on alert because of the actual health issue and also because of the experience of visiting the professional. We can certainly impact upon this in a positive way by thinking about our interface with the patient, use techniques to reduce anxiety and construct an environment that is conducive to better outcomes. Nothing happens in isolation.

For further information about our clinics visit The Specialist Pain Physio Website here

Posture | Embodiment of what we are doing and thinking

Posted on by under Chronic pain, Posture, Stress

Back pain and neck pain | Posture embodies what we are doing & thinking

Back pain and neck pain are very common and costly problems, both personally and economically. Many people suffer bouts of such pain and some continue to suffer on-going pain and consequences.

Posture is often quoted as being a causative factor although this is really too simple to explain back pain and neck pain. Of course, when we are suffering pain, the way in which we sit and stand has a bearing upon the pain with some positions making the pain worse and some offering relief. In very acute episodes or during a flare-up, an unfortunate individual may find it very difficult to find any comfortable position although this is usually short lived – if you are currently experiencing such pain you should seek the advice of your doctor or healthcare professional as early pain relief, perhaps by medication, is very important for early coping.

When we are sitting in a particular form, we embody what we are doing and thinking about. This means that the effects of maintaining a position are not purely a consequence of the posture but rather a combination of the body’s configuration and what is going on physiologically. In particular, I am referring to the effects of stress when we perceive a situation to be out of our control. This in combination with the particular posture is what leads to pain and discomfort in the ‘end organ’, the musculoskeletal tissues of the body.

What emerges when we sit for long periods at the desk is a consequence of how we are sitting, what we are thinking and how we are feeling

There are some fundamental factors to address when treating low back pain and neck pain. These include education about the pain mechanisms and the problem to reduce the threat and empower the individual to be proactive and the maintenance of activity levels. Around this can be a range of therapies and strategies that should all point the compass towards the restoration of healthy movement and healthy metaphor, both emergent from the individual.

A significant consideration for developing healthy tissues and movement is posture as a construct of the aforementioned factors: position + cognitive/emotional state. Addressing this in detail is vital, especially for those who spend time at a desk, as this is a large chunk of their time. It is not simply a case of suggesting an ‘ideal’ posture but rather an active, nourishing approach to the physical, cognitive and emotional dimensions of pain.

For more details on our proactive postural programme for individuals and businesses call us now: 07932 689081 or email: richmond@specialistpainphysio.com

Clinic website here

CRPS Bugle | 11 May

Posted on by under Complex Regional Pain Syndrome, CRPS, Laterality, Left Right judgement, Neglect

CRPS BugleCRPS Bugle

Having different feelings toward the affected area is not uncommon. In stroke, neglect is a well known feature and it is seen in CRPS. Kolb et al. (2012) looked at this phenomena and concluded that there could be a ‘neglect-like syndrome’ that differs from typical neglect.

Pain. 2012 May;153(5):1063-73. doi: 10.1016/j.pain.2012.02.014. Epub 2012 Mar 16.

Cognitive correlates of “neglect-like syndrome” in patients with complex regional pain syndrome.

Kolb L, Lang C, Seifert F, Maihöfner C.

Abstract

Patients with complex regional pain syndrome (CRPS) often show distinct neurocognitive dysfunctions, which were initially termed “neglect-like symptoms.” So far, particularly the patients’ feelings about the affected extremity, motor, and sensory aspects of the “neglect-like symptoms” have been investigated, possibly pointing to a disturbed body schema. Because patients with classical neurological neglect show diminished awareness regarding the perception of their body, as well as of the space around them, our hypothesis was that CRPS patients exhibit some signs of personal neglect and extrapersonal visuospatial problems over and beyond those seen in patients simply suffering from limb pain. We used quantitative sensory testing and motor assessment aimed at detecting motor and sensory loss, a standardized questionnaire calculating a neglect score, and applied a detailed neuropsychological test battery assessing different parietal lobe functions, including visual neglect. We examined 20 CRPS patients and 2 matched control groups, one consisting of healthy subjects and the other one of patients with limb pain other than CRPS. Results show significant higher neglect scores for CRPS patients and the pain control group, but interestingly, CRPS patients and pain patients were indistinguishable. The results of the neuropsychological test battery did not demonstrate systematic variances, which would be indicative of a classical neurological neglect in CRPS patients, even though there were 3 CRPS patients who differed ≥ 2 SD from the mean of our healthy control group, with poorer results in ≥ 3 different tests. We assume that the “neglect-like syndrome” in most CRPS patients is different from typical neglect.

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This paper a few years ago, highlighted the change in body schema in CRPS. This adaptation is a large focus for treatment certainly at our clinic with sensorimotor training forming part of the programme.

Neurosci Lett. 2010 Dec 17;486(3):240-5. doi: 10.1016/j.neulet.2010.09.062. Epub 2010 Sep 29.

Left is where the L is right. Significantly delayed reaction time in limb laterality recognition in both CRPS and phantom limb pain patients.

Reinersmann A, Haarmeyer GS, Blankenburg M, Frettlöh J, Krumova EK, Ocklenburg S, Maier C.

Abstract

The body schema is based on an intact cortical body representation. Its disruption is indicated by delayed reaction times (RT) and high error rates when deciding on the laterality of a pictured hand in a limb laterality recognition task. Similarities in both cortical reorganisation and disrupted body schema have been found in two different unilateral pain syndromes, one with deafferentation (phantom limb pain, PLP) and one with pain-induced dysfunction (complex regional pain syndrome, CRPS). This study aims to compare the extent of impaired laterality recognition in these two groups. Performance on a test battery for attentional performance (TAP 2.0) and on a limb laterality recognition task was evaluated in CRPS (n=12), PLP (n=12) and healthy subjects (n=38). Differences between recognising affected and unaffected hands were analysed. CRPS patients and healthy subjects additionally completed a four-day training of limb laterality recognition. Reaction time was significantly delayed in both CRPS (2278±735.7ms) and PLP (2301.3±809.3ms) compared to healthy subjects (1826.5±517.0ms), despite normal TAP values in all groups. There were no differences between recognition of affected and unaffected hands in both patient groups. Both healthy subjects and CRPS patients improved during training, but RTs of CRPS patients (1874.5±613.3ms) remain slower (p<0.01) than those of healthy subjects (1280.6±343.2ms) after four-day training. Despite different pathomechanisms, the body schema is equally disrupted in PLP and CRPS patients, uninfluenced by attention and pain and cannot be fully reversed by training alone. This suggests the involvement of complex central nervous system mechanisms in the disruption of the body schema.

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For further information or to book an appointment, call us on 07932 689081 or see the main clinic website here.

Report from the 2nd International Congress on Treatment of Dystonia

Posted on by under Botox, Botulinum toxin, Chronic pain, Dystonia

The 2nd International Congress on Treatment of Dystonia

The programme has been packed with talks, discussions and workshops looking at the current state of the knowledge about treating dystonia. Some have looked at the condition from a movement perspective and others have highlighted what we know about the brain and how it changes in dystonia. There is good data upon how the brain has adapted including the basal ganglia, the cerebellum and sensorimotor areas. Similar to pain though, there is not any one region of the brain to consider but rather how the cortical networks change structurally and in terms of connectivity. Additionally, it is not clear whether the changes are causative or consequential. But, we do know that they are there is defective sensorimotor integration that manifests as issues with the body schema and control of movement.

Retraining normal movement was a focus, with a range of speakers talking about their methods. They adhere to the principles of rehabilitation by breaking movements down and gradually building up the challenge and function whether it be for writing, controlling posture and head movement, playing a musical instrument or in sport (the yips). All started with simple movements, or ‘actual movements’ as I term them, as opposed to working with the planning stages of movement.

Dystonia | Cervical Dystonia | Writer’s Cramp | Musician’s Cramp

Of course the way in which the brain plans movement affects the outcome and the final quality of the movement that is emergent. Similar to a pain state when sensitivity and protection are implemented at a planning stage, this requires consideration when designing a programme for dystonia. Where do we start? Actual or motor imagery based? The assessment will guide the baseline.

The focus of our treatment programme is retraining normal sensorimotor integration and hence reconstructing a sense of self and body awareness concurrent with motor strategies. This sits alongside strategies that target some of the influences upon dystonia. At the conference there was talk of the ‘non-motor’ factors such as beliefs, anxiety, depression, stress and self-efficacy. My view is that labelling motor and non-motor is acceptable for explanatory purposes but in practical terms are so interlinked that the focus needs to be more about the person and how the condition manifests and is narrated. For example, who we are with and how we are feeling will produce different types of movement, highly relevant to a movement disorder. We have to address these factors as part of a comprehensive treatment and training programme for dystonia.

The training programmes are often implemented as part of a combined approach with Botulinum toxin. A significant part of the Congress programme is dedicated to the use of the toxin, describing its potency and specificity for dystonia but also for pain. Working out the lowest dose for the greatest effect is the challenge facing the clinician injecting. For more on the use of Botulinum, see the website of Dr Marie-Helene Marion who is a very experienced neurology consultant specialising in movement disorders.

For more details on our treatment programme for dystonia, click here or call us on 07932 689081