Tag Archives: Chronic pain

Doctors hate pain | New York Times Blog

Posted on by under Chronic pain, Drugs, Medication, Medicine and pain

Pain

This blog caught my eye and piqued my interest as an honest account from an MD about pain. I think that the same points ring true for many in healthcare where pain education is minimal. This is extraordinary bearing in mind that the vast number of consultations that involve pain descriptions.

Simply, we need pain education to form a much bigger part of training healthcare professionals and high quality courses, seminars and discussion forums to further understanding as the science base changes Fortunately the science base is changing rapidly, meaning that we can tackle pain in many different ways, beginning with reconceptualising pain for patients. Developing a pain sufferer’s understanding of their experience is fundamental to moving forward, creating the fertile ground from where they can flourish and evolve a better quality of life. We are designed to change, the nervous system and immune systems both consistently learning and adapting . It is our job to help facilitate this process in pain and empower patients.

RS

Hard Cases: The Traps of Treating Pain

I hadn’t seen Larry in a dozen years when he reappeared in my office a few months ago, grinning. We were both grinning. I always liked Larry, even though he was a bit of a hustler, a little erratic in his appointments, a persistent dabbler in a variety of illegal substances. But he was always careful to avoid the hard stuff; he said he had a bad problem as a teenager and was going to stay out of trouble.

It was to stay out of trouble that he left town all those years ago, and now he was back, grayer and thinner but still smiling. Then he pulled out a list of the medications he needed, and we both stopped smiling.

According to Larry’s list, he was now taking giant quantities of one of the most addictive painkillers around, an immensely popular black-market drug most doctors automatically avoid prescribing except under the most exceptional circumstances.

“I got a bad back now, Doc,” Larry said.

Doctors hate pain. Let me count the ways. We hate it because we are (mostly) kindhearted and hate to see people suffer. We hate it because it is invisible, cannot be measured or monitored, and varies wildly and unpredictably from person to person. We hate it because it can drag us closer to the perilous zones of illegal practice than any other complaint.

And we hate it most of all because unless we specifically seek out training in how to manage pain, we get virtually none at all, and wind up flying over all kinds of scary territory absolutely solo, without a map or a net.

Read the rest of the article by Abigail Zuger MD here

For further information about our clinics for chronic, persisting & complex pain, click here

 

Women and Pain | Part 3

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

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.

 

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

When in Rome….

Posted on by under Musings on pain, Pain and emotion, Pain behaviours, Uncategorized

When in Rome….

The phrase ‘When in Rome, do as the Romans do’ is a polite way of saying that you should follow the culture of the place where you are situated. ‘Fitting in’ is something that many seek to achieve yet it can be a challenging task in the workplace, in the sports team and even at home. We often like to belong as it can create a sense of meaning.

When it comes to pain, the experience is individual and subjective. Only that person can reside in that world and it is a lonely place despite others’ efforts to understand. Interestingly there are some contrasts whereby despite the isolation that pain can bring, there are many common behaviours that are adopted. For example we limp when our knee or ankle hurt, we draw in and elevate a painful shoulder and keep our backs rigid on attempting to bend, often with an accompanying grunt, groan and facial contorsion. These associated actions attract attention and warn others nearby that there is something wrong. Interestingly we can create a habit of doing this and continue to ‘ooh’, ‘ahh’ and suck backwards through our teeth even if the movement no longer hurts. They are all emergent expressions of pain just as the experience of pain itself is emergent from the self.

So we could say that there is a culture around pain and that ‘when in pain, do as the painful do’. This means fitting in with others who have pain although in fact we are all isolated in our own unique experiences. We can fundamentally only feel what we feel. I can think that I know what you are feeling because I have been somewhere similar, but alas it is only an illusion.

It may be useful to demonstrate pain behaviours, for this is what I have been describing, in the early stages. This may help me to gain assistance and to protect the healing tissues. Biologically this is very useful. As time trundles on, if the pain persists then understandably so do the behaviours. Seeking to change the emergent behaviours, metaphors and language become part of tackling the sensitivity. Our thinking is as much part of the process of sensitisation as is movement. Our thinking emerges from our belief system which in turn drives behaviours.

So, it is useful to fit into the culture of pain if we can use that term, for a period of time before seeking to change our behaviours via beliefs and point our compass towards physical and mental wellness.

RS – come and visit our clinic site here

Narratives | words and metaphors emerging from the individual

Posted on by under Uncategorized

An individual’s experience can only be described by themselves in their own words and language.  This verbal expression emerges from the self with accompanying body language that together communicate to others. The communicated data cannot have the same meaning to the recipient as to the deliverer as they are both unique  We can empathise though, particularly if we have had a similar experience. Of course when we resonate with someone, the process flows smoothly with utter ease and we feel good. Probably, those mirror neurons are bubbling away happily.

All too often in healthcare the patient is not permitted ‘freedom of speech’. Either due to time constraints or a feeling that they do not want to describe certain features of their condition for fear of being made to feel foolish or be accused of making symptoms up. This is common in CRPS because of the range of unusual feelings and experiences that people encounter. For example, an altered sense of where the affected body part is in space or a change in the perceived size. Both of these are very real and of course genuine. Those with an understanding of the science will appreciate both the ‘what’ and the ‘how’, in other words the symptoms and what is happening in the neuroimmune system to cause this emergent experience from the self, i.e. in the body part that the feeling is noted.

On this, I’d like to invite readers to post their own descriptions and metaphors about their experiences. You can use any language or metaphors that have meaning to you. Really express yourself. Of course, you do not need to identify yourself, this is a blog to synthesise the vocabulary of pain and CRPS. It needn’t be CRPS, any persisting pain experience illustrations are welcomed.

RS – Specialist Pain Physio Clinics, London

CRPS Bugle Extra | CRPS Treatment | Systematic review 2013 #CRPS

Posted on by under Chronic pain, Complex Regional Pain Syndrome, CRPS, Research, RSD, Treatment

Specialist Pain Physio Clinics, LondonCossins et al. (2013) have just published a systematic review of the treatments for complex regional pain syndrome (CRPS).

Here is the abstract:

Complex regional pain syndrome (CRPS) is a disabling pain condition with sensory, motor and autonomic manifestations. Uncertainty remains about how CRPS can be effectively managed. We conducted a systematic review of randomized controlled trials (RCTs) for treatment and prophylactic interventions for CRPS published during the period 2000–2012, building on previous work by another group reviewing the period 1966–2000. Bibliographic database searches identified 173 papers which were filtered by three reviewers. This process generated 29 trials suitable for further analysis, each of which was reviewed and scored by two independent reviewers for methodological quality using a 15-item checklist. A number of novel and potentially effective treatments were investigated. Analysing the results from both review periods in combination, there was a steep rise in the number of published RCTs per review decade. There is evidence for the efficacy of 10 treatments (3¥ strong – bisphosphonates, repetitive transcranial magnetic stimulation and graded motor imagery, 1¥ moderate and 6¥ limited evidence), and against the efficacy of 15 treatments (1¥ strong, 1¥ moderate and ¥13 limited). The heterogeneity of trialled inter- ventions and the pilot nature of many trials militate against drawing clear conclusions about the clinical usefulness of most interventions. This and the observed phenomenon of excellent responses in CRPS subgroups would support the case for a network- and multi-centre approach in the conduct of future clinical trials. Most published trials in CRPS are small with a short follow-up period, although several novel interventions inves- tigated from 2000 to 2012 appear promising.

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Within the authors’ analysis they discuss medications, interventions and physiotherapy:

‘There is string evidence that rehabilitation/physiotherapy interventions can reduce pain and improve function for people with CRPS’

The problem with this is that it does not define what physiotherapy actually constitutes. This is with the exception of graded motor imagery (GMI) that is termed ‘a complex physiotherapy intervention’. I use GMI training for rehabilitation in CRPS, teaching individuals the principles of motor learning before guiding their training through the stages – see here. Typically alongside the GMI programme I run a range of strategies that are designed to develop resilience to the stress and anxiety associated with on-going pain. These techniques are skills that the individual learns and becomes accomplished at using to optimise their outcomes by grooving a positive mindset for rehabilitation. The benefits often pervade into other aspects of life as well as they become proficient at controlling attention and regulating emotion. This is a comprehensive and holistic approach to persisting pain using an integrated physical-cognitive-emotional model of care. Pain is multidimensional as is relief and both must be thought of in this way.

It is very useful to have a systematic review. The only omission as far as I can see is that of the effects of cognitive strategies in CRPS. In the general chronic pain literature there is a mass of evidence of the benefit and hence the absolute need to interlace such strategies into a programme.

Full article here: Treatment of CRPS | A systematic review

Visit our clinic page here: Specialist Pain Physio Clinics London