Thursday, 10 March 2016

The Joy and Pain of watching Leicester City!

I’m a Leicester City fan and for those of you that follow football, you will know that they are having an incredible season and are currently top of the premier league! Before the season they were relegation favourites and in my wildest dreams I couldn’t have predicted this happening. So it is all very exciting!

This weekend I watched them play against Watford and they won 1-0. It was a great result and it meant they went five points clear at the top of the league. Although it was a great result, until the final whistle was blown I couldn’t relax, I was a bundle of nerves, jumping out my seat and biting my lip. At times I felt like I was physically shaking. Even after the match had finished it took me a while to calm down. I text some of my friends and joked that I wasn’t sure I could watch for the rest of the season as I might have a heart attack!

The next day I read a report on the BBC website explaining how positive events create stress and place strain on the heart that can cause a condition called ‘acute stress cardiomyopathy’. A bit depressing really! It explained how exciting and happy life events, such as getting married, someone having a baby…or your favourite team being top of the league, although positive, create stress and put extra pressure on your heart. In summary positive life events can be as stressful as negative ones can. You can read the article here:BBC article

Luckily I already knew this so didn’t feel too down. It is something that I’m often explaining to people, but find they have difficulty accepting. When I am working with people in pain I try to help them understand the link between their stress and pain. If I explain that the promotion at work or finding out your wife is pregnant is a cause of stress, people often question it by saying ‘But it was a really positive time for me?’ and their right, it is a positive time, but it can also increase stress levels. It creates extra physiological load, increases heart rate, blood pressure and may not allow you to sleep properly. If this carries on the unconscious part of your brain may activate a protective mechanism to try and make you slow down. Pain is often that mechanism, as it makes you stop, slow down or makes you rest.

This all may seem very depressing, but it’s not if you can recognise it. If you recognise it you can do things to balance and counteract the level of stress. You can make sure you do things that help you to relax, like exercise, walks in the countryside, meditation, offloading by talking to friends or writing things down.

So, even though I know it’s stressful, am I going to stop watching Leicester City this season? No
chance! This is the most exciting season I’ve seen as a Leicester City fan! Even if you don’t follow them you have to be impressed by what they’ve done. I’ll just make sure that the level of stress it creates between now and the end of the season is counterbalanced with time spent switching off!

Come on the foxes!!!

Thursday, 24 December 2015

Look after yourself this Christmas!

Every year around Christmas time I have a number of people come in to see me with lower 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

Look after yourself and have a Great Christmas!

Monday, 28 September 2015

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 you. 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 willpower 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, 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:

Tuesday, 15 September 2015

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 or 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 overactive 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.

Monday, 3 August 2015

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.

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 injury 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 isn’t causing 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. 

Sunday, 7 September 2014

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 know 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. If 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.

Sunday, 3 August 2014

"Yoga or Pilates?"

This is a question I am asked a lot by people who come to see me. They ask which one would best suit their back. Is it better to do yoga or pilates? Well I think it does not matter, my answer is; do the one you enjoy doing. There is no point doing any exercise unless you enjoy it! Both of them will be beneficial, but you are more likely to continue doing it if you enjoy it.

The one thing I would like to say, and this is very important, is that you don’t have to do either to prevent back pain. I feel it is a common misconception that our backs are inherently weak and we need to do specific exercises to strengthen them up. Both of these exercise programmes are very good at improving flexibility, relaxing muscles that are prone to over-activity, improving core control and are a good general workout, but you don’t have to do them to improve back pain.

As I have said in previous blogs, pain is not always mechanical; in fact, it often is not. Pain is usually caused by the brain and the nervous system, but then unfortunately gets attributed to something mechanical, like prolasped discs or osteoarthritis. We then think that there must be a weakness in the back and seek activities that help to strengthen the back, like Pilates. The problem is if you tell yourself that you need to do Pilates to strengthen your weak back, you will continue to reinforce that your back is weak. By doing this, it may actually make pain worse and cause the muscles in the back to tighten up even more, because they respond to your thought processes.

My advice would be to carry on doing yoga or pilates if you enjoy it, but don’t tell yourself you need to do this for your back. Do it for you, for the health benefits it will bring you and not because your back is weak. You can also work your core muscles by doing lots of other types of exercise like swimming, running, cycling, tennis and pretty much any fairly vigorous activity.

Personally, out of the two, I go for yoga, because I find it is more relaxing. I feel it works in a similar way to meditation and gives you a physical and mental work out and helps you to switch off!

Happy exercising whatever you decide to do!