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Removing ‘the pain bit’

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Photo by Kat Jayne on Pexels.com

The body is not out of order, the brain is not damaged, your body is doing exactly what it thinks it needs to do to protect you.

It amazes me every day the stories I hear about what clients have been told, or understand about pain. People have been told things like “chronic pain is like having brain damage” or “if I dissected you right now, we wouldn’t find your pain”. I think I understand what people are trying to get at with statements like this but these individuals are not then checking with their patients what they themselves have understood by such words. Consequently if we aren’t checking what the person in front of us understands after receiving news like ‘you have brain damage’, they also are failing to acknowledge the long term effect of their words on that individual.

You see, a clinician may well tell someone not to worry because it’s only a bit of degeneration in the spine and neck, or that chronic pain affects brain function, a bit like having brain damage, but the likelihood is, that the client will be a bit freaked out by this news. I am pretty sure, the bombshell of having brain damage will almost never leave their thoughts and may have a significant impact on how they then go out and live their life.

Clinicians are well meaning people, eager to do the best for those who present to them with pain, we often pat ourselves on the back and think that “I did a good job there”, I would understand my problem of pain more now. But patients seeking help for pain are not clinicians, they do not have the necessary background to put into context that pain is influenced greatly by multiple factors, or that pain itself is produced in the brain but contributed to by many different things other than injury sustained to the body.

I think there is also an assumption that individuals in pain may not either understand the science, or indeed they may not actually want to know why they are in pain. Maybe health professionals think patients are happy popping pills and sitting at home. Well I absolutely know that is not the case and I think it’s time we gave credit to the everyday person in Society that they are more than capable of understanding pain and doing something about it. In fact, most people are delighted to know that they can change, they can get fitter, stronger and change the way they feel about pain. It’s not rocket science, it’s simply giving people the information they need to make an informed decision about how to move forward.

In the group education sessions I run, there are attendees from mid 20’s to late 70’s, all of whom are not idiots and have more than enough intelligence to understand the information I give them about pain. We discuss it, sleep on it and come back with different questions to consider the following week. When people understand something, they are less fearful of it, they can take ownership and begin to become objective about what and how they feel. Education is indeed and analgesic.

It’s all about understanding and perspective, giving people the right information, and enough of that information for them to be able to understand. We can’t expect people not to be scared witless by being told they have brain damage, but put in the right context of explaining how the brain works to protect in a pain experience, how multiple different output system meet and work together and how the brain is plastic and can change, may just put a different and less fearful spin on things. Degeneration, I was told recently, sounds like “I’m about to die”. Again, for a medically trained person it’s pretty standard language but for Barbara it’s pretty bloody scary. By the time clients seek help, this word has been playing on their mind for a number of weeks or even longer, enter massive amounts of stress and worry to bombard the system!

We all know that you can’t “just remove the bit that causes pain?” (which is probably what was meant by the comment “if I dissected you right now I wouldn’t find your pain”). Pain is much more complex, but it would be lovely to be able to say, ‘yes, go on then, lie down and I’ll sort that for you know’.

The thing is, we can go a long way to removing the ‘pain bit’, but by confronting all the other contributing factors in life, understanding and good education, not by dissection.

Sally Allbrighton

BSc (Hons) Physiotherapy, MSc Neuromusculoskeletal Healthcare, Lecturer Noi UK

 

The pain genes

It’s funny how it appears to be our human nature to look for someone or something else to blame. Particularly in recent years it seems that everyone is quick to look for an external cause to suffering or simply when things don’t go our way.

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Photo by Mica Asato on Pexels.com

Maybe it’s a generational thing? There are certain generations that don’t want to seek help or advice, they want to bury their heads in the sand and plough on through – admirable in some senses, stubborn and unhelpful in others.

I have already spoken about my views on the need of medical-legal companies to promote and maintain illness rather than wellness behaviour and I see this reinforces the need for people to look towards external factors as a reason for problems in day to day life.

I was told in clinic recently that “I’ve inherited my dad’s pain gene”, it made me think that this is simply another external factor that we look to to find a solution for what’s wrong. I have pain because of this or that. David Butler talks about a magic bullet, where would we send it to resolve our pain? This client is under the impression that if she had different parents (they both have chronic pain) then she wouldn’t suffer – is she right or wrong?

I am reading a book at the moment called the Epigenetics Revolution, an interesting read and one part in the early Chapters of the book made me think. It is a study done on pregnant women in the Second World War. They looked at baby weights from mothers who were in the third trimester of pregnancy when rations were introduced compared to mothers who got pregnant during the later stages of the war and for whom rations were lifted in their final trimester.

The findings initially were much as expected, babies born to mothers who had less available food during their final trimester were smaller and those who had access to greater amounts of food in the latter stages had bigger babies. We all know that babies gain weight mostly in the third trimester so this doesn’t seem too odd.

What is interesting is that researchers studied following generations and found that all subsequent generations of the smaller weight babies had small babies and struggled to gain weight, making them naturally slimmer throughout life. Likewise, those of higher birthweight had babies who were heavier and each generation gained weight more easily.

Therefore can it be inferred that a behavioural or environmental change in the key growth period during the foetal developmental stage had an effect on genetic expression that was passed down generation to generation?

I started to think that maybe this could also work for pain. Maybe those who have been exposed generation after generation to long term pain conditions, behaviours and stressors during the foetal developmental stage also causes an alteration to gene expression. Maybe this contributes to the familial link of persistent pain conditions. Maybe it’s more than just purely nurture, growing up in a pain related environment, maybe there are some genetic changes as a result of the behaviour and environment of their home before they were even born. I am under no illusion, by the way, that Nature plays an incredibly significant role in the future development, behaviour and perceptions an individual has as they grow. It would be impossible to test this out, I know this too but the thought is still there, are some pre-disposed to pain related conditions? There is the same argument about depression, addictions and other medical conditions.

I see a lot of young clients with chronic pain who attend with parents with chronic pain who are all in need of good quality pain education that they can understand and then use to move forward. As therapists we have the ability to change people’s perception of pain and influence or de-threaten the fear of activity or movement. Many of them have been told that there is nothing that can be done or they believe they have “the pain gene” and therefore expect that this is their lot in life because dad and grandad had the same thing.

From a Neuroscience perspective we know that the brain is plastic and neurotags can be changed. Parts of the brain activated during a pain experience or in the case of a perceived threat can be ignited but this surely means that they can also be pruned, broken down or removed in the same way by exposure and paced activity.

If there is some epigenetic link with families in pain, or it’s just reinforced behaviour through environmental influence then maybe this can be changed for their next generation. It’s not about looking for external factors to blame, it’s about changing the way people think about pain and helping people to find the answers for themselves.

Sally Allbrighton BSc (Hons) Physiotherapy, Msc, Lecturer NOI UK

Root Cause

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So the price of alcohol is increasing again. Apparently this is going to reduce the amount of people dependent on alcohol or those who binge drink. I’m not so sure.

Alcohol is a form of escape for many, a relief at the end of the week from stressful jobs, busy schedules and expectations placed on people from the workplace, from families and from themselves. Often these expectations are unrealistic and cause stress, hence turning to alcohol. I’m not saying this is right and I absolutely think that others that don’t drink find equal peace and relaxation  in meditation and yoga, brilliant, but we’re not talking about those people in this instance. I have no doubt that by increasing the price of alcohol there is good intention to assume that people will reduce their drinking and maybe seek alternative forms of relaxation. However, I am also not naive enough to think this will be through mediation and mindfulness in most cases.

Increasing the price of alcohol will indeed cause people to look at other options and some may turn to drugs, so by increasing the cost of alcohol we may be contributing further to the ever developing epidemic of drug culture in society.

Drugs are readily available, highly addictive and in many cases cheaper than alcohol. So are we so blinded by the Government appearing to do something positive about the amount of alcohol used today, or are we just pushing individuals into a different and more destructive lifestyle?

Alcohol and drugs are not the cause of the problems, they are the symptoms of an unhealthy society, fuelled by ever increasing inflation, homes being too expensive to buy, lack of jobs and limited resources in education and the NHS. Not to mention ever growing retirement ages and expectations that we will work ourselves into an early grave.

Where is the wellness education and support for those working long hours in underpaid and understaffed jobs? Where are the lunch breaks to get away from your desk? In many Countries there is supported wellness, to get away, flexible hours to allow you to see the family and gyms provided at work for relaxation. Some places of work even employ staff to provide massage and stress relief methods within working hours.

We all recognise there is a problem but there is no money to sort it out so we resort to deflecting the attention from the root cause to blame another problem in society.

In the medical profession we constantly see victims of this high pressure expectation we have created in the UK. Not only are we seeing younger people having heart attacks and strokes but also the effects of this through drug and alcohol abuse. we must not forget that substance abuse is a form of escape from life and all it’s pressures. Again, I am not looking at life through rose tinted spectacles, but simply trying to see the balance.

In today’s society there remains a reinforcement of illness behaviour, I know this has been targeted in the past but it is still a very real issue that is extremely difficult to tackle and no, I don’t have the answers.

There seems to be a juxtaposition (haven’t had chance to use that word for a while!) between what we are told to reinforce as medical professionals and healthcare providers and what is actually being thrown at us from all angles by the media.

Can people really be expected to choose self-management and self-help with advice from a Health professional that they may get to see if they can be squeezed onto a GP list, or after they have waited 6 weeks (at least) for a health care appointment? Or will their views and perceptions of what should be done be influenced more by what they see on the TV, in the ad breaks, read in the papers or on the internet?

We are all influenced by social exposure friends, families and the culture of the Society we live in. Our views and beliefs are shaped by what we see, read and hear. A culture of illness behaviour continues that seems to reward being off work, eeking out rehabilitation times to get a greater payout and emphasising injuries to increase a claim. How can we be expected to make informed decisions about our health when we are unable to access services quickly enough or get the right information altogether. Our mind is quick to believe the hyperbole put out there in the media, not because they care but because it sells papers and makes money for the insurance companies. Companies that need people to be ill to continue to make a profit.

It’s not about increasing the price of alcohol, it’s about tackling the root cause of the problems we have created for ourselves in Society.

As long as this is the case, how is it ever going to change?

Sally Allbrighton

Physiotherapist BSc (Hons), MSc, NOI UK Lecturer

A different world

pexels-photo-225017.jpegI was out recently with some old school friends, as the drinks flowed we started the inevitable chat about our memories of school, friends and growing up. We all went to the same school, we were in the same classes and we spent 5 years of High School living in each others pockets. We knew everything about each other and all the trials and tribulations that go hand in hand with going through our teenage years and managing to come out the other side still alive and relatively unscathed!

What was interesting about our night and our memories of teenage-dom was that every single one of us had different experiences of the same events. It struck me more than anything  that although we were in the same environment, going through the same challenges with the same people, each and every one of us had a different interpretation and memory of those times. After all these years we could talk about how we actually felt about this time of our lives rather than trying to comply and conform to what was expected of us at that time. Our understanding and probably our memories of those days is completely different now to 20 years ago when we were going through it. We spent a lot of time expressing our concern and saying ‘why didn’t you say that at the time? we would have helped’ and  ‘I never knew you felt like that’.

One of my friends said at one point ‘even my sister and I have very different memories of our childhood’. 

There are two glaringly obvious things to address here. Firstly, our need to comply with the expectations of society during our teenage years far outweigh possibly any other time in our life. This is a time that we are finding out who we are, what we want and starting to stand alone. We are carving out ‘who we are’ but at the same time needing affirmation from our peers that being ‘who we are’ is ok. This is a huge mess at times and we rely heavily on our friends to find our place of acceptance in the world as well as shaping our views of the World we live in and how we interact with that world.

Sadly, despite time and experience, it seems that we still feel the need to conform and comply with what and who society expects us to be. Maybe you are the man of the house afraid to show you’re having difficulty coping. Maybe you’re a mum who hasn’t a clue what she’s doing and puts on a face to the rest of the world that life’s easy and going exactly to plan (I am this one). Perhaps you are worried about money, work, family and have no idea who to turn to for help. But we are British so we do what is expected of us, stiff upper lip and all that, bottle it up and carry on. Don’t let how you feel inside show on the outside for fear of being ridiculed or perceived as weak. Somehow this has to come out and our bodies will start to show the strain.

If we look we will see. We might see the homeless man at under the subway using drugs to blot out the memories and painful experiences of life. We can see the man standing at the door waiting for the pub to open who is also the last one to leave. We hear about the girl in the clinic bingeing and purging to gain control of one part of her life and we can see the woman in clinic who has persistent pain for no known reason, she’s been referred to numerous clinicians and had all the tests but no definitive diagnosis. The body finds a way to express itself, and we need to listen.

Secondly, memory is not a snapshot of life, it is an interpretation of past events based on how we feel now in retrospect about a certain situation. Memories can be distorted, changed and are definitely not an accurate representation of what actually happened in our lives. We constantly make memories but our memory itself cannot totally be trusted, we can be very easily influenced as we grow older and wiser. Language and attitudes of others can shape our memories of childhood, words play a big part in activating parts of the brain that trigger memories. These memories are now linked with emotion, sometimes fear or upset. Our sympathetic nervous system can kick off if we think about a particularly embarrassing event (in teenage years there are too many to choose from), we flush, get sweaty palms and feel sick in some cases. This distorts our memory of what actually may have happened but the feelings may be very fresh and the fear remains.

So how does this relate to this pain blog? 

Well, pain experience can be the same. We may grow up in an environment with siblings and have the same input, the same friends and the same rules but each individual experience and memory of an event is dissimilar, triggering different emotional experiences and feelings in each person. We all have different genetic make-up and, due to multiple factors, we all react in a variable way when faced with the same situation.

In an event that is perceived as threatening or traumatic, we each have a different experience that ignites various parts of the brain producing a reaction. Some find that experience tells us not to worry and guides us to safety where we can access the right information and management and go on to make a complete recovery. For others this may not run as smoothly. Perhaps this event triggers a cascade of memories of other traumatic events in our childhood or early adulthood. This may result in longer term pain and functional problems, withdrawal from friends and family and perpetuate worries day to day. Because memory is not a concrete piece of our past and is likely to be coloured by a number of experiences, we can’t simply rely on what we remember to accurately predict our future. Just as our past memories can change, so can the future through how we react and the next step that we take.

Amazingly by changing the way we think about something, we can have a profound effect on the physiology of the body, meaning by altering thought processes, we can create physical change.

There has been mounting evidence over the years that by understanding a bit more about what happens to the body in pain, we can move forward feeling more in control and the outcome of this is a reduced pain experience, greater confidence and return to more normal living. What could be better?

We all have very different memories and experiences that are built upon by the Society and Culture that we live in but just as everything in the world can change, so can we. We are Bioplastic and have the ability to adapt to a number of differing circumstances and rise to the challenge of change. We have been doing it for millions of years so lets not stop believing we can now.

Don’t look back, you’re not going that way (Mary Engelbreit)

Sally Allbrighton

BSc (Hons) Physiotherapy, MSc Neuromusculoskeletal Healthcare, Lecturer NOI UK

Smashed

Ever seen the plate smashing that happens in Greek restaurants (on the telly at least)? Plates smash into a thousand pieces on the floor, small fragments strewn across the room and probably missing bits found for months after in small corners of the kitchen. Now imagine trying to pick up those pieces and stick them back together. Impossible don’t you agree?

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Now imagine you have had an accident, are semi-conscious and taken via ambulance to A&E. You wake slightly at the bright lights and noise of the busy department, in the haze of pain, drugs and shock you are told that your elbow has been smashed “like a china plate” and will be incredibly difficult to put back together. You’re taken to theatre and are told they “did their best”.  Bit frightening hey?! Neurotag overload – firing of multiple brain parts to induce fear, anxiety and pain.

Two things are at play here I suppose. One, the language used creates a very vivid picture in your head about what has happened in this case. This isn’t a china plate though, this is your elbow, a part of your body that you reply on and hoped to have with you as a working part until you left the earth. To suddenly have the realisation this may not happen is like being hit with a hammer. The second thing relies on perspective, interpretation and outlook. Something that is embedded in all of us but depending on life interaction and experiences, can manifest in very different ways.

If you happen to be a ‘cup half full’ kinda guy you might brush the “smashed like a china plate” comment off and plough on with life without any problems. You might face things head on with the attitude that movement and function will return fine and if it does’t then you’ll manage to get by anyway.

The other type of ‘why does everything always happen to me?” or “that’s my life/job/happiness ruined” person is equally likely to be met with this situation. But how do we know from a drugged up semi-concious, new from an accident chap we have in A&E?

We don’t.

So maybe we need to think a little more about what we say and the words that are chosen when people are at their most vulnerable. Maybe we just need to think about what comes out of our mouth before we say it.

Luckily the chap I saw in clinic was a ‘cup-half full’ and made an excellent recovery but I may well have been writing a completely different story if he wasn’t.

Sally Allbrighton

BSc (Hons) Physiotherapy, MSc, Noi UK Lecturer

There’s nothing more we can do…at 25!!

cycling-bike-trail-sport-161172.jpegBit of a rant today. I make no apologies for that though. Sometimes the system fails us and as much as I believe whole heartedly in the NHS, unfortunately some people fall through the net.

Today I saw a lovely young woman in clinic, she was 25 years old, she has fallen through the net. She has two small children and manages to hold down a full time job as best she can. She has had a difficult past but that is no excuse for her to miss out on much needed intervention.  Until four years ago she had no idea why she experienced so much joint and muscular pain. Aged 21 she was eventually diagnosed with hyper mobility syndrome which she found out was in her medical history but nothing had been done about it. This was the first time she had been referred to Rheumatology or for any other medical intervention.

She was understandably very angry when she entered the clinic, frustrated and emotional, She can’t do much with the children or even straighten her hair due to pain. She has been referred to Physiotherapy twice in the past, both times she wasn’t examined but was told that because she hadn’t had Physio as a teenager there was nothing they could do. She returned to the GP only to be told that she should’ve joined the circus!! Not that helpful when you’re struggling with two small children and no-one seems to understand.

Outwardly she is a very pretty, fit and healthy young woman but she has been living on extremely heavy duty pain killers for 4 years, at one point she was on Diazepam, Fentanyl and morphine. She is now on maximum dose Gabapentin as well as over the counter medication. I feel the need to say again – she is 25!!!

Her current GP tried to refer pain management but they wouldn’t accept the referral because her needs were too complex -wow!! After seeing her for 30 minutes I was frustrated so I have no idea how she must feel – frightened, worried, scared for the future of her children?.

In light of the recent Lancet publications about low back pain treatment and management I can’t stress enough that drugs are not the answer. What about good physiotherapy management, goal oriented treatment and graded strengthening? What about quality of life and not protocols and guidelines. My Masters thesis was on guidelines in clinical practice and we need to understand that not everyone fits into these boxes, they are only guidelines. Our autonomy should prevail and the person in front of us is the reason we are in our jobs, we should treat each person individually for the symptoms they present with and the psychosocial factors that may explain a lot more.

At 25 she thinks her life is over, she has no positive future -reinforced by health professionals along the way. I feel this is really sad and totally unfair.

When are we going to stop using negativity and reinforcing the ‘can’t and won’t’ in life and focusing on what can still be achieved. She doesn’t expect to be climbing Everest but she does want to take her children to the park, is that too much to ask at 25??

Lets see the horizon not the downhill slide.

Sally Allbrighton

BSc (Hons), MSc, MHCPC, Lecturer noiUK

I know my limits

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When I talk to patients in my clinic, the majority of them hold the belief that hurt equals harm. They are a little taken aback when I say that pain is normal, expected in certain circumstances and doesn’t always mean that movement is going to cause more damage.

This can be quite difficult to get your head around. Surely pain is there to stop us, prevent us from doing more damage and to protect the tissues. Yes, in some cases this is true but in most cases the body also needs movement and gentle activity in order to heal, but this thinking goes against the grain.

We have probably heard a million times that pain means damage, or have been told to only work within pain limits or stop when you get pain. This view may be reinforced by health professionals, family members, even strangers in Tesco who appear to become experts in pain science (other supermarkets are available). Over time. we build up an understanding of what pain means and most of the time we worry if it doesn’t settle. One of the things most people do in this situation is to reduce activity, we feel in control if we do that. Someone told me once that if they felt they were “creeping around pain”, if they moved slowly and carefully the pain wouldn’t notice the movement and therefore wouldn’t hurt!

Think about it though, the body is designed to move. It moves, not only to reduce joint stiffness and prevent muscle wastage but also to help the nervous system and the immune system to direct cells to where they are needed in order to promote healing. The body needs movement to tell other systems what to do and hopefully they will mount the appropriate response for recovery. The body relies on this feedback system to be healthy and maintain homeostasis and balance in all systems. An alteration or perturbation in one system will likely have an effect on another. This naturally causes worry and concern, ‘what’s happening?’ ‘why does it hurt when I reach forward?’, ‘it hurts to drive the car and I need to get to work’. The common reaction is ‘well I won’t do that activity then’. Suddenly we link to bigger things as the fear of pain may have far reaching consequences.

We fear what we don’t fully understand and to be fair, pain science isn’t really explained that well in many cases and if you Google search info on pain it can be confusing and not that accurate in the advice it provides.

In the book Explain Pain by David Butler, there is a lovely picture of the twin peaks where tissue tolerance and pain are depicted and it explains beautifully how reducing activity can further reduce our tolerance to activity and pain may be felt earlier than pre injury. If we do less, we get pain earlier, so we do even less and so on. This is a common mistake which causes more worry and stress.

But don’t panic because there are ways we can increase tolerance to activity once again and get back the confidence to do more without damaging the tissues, or worrying about damaging the tissues. I am by no means saying that it should be ‘No pain, no gain’ but pain doesn’t’ have to mean STOP. We can de-threaten using a little graded exposure, gradual movement and education can help restore that balance in our body and its integrated systems. Slowly, with tolerance and by pushing a little further each day the tolerance level gets higher, step by step we can do more before pain sets in.

 

It’s amazing how simple reassurance and supported rehabilitation with education and understanding can get people back on track. They no longer have to stop or avoid certain activity, they can push the limits and get back to normal. It’s no longer a stop sign, just a give way.