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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.

That’s not my Pirate!

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When my children were small they had a book that I had to read every night (as you do to small children). The book was called ‘That’s not my Pirate’, it was about a little girl looking for her lost Pirate, she looked at different Pirates that were nearly the same but not exactly. They might have different hair, different clothes or a different smile but they just were’t the right Pirate.

I was reminded of this book today when I was trying to explain how the body went through changes in a persistent pain state. I explained that there are changes not only in the tissues after an injury but also in the messages that go to the spinal cord and the brain, conveying information about stuff happening in the body. In chronic or persistent pain this gets a bit muddled, I likened it to Chinese whispers or predictive text. What you put in -or indeed think you put into the body- doesn’t always produce the response you expect. This may be more due to changes in the central nervous system and the brain rather than in the periphery.

Just like the Pirate in the book, pain can look different from one person to another, maybe someone in pain may shy away from activity, someone else will face it head on and ‘push through it’, others may look tired or adopt a protective posture to help alleviate symptoms. Pain can feel different, no two pains are identical and no-one experiences the same pain as the next person -fact! Finally pain can show itself in different ways, perhaps someones language will change, they may become withdrawn or low in mood as a result or it changes behaviour – you’re just not you.

Sometimes the person you see in the mirror looks like you but just isn’t you. 

 

Pain is a complex thing, it relies on previous experience, feelings, context, understanding and origins of current knowledge. It isn’t linear and once it becomes persistent, there is no longer a direct link between cause and effect. This is why everyone experiences pain differently and there is no one pain or one pain centre in the brain, we all bring our individual quirks to the party.

This fact alone makes life tough when trying to explain pain. I use a lot of examples, stories and sharing of information with my patients and try to put a point in a number of different ways. I hope this helps people to pick the right analogy that fits with their life and understanding. Sometimes this works, sometimes not so much but I do my best.

As I finished explaining a little more about persistent pain changes on the body he became quite animated, saying he found it really interesting and that he would like to know more. He told me the brain was a fascinating thing and he totally believed that thoughts and feelings had significant impact on the physical self. He said he had read about this kind of stuff before.

Hooray I thought, after a weeks of trying to scratch the surface and show him a different way of looking at pain he’s got it, just enough to want to know more and then he said this…”but that’s not my pain!”

Sally Allbrighton

BSc (Hons) Physiotherapy, MSc

Physiotherapist, Lecturer noiUK

F**k Pain

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It can’t be denied that we love to swear! In Britain we swear to express happiness, sadness, love and pain amongst other emotions. Particularly pain. It’s funny how when we hurt ourselves the first thing that often comes out of our mouth is “oh s**t” or “f**k that hurts”. We are all guilty that’s for sure. Maybe it’s a cultural thing, maybe is environmental or social or maybe it’s purely that language and culture have evolved from swearing being taboo to it being mainstream. Right or wrong, that’s just how it is.

I saw a Meme once that said “when I bang my toe it’s like I’ve pressed play to shout all the swear words I know”. Totally can’t argue with that statement!

Why am I talking about swearing? Well it seems that when we are in pain we swear a lot and rather than it representing an increased pain experience to the outside world, it actually appears to reduce our pain experience.

Some studies asked volunteers to put their hands in a bucket of ice for as long as they could stand. There were two groups, one shouted swear words (the most popular were f**k, s**t and b****r apparently) and the other group used other non-swearing vocabulary. The findings showed that not only could swearing help volunteers to keep their hands in iced water for longer, but also it reduced their pain score reporting and lowered the heart rate.

Interesting that our physical expression of verbalising and externalising our pain experiences reduce the actual rating and experience of pain. Think about women in labour, they really do go for it in the swearing stakes, I pretty much shouted the dictionary of swear words when I was in labour! If you’ve been there, you know you have to get through it somehow and I’m glad I didn’t choose to have a Scientology silent birth that’s for sure!

I get it though, it’s a bit like sport, channelling aggression through sport is cathartic, we learn to externalise how we feel through various means. Sport may help reduce work stress and life stresses through kicking a ball or smashing a tennis racket around or punching a bag, and swearing helps to reduce our pain experience.

This is a great example of how intrinsically linked our brains and bodies are in their output mechanisms. We experience pain, swear to release and externalise our emotional response, this lowers the heart rate and reduces pain rating. Funny how this all happens without any amount of conscious thought. Fascinating research looking at how language and pain are so connected, not only by how we understand others and to express ourselves, but also the physical effect our choice of words has on the physical body.

Moral of the story, swearing is good for you, f*****g go for it!

 

More than the sum of my parts

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This week a chap said to me “I am more than just a bunch of scans and tests”. I spoke to a lady this morning on the phone who said exactly the same thing.

Both these clients had experience of attending numerous medical appointments over a long period of time, test after test and scan after scan came back inconclusive or ‘clear’. But these people are still in pain.

It reminds me of my A’Level Psychology lessons about the Gestalt Theory stating ‘the whole is other than the sum of it’s parts’. Objectively we can look at individual aspects, get results and analyse each separately to come up with an answer as to what is going on in the body. Unfortunately when we look at individual parts, we can fail to see the bigger picture.

The ‘lived in’ experience of the patient is totally different from the individual test results that sit on our desk. Although it is impossible to experience the life of another and ‘walk in their shoes’, we do need to listen to the whole story from the person in front of us. This will give us a much better indication for correct management  and give them faith in us as clinicians. We need to see the bigger picture. As my client said to me this morning “stops looking at numbers and scans and start asking me how I feel”.

Sally Allbrighton

BSc (Hons) Physiotherapy, MSc, Lecturer for NOI, Physiotherapy Clinician

More than the sum of my parts

pexels-photo-164531.jpeg

This week a chap said to me “I am more than just a bunch of scans and tests”. I spoke to a lady this morning on the phone who said exactly the same thing.

Both these clients had experience of attending numerous medical appointments over a long period of time, test after test and scan after scan came back inconclusive or ‘clear’. But these people are still in pain.

It reminds me of my A’Level Psychology lessons about the Gestalt Theory stating ‘the whole is other than the sum of it’s parts’. Objectively we can look at individual aspects, get results and analyse each separately to come up with an answer as to what is going on in the body. Unfortunately when we look at individual parts, we can fail to see the bigger picture.

The ‘lived in’ experience of the patient is totally different from the individual test results that sit on our desk. Although it is impossible to experience the life of another and ‘walk in their shoes’, we do need to listen to the whole story from the person in front of us. This will give us a much better indication for correct management  and give them faith in us as clinicians. We need to see the bigger picture. As my client said to me this morning “stops looking at numbers and scans and start asking me how I feel”.

Sally Allbrighton

BSc (Hons) Physiotherapy, MSc, Lecturer for NOI, Physiotherapy Clinician