Osteoarthritis & the knee:

Key messages: 

 ……for most people ( not all unfortunately) it is …..

  • It is an up and down journey – episodes, NOT just downhill destruction.
  • The episodes are about “repair & remodelling” : healing if you like ! “wear & repair ” rather than “wear and tear”
  • You can manage it BUT the self management is for LIFE not just for while it hurts or you are on “therapy”.
  • You have every reason to be positive: YES it is painful …..YES it makes life difficult. BUT being as active as you can, getting specific exercises AND advice form your GP and in particular from a PHYSIOTHERAPIST.
  • Medication can be very helpful, supports and insoles occasionally helpful to.
  • Will loosing weight and looking at my diet help ……..

          ……………YES it will, but getting a little fitter, more mobility in your knee and strengthening up the right muscles – these are more important.

  • the NHS has some very useful links, exercise sheets and videos.

  • look for an ESCAPE PAIN exercise group they are specifically for lower limb arthritis – there is probably a group in your area. Ask at your GP & local fitness centres.


Twenty sixteen ….

I don’t know about you but 2015 was made up of a few significant lows but some good times to – personally anyway I am glad to see the back of it; but there I go wishing time away and the lows well they were always going happen and it all come down to missing someone important & regrets. Regrets – now there is a thing –  “I wished I had said  / done ….. OR why did I bother saying or doing that …”. If you’ve no regrets maybe you are living in a vacuum !

There are things I’d like to have done differently. But it is an opportunity to make 2016 better by learning from 2015. Some “stuff” just “was” & not changeable but now on reflection made me dig deep into my coping strategies – didn’t know had any !!

The main thing for me as far as my professional life goes made me realise just how weird & nonsensical our bodies are or feel to be. Making sense of our symptoms is impossible – we often ignore them or expand them. (See my previous blog on “stress biology” for some insight into this). What is clear is it takes a long time to wind down to “normal”.

Clearly the business of  coping whilst you have to find your own way/skills/strategies – doing it alone must be tough. Sharing how you feel with another soul is important. This is not “dumping on” – I know without a significant few in my life getting to where I am now would have been very difficult. Also as a health professional my patients have been good therapy for me (how lucky I am to have a career that allows me to care and be cared for all at the same time). Don’t suffer alone – your GP may need to be involved – to rule out concerns at the very least – perspective also is good.

SO .. twenty sixteen then, got some goals? something achievable; positive change of attitude? and LIVE fully.

Stress …. just a medical fob off or not ? a personal experience !

  • IT IS REAL – IT IS AS MUCH PHYSIO logical  AS PSYCHO logical….    In other words it messes with body and  your mind !!

Lets not get into percentages here as it could be 99% in the mind or the opposite. This is what GP’s, psychologists and other specialists can help with ……

  • We all will experience it at some time …………..

  • It can be good ! Eustress may even be essential. It is not just “adrenaline junkies” that may thrive on it…..

  • It is experienced by each of us in SO many different ways, for example …..

    • Emotional – anger, tears and more

    • Physical – headaches, stomach aches or pains, pounding heart, palpations, breathlessness ….

    • Coping – a lack of !

    • Irrational responses to those around us

    • Hyperawareness – to comments made to us, or of every twitch and signal our body gives us..

      There are many good sites to use  and healthcare practitioners, GP’s who can sign post you to the right techniques, treatments that you need. So this blog will not discuss treatments.

    • BUT: having experienced the effects of significant stress / panic / anxiety 1st hand I can tell you it is SCARY, POWERFUL, OVERWHELMING, UN-UNDERSTANDABLE ….. but treatment works, time helps, and support from GP’s, friends & family helps …. so seek help – admit the problem and get back control.

      A fantastic book that I found helpful when trying to understand “stress” and in particular the physiology ( what it could do to my body, my feelings and responses)  although the title will make you raise your eyebrows is called “why don’t zebras get ulcers” by Professor Robert Sapolsky.


There  are two types of stress (three if you include eustress or good stress)

  • Acute – useful, usually.

  • Chronic – ongoing, purposeless.

  • The effect of stress on us varies from one person to the next. It is thought that it may to do with the type of stress & person we are :-

  • “exam stress” as against “war stress”;

  • it may have a lot to do with our life history and experiences;

  • it may have a lot to do with our character traits & tendencies to under or over react

STRESS CHEMICALS !!!  there are two types – hormones (slow – endocrine systems) and neurotransmitters (fast – central nervous system) these are messengers to and from the brain and body: these two messenger systems work together. They aim to control most aspects of how our bodies work and stay IN-Balance & healthy. The right amount at the right time and all is good. The wrong amount at the wrong time or going ON & ON or chronically ( there is a word we’ve  used before) – going on without purpose or BENEFIT – problems.

Some of them maximise your awareness and physical responses like adrenaline & cortisol to literally or metaphorically  help you run away from OR DEAL with the “lion in the room” .

Here is brief list of some messengers:  Some increase activity in the brain, glands and organs they connect to and some decrease or suppress. Lets not get bogged down with the detail. They are REAL & VERY POWERFUL.

  1. Cortisol

  2. adrenaline

  3. Vasopressin

  4. Insulin

  5. Prolactin

  6. Growth hormone

  7. Thyroid hormones

  8. Gonadotropin

  9. Seratonin

These transmitters and hormones are useful at the right time ….

Personally, “I wasn’t stressed” I was dying !! my heart was pounding I had palpations, I had periods of being sweaty, chest and left arm “discomfort” and usually worse at night.  Common sense was gone ….. When I exercised or was busy engaged with work generally no problems !! Duh! Yes I saw my GP he did tests and spoke to me and gave me perspective; reassured me, listened to me.

BREATHING exercises are a key ingredient in managing stress and I found them helpful PLUS realising my symptoms were STRESS generated.

Even now I get the odd night or very occasionally hour in the day when I feel “weird” or panicky, it is still scary though but it is lessening and I am gaining confidence in my own coping and that  “I WILL BE ALRIGHT – this will pass!

Generally it seems the de-stressing period is slower to resolve than the getting stressed. The issue is do you recognise these symptoms as stress, are you ignoring these symptoms, not bothering your GP, friends and loved ones with these symptoms.

Take the 1st step – admit a problem, get them checked out and then if there is nothing physical to worry about you can get on with the hard road to feeling better. It shouldn’t be complicated even if it is difficult.

As always with my blog if you find it helpful – great. If it makes no sense IGNORE it but keep looking for help

Tendonitis – what is it ? how to treat it? & when to seek physiotherapy

The Information here is pulled from a variety of quality sources and also based on my own clinical experience.

There is not necessarily ONE way to treat anything and opinion will vary. I hope this helps you understand tendons and gives you some treatment guidance.

Like what you like ignore what you don’t !

Tendons join muscles to bone ( see example of the Achilles tendon). They are usually white-ish as they are relatively poorly supplied with blood. – This is important as you will discover.

All tendons are interesting and clever but the Achilles particularly so and is a common site of injury seen in my clinics. So I will refer to it mostly however the info on this blog is relevant for tendon based injuries.


Tendons are incredibly strong, the tendo-achilles above is able to transmit forces up to 7x your body weight but also unique amongst tendons as it just doesn’t join muscle to bone it actually spirals on itself giving it the ability to generate force itself like a coiling of a spring – hence why some humans can jump so high or so far. Its seems it was absent in one of our forbearers Australopithecus and appeared in Homo erectus about 3 million years ago .

BLOOD SUPPLY: As we have already said tendons do not have a great blood supply – but they are not meant to either and problems arise when then they get one – termed hyper vascularisation & where blood supply goes nerves follow more blood more nerves and therefore possibly MORE PAIN. The Achilles has a portion of its tendon about 2-6cm above the heel that has an “avascular zone” or a bit with virtually no blood supply !! and at the tightest part of the coil. Like the wringing out of a tea towel…….

Tendinopathy (tendon injuries) can develop in any tendon of the body. Most experts now use the term  tendinopathy to include both inflammation and micro-tears. Indeed there may often be no sign of inflammation at all.But many still use the term tendonitis out of habit.

Typically, tendon injuries occur in three areas:

  • musculotendinous junction (where the tendon joins the muscle)
  • mid-tendon (non-insertional tendinopathy)
  • tendon insertion (eg into bone)

Non-insertional tendinopathies tends to be caused by a cumulative microtrauma from repetitive overloading eg overtraining.

What is a Tendon Injury?

Tendons are the tough fibres that connect muscle to bone. Most tendon injuries occur near joints, such as the shoulder, elbow, knee, and ankle. A tendon injury may seem to happen suddenly, but usually it is the result of repetitive tendon overloading. Health professionals may use different terms to describe a tendon injury. You may hear:

Tendinitis (or Tendonitis): This actually means “inflammation of the tendon,” but inflammation is actually normal tendon healing response which can cause some tendon pain. This is known as the reactive phase and is a good tendon healing response.

The problem really occurs when you healing rate is less than the injury rate – known as tendon dysrepair – which is when tendinopathies can quickly deteriorate into the degenerative (cell death) phase. This is characterised by collagen (main building constituent of most of our tissues)degeneration in the tendon due to repetitive overloading. These tendinopathies therefore do not respond well to anti-inflammatory treatments and are best treated with functional rehabilitation. The best results occur with early diagnosis and intervention.

 Factors in Tendon Injury?

Most tendon injuries are the result of gradual wear and tear to the tendon from overuse or ageing. Anyone can have a tendon injury, but people who make the same motions over and over in their jobs, sports, or daily activities are more likely to damage a tendon.

Your tendons are designed to withstand high, repetitive loading, however, on occasions, when the load being applied to the tendon is too great for the tendon to withstand, the tendon begins to become stressed.

When tendons become stressed, they sustain small micro tears, which encourage inflammatory chemicals and swelling, which can quickly heal if managed appropriately.

However, if the load is continually applied to the tendon, these lesions occurring in the tendon can exceed the rate of repair. The damage will progressively become worse, causing pain and dysfunction. The result is a tendinopathy or tendinosis.

Researchers current opinion implicates the cumulative microtrauma associated with high tensile and compressive forces generated during sport or an activity causes a tendinopathy.

For example, in explosive jumping movements, forces delivered to the patellar tendon can be seven – eight times your body weight. Cumulative microtrauma appears to exceed the tendon’s capacity to heal and remodel.

Systemic Risk Factors

Evidence is growing that it is more than just the tendon and overload that causes a tendinopathy. Diabetics, post-menopausal women and men with high central adiposity (body fat) seem to be predisposed to tendinopathies and will need to carefully watch their training loads.

What are the Symptoms of Tendinopathy?

Tendinopathy usually causes pain, stiffness, and loss of strength in the affected area.

  • The pain may get worse when you use the tendon.
  • You may have more pain and stiffness during the night or when you get up in the morning.
  • The area may be tender, red, warm, or swollen if there is inflammation.
  • You may notice a crunchy sound or feeling when you use the tendon.

Tendinopathy Phases

The inability of your tendon to adapt to the load quickly enough causes tendon to progress through four phases of tendon injury. While it is healthy for normal tissue adaptation during phase one, further progression can lead to tendon cell death and subsequent tendon rupture.

1. Reactive Tendinopathy

  • Normal tissue adaptation phase
  • Prognosis: Excellent. Normal Recovery!

2. Tendon Dysrepair

  • Injury rate > Repair rate
  • Prognosis: Good. Tissue is attempting to heal.
  • It is vital that you prevent deterioration and progression to permanent cell death (phase 3).

3. Degenerative Tendinopathy

  • Cell death occurs
  • Poor Prognosis – Tendon cells are giving up!

4. Tendon Tear or Rupture

  • Catastrophic tissue breakdown
  • Loss of function.
  • Prognosis: very poor.
  • Surgery is often the only option.

It is very important to have your tendinopathy professionally assessed to identify it’s injury phase. Identifying your tendinopathy phase is also vital to direct your most effective treatment, since certain modalities or exercises should only be applied or undertaken in specific tendon healing phases.

How is a Tendon Injury Diagnosed?

To diagnose a tendon injury, your physiotherapist will ask questions about your past health, your symptoms and exercise regime. They’ll then do a physical examination to confirm the diagnosis. If your symptoms are severe or you do not improve with early treatment, specific diagnostic tests may be requested, such as an ultrasound scan or MRI.

How is Tendinopathy Treated?

The Achilles is used in this example but is in principle the same with arm tendons: gripping or lifting may be the activities that need adapting or occasionally avoiding.

Researchers have concluded that there are essentially 7 stages that need to be covered to effectively rehabilitate these injuries and prevent recurrence.

Phase 1 – Early Injury Protection: Pain Reduction & Anti-inflammatory Phase

As with most soft tissue injuries the initial treatment is RICE  (or MICE) – Rest (or Modified activity actually), Ice, Compression and Elevation.

In the early phase you’ll be unable to walk without a limp, so your Achilles tendon needs some active rest from weight-bearing loads. You may need to be non or partial-weight-bearing, utilise crutches, a wedged achilles walking boot or heel wedges to temporarily relieve some of the pressure on the Achilles tendon. Your physiotherapist will advise you on what they feel is best for you. Avoidance of stretching maybe advised – and may go against common sense or urge to stretch!

Ice is a simple and effective modality to reduce your pain and swelling. Apply for 20-30 minutes every 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot. Anti-inflammatory medication (if tolerated) and natural substances eg arnica may help reduce your pain and swelling. However, it is best to avoid anti-inflammatory drugs during the initial 48 to 72 hours when they may encourage additional bleeding. Most people can tolerate paracetamol as a pain reducing medication. Take medical advise as most therapists are unable to prescribe.

As you improve strapping and supports may be worth a try and  kinesiotape style supportive taping is also proving useful to both support & heal the injured soft tissue. How they actually or if they actually support is questionable – but if folk feel benefits I’ll not argue !

Phase 2: Regain Full Range of Motion

If you protect your injured Achilles tendon appropriately the torn tendon fibre will successfully reattach. Mature scar formation takes at least six weeks. During this time period you should be aiming to optimally remould your scar tissue to prevent a poorly formed scar that will re-tear in the future.

It is important to lengthen and orientate your healing scar tissue via massage, muscle stretches, neurodynamic (nerve based mobility exercises – yes they move !) mobilisations (massage or other forms of hands on therapy) and eccentric exercises (See phase 3 video link – IMPORTANT). Signs that your have full soft tissue extensibility includes being able to walk without a limp and able to perform Achilles tendon stretches with a similar end of range stretch feeling.

Phase 3: Restore Eccentric Muscle Strength: See attached you tube video


The video shown is for the right calf/ Achilles. In” settings” on the you tube video it can be set to better quality and slowed down. This exercise is part 3. Part one is the same except the heels are on the book, part two uses no book. The exercise is the same. 12-15 reps; 10-14 days on each part is usual. But may be less or more. It is shown with all the weight being borne on the injured leg – this the goal to be able to do this painlessly for 12-15 reps but may need to begin with some weight on both gradually moving to the single leg lower.

There are many versions and progressions to this but this is a good basic.

Calf muscles work in two directions. They push you up (concentric) and control you down (eccentric). Most Achilles injuries occur during the controlled lengthening (eccentric) phase. Your physiotherapist will guide you on an eccentric calf strengthening program when your injury healing allows.

Phase 4: Restore Concentric Muscle Strength

Calf strength and power should be gradually progressed from non-weight bear to partial and then full weight bear and resistance loaded exercises. You may also require strengthening for other leg, gluteal and lower core muscles depending on your assessment findings. Your physiotherapist will guide you.

Phase 5: Normalise Foot Biomechanics

Achilles tendon injuries can occur from poor foot biomechanics eg: some types of flat foot. In order to prevent a recurrence, your foot will be assessed. In some instances you may require a foot orthotic (shoe insert) or you may be a candidate for the Active Foot Posture Stabilisation program.

Your physiotherapist will happily discuss the pros and cons of both options to you.

Phase 6: Restore High Speed, Power, Proprioception & Agility

Most Achilles tendon injuries occur during high speed activities, which place enormous forces on your body (contractile and non-contractile). In order to prevent a recurrence as you return to sport, your physiotherapist will guide you with exercises to address these important components of rehabilitation to both prevent a recurrence and improve your sporting performance.

Depending on what your sport or lifestyle entails, a speed, agility, proprioception and power program will be customised to prepares you for light sport-specific training.

Phase 7: Return to Sport

Depending on the demands of your chosen sport, you will require specific sport-specific exercises and a progressed training regime to enable a safe and injury-free return to your chosen sport.

In most cases, you can start treating a tendon injury at home. To get the best results, start these steps right away:

  • Rest the painful area, and avoid any activity that makes the pain worse.
  • Apply ice or cold packs for 20 minutes at a time, as often as 2 times an hour, for the first 72 hours. Keep using ice as long as it helps.
  • Do gentle pain free  range-of-motion exercises to prevent stiffness.
  • Have your biomechanics assessed by a sports physiotherapist.
  • Undertake an Eccentric Strengthen Program. This is vital!

How to Return to Sport OR indeed full work or life activities such as gardening !

It may take weeks or months for a tendon injury to heal. Be patient, and stick with your treatment. If you start using the injured tendon too soon, it can lead to more damage.

To keep from hurting your tendon again, you may need to make some long-term changes to your activities. These should be discussed with your physiotherapist.

  • Try changing your activities or how you do them.
  • If exercise caused the problem, check your technique with a coach or sports physiotherapist.
  • Perform regular eccentric style exercises.
  • Closely monitor and record your exercise loads. Discuss your loading with your physiotherapist and coach.
  • Always take time to warm up before and cool down / stretch after you exercise.

Persisting tendon injuries are best managed by a sports physiotherapist with an interest in tendinopathies. Researchers have found that tendon injuries respond differently to muscle injuries and can take months to solve or leave you vulnerable to tendon ruptures, which usually require surgery. This has two important issues:

  • Ensure you have an accurate diagnosis.
  • Ensure that your rehabilitation is targeted at either the muscle injury or tendinopathy.

This blog has quite a bit of detail and terms within it. I found it unavoidable. I hope things have been explained and there is something there to help you. If in doubt discuss with your GP or physio.

Remember there are various views and this doesn’t mean we disagree – it is often more about use of terms.


“Pinched Nerves” ! … a simple link

We’ve at least heard people use this phrase and it conjures up a clear image doesn’t it? a bit like the character below !!

(ignore the words of wisdom in the cartoon !)

pinched nerve

But what is the reality? that is the topic of this post.


This post is a simple link to a very useful source of quality information for physio’s AND patients. Based in Australia but educating internationally: headed up  by Dr David Butler (a physio) and professor Lorimer Mosely (a physio to) yep we are that bright.

These guys at The Neuro Orthopaedic Institute or NOI organisation have helped revolutionise not just physio thinking but medical thinking to.The posts’ link below will explain and talk about the current understanding of the phrase “I think I’ve got a pinched nerve….”.

The NOI organisation also have a wonderful book for all therapists and patients alike called EXPLAIN PAIN. Available though the NOI or online, it may seem pricey but takes pain in all its guises and presentations and gives clear de-medicalised thinking and some beautiful art to support the words & there is a Handbook (protectometer !! included…) to accompany it.


 I hope you find this NOI blog helpful. Once again the message is movement not “going to war ” with your body but thoughtful simple movements. The nerves and all parts of the nervous system seem to like movement and have “fitness”.

Quite a thought isn’t it?

There will be many more posts on nerves – what they do, how they become injured, repair and how physio can help many of the agonising and complex problems associated to nerves & the nervous system

Anterior (front) Knee Pain: 3 simple exercises to try

There are many possible causes of pain over the front or “deep in” the front of the knee or knee cap. These include damage to muscles, tendons, ligaments, cartilage, may be related to “wear & tear” (later BLOG on this !), alignment or even from the hip (referred pain – Later BLOG on this to). 

NONE OF THE EXERCISES SHOULD CAUSE PAIN- during or after them: They should strengthen and make your knees feel good.

“Guinea Pig Exercise”: Intrigued ? see 2 photos below …..

Imagine the towel is living guinea pig (gp) you are trying to hold the gp with your knees so it cannot run away  DO NOT Squash it! This pressure is maintained THROUGHOUT the exercise which should take about 30 seconds.
As you can see the ankles are also crossed first one way then repeated for another 30 seconds the other ankle on top. So the whole exercise routine should take 1 Min approx. The exercise is as follows:-
  • NOW, this is the clever bit ! 1st press your knees together against towel guinea pig (keep this pressure) NOW press your ankles against each other (1 forward, the other  backwards) for 5 seconds and release briefly and repeat 5 times BUT DO NOT let the pressure at the gp change …….. NO MORE & NO LESS pressure – it takes CO-ORDINATION & MUST NOT HURT AT ALL, maximum pressure but no PAIN!


 Sandwich Exercise: Diagram below

Called this as the first part (A) is repeated 1st and last and the middle part (B) is like a filling in the middle … does that make sense?

Part (A) – (the bread): A firm pad is placed under the back of the knee. The 1 in the circle means do this first – press your thigh down against the pad firmly but painlessly and maintain this throughout part (A). Next straighten lower leg shown by the dotted line and by the 2 in a circle. There will be stretch down the back of your leg and the front thigh muscle (the quads) should feel firm. No pain.

Part (B) – (the filling): The pad moves down to behind your ankle. downward pressure against pad is exerted now at the knee and ankle at the same time as shown by the 1’s in the circles. Again some stretch and firmness to the quad muscle. No pain

Do 5 repetitions of each  Part (A), (B) & (A – again) so that is a total of 15 reps……

sandwich knee exercise


Single Leg Balance: Just Play video.

This shows someone standing and balancing for a few seconds on a pillow with their eyes open. You could try at first WITHOUT pillow & even start with holding onto something stable, much later on try with your eyes closed and gradually increase to 1 Min. Start where you feel confident & gradually make harder.

As with all these health BLOGs like what you like, ignore what you don’t. But it might make you want and go and discuss your problem with your GP or Physio

Enjoy  Alan

Whiplash: what is it & what should you do?

My aim with this blog is to present some information which is useful whether you are medically trained or not; so breeze through the jargon that means nothing to you do NOT get bogged down with terms. The term whiplash has been hijacked by the claim culture “system” the same thing happened to “RSI – repetitive strain injury” ; sooner or later it seemed to get outlawed and the claims have largely disappeared. The same could happen to whiplash …. because of a few making good (bad!!) money out of claims. This affects the majority of genuine injuries seeking help.

Whiplash Associated Disorder (WAD) :

Whiplash is an injury usually to the  neck area but can affect any part of the back or even shoulders. It is due to a forceful, rapid back-and-forth movement of the body, the nature of the injuries depend also on the direction of impact, whether the car was spun or rolled. Whiplash most often occurs during a road traffic accident, however the injury can also result from a sports accident, physical abuse or other trauma.

Common signs and symptoms of whiplash include neck pain, neck  stiffness and headaches. Pain may be referred to other areas and tenderness felt widely as well. For most people the whiplash  symptoms will  recover within a few months after a course of pain medication, exercise and other treatments.

Some people, however will continue to experience chronic neck pain and other ongoing complications including psychological & emotional effects along with aches and pains that are difficult to adequately explain. Whilst the stats are VERY MUCH in favour of a happy recovery. It is still a miserable time.

For a more technical summary of Whiplash see the attached document  (below in red) by the IASP (THE international ” go to” pain people ).


It is quite detailed and technical so “don’t get confused”  or bogged down. Remember what I always say  “like what you like , ignore what you don’t”

THE recognised grading system for whiplash used in medicine is called the Quebec Task Force Classification (see below): There have been updated suggested revisions of this with 7 categories (Michelle Sterling, 2004. In manual Therapy, 9,60-70)

Québec Task Force

The Québec Task Force (QTF) has divided whiplash-associated disorders into five  grades:

  • Grade 0: no neck pain, stiffness, or any physical signs are noticed
  • Grade 1: neck complaints of pain, stiffness or tenderness only but no physical signs are noted by the examining physician.
  • Grade 2: neck complaints and the examining physician finds decreased range of motion and point tenderness in the neck.
  • Grade 3: neck complaints plus neurological signs such as decreased deep tendon reflexes, weakness and sensory deficits.
  • Grade 4: neck complaints and fracture or dislocation, or injury to the spinal cord.


There appears to be some common risk factors of developing a difficult to shift whiplash pain, they are similar risk factors for any pain being difficult to shift. This type of pain is called  CHRONIC PAINlater  BLOGS on  this ….

Risk Factors: for  chronic symptoms like pain & stiffness. The table below shows the factors which do and appear not to relate to the chances of developing an outcome or prognosis of chronic pain: The box on the left shows the ones most likely or possible to lead to chronic symptoms; possible only! 

There are loads of these “risk factor lists” but the one here is a reasonable example:

prognostic risks whiplash

Managing Whiplash early on: (1st 12 weeks): Have you been checked out ?? Maybe at the scene, by your GP, at A/E or by your therapist; do you need to ? SELF ASSESS ..

Amazingly most people suffer only soft tissue injuries to the neck, low back or shoulders. Major nerve or bone damage seems uncommon. Although  the injuries are more like a sprain or strain type injury they often strangely take longer than would be expected and with an tendency to vary between good periods and bad quite randomly. The thing to take from this is slight quirkiness is that it is normal (not easily explainable but quite normal). In this 1st 12 weeks you need to do the basics WELL. 

Move & Soothe !

I know this seems too simple. first week or two look after your posture, use pain relief which should include heat or ice (whichever works for you), simple rubs and creams, move you neck or injured part through an gradually increasing range of movement, try to get on with work or chores. Your work may need to be involved some employers won’t want you there unless you are 100% or unless cleared medically to be there.

Video Series: Exercises for Whiplash

Learn 3 Neck Stretches and Exercises


(with permission from spine universe)

The link above (in RED)is quite useful for some simple exercises early on. There are three videos. They will talk about holding some positions for 20 seconds but this should built towards and I would suggest 3-5 second holds. They should not be painful – “pleasant stretchy pain” that get easier as the days go by. Done twice a day ideally.

Managing Whiplash when it is going on & on ….. (after week 12):

There is a lot of help out there. Have you had Physio? if this hasn’t worked for you there are specialist pain rehabilitation teams accessible via your GP

 For the most part the healing process in the majority of whiplash injuries which as we have already said are soft tissue based (ligament, muscle and tendon based) are now HEALED.  They might need toughing up a bit more, stretching, loosening “unspasming” but this is the prettying up or “painting and decorating” stage of healing. BUT YOU STILL HURT ! pain  without purpose – pointless BUT certainly agony, miserable, terrifying AND  REAL.

YES there may also be psychological factors, sociological, financial, personal life changing factors that could be part of your whole experience of the pain you still feel. Mind & Body – always together not one or the other ….

 ARE there some mis-diagnosed, mis -managed, misunderstood whiplash problems YES there are …..but they are very, very few, MORE usually they are  impossibly complicated. BUT this BLOG is about the majority HEALED but STILL HURTING. 


You are on staircase to a better life EVEN with your pain – REALLY ! well yes probably:  plan for the worst. YOU  have to get on with life – to live – You can & YOU will….

  1. PLAN – small steps. Plan your activity whether it is housework, a walk or whatever. Think  like an ATHLETE but you are you’re own coach: what are you going to do? how much? & for  how long. NOT UNTIL IT HURTS LIKE HELL – WRONG

  2. PACE – make your activity achievable, small victories are best.

  3. GRADED EXPOSURE – gradually increase your exposure to activity, chores and exercises (walking, gentle keep fit, tai chi, yoga, Pilates  – are reasonable early suggestions) plan the exposure NO leaps into the unknown

  4. PLAN – review the success of your 1st step – plan the next step: slightly more slightly less or repeat the same.

There will be some UP’s and some DOWN’s – you will not get it right all the time. Increases in PAIN are to be expected and will most often be FOR NO REASON – so don’t over analysis.


Do not get controlled by the good day / bad day swing door – do Too much on the Good days and do nothing on the bad !!  Sometimes called the under activity / over activity trap.


Do what you planned, Stick to the plan NOT more Not less. Build in rest – this might be a lie down but could easily be a lighter activity. But PLAN it – DO IT.

good day bad day swing door

There is light at the end of the tunnel. The body can recover, the nervous system can “re-wire” (more about this idea in later BLOGS on chronic pain) so it is not impossible for the symptoms of whiplash to go away. I have had many people tell me 1-2 year after the injury they have returned to normal.

However, and I know it seems a great big fat lie but you can live and live well even with pain. I hope this BlOG gives you some pointers, some hope. You shouldn’t have to do it alone there are some inspirational PAIN SPECIALIST PHYSIO’s . Whether I am a specialist or not I don’t know but I spend a lot of my day to practice working with people like you.


light at the end

Good luck, I hope you have enjoyed & been helped







Faulty Pain !!

PAIN…Faulty !

Pain is supposed to be useful. It warns us of injury, illness – to avoid putting our foot back on the floor when we have stepped on a tack…..BUT sometimes even this useful system goes wrong – that is what this blog is looking at.

 Lets start with a definition: As defined by the leading world authority on the subject –  The International Association for the Study of Pain (IASP).

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.

There is lots of detail to understand in that definition. Note the use of the word emotional – pain is miserable, depressing, agonising and so much more than this. The sensory bit is things like dull, sharp, stabbing, aching. Also note the use of words ACTUAL – meaning you are damaged and the word POTENTIAL – there isn’t any damage but the threat is sufficient to produce a response !


The image above is trying to show that acute pain (new pain or damage pain – “useful pain !! there’s a thought for you) is relatively simple: damage produces a simple “ON & OFF” switch of pain that is proportional or correct for the level of damage. Switches off when the problem is sorted.

The Chronic Pain device is filled with complicated dials and no obvious “OFF” switch.

Chronic pain can be due to a long term medical problem and therefore appropriate (many of the “arthritis” conditions are examples, there are about 200 different types of arthritis !!) BUT more often chronic pain is FAULTY, pointless, useless, greater than the level of any remaining damage, existing when NO damage exists anymore, going up & down for no obvious reason.

YES: It is still miserable, agonising, depressing, and affects your life & REAL.

NO; it is not imagined or made up….. BUT….


how dow know it is chronic pain

… how do we know?? – well we don’t absolutely  BUT  “what’s left?”


Of course you need to be sure that there is no cause, disease or that something has been overlooked. Then what? …..

…..well, this is whole new world, a change of what you believe,  your body seems to telling to you there is something wrong BUT there isn’t. The “spark” that seems to ignite your pain is often small, “a draft”, “I sat wrong” or so many other triggers which get blamed for causing a flare up. Stress is a significant factor in amplifying, influencing pain. Stress chemicals are evil and do affect how we experience pain and cope with pain.

But if you want to move on and” get your life back” changing  your thinking  is what you must do. And yes it is absolutely possible millions of people do … they get to enjoy life, living “despite pain” !! …. So on with the concept of how do you get started.

Have a look at this simple 10 min video link about “acute” pain and in particular “chronic” pain:



You are on staircase to a better life EVEN with your pain – REALLY ! well yes probably:  plan for the worst. YOU  have to get on with life – to live – You can & YOU will….

  1. PLAN – small steps. Plan your activity whether it is housework, a walk or whatever. Think  like an ATHLETE but you are you’re own coach: what are you going to do? how much? & for  how long. NOT UNTIL IT HURTS LIKE HELL – WRONG

  2. PACE – make your activity achievable, small victories are best.

  3. GRADED EXPOSURE – gradually increase your exposure to activity, chores and exercises (walking, gentle keep fit, tai chi, yoga, Pilates  – are reasonable early suggestions) plan the exposure NO leaps into the unknown

  4. PLAN – review the success of your 1st step – plan the next step: slightly more slightly less or repeat the same.

There will be some UP’s and some DOWN’s – you will not get it right all the time. Increases in PAIN are to be expected and will most often be FOR NO REASON – so don’t over analysis.

So go on get out an old fashion note pad. Set a couple goals – to leave the house, to do something in the garden, to meet up with a couple of friends, do a walk.

SMALL, ACHIEVABLE – PLAN it DO IT. Success or failure DO IT AGAIN make some SMALL changes – DO IT

Do not get controlled by the good day / bad day swing door – do Too much on the Good days and do nothing on the bad !!  Sometimes called the under activity / over activity trap.


Do what you planned, Stick to the plan NOT more Not less. Build in rest – this might be a lie down but could easily be a lighter activity. But PLAN it – DO IT.




The use of Metaphors in medicine: confusing or an enlightening use of language?

Let’s start with a definition:

METAPHOR; generally there are two types (an analogy and a simile). A metaphor is a figure of speech usually to imply a comparison between to different things or not dissimilar things. For example;

  • As busy as a bee
  • The curtain of the night
  • life is like a box of chocolates, you never know what you’re gonna get…..

Image result for forrest gump

  • Diagnosis is more like an umbrella term…..
  • Your explanation is as clear as mud. (Simile)
  • A doctor’s diagnostic method is like a detective’s investigation.(analogy)

Sometimes the metaphor is an exaggeration (a hyperbole) and sometimes used to make a point and be precise (an antithesis). An ANALOGY is usually where the comparison is more literal or similar. A SIMILE – usually different things are compared.

The (hopefully) useful thing about metaphors is they can help put complicated medical jargon or descriptions into “layman speak” or ways that seem familiar. So this may be in work terms such as comparing nerves to electrical cable for electricians, or the complexities of the healing process to say road repairs or building an house extension – I’ll use these later in this BLOG mainly in areas of pain and healing.

Medical researchers seem mixed in their agreement about whether metaphors are good or indeed just a different sort of bad and not enlightening at all!! but here goes……………..

“Metaphors may be as necessary to illness as they are to literature, 
as comforting as a bathrobe and slippers.” (Broyard, 1992)

Let’s start with some simple analogies used in medicine to help with discussing pain especially when pain is faulty!! (More BLOGS to follow on this … PAIN FAULTY !!!….. we’ll get to it !)

Pain : An Alarm system

There are several variations on the use of an alarm system as an analogy for persistent pain. The idea is that the original trigger for the pain has ceased, but the pain signals (alarm) continue to be transmitted.

  • Persistent pain is like a doorbell that goes haywire. Usually when you press a doorbell it rings one house one time and that’s all. But, in the case of chronic pain, it’s as if the doorbell on one house actually rings every house on the block. And the doorbell doesn’t just ring once, it rings all day and all night (Tupper, 2012).

  • Chronic pain is like a broken alarm clock. Imagine that your morning alarm clock goes off at 7 am, and you roll over to hit the snooze button, but it doesn’t turn off like it’s supposed to do. You try banging the snooze bar, switching the alarm off, unplugging the clock, taking out the batteries, and even throwing it out the window, but it still keeps ringing. You’re clearly awake at this point, so the ringing alarm clock is not doing any good anymore, but it just won’t turn off. The pain alarm in our body can be just like this broken alarm clock. It can just keep ringing and ringing even though it’s not helping us in any way (R. Coakley).

  • Chronic pain is like a car alarm. Sometimes a car alarm can go off even when there is no sign of danger. For example, sometimes a large truck passing by can accidentally set off a car alarm in a parked car. Or, sometimes a car just needs to be gently bumped in order to activate the car alarm. Some car alarms, it seems, are very sensitive, while others hardly go off at all. The purpose of the car alarm is to alert other people that the car is in danger. However, when the alarm goes off accidentally and there is no sign of danger, it’s really just a false alarm. Cars with sensitive alarms send out more false alarms and people with more sensitive nervous system can have more false alarms (pain sensations) as well (C.T. Chambers, personal communication, 2013).

Let’s look at metaphors for how impulses like pain, touch, temperature & many others travel up and down form the body part to the brain and back (Yep they go both ways!). There are many filters in the system that can be thought of as “like” gates…..

Chemical bridges  (called – neuro transmitters) bridge the space at these filters or gates along the impulses journey up and down the nerve, they are not supposed to be permanent. The bridge or gate should not be constantly open. See below…….. the railway gate analogy…

a synatic gate

Railway crossing gate

The gate control theory is a very popular theory, originated in the early 1960’s by Melzack and Wall. Whilst now it is known that  this not absolutely the way it is, it is still a valuable concept. This theory posits that there is a virtual gate that controls the magnitude of the pain signal that reaches the brain (Melzack & Wall, 1965). It can be helpful to describe the path to people as an actual gate.

You can think about pain signals being like trains passing through a railway crossing gate. When the gate is all the way open, trains pass right through. Similarly, when the gate to your brain is open, pain signals have free access to your brain. Medication might close the gate partway, but for many people, medications may not close the gate completely. The key idea here is that treatment whether it be physical therapy, manipulative therapy, acupuncture  or  talking therapies like CBT or mindfullness can help “shut the gate”

HEALING: There are lots of useful metaphors for healing here are a couple of my favourites that seem to make sense to my patients:

Healing is like …

  • a building project. 

Here I discuss that there are stages, you don’t put up a roof without walls ! a good foundation is essential. In healing there are 3 stages: acute phase – lots of mess but hopefully a good foundation, then the sub-acute phase – the building of the structure and finally the  remodelling phase – the painting, decorating making it useful. Now with every building project not everything may go smoothly or may need bits re-doing, maybe the plumber doesn’t turn as expected……hopefully you can see the analogy unfolding into something familiar.

  • repair on a motorway

Similar to above but I use it for a slightly different emphasis: the analogy is used to explain “reflex muscle protection” or spasm in the analogy the miles of bollards used to protect the work force may seem excessive – they aren’t – but are a “pain” to all drivers!

I tend to ask my clients what they understand from the analogy and see if it does indeed prove helpful..!

The debate goes on in the literature are metaphors good or bad. The right ones work in the right hands for the right people !! Get them right and they are so EMPOWERING and HEALING in their own right.

Facilitate the mind to allow the body to heal – It is a two way street!!! 

As ever like the bits you like, maybe see how they might work in your situation. Ignore if you wish… Enjoy.

Thank you for reading.



Physiotherapy: What is the future – a Plea more than a rant!

When I first qualified 32 years ago as a Remedial Gymnast and then as a Physiotherapist after the two professions merged, we were still largely under the direct control of Dr’s.  Not carrying out treatments based on our own skilled assessments using clinical reasoning and the latest research. We were told do “x” for “x” number of sessions for “x” number of weeks and then discharge.

All this despite being trained to examine, reason, and diagnose -thankfully our independence and clinical standing came quite quickly and the profession made enormous steps in become lead “players” in the world of medicine in every area of healthcare.

I’d argue none more so than the area in which I work – musculoskeletal medicine and pain management.

We have become essential and key to the progression of knowledge within these areas, indeed in the area of pain management physio has been at the forefront of the revolution in this and in particular with the management of chronic pain.

Physiotherapist in recent years have gained new roles, became recognised as CONSULTANTS, EXTENDED SCOPE PRACTITIONERS, PRESCRIBER’S; This is so fantastic that we are recognised as being skilled and competent, yet there is something going on beneath our feet !!

Now I am a big advocate of talking, educating, listening, encouraging, guiding, motivating patients to self manage and take control for themselves. BUT…….there appears to a gradual and insidious sneaky almost, dissolving of many of key skills.

We touch, examine, manipulate, massage, exercise, teach, handle & facilitate

I hear of physio’s being told that in “our dept” we are not allowed to touch patients, not use ultrasound, not use massage. THIS IS ABSURD / IT IS DISTRESSING and will DESTROY our profession.

The GREAT’s who gave us the improved skills, belief, insight into examination & manual therapy – people like James Cyriax, Geoff Maitland, Greg Grieve, Freddy kalternborn, Brian Edwards, Louis Gifford to name but a few – these inspirational people who taught us how to feel & interpret joint movement and soft tissues to understand these specific details and treat our patients with improved accuracy- what would they say at the denuding  of all these skills ?

The age of the telephone therapist – MY GOD what is going on; “it’s cheaper ,just as effective”  – REALLY!! 

I hear patients all the time saying I had to wait weeks to talk to a physio on the telephone, they sent me exercises ! I eventually saw a physio – who didn’t touch me or do anything and gave me a sheet of exercises, which I haven’t done.

Now, I am not that dumb, YES some people can be listened to and a reasonable impression gained of the problem and yes exercise is a powerful tool. BUT don’t make this PHYSIOTHERAPY.

It is a short step to “crib sheets” then anyone can be the physio !!!

Be very careful people there are other professions out there, very well qualified and eager to get in our shoes. Masseurs, Exercise Physiologists, other manual therapists , Sports Therapists !! I have nothing against any of these I have worked with all of them and like and admire their drive and determination to better their professional status.


As always if you like and agree please click the like button or share; if not free to ignore this particular BLOG. Thankk you for reading   Alan