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).

Pain
“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 !

acutechronic

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….

YOU ARE NOT DAMAGED OR BEING DAMAGED DESPITE WHAT IT FEELS LIKE !!

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:

https://www.youtube.com/watch?t=14&v=KfYC6zfrV80

THE CONCEPTS:

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.

FIND A LEVEL THAT YOU CAN DO REGARDLESS

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.

: IF YOU NEED SUPPORT –  LOTS OF PHYSIO’s WORK IN THIS AREA, THERE ARE CHRONIC PAIN SERVICES – ASK YOUR GP. EVEN IF YOU FEEL YOU HAVE BEEN LET DOWN BY HEATHCARE TO-DATE…… GOOD LUCK, YOU CAN 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.

Alan

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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.

BUT NOT AT MY PROFESSIONS EXPENSE !

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

STAY POSITIVE: Despite the Pain:

STAYING POSITIVE WITH PAIN: irrespective of the cause

Become a COPER

The information below will help you to become a Coper and
prevent unnecessary suffering. Follow these guidelines –

You really can help yourself!

Live life as normally as possible. This is much better than staying in bed.

• Keep up daily activities – they will not cause damage. Just avoid really heavy things.

• Try to stay fit – walking, cycling or swimming will exercise your back and should make you feel better. And continue even after your back
feels better.

• Start gradually and do a little more each day so you can see the progress you are making.

• Either stay at work or go back to work as soon as possible. If necessary, ask if you can get lighter duties for a week or two.

• Be patient. It is normal to get aches or twinges for a time. Don’t just rely on pain killers.

Stay positive and take control of the pain yourself – try not let the pain control you

• Don’t stay at home or give up doing things you enjoy.

• Don’t worry, It does not mean you are going to become an invalid.

All this is very easy to say –  & hard to put into practise – but POSSIBLE. Do not “SWING DOOR” your activity between doing lots on good days and “paying for it” and therefore under-doing it…….

good day bad day swing door

Find a level you can do even on bad days; whether this is home chores, some physical activity such as a walk or being sociable –

“DON’T BUTT OUT of LIFE”.

Find a level to start at – you are on a staircase back to normal, so one step at a time – make them small and doable

Congratulate yourself for every time you do keep going or go up the next step …

BUT DO NOT get down on yourself for any backward steps…… This is just a “snifter” of info there will be much more on this on future BLOGs to come.

Posture: a slightly different twist !

Posture is often viewed as being in the “right position”  – to stand or sit right. The body is built to MOVE and has the ability to do incredible things you just need to marvel at Olympic gymnasts.

In 30 something years I have seen people as close to “ideal” as it seems possible to get and people far from “ideal” & It seems that many of the aches, pains, back problems and strains that afflict anyone affect the ideal and not ideal similarly. Lets be clear IDEAL I don’t mean beautiful/handsome, clever, wealthy but physically aligned, muscle balanced and posturally “spot on”.

If, as it appears to me, that this is the case. then what has been the remedy? Well across the board for everyone the answer will include MOVEMENT with almost anything – just get moving; now there may well be other treatments but without movement the results are worse.

Why would you have joints as complex as they are particularly as those of the spine if movement wasn’t the key. The move to standing office spaces rather than sitting is an improvement as movement is more likely. But sitting is ok and even sitting “badly” is ok. providing it is not all you do. Sustained standing will hurt sooner or later. You can imagine the issues if your work has paid for an expensive chair and new desk etc “you dare not move!!

Similarly SYMMETRY is not normal either. Don’t get me wrong there are times when helping people to stand or sit or move in better posture or with improvements in symmetry is very relevant.

But saying “your posture is the problem” is right up there as a fob off with you’re the wrong weight for your height ……

POSTURE – I think is an ingredient in some peoples problems. Usually a small part and some sometimes irrelevant. MOVEMENT is the key … do you move at all? ….. enough?…..  do you use all ranges and directions enough?

“YOGA” type exercises and programmes are about this – correct classes should be able to deal with all shapes and abilities  – it should not be about tying you in knots, it does not have to be spiritual unless you want that to, it should be about BREATHING.

What do you think ? as always it is just my thoughts I hope you find it interesting! …. Regards Alan

Making sense out of the language of medicine: cutting out the unneeded harm

Words can hurt !!! but words can aid healing.

This is the point of this blog … getting this right can have a very powerful effect on therapy given and in helping our bodies attempts to heal ………….

“You have crumbling bones”!!

” you have a trapped nerve”

“It is just arthritis, live with it”

These some examples of phrases I have heard said and had my patients tell me they have been told. But you know words that are spoken to us have the added benefit or problem in HOW they are delivered. The voice used, the non-verbal body language that infers things like “caring”, honesty, eye contact these sorts of things that suggest we are trying get the right message to you. Do you get listened to in a way that allows me to reply with the right terms and language that you recognise & understand but still get over the diagnosis (what is wrong) and the prognosis (treatment and expected results) correctly.

Many medical terms can be thought of as “umbrella terms”  for instance LOW BACK PAIN; what does that tell you? it tells you what you told me !!! but what is the cause? … is it ligament, muscle, bone, disc, alignment, “out of joint”, muscle imbalance, postural; ’cause you’re over weight!, is it a major problem, genetic, lifestyle based,does it come from somewhere else (referred pain) kidneys for example. What is most likely it is NOT an either or issue. There will be muscle issues, mobility/stiffness issues possibly nerve issues there will be many INGREDIENTS; the Doctors or Physio’s interpretation may vary depending on the questions we ask, the answers you give, on how you are that day. The process I often think is like dealing with a crime-scene; facts gathered and eventually some suspects or PROVISIONAL DIAGNOSIS can be made. Your condition should change (ideally improve) so the suspects or diagnosis may change to … this is how it is.

Other similar umbrella terms are:-

non-specific low back pain – which translates as ” not sure what it is but it’s not serious and should get better”

Mechanical low back pain – it’s the machinery (muscles etc)nothing serious

Tennis elbow – pain on the outer bony area of the elbow with an ache in the forearm: Probably to do with forearm tendons/muscles. But could be referred.

Sciatica –  shouldn’t be used as “umbrella” term but not infrequently is. Pain down back of leg from a “trapped nerve” (there’s another one!!!) Sciatica should only really be used if the nerve fibres that conduct the impulses up and down the nerve to and from the brain are damaged. And NOT if the outer covering or sheath is pressed or inflamed. Think of an electrical cable if the outer white cable is indented or cut this often has no effect on the connection to the electrical system – its is similar with a nerve. Continue reading

My 1st Blog; Why blog at all and a little about me !!

February 17th 2015:

 

CPD: Starting a domain and blog. What is the purpose?

Two main reasons I think? I’ve got knowledge, useful information and things to say (to anyone who will listen) and secondly how get people seek help for healthcare concerns and to then choose physiotherapy and ideally me!!

I have been considering ways of promoting physiotherapy to aid referrals as the ebb and flow of referrals has been ever changing. Reasons??, Well for one RTA insurance claims and those go-between companies who were set up I suppose to aid the injured whiplash suffer hastily through to treatment were for a long time keen to do just that it seemed and still make a buck themselves.

Something changed somewhere in the journey from insurer, solicitor to go-betweeners :I assume the cash was the issue someone was making less, was less interested: I am sure you know how it goes. But the calls started coming through to us “can you see our patients for less!!, can you see them sooner, can you complete the treatment faster”. There will always be some who will do just that- do it for less and jump the hoops.

The issue here is quality costs if I have spent the last 30 years honing my skills, studying & attending courses – it cost this (x) AND it will take what it takes to get the client right both in terms of how many sessions and over the right period of time. People are not widgets – they are complex physical & emotional beings – and each so different. Unfortunately a lot of the “whiplash” type work has gone out into the private sector for so many reasons. Are the insurers, solicitors and go-betweeners all cutting their profit margins? I do not stretch out treatments, give unnecessary treatments or over charge.

Other reasons for drops and rises in referral – certainly people have been watching their cash (except for essentials like nails and hair!!) other health insurers have altered their excesses and accesses and filtered which therapists are on their “lists”.

Anyway, it seems people like the try before you buy idea – the blog and website lets people make a judgement about “YOU” and “the service” you offer. An offering of advice and information can be very powerful. I have been on the buying side for years for holidays and products without realising it isn’t just the price. The aesthetics the “feel” you get from seeing & using the website before even dealing with a real person is something I have not considered or appreciated.

So, how much more so when our health is concerned!

So, I have started the process of learning how to set up a domain and then blog. Why blog (incidentally I dislike the term enormously )well, there is getting less for me to learn that actually make a difference to the day to day work – the techniques anyway, knowledge always changes and is endlessly fascinating and sometimes can be used in my daily work.

The biggy for me is the language of healthcare to aid/promote healing – the belief in healing possibility. We have all heard stories of medical words that do nothing but frighten patients or the disinterested throw away comments as the healthcare giver breezes out of the room/cubicle. I am going to BANG on and on about language in my “info-blogs” when I finally understand how to do blog properly.

Bear with me – please. My intentions are pure and heart felt: my English and language well, I aim to get better. I can see learning how to use the “net” and to “blog” will take some time but I am convinced it will be useful – I hope YOU go to dear reader.

Like the ideas you like, discard the things that make no sense or you don’t like.

I may open up some new thought or make you look further. Whether you seek me out or seek others help is all that is important. There may well be help out there – so don’t give up. It may be the therapist not the therapy.

Also, if it sounds like bunkum or too good – just maybe it is.

 

Alan Leigh MCSP, MSc, HCPC