Why I Love Treating Long Term Pain and How to Solve It

So you’ve probably experienced this before.

When you’re working with someone and you just can’t clear that long standing hip pain, back pain headaches and jaw pain.

When you have done the testing and assessing, and you still can’t find just what is causing the problem.

When the pain is moving around the body.

When the patient in front of you has tried physio, acupuncture, multi-body work techniques and they have heard you’re good so they’re giving you a try.

We want to help – and then question – can we? Should we choose as therapist’s to take these people on?

Here’s my confession. I love treating these patients. I love thinking how can I help, what did all these other practitioners miss. Did you ever watch the medical programme House? Think of yourself like Dr Gregory House, M.D., an elite diagnostician with a puzzle to unravel – without the drug habit, terrible bed side manner and limp, preferably.

Let’s start with my checklist – often people have missed asking these questions (some of which are clearly gender dependent).

  • Do you have children? How was childbirth?
  • What sport did you play as a child?
  • Were you ever involved in a road traffic accident?
  • Have you ever been physically assaulted as a child/adult?
  • Have you ever been bullied? As a child or adult?
  • Have you ever fallen out of tree, off a rock climbing or at pony club?
  • Have you ever felt so stressed you have needed time off work, or an extended holiday?
  • Have you ever been so frightened or fearful that you might not survive the moment you’re in?
  • Do you have any scars? From childhood or surgeries?

These questions in my experience have not always been asked. And that’s because they’re quite intense. They take a lot to ask, for the practitioner and the patient. But often they’re the only way get to the root cause of someone’s pain.

It’s all down to whether you are willing as a therapist to hear the whole story, and be open to hearing the whole story of their body. Be open with no judgment, offering curious compassion.

All these incidents I’ve listed can cause, if unaddressed, tension and compression throughout the body, often accumulating in the mid body/abdominals.

People find ways to unconsciously compensate. It usually involves at lot of holding themselves with tension, at an unconscious level. Here’s how things develop over time.

  • Foot pain > altered gait
  • Altered gait > lumber pain
  • Unexplained knee pain > disruption in the pelvis
  • Kyphotic posture with a forward head > digestive issues, tight breathing, holding breath.
  • Tightness or holding in the TMJ (jaw) > headaches and shoulder pain.

When patients have suffered trauma in the past, it creates a false baseline for the nervous system. Whilst the patient might have developed a mental resilience which can make them forget the extent of their trauma, this isn’t reflected in the body. The body instead is more sensitive to future pain and future trauma, as it’s on a constant high alert – the signals being received by this new trauma are interpreted at a more extreme level.

This is something I have seen time and time again in my practice, and has been explained further by research completed by the Noigroup. If you’re interested more in this, I recommend the book Explain Pain.

This is why it’s so important to understand the patient’s history and know where their baseline is at.

Here’s a good place to start.

  • Ask them what would be a good outcome for them?
  • Ask them what be a great outcome for them?

This means you can work toward a small improvement on their way to their idea of wellness. Sometimes in the beginning small changes, indicate that greater changes can come.

I explain to the patient what will happen once the whole story is told. Here’s what I think should be said next, based on my experience.

  • We’re going to work through small steps so we don’t set up a fear response in the nervous system
  • Would reducing the pain be a good outcome? Even though I may not be able to change the soft tissue injury
  • I’m going to make the treatment as pain free as possible so it doesn’t pose a threat to your nervous system
  • You’ll be in charge of overseeing your recovery
  • Are you ready to take on small movements at home to support your recovery?

I always start with holding the feet, and slowly moving on from there I create a protocol that is just for them which could contain any or all of the below.

All from a supine position:

  • Holding the feet first allows the nervous system to feel input that isn’t a threat
  • Use HM soft tissue mobilisations for calfs, hamstring, and quads
  • Abdominal massage, NIM style
  • HM soft tissue for neck and jaw

I find this begins to calm the nervous system. Remember that them being open to the plan changing as change begins to take place is key. Work with the confidence that your knowledge and learning will back up what you intuitively find and help the patient feel safe in your hands.

 

 

 

 

Assessment: My Experience and Beliefs

I started my career by training at the Northern Institute of Massage way back in 1991. This was a career change, and I I fell in love with treating people, helping them, which quickly developed into exploring how you enable people to wellness.

I believe assessment is so key to finding how we are going to treat and enable people to move out of their injury, from chronic pain to sports injury dysfunction.

In the beginning, I was trained by Ken Woodward, the principal Northern Institute of Massage. I was taught to see the whole body, how we treat not just one problem but something which is a part of a larger network.

Ken would say the whole body is connected, some student would enquire “how do you know?” “Where did you read this?” He would give a withering look, and reply “I don’t have to read about it! I know because I can feel it, my hands tell me the truth”.  The term ‘biotensegral body’ wasn’t really in the therapist vocabulary at this moment in time, but I would now say that this is exactly what Ken was talking about.

We then went on to explore issues and dysfunction in separate areas i.e. shoulder pain, hip dysfunction, lower back pain and neck pain. The trick was not becoming so focused on the pain site, and instead to enquire how and why there is pain here. Ken would challenge us by saying “can you treat the lower back pain and still see the whole body?”

My view is that as developing therapists we almost get fixed on needing to ‘sort’ the injury, ease the pain, and most of the time the person we are treating just wants us to remove the pain, get them back running, get them back to work. We can then be influenced by their desperation to be well.

Understanding assessment became a super goal of mine. I started out aiming to completely understand ROM and angles of degrees on ROM; I wanted to be able to land mark with confidence and speed. I read Hoppenfield’s Physical Examination of the Spine and Extremities, Kendell’s Muscles, Testing & Function with Posture and Pain and Neuromusculoskeletal Examination and Assessment by Nicola J Petty & Ann P Moore.

Through all this reading I began to see that many of these assessment protocols would only test one point of the body and tell me if that was painful, without referencing that this was only a small piece of the bigger story.

We can measure a levels and ranges of movement; however, these are just little pieces of the puzzle. Can we work out compensations? Can we workout if there is a scar, adhesions or postural fatigue brought about by occupational behavior? Can we see the whole picture of what we treat first to allow the body to, for want of a better word, unravel, reverting back to be balanced so the treatment plan we create for them gives a long-lasting effect. The secret is being able to explain their treatment plan, our thoughts and knowledge in a way that makes perfect sense for them. Once on board I find they really commit to their return to well-being, and pain-free lives.

Training with Tom Hendrickson confirmed my belief we have to understand how dysfunction comes about, that the pain is only just the end of a bigger picture. Training with Tom and learning the Hendrickson Method embedded knowledge I had gained at the start of my career. His wave and soft tissue mobilisation technique gave me precise movements to make my treatment able to reach the whole body with each visit.

I became aware that my assessment began as soon as I opened the door to greet my patients. Typically, within the first 40 seconds you begin the assessment process. With students, I ask them to recreate that moment in class to trigger what the therapist is thinking back in their clinic space. The feedback is very positive and enables the therapist to have a greater understanding of how soon the assessment process begins.

For me it’s always

  • Eyes
  • Jaw
  • How are and where are they breathing from?

Over the years it informed me of how their nervous system is resting. This is important as it can influence treatment outcome, it can be so easy to over treat a patient that has a raised sympathetic nervous system.

Over time, I gained confidence in being able to say to patients that the first treatment consultation is all about the history of the injury, and the journey your body has had over the years. The more extensive the history gives us a clearer picture on which to base a treatment plan. I explain how the body is so connected; how different parts of the body can influence injury. I go on to explain about the fascia and how it gives our body its shape, how it interweaves with the fibres, it holds us.

When I am taking a client’s history, I always go in curious, wondering, asking open questions, leaving them with the feeling that their story is super interesting, which of course, it is. Through this I discover falls in childhood that could have created compression and compensations or stickiness in the tissues and fascia, which could be impacting on the new restriction or injury.

I believe we have to listen well. I was listening to Tarana Bruke creator of the #MeToo foundation, her statement was “If you don’t hear me, you can’t see me”. It was a real moment of clarity, I thought this so well describes that moment we hear a patient’s history of their injury.

When we are chatting about their story, I ask if there are any scars no matter how old. Often patients dismiss childhood falls, bumps and scraps. I am considering where they may be in their body adding to any tethering or pulling that may have been around a long time. Here’s a list of questions I will ask, using a compassionate kind manner.

  • When and how?
  • How do they feel about the scar?
  • Is there any sensation?
  • Are they aware of it in their day-to-day life, does it pull or have tension?
  • Have they ever had treatment on or around the scar?
  • Is there pain or tenderness?

When it comes to the standing assessment, I like them to keep their clothes on, they stand in their comfy selves, and I believe I get a truer picture of what patterns are occurring in the body. Now more than ever I have a feeling people feel vulnerable standing in their underwear, and they hold a position that can be tight, then we get a strange untrue picture of what’s going off with in their tissues.

I like to start with the feet, if they have comfy clothes on, (I prep patients not to arrive wearing jeans). Remember soft touch, gentle hands gather more information.

  • You can check for pronation or supination, and also gentle palpate the gastrocnemius – are they the same feel and density?
  • Examine gently knees, hamstring, quadriceps, with an open mind, looking again at density and also size. We can pick this up all through clothing.
  • Look at the pelvis and ribs; is there rotation, are there any pos/ant tilts, is there a height difference on the ilium?
  • Can you see any internal or external femur rotation?
  • Are there any scoliosis, kyphosis, or lordosis?
  • Check their head tilt, tension within anterior neck; scalene, SCM, TMJ, how does the humerus sit in the GH joint, is there an anterior rotation?

I find gentle, positive, tactile cuing, puts the patients at ease. Once you have enabled a client to feel at ease with you, it is at this point when I feel more able to ask if I can see any scarring. I find at this stage rapport has begun and they are happy to share more openly even those who have a deeper emotional attachment to old injuries.

We begin to build a picture of the journey that the patient’s body has been on. We create a treatment plan that the patient fully understands what we are thinking. I believe if the patients truly understand our thoughts and insights their become deeper invested in the process back to wellness, owning they part they play, rehabilitation movements, dietary changes, or even committing to coming to a series of regular treatments.

When I am teaching the Hendrickson Method, or other bodywork technique workshops. I always create space to check in with our own selves. Where is our awareness of our own-selves? What drives our desire to help people?

I often share a little something that came up for me when I was in social work, especially when I have that initial consolation. It is a question that I will often ask of therapists when they attend my workshops. When we assess do we have the intent of:

  • Power with
  • Power to
  • Power within
  • Power over

I find it’s always useful to check where our ego is at when beginning to embark on assessment processes and going on to build a treatment plan.

Covid Times

I found closing the practice at the beginning of lock down, a little sad, and a little strange as  mentioned in a previous Blog.

I thought I would catch up on books, pertaining to work, the surprise was I enjoyed the quiet space to be still, and to reflect on my practice as a therapist.

I did enjoy the space more than I thought I would. For the first time in years a started to read a story book, more often known as novels . However the word novel doesn’t work for me really, books are stories, a view into someone else’s imagination. Their story can captivate us, and we are in for the ride the book will take us on.

I have been reading Robin Hobbs, ‘The Farseer Trilogy’, the hero of our story isn’t really a hero, he’s a change maker, a catalyst. So he makes mistakes, intends to be successful, and best of all wakes up dragons!. However he has had his pain, sorrow, and disappointments. At one point he sinks all of his awful memoirs into the dragon leaving him free not to feel the pain!, However this leads to him not living his life fully. Fast forward to 3 books later, ( yes I know your thinking how many has she read ) There’s a point when he gets the chance to take back all his sorrow and painful memories . Only when he feels his life in the the fullness of all emotions, sorrow, pain and joy can he move forward and claim soul filling happiness.

We often talk of feeling and owning the whole of our lives when treating those folks who have long term pain states, or helping a sports person investigate what’s stopping them from regaining fitness or solving an injury that just won’t clear up.

The books also lead me to reflect on now, this moment in time. There is no doubt these are truly challenging times, challenging our spirit, soul, practice and asking what is truly important to us. I make sure I own how I feel each day, riding the emotions either good, happy , sad or frustrating. I ask myself what can I do to lift a sad moment without impacting others.

I remember how truly grateful I am for the life I live, the people that are there with me, my family and friends, and the fact that I am able to facilitate and support the people who want to make change for themselves.

We were so pleased when we could once more open the practice. However I won’t lie, Ros and I have found it physically challenging on our body’s working/treating in full ppe. However,  we wouldn’t change a thing, and have been genuinely thrilled to be back treating once more.

The ‘Masks’ are keeping us all very safe and sound. I do find myself ‘mouth breathing’, finding it a struggle breathing ‘in through the nose out through the mouth’, so my poor diaphragms end up feeling left out and tight, leading to headaches, a little jaw pain , and a rather achy thoracic spine ( the bit between your shoulder blades )

I now do have a little routine at the end of each day, so I feel a little restored. So  I thought I would share a little something that I have found really helpful.

A breathing routine.

  • Side lying on cushion and pillows with the arm reaching over head, allow the ribs to open, deep breath, both sides
  • Then moving prone ( tummy down) over the cushions, breathing in the back ribs, opening muscles that feel tight at the end of my day
  • Then supine, ( over the cushions, chest and tummy to the ceiling ) with head supported on a cushion if needed, breathing into lower ribs, and imaging my organs saying thank you and relaxing.

This leaves me feeling open and relaxed, ready for my next day!!

Give it a try, let me know how you get on.

P.S thought I would share a wild garlic picture because it just makes me smile

 

 

 

 

 

 

 

 

 

 

 

Covid – 19 Protocol

Flexible Healing has established a new protocol to treat patients safely amongst the pandemic. As a HCPC registered physiotherapy clinic, we are committed to continue to treat patients in need of care and will be acting in accordance with guidelines from our governing body the LCSP Register. These are the procedures we would like our patients to follow.

Continue reading “Covid – 19 Protocol”

What makes us resilient

I don’t you about you but in these strange times my mood dips and rises, going from feelings of inconsolable sadness to sunny moments when I feel full of gratitude, lucky and brave.

These strange times are asking us to dig deep into our souls and to find our bravery. They’re testing our resilience to keep going with our beliefs and values in place, our ability to find the inner strength and resources to be positive, upbeat and think ‘we can do this’.

Continue reading “What makes us resilient”