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Understanding pain part 4: persistent pain

08 Nov 2017

Pirate attack (640x396)

Key message 1: pain is an output of the brain in response to multiple inputs.  Inputs come not just from pain sensors, but also from memories, beliefs and attitudes, fear, stress, fatigue and so on.

Key message 2: sometimes the output of pain exceeds the need for pain.  The danger has passed, but the brain is still receiving information that vigilance is needed and pain persists.

Key message 3: understanding the pain mechanism can help us to “self-audit” i.e., ask ourselves what other inputs may be fueling or sustaining our pain experience?

Key message 4:  we are inherently adaptable and can habituate to pain.  With the right help and a staged return to meaningful activities our response to danger signals from our tissues can diminish.

In part one of this series I used Greg Lehman‘s analogy between the way an alarm sounded by a ship’s lookout gets passed up the chain of command to the Captain and how nociceptors ( the body’s pain sensors) pass information up to the brain.  At various levels in the chain of command a decision is made as to whether the alarm warrants action – and so gets passed further up the chain – or can be ignored.

Sighting a light off on the starboard side would be a normal occurrence on a ship and on hearing the lookout’s alarm the first mate/spinal cord may decide there is no reason to notify the Captain.  If, on the other hand the ship was navigating pirate infested waters then the first mate would be sure to notify the Captain and she may well decide to change course.

Persistent pain/Sensitisation

The ship may have left the pirate infested waters where vigilance was necessary to protect it, but if the fear of pirates remains it can stay on high alert and be over-sensitive to information it receives.  In the same way the body can continue to experience pain long after the potential threat has passed.  We become “sensitised”:  pain becomes a learned response.  Sensitisation, as it is called, has to be considered whenever someone has been experiencing pain for a prolonged period of time.


The opposite of sensitisation is habituation.  Habituation means that for the same input over time the output is smaller.  If you get into a hot bath with cold feet the water can at first seem intolerably hot, but very soon we habituate to the temperature and it feels fine.  It’s the same with pain.  We can start to build our tolerance to performing meaningful activities, which can lead to habituation and less pain.  We know that pain doesn’t always mean damage and that we can gradually “turn down” our response to danger signals from our tissues.

When you have been experiencing pain for a long time it is important to return to physical activity just as it is after a shorter episode of pain.  The progression back to exercise will be slower and there may well be setbacks along the way.  Understanding that this is the case can help to overcome any setbacks.

The Captain (brain) can also send information back down the chain.  She can say it’s okay, we know what those lights are; you don’t need to worry about them anymore – the danger has passed.


Abdominal exercises sitting and using lunge sequences

07 Nov 2017

Abdominal exercises performed upright and in our normal relationship to gravity have better carryover to daily activities like lifting children into car seats (one of my own personal training objectives!).  I show a couple of examples here from which you can extrapolate.  The possibilities are, of course, endless.


Understanding Pain – part 3: why load is good

18 Oct 2017


The majority of patients I see in clinic have non-specific pain, that is, it cannot be attributed to a specific pathology like a fracture, tear, or sprain.  Nevertheless, the pain alarm has been triggered indicating that action needs to be taken.

It can feel like a joint is out of place, but we know that most joints don’t go out of place unless there is significant trauma.  It’s more accurate to think of the body in its current state as being unable to find a solution to performing a particular movement.

The purpose of what I do as an osteopath/movement therapist is to enable the body to find a solution by giving it more movement options; to allow it to take another path; a path that doesn’t keep using the same fatigued, sensitised, and sometimes degenerate tissue.

A way of making that process more effective is to work with the body upright and moving, and, provided the area in question isn’t too painful, to start applying load (resistance) to the painful area at an early stage.

Load could mean use of a weight or resistance band, but could equally be a step, lunge, jump, squat (lower body) or a push-up (upper body), which make use of gravity and ground reaction force acting on the mass of the body.

What does load do?  In a nutshell it accelerates an adaptive process within the body.  What do I mean by adaptive process?

In simple terms, I mean tissues like muscles and tendon become stronger; new healthy tissue gets laid down around the damaged or degenerate tissue.

Our nervous system adapts and learns to coordinate movements differently, and with greater speed and efficiency.

But there is a further benefit.  You are able to lift weight or bend with weights.  You might still experience a little pain, perhaps no pain.  You don’t just feel stronger physically, you feel stronger mentally.  You have less of a sense of vulnerability, less fear, less need for your protective mechanism.

You have less pain!


Understanding Pain – Part 2: Pain doesn’t mean damage

28 Sep 2017


A few facts about damage and pain:

  • 96% of athletes younger than 22 will show changes on an MRI that some people call “abnormal”. But since everyone has them how “abnormal” can they be? (Rajaswaran 2014)
  • 37% of 20 year olds with NO PAIN have disc degeneration in their spine (Brinjikji 2015)
  • 57% of 20-50 year olds with no hip pain will have cartilage and ligament tears (Tresch 2016)

Source: Pain Guidebook – Greg Lehman

Key message 1: pain does not mean damage

Key message 2: damage shown on scan results does not necessarily mean it is the source of your pain.

Key message 3: pain is multidimensional; it is an output of the brain in response to a whole range of inputs not just relating to pain receptors but also to sleep, anxiety, fear, beliefs and so on.

Damage is poorly correlated to pain.  You can have damage – it might show clearly on a scan – and not have pain.  Conversely you can be in pain, without there being any tissue damage.  You can, of course, have damage and have pain  – think fractured bone, sprained ankle –  though not necessarily so.

The concept of pain without damage is perhaps a surprising one.  In  what circumstances might we have pain without damage?  In circumstances in which the brain perceives sufficient threat to the body to trigger the pain alarm.

And for good reason.  There may well be an issue of tissues becoming overloaded: perhaps you have not built up sufficient capacity (flexibility, strength, coordination) to undertake the activity  you are engaging in.

Perhaps you have a limitation elsewhere in the body that is restricting another part’s ability to find movement solutions e.g., make small changes in position during prolonged periods of sitting,  or load the lower extremity efficiently during running/walking.

But remember, the pain response is also multi-dimensional. So it may be an increase in stress, anxiety, or lack of sleep that lowers the threshold at which the brain triggers the pain alarm.

Key message 1: pain does not mean damage

Key message 2: damage shown on scan results does not necessarily mean it is the source of your pain.

Key message 3: pain is multidimensional; it is an output of the brain in response to a whole range of inputs not just relating to pain receptors but also to sleep, anxiety, fear, beliefs and so on.


  • An MRI scan showing a bulging disc, or tendinopathy doesn’t mean you are destined to be in pain or that you will damage yourself further by continuing to move or exercise.
  • Get moving as best you can; you won’t damage yourself and it’s okay to feel some pain, though be careful not to push through pain too much, especially if doing so makes it worse – this can cause you to become more sensitised ( a delicate path to be trodden sometimes).
  • Try to self-audit and deal with those areas that may be contributing to your pain – stress, fear, sleep.
  • You are adaptable and can overcome pain. (More about adaptability in the next newsletter)




Understanding Pain – Part 1: The Process of Pain

19 Sep 2017

If we want to understand how best to treat and rehabilitate ourselves after an episode of pain then it helps to have an understanding of the mechanism of pain, the things that influence it, and the circumstances which might give rise to it.

To understand anything about pain you need first to understand the process of pain. In this short series on the subject of pain I’ve re-worked content from “Pain Guidebook” – a free downloadable resource produced by Canadian physiotherapist, researcher, and educator Greg Lehman ( –   in order to deliver a few bite-size explanations about different aspects of pain science.  The guidebook makes use of analogies that make the mechanism of pain easy to understand.

Key messages 1: Pain is an output of the brain and is multi-factorial; it is affected by more than just body tissues (though they remain important).  Our emotions, beliefs and attitudes, stress levels, sleep, all affect pain.

Key message 2: We can become “sensitised to pain”.  That is, the response to pain sensors being triggered can be “turned-up” or “turned-down” by other factors – expectations, past experiences, beliefs etc. (This can lead to persistent pain)

and perhaps the most significant message:

Key message 3: You can have pain without damage. (subject of next blog entry)

Implication for rehabilitation: We have many ways of coming at pain and need to consider what other factors may be influencing our pain response.  Understanding the mechanism of pain can help us get back to meaningful activity, exercise, and worry less about experiencing pain (pain doesn’t necessarily mean damage).

Pain can be described as: “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”


The process of pain – nociceptors

Sensors called nociceptors get triggered by a noxious (unpleasant) stimuli and send a message to the spinal cord.

Nociceptors are like the look-out on a ship. They report when they see something. They don’t always care if it’s a massive ship or some small dingy. The look-out just says that there is a light off in the distance and sends that information on to someone else – let’s say the first mate (which can be thought of as the spinal cord).

The first mate can has to make a decision whether this information is important enough to send up to the Captain (brain) or whether to just ignore it.

If the light gets reported to the Captain then he decides whether to ignore it or whether to sound an alarm and trigger a change of course.

The Captain’s response (like the brain’s) will be influenced by many factors – where the ship is, what has being happening in the past, and insight from other officers. The brain works the same way. Expectations, past experiences, beliefs, attitude and emotions can all influence how much or whether you have pain. This is why for the same information (e.g. same nociception) you can have vastly different pain responses.

But let’s go back to the first mate (spinal cord level) His decision will depend on a lot of factors. If the Captain previously told the first mate that there might be some issues with Pirates in the area you bet that the first mate will send that information to the Captain and the Situation Room. If the first mate is nervous, ignored something in the past and got in trouble, that first mate will probably be sending on more information.

Nociception works the same way. Based on descending (instructions from the brain) inhibition (turning down) or facilitation (turning up) from the brain the spinal cord can alter its sensitivity and alter how much signal gets sent up to the brain.

The brain doesn’t just produce pain just like the Captain won’t just sound an alarm. The Captain will do other things as well. There are a bunch of decisions to make and all are meant to help protect. Pain can occur but so can muscle tightness, releasing of different chemicals or a stress reaction.

Any information that convinces you and your brain that you might need protection or that increases your danger alarm can contribute to your pain. This is why we say pain is more about sensitivity than damage. Yes, damage can certainly be a factor in pain but it is not the only factor. And you don’t need damage to have ongoing pain. You and your nervous system can become sensitized. And this sensitivity can come from a number of areas in your life. Depression, anxiety, rumination, fear of movement, a low sense of control, the loss of meaningful activites or poor coping strategies are factors that might influence your sensitivity and ongoing pain.

Key messages 1: Pain is an output of the brain and is multi-factorial; it is affected by more than just body tissues (though these are of course factors).  Our emotions, beliefs and attitudes, stress levels, sleep, all affect pain.

Key message 2: We can become “sensitised to pain”.  That is, the response to pain sensors being triggered can be “turned-up” or “turned-down” by other factors – expectations, past experiences, beliefs etc. (This can lead to persistent pain)

And perhaps the most significant message:

Key message 3: You can have pain without damage.

The next blog entry will delve deeper into the poor correlation between pain and damage.


A shoulder problem that started at the foot

22 Feb 2017

My sister asked me to take a look at my 12 year old niece Grace at the weekend, as she was worried about a lump on her shoulder (she also has left knee pain). 

The lump turned out to be her collar bone, which was more pronounced on the left due to compensations occurring through her body because of an unstable left foot. The photo below shows the position of the foot, though it is really how the foot is functioning that is the problem.

The foot has also caused limitation of her left hip as the big muscles of the hip attempt to control it.  Her knee, caught in the middle, is taking the hit.

“She’s all wonky” exclaimed my sister before instructing her daughter to stand up straight and roll her foot out. “I think that’s what Katie has” said my mum “She’s getting insoles”.

I was struck by how little my family know about my professional beliefs and the principles by which I am guided – drawing on success; highlighting the positive; the body’s immense intelligence and ability to adapt and take a different path; the subconscious nature of movement and need to re-pattern movement without too much conscious thought on the part of the patient. 

As soon as Grace takes a step, gravity, ground reaction force, and the mass and momentum of the body will drive the foot and conscious attempts at controlling the motion will at best fail and at worst cause a problem elsewhere.

So we have commenced functional exercises directed at stabilising the foot and reversing the compensations in the hip and trunk. 

No conscious holding of a position, no insoles (unless we find we need them), just the use of the principles of movement to direct the body to take a new path.

Grace's feet and ankles; the left ankle/foot rolls inwards

Grace’s feet and ankles; the left ankle/foot rolls inwards


5 Tips to Counter the Health Risks of Sitting

08 Nov 2016

wedge cushion kidssmall

Most of us are aware that sitting for long periods has serious consequences for our health, leaving us at higher risk of diabetes, heart disease, and, of course, back, neck, and shoulder pain.

Unfortunately many of us have desk-based jobs which require us to sit.  So what can you do to counter the effects of sitting?

  1. Fidget. Shifting around in your chair is beneficial.  Even changing your foot position is advantageous. Try placing one foot under your chair for example; it will have the effect of tilting your pelvis forward, forcing you to sit upright.


  1. Sit on a wobble cushion.  An inexpensive wobble cushion placed on your chair will help you to keep moving while you sit.   Most importantly, it varies the position in which your hips are held.


  1. Stretch.  As a mentor of mine likes to say “motion begets motion”.  It doesn’t matter too much what you do; move and stretch your body, challenge the effects of gravity, and you will do yourself some good.  See the video in my blog about stretches for the trunk (thoracic spine), if you need inspiration.


  1. Take regular breaks from sitting.  1 minute every 10-15 minutes ideally.


  1. Consider a standing desk.  Several studies show that standing desks can dramatically improve low back pain either caused or aggravated by sitting.  Other studies demonstrate benefits in terms of weight loss, decreased blood sugar levels, and decreased risk of heart disease.



Training to Avoid Muscle Strains

27 Sep 2016


I hope you have all had a good summer, and feel fresh and raring to go as we enter the autumn months.

If, like me, you are getting back to your workouts after a break in routine, then you might consider how to prevent a muscle strain occurring. The subject of the following podcast by the Gray Institute relates to hamstring injuries, but the same really goes for all muscles in the body:

The gist is – as with most muscles – that we need to train the hamstrings to do that which we do in function: walk, run, jump, twist etc. Therefore, training hamstrings for flexibility, strength, stability, and endurance, is best done with a variety of functional movements – lunges, squats, jumps, reaches – that occur in three planes of motion (as opposed, for example, to strengthening using a machine performing exercises like hamstring curls, and/or stretching in one plane of motion). If the hamstrings could speak, they might ask why would we choose to train them in a way in which they don’t function in daily life?

Happy training!



Stretches for the hip using a doorway for stability

09 Jun 2016

In this video clip I make use of a chair and doorway to help achieve some really effective stretching. The doorpost affords increased stability and therefore makes stretching in all three planes of motion easier, whilst enabling us to get deep into the stretch. You’ll need to put a non-slip mat under the chair if your floors are slippery like mine!