Southwest Pain Specialists

05/03/2024

What we see (AND FEEL) are not always an accurate reflection of reality.

When we see a visual illusion, we are usually intrigued by it and are happy to see it as our brains playing a cool little sensory trick on us making what we perceive a little bit different to the reality in front of our eyes.

On the classic checker board illusion below, squares A and B clearly look the same to start with. But with context (square B ends up in the shadow of the cylinder) B ends up being perceived as a lighter shade of grey as a result.

Sometimes, when healthcare professionals suggest to patients with persistent pain that perhaps how we perceive bodily sensations is not always an accurate interpretation of what is actually happening in the tissues, the response can be quite defensive as if in some way we do not understand what they are going through. Of course nobody else can really understand another person’s internal feelings, and I often hear from new patients that these ideas have previously been explained with a lack of empathy, humility and can be worded clumsily, but we really do understand the science behind how your sensory perceptions can sometimes be tricked. Pain that persists is very often to do with the perceived causes of the sensory activity in our bodies rather than the sensory activity itself.

Those who are able to grasp this and demonstrate what we call 'cognitive flexibility' are usually the ones who get rid of chronic pain (permanently).

23/01/2024

THE TRUTH ABOUT LOW BACK PAIN
Transform your life with these 20 insights

Do you still have back pain despite medical help and your own best efforts? Perhaps it is time to consider a different approach; one based on modern pain science rather than surgery, medicine and outdated therapies. Challenging your understanding about chronic pain does not make your symptoms any less valid, just different. And perhaps needing a bit of a rethink as to the best ways to treat it successfully.

I see lots of posts discussing 'degenerative disc disease', 'arthritis' and other observations as being the causes of pain, and talk of injections, medicine and surgery as ways to ‘correct’ what appears ‘wrong’ on a scan.

The fact is, neuroscience research clearly shows that this is NOT how pain works. So, I would really like to share some key insights gained from over 2 decades of helping patients with chronic back pain, reading all the relevant scientific research and successfully applying it to empower people to transform their lives.

Doctors and surgeons working with back pain patients know all of this too. But it’s not in their own treatment tool box, so they continue to advise medication, injections and surgery despite their limited efficacy and obvious risks.

1. Acute pain is useful. It is a pretty reliable marker of tissue damage and so essential for our survival prospects. Most chronic pain, on the other hand, has very little to do with tissue quality and serves no useful purpose. This does not mean that tissue quality is unimportant, just that in most persistent pain it only has a minor role to play.

2. Although back pain feels as though it must come directly from the tissues in your back, all pain is ultimately created by your brain. Think about it, this is where all your conscious experiences are generated.

3. IMPORTANTLY, this does not make it any less real or somehow in your head. All pain is EXACTLY WHAT THE PERSON SUFFERING SAYS IT IS.

4. The brain gathers sensory activity from many body systems including, but not limited to, the nervous system.

5. These include the immune system (fighting infection), autonomic nervous system (fight or flight stress response) and the endocrine system (hormones), and so pain often has lots of hidden influences.

6. These systems constantly talk to each other to create sensory activity reflecting your whole body wellness. Your brain uses this sensory ‘noise’ to create a conscious perception of how well your body is doing. Are you feeling hungry, tired, sad or in pain?

7. A heightened response in any one of these systems will create a heightened response in the others, including the pain system.

8. YOU CANNOT SCAN PAIN. You can only make an assumption that, for some reason, a tissue visible on MRI may in some way be directly contributing to your sensory awareness of that body part.

9. But as you age, scans will inevitably show that your skeleton, joints, discs and other tissues look older. So-called ‘degenerative’ changes, ‘disc disease’, small or even moderate ‘disc bulges’, and ‘arthritis’ in spinal joints are all normal signs of ageing, NOT diseases. People with NO back pain have the same signs of ageing on their scans too. These findings are therefore not a barrier to getting better.

10. So, MRI scans are not useful most of the time in assessing persistent pain. In fact they often make people unnecessarily worried when not explained properly, something that itself can heighten pain and reinforce a vicious cycle.

11. Scans ARE useful if there is reason to suspect an injury or serious medical problem such as a fracture, infection or even malignancy. These are very rare (less than 5% of back pain) and usually quite obvious to pain specialists when discussing your medical history.

12. Once medical reasons for ongoing pain are ruled out, 95% of back pain should not be viewed as a medical problem and therefore not treated as such. However, THIS IS WHERE OUR HIGHLY MEDICALISED HEALTHCARE SYSTEMS HAVE GONE WRONG.

13. Sensory nerves connecting your body tissues to your brain do not carry ‘information’.

14. A nerve cell is either ‘ON’ or ‘OFF’. When it is ‘ON’, or ‘firing’, there is no coded message; it is simply an electrical current. There is no such thing as a ‘pain message’ from your lower back. EVER. FACT. Instead, your brain just receives streams of ambiguous sensory ‘noise’. Drawing from your life’s experiences, and context in the moment, you learn to interpret this sensory activity into a reliable perception of how well your body is doing.

15. If the sensory evidence from your tissues matches what your brain has learned to predict as a healthy body condition, nothing needs to happen; you have no need for any conscious awareness of your body at that moment in time and this sensory activity is filtered out before it has the potential to influence a conscious experience. If, for some reason, your brain's prediction of a healthy body state is violated by salient deviations from its ‘normal’ sensory activity, there is an error in your internal model of what a healthy body feels like which then needs updating. In this instance a conscious experience such as pain might well be appropriate as a call to action in order to keep you safe.

16. Visual experiences are the same. Here, your brain learns to interpret electrical signals from the eyes into a visual experience so that you can safely navigate the world around you; but your brain does not have direct access to the world and so what we see is not the world as it actually is.

17. Similarly, what we feel is only an indirect interpretation of our internal physiological states. As such, PAIN IS A PERCEPTUAL BEST GUESS ABOUT YOUR BODILY HEALTH. And so its causes are not always what they appear to be. This is why people with a more flexible mindset generally do well in treatment because they are able to change potential misconceptions about the causes of sensory activity in the body. How we think really does strongly influence what we end up feeling.

18. Research strongly points to the DEVELOPMENT OF STRONG, BUT INACCURATE, NEGATIVE BELIEFS ABOUT PHYSICAL HEALTH AND ILLNESS, rather than poor tissue quality, as the main reason for chronic pain states.

19. It therefore follows that the most powerful way to change chronic pain is to change sensory perception by retraining the nervous system and NOT just treating the body part that we sense hurting e.g. with manipulation, medicine, injections and surgery.

20. This allows you to move again without fear of ‘doing the wrong thing’ and in a relaxed and confident way rather than by protecting yourself with stiff guarded muscle contraction, something that usually makes pain worse. And, as this is a cognitive, behavioural approach to retraining pain, unlike medicine or injections, it has PROVEN LASTING RESULTS.

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13/12/2023

Nice testimonial from a recent client.

“I have been seeing Nick for a few weeks at his clinic in Exeter and he has helped tremendously with my chronic pain. I now feel I can get on with my life not fearing the pain and worrying about what was causing it. I now understand the mechanism by which my brain was misinterpreting signals and that the pain was not indicating that I had a serious anatomical problem. He is the only person who has truly listened to me and understood how I was feeling. Hope is a wonderful thing and that is what he gave me. He took the time to examine me and reassure me while never doubting that what I was experiencing was real and significant. I have got back my quality of life.”

Jackie, Exeter

18/07/2022

ACUTE PAIN is useful; it prompts us to be careful if we’re injured.
CHRONIC PAIN is definitely NOT; it tricks us into being overly protective, fearful of movement or avoid activity altogether when our body tissues are actually not under threat

09/06/2022

Pain is NOT simply a direct consequence of electrical signals from inflamed or damaged body tissues…

Pain is a conscious state of awareness we feel in a body part when our brain perceives threat and so it is a perception and not a direct sensation from that part of the body. It can certainly be influenced by tissue quality but is largely a prediction of the potential for harm in a given situation based on prior knowledge, beliefs and expectations, something we all learn in unique ways as we journey through life. Our feelings of pain are therefore like our fingerprints; nobody feels pain in the exact same way as you do because nobody has had exactly the same experiences and influences as you. Pain can be strongly related to past emotional experiences that, on the face of it, may appear to have little or nothing to do with the current problem. But we know that traumatic events from the past teach our ‘fight or flight’ system to stay on high alert priming it to activate our pain systems more easily so that relatively minor changes in body physiology, something that in people without chronic symptoms would go unnoticed, ensures that the brain infers harm as the cause and increases pain as a result.

Persistent pain is very complex. However, we all tend to grow up with the simple belief that when something hurts it must be a sign that something is structurally wrong or damaged. This default belief system is appealing because it is simple and as humans we like to try and understand things as best we can.

The old world view of pain, where it always represents harm, fails to explain pain that affects a great many people in the UK as well as the following commonly observed clinical situations:

1. Phantom pain, i.e. pain in a body part that no longer exists, cannot be due to a structural problem. These phantom feelings are often non-painful ones. For example, an itch that is still felt in a hand that has been removed can often be relieved by scratching the position in space where the itch is being felt! More remarkable still are the experiences of phantom sensations in people who were born with congenital limb loss. In one case report a young girl recalls how she first learned to count just like everyone else in her class did, on her fingers - only she was born without hands!! In her mind her hands were very real. The image below helps us to understand this; it shows the somatosensory cortex in our brain, where the location of pain is perceived. You can remove an actual body part but you cannot remove the part of the brain that represents that body part. Note that areas of the body that are especially adapted to touch, like the hands, feet and face are disproportionately large in our brains.

2. Research consistently shows that the same disc degeneration, disc bulges and arthritis seen in the lumbar vertebrae of patients with low back pain are also seen in people of the same age without any back pain at all. We also know that having an MRI scan, for many people with back pain, may even worsen their recovery. Perhaps it makes some people worry more if those scan findings are not put into context properly - our patients often tell us that this is the case. Unless your clinician suspects a potentially serious medical cause for your back pain, MRI scans are not routinely recommended.

3. Patients with widespread pain disorders such as fibromyalgia do not have anything unusual on their MRI scans and blood tests. These are people with considerable pain and suffering who have no evidence of damaged or inflamed tissues at all and so their pain is not directly related to tissue damage or structural changes.

4. Placebo analgesia is a very powerful and reliable phenomenon. Strong beliefs about the likely effects of a treatment can have a significant impact on a patient’s symptoms. This includes simple experiments where patients receiving a sugar pill, rather than strong pain-relieving medicine, still experience significant pain relief. Placebo has even been observed with 'sham' knee arthroscopy where a surgeon simply made small superficial incisions which were then immediately stitched up again. When the patients came round from their anaesthetic they were told that everything went really well and that their knee was thoroughly examined and looked healthy. These patients had been living with years of knee pain but reported significant improvement in both pain and function after their 'treatment'.

5. Nocebo is the opposite of placebo. Prior knowledge that is introduced about the possible side effects of certain drugs results in greater reporting of those side effects compared with subjects taking the same medicine but no awareness of these potential ill effects.

PAIN IS A PERCEPTION AND NOT AN INEVITABLE, DIRECT SENSATION RESULTING FROM CHANGES TO OUR BODY TISSUES

22/05/2022

We are currently seeing an increase in the number of people, mostly women, asking about fibromyalgia (FM). The link below covers many of the problems that they encounter. Typically they are not well understood and it can take quite some time to get a diagnosis. But whilst many of our patients initially feel relieved that a diagnosis means they are finally believed, they often say it leaves them frustrated again due to a lack of effective care. Ironically FM is a medical diagnosis for a ‘medically unexplained condition’ in that there are no scans or blood tests that reliably show what triggers it. It is far better to look at it as a generalised pain hypersensitivity disorder and viewed from a biopsychosocial perspective. Pain takes over peoples lives and decreases the sufferers ability to engage in the world. Patients report a loss of control or agency and feel that something is taking over their body leaving them feeling helpless. Chronic pain affects our very sense of self. It affects our relationships, personal lives and ability to function at school or in work.

What it's like to live with fibromyalgia.

13/05/2022

These are the kinds of patients we see on a regular basis and they also have great results using this and other similar treatment strategies

11/05/2022

https://www.washingtonpost.com/outlook/2021/10/15/chronic-pain-brain-plasticity/

An unexpected therapy shows results.

11/05/2022

https://www.bbc.co.uk/news/health-61309962

Specialists warn the NHS is not set up to deal with such complex conditions.

11/05/2022

Southwest Pain Specialists launches next week, Monday 16 May.

In person in Exeter | Online from anywhere

Specialists in pain physiotherapy, pain coaching, CBT and cognitive reappraisal for pain, clinical psychology and medical management.

This is a private Pain Management Group using latest research in neuroscience and techniques in the treatment of chronic pain. We are based in Exeter currently and are available for online sessions as well as in person treatment.

Sadly, it is becoming very difficult to access to NHS chronic pain services now and our patients tell us that after waiting a long time to access care the clinical approach is often brief and out-dated.