1
Recovery from chronic pain
Georgie Oldfield MCSP
www.sirpauk.com
Georgie Oldfield MCSP
Physiotherapist & Founder of SIRPA Ltd
‘Stress Illness Recovery Practitioners Association’
2
Learning Objectives
To understand:
•The concept of stress-induced chronic pain
•How SIRPA’s approach can help patients suf...
Hippocrates
“It is more important
to know what sort
of person has
the disease than
the disease the
person has”
460 BC – c....
New interventions for LBP needed
European Spine Journal : Review article
Volume 16, Number 11 / November, 2007 Pages 1776-...
Current confusion
Anomalies
7
• Symptoms often don’t match the diagnosis
• The onset of pain is often after doing
something completely innoc...
79 year old lady with 4 week h/o severe back
pain and bilateral leg pain with numbness,
resulting in her inability to walk...
79 year old lady with 4 week h/o severe back
pain and bilateral leg pain with numbness,
resulting in her inability to walk...
Signs versus symptoms
10
Pain can be present whether or not a physical
abnormality/problem is present.
Common Anomalies
No Pain? Pain?
Research into MRI scans of
people without back pain
1) The Journal of Bone and Joint Surgery, Vol 72, Issue 3
403-408, 199...
Research into MRI
scans of the spine (2)
3) Ann Rheum Dis. Vol. 62: 371-372 (2003 ) Centeno and
Fleishman ‘Degenerative di...
Pain versus
Posture/Structure/Biomechanics
The fall of the postural–structural–biomechanical
model in manual and physical ...
UK National Regulation
Display Screen Equipment EEC Manual Handling
15
Back pain and RSI
The number of people developing Back pain
and RSI continues to rise, despite the
introduction of these n...
Work environment
and back pain
Work and back pain: a prospective study of
psychological, social and mechanical predictors ...
The role of physical and
psychological factors in
occupational low back pain
Occup Environ Med 2000; 57: 116 – 120 (Februa...
• ‘No stress, No whiplash’ (Castro et al., 2001) and demolition
derby drivers have less chronic neck pain (Simotas & Shen,...
Emotional & physical pain
• Physical and emotional pain have been shown to
trigger the same areas of the brain
Kross et al...
The concept underlying
the SIRPA approach
• Physical and/or psychological symptoms
become the escape mechanism for
unresol...
• Current Life stresses/responsibilities
• Childhood, or past, ‘traumas’ or pressures
• Self-induced pressures due to; per...
Are you saying the pain
is all in the head?
Symptoms are a result of unconscious and automatic
responses in the brain and ...
Emotion
Neuropeptides (molecules of emotion) flood the body and brain
Stimulate the emotional brain e.g. the Amygdala
The ...
The ‘fight and flight’
response is a
survival/protective
response to a
perceived ‘threat’.
Physiological changes
occur via...
Modern stress/threats
Are mainly psychological
However………….
Our perceived stress is only 10% due to what happens to us
(ph...
79 year old lady with 4 week
h/o severe back pain & bilateral
leg pain with numbness
27
If you remember this lady, her pai...
Symptoms protect
A GP had been unable to write for
months. During an in-depth
assessment it turned out he had not been
abl...
Case study: 6 month
exacerbation of chronic LBP
MRI results: ‘massive disc protrusion at L5/S1, compressing both
S1 nerve ...
A&E with
intravenous opioids
This lady’s nerve pain
pathways had become learned
and during the previous 6
months she had b...
31
3 years later
Still fit and healthy 3
years later and
bouncing on a
trampoline.
32
No exercise, drugs, hands on therapy or surgery
The symptoms are a result of physiological changes in
the body and as the ...
Cautions
• Any more serious cause of the symptoms need to be
ruled out, such as; cancer, infection, fracture or an
auto-im...
• Accepting that the symptoms are stress-induced and not due to
a physical cause is important for a full recovery. N.B.
So...
Treatment progression
Educational, self-empowering
and very often can be self-directed
In-depth SIRPA™ Assessment
(a Stres...
• Therapeutic journaling – to identify, acknowledge and
gain perspective in order to let go and move on
• Mindfulness and ...
Some evidence for a few of the
treatment strategies used
• Mindfulness meditation reduces
stress and amygdala activation
(...
www.sirpauk.com
enquiries@sirpauk.com
www.twitter.com/SIRPAUK
www.facebook.com/SIRPAUK
www.linkedin.com/in/GeorgieOldfield...
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Recovery from chronic pain is possible

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Chronic pain is debilitating to individuals and to our economy, yet most treatments are based on the assumption that it is due to a physical cause. Once it is recognised that chronic pain is caused by our brain and central nervous system as part of a protective stress-processing response, then as this process is reversible, full recovery is possible.

SIRPA Ltd was set up to train health professionals to integrate into their own work the pioneering SIRPA approach, where the emphasis is on recovering from chronic pain, rather than management.

www.sirpauk.com

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  • Not here to convince, can’t convince how long standing or severe is not usually an issue
  • To demonstrate how even very real physical ‘abnormalities’ are usually not the cause of pain
  • To demonstrate how even very real physical ‘abnormalities’ are usually not the cause of pain
  • We all expect someone with a knee like this on the left to have pain, yet some don’t – why? Yet often people present with no abnormality, nor any injury and yet have pain. Studies now show that the brain can create pain, without there having been any physical trauma.
  • Yet often people present with no abnormality, nor any injury and yet have pain. Studies now show that the brain can create pain, without there having been any physical trauma. Normal activities resulting in pain, waking up, no cause etc
  • More recent
  • Physiotherapist - transition was gradual Slipped discs –anomalies between nerve ‘compressed’ and symptoms, stenosis – cancelled surgery Minor incident causing back pain e.g. picking up a pen, waking up with pain, chronic pain no diagnosis. RSI – same work for years, yet suddenly begin with pain. display screen equipment regs and often no signs apart from pain
  • Norway Occy Health study Taking responsibility, feeling self-empowered.
  • - Castro et al tested 51 people in a low velocity rear end collision. They asked subjects to fill out a questionairre prioir to the collision, immediately after, 3 days after and 4 weeks post collision. They used the Freiburger Personality Inventory, as psycho-analysis. They found that subjects who score high on pain immediately after and three days after scored higher on the psychosomatic disorder and emotional instability. - Simotas & Shen questioned 40 demolition derby drivers, who were involved in 30 career events, with a total of 52 rear end collisions during each event. Only two of the drivers reported their post participation neck pain lasted more than 3 months. In a population it has been reported to be as 14-40% who report chronic whiplash. They suggest it may be motivational differences between demolition drivers and normals that cause this. Hauser et al performed a meta analysis of 18 studies and found that there was a significant association between physical and sexual abuse in childhood and adulthood and developing fibromyalgia later in life. - Kivimaki et al conducted a prospective study of 4791 individuals, 90% female, who had no diagnosis of fibromyalgia at the outset. They were asked to fill out a survey at the outset and 2 years later. 81% of the people responded, workplace bullying had the strongest association with fibromyalgia, followed by high workload. - Rees et al also conducted a prospective study of 1580 individuals, who provided information on spinal pain and child behaviour checklists. They found a significant association between mental health problems and spinal pain. The strongest link was found in those that internalise and externalise through unsociable behaviours.
  • Symptom less important than the underlying cause.
  • 10%/90% Could be minor trigger – e.g. angry boss, anniversary, causing emotional trigger
  • Primal response. These days more psychological threats. Protect us – explain. Waking the Tiger example – gazelle/lion
  • What health professionals say and google plays a big part in whether someone gets worse or better afterwards
  • Holzel et al examined 26 individuals who were stressed on a perceived stress rating scale but otherwise healthy, before and after an 8 week mindfullness meditation programme. There was a decrease in perceived stress and a reduction in amygdala activity compared to pre programme MRIs. Brown & Jones found that people with experience in meditation reported less unpleasantness to laser heat stimulus compared to controls. They were asked to report this during the laser stimulus. People did various different types of meditation. Gillis et al found that private emotional disclosure lead to a decrease in pain after 3 months compared to writing about time management.
  • Recovery from chronic pain is possible

    1. 1. 1 Recovery from chronic pain Georgie Oldfield MCSP www.sirpauk.com
    2. 2. Georgie Oldfield MCSP Physiotherapist & Founder of SIRPA Ltd ‘Stress Illness Recovery Practitioners Association’ 2
    3. 3. Learning Objectives To understand: •The concept of stress-induced chronic pain •How SIRPA’s approach can help patients suffering from chronic pain recover based on this understanding 3
    4. 4. Hippocrates “It is more important to know what sort of person has the disease than the disease the person has” 460 BC – c. 370 BC 4
    5. 5. New interventions for LBP needed European Spine Journal : Review article Volume 16, Number 11 / November, 2007 Pages 1776-1788 ‘Effect sizes of non-surgical treatments on non-specific low-back pain’ Conclusions: ‘The effect of treatments for LBP is only small to moderate. Therefore, there is a dire need for developing more effective interventions.’
    6. 6. Current confusion
    7. 7. Anomalies 7 • Symptoms often don’t match the diagnosis • The onset of pain is often after doing something completely innocuous or something the patient normally does with no problem • The onset of pain can often not be linked to any physical incident e.g. they wake up with it. • People with postural, structural or biomechanical ‘abnormalities’ often recover, despite these remaining unaltered • Chronic pain is often non-specific and medically unexplained.
    8. 8. 79 year old lady with 4 week h/o severe back pain and bilateral leg pain with numbness, resulting in her inability to walk unaided “Widespread degeneration throughout the lumbar spine with almost total effacement of the epidural and CSF signals at the L4/5 level, confirming subtotal spinal block” 8
    9. 9. 79 year old lady with 4 week h/o severe back pain and bilateral leg pain with numbness, resulting in her inability to walk unaided Questions to consider: •Why had she only had pain for 4 weeks, yet this sort of spinal degeneration takes decades to develop? •How was she able to recover fully within 6 weeks with very gentle treatment, despite her spinal degeneration remaining unaltered, such as the stenosis? •Why was she able to remain pain free if the spinal degeneration was the cause of her symptoms? - see later
    10. 10. Signs versus symptoms 10 Pain can be present whether or not a physical abnormality/problem is present.
    11. 11. Common Anomalies No Pain? Pain?
    12. 12. Research into MRI scans of people without back pain 1) The Journal of Bone and Joint Surgery, Vol 72, Issue 3 403-408, 1990 SD Boden et al Conclusions: About one-third of the subjects were found to have a substantialabnormality (57% in the over 60s) 2)New England Journal of Medicine: Vol 331; 69 – 73, July 14th 1994, No. 2 Maureen C Jensen et al Conclusions: The discovery by MRI of bulges or protrusions in people withlow back pain may frequently be coincidental 12
    13. 13. Research into MRI scans of the spine (2) 3) Ann Rheum Dis. Vol. 62: 371-372 (2003 ) Centeno and Fleishman ‘Degenerative disc disease and pre-existing spinal pain’ Conclusion: “Degenerative disc disease, as seen on imaging, is not a painfulcondition.” 4) The Journal of Bone and Joint Surgery (American) 83:1306-1311 (2001) David G. Borenstein et al The Value of MRI of the Lumbar Spine to Predict Low-Back Pain in Asymptomatic Subjects’ A Seven-Year Follow-up Study Conclusions: The findings on magnetic resonance scans were not predictive of the development or duration of low-back pain.
    14. 14. Pain versus Posture/Structure/Biomechanics The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain Findings – There is no correlation between pain and posture, structure or biomechanics of the spine. by Eyal Lederman CPDO Online Journal (2010), March, p1-14. www.cpdo.net 14
    15. 15. UK National Regulation Display Screen Equipment EEC Manual Handling 15
    16. 16. Back pain and RSI The number of people developing Back pain and RSI continues to rise, despite the introduction of these national regulations in the early 1990’s. These regulations are addressing the widespread current belief that there is a physical cause for these conditions. But what if they aren’t physically induced? 16
    17. 17. Work environment and back pain Work and back pain: a prospective study of psychological, social and mechanical predictors of back pain severity. Christensen J O et al. Eur J Pain. 2012 Jul;16(6):921-33 Conclusions: The most consistent predictors of back pain prevention were found to be decision control, empowering leadership and fair leadership
    18. 18. The role of physical and psychological factors in occupational low back pain Occup Environ Med 2000; 57: 116 – 120 (February) Anne- Marie Feyeret al New Zealand 1999 Conclusions: Other than a history of LBP, pre-existing psychological distress was the only factor found to have a pre- existing influenceon new episodes of LBP N.B. This could have included stressors such as; exam worries, relationship issues etc
    19. 19. • ‘No stress, No whiplash’ (Castro et al., 2001) and demolition derby drivers have less chronic neck pain (Simotas & Shen, 2005) • Hauser et al. (2011) report there is a significant association between sexual and physical abuse in childhood and fibromyalgia. Work place bullying was also found to increase the incidence of newly diagnosed fibromyalgia (Kivimaki et al., 2004) • Higher percentage of back pain in adolescents with mental health problems (Rees et al., 2011) Evidence linking stress to pain 19
    20. 20. Emotional & physical pain • Physical and emotional pain have been shown to trigger the same areas of the brain Kross et al. ‘Social rejection shares somatosensory representations with physical pain’. Proceedings of the National Academy of Sciences in the USA. 2003, 23: 15280 – 15283 • The emotional brain is activated by fear and worry, which cause pain pathways to become more pronounced Bailey et al. ‘Treatments addressing pain-related fear and anxiety in patients with chronic musculoskeletal pain: A preliminary review’. Cognitive Behaviour Therapy. 2009, epub. August 20, 2009 Asmundson G et all. ‘Understanding co-occurrence of anxiety disorders and chronic pain: State of the art.’ Depression and Anxiety. 2009, 26: 888-901 20
    21. 21. The concept underlying the SIRPA approach • Physical and/or psychological symptoms become the escape mechanism for unresolved emotions when they build up and for which there is no other outlet. • The symptoms are part of a protective, stress-processing response, which is automatic and unconscious. 21
    22. 22. • Current Life stresses/responsibilities • Childhood, or past, ‘traumas’ or pressures • Self-induced pressures due to; personality traits, learned behaviours & beliefs e.g. being overly analytical or self critical, the need to please/be good/perfect etc, and/or the belief that they have a ‘weak/damaged’ back/neck/shoulder etc • Being constantly on the go, overstimulation, overwhelm & lack of time to ‘defuse’ Underlying causes of psychophysiological symptoms 22
    23. 23. Are you saying the pain is all in the head? Symptoms are a result of unconscious and automatic responses in the brain and central nervous system when the emotional brain has been triggered. NO!
    24. 24. Emotion Neuropeptides (molecules of emotion) flood the body and brain Stimulate the emotional brain e.g. the Amygdala The Hypothalamus triggers physiological changes via the Autonomic Nervous System (ANS) Basic Neurophysiology 24
    25. 25. The ‘fight and flight’ response is a survival/protective response to a perceived ‘threat’. Physiological changes occur via the ANS – and is automatic and unconscious. The Stress Response 25
    26. 26. Modern stress/threats Are mainly psychological However…………. Our perceived stress is only 10% due to what happens to us (physical or psychological) and 90% how we deal with it. i.e. psychological - self-induced stress e.g. ruminating over things or over-analysing. Being self critical, a perfectionist, a people-pleaser, a ‘coper’, conscientious etc
    27. 27. 79 year old lady with 4 week h/o severe back pain & bilateral leg pain with numbness 27 If you remember this lady, her pain came on just before her daughter left for a month’s holiday in Australia. For an elderly person this was a huge stress. She was fearful of being on her own and also having strangers (Home Care staff) coming into her home each day, but she bottled up how she felt because she didn’t want her daughter to worry about her. The symptoms were protecting her from falling apart emotionally and/or having to deal with these ‘dangerous’ emotions. She recovered after offloading her fears , getting used to the new staff and then as she was improving, her daughter returned home. There was no further need for her symptoms to ‘protect her’.
    28. 28. Symptoms protect A GP had been unable to write for months. During an in-depth assessment it turned out he had not been able to write since he collapsed (while writing) and had to have life-saving heart surgery N.B. He could type all day and had no other problems with his hand at all. His brain had associated his nearly dying with writing, so the unconscious ‘stress response’ would cause his hand to “go dead” to protect him from this ‘life- threatening’ activity. Recovery was swift with simple, self-empowering strategies. 28
    29. 29. Case study: 6 month exacerbation of chronic LBP MRI results: ‘massive disc protrusion at L5/S1, compressing both S1 nerve roots and causing marked central canal stenosis’. (see slide 11) Symptoms: bilateral constant sciatica, pain was scored from 6 – 10, (with 10 the maximum) plus numbness laterally over both ankles and feet. Signs: Reduced Lx ROM, loss of bilateral ankle reflexes and minimal strength in left plantar flexors. Pain Medication: Gabapentin, Dihydrocodeine, Diclofenac, Paracetamol 29
    30. 30. A&E with intravenous opioids This lady’s nerve pain pathways had become learned and during the previous 6 months she had been unable to sleep for more than 20 minutes at a time. The following slide shows a graph she completed herself during her recovery while following the SIRPA Recovery Programme. 30
    31. 31. 31
    32. 32. 3 years later Still fit and healthy 3 years later and bouncing on a trampoline. 32
    33. 33. No exercise, drugs, hands on therapy or surgery The symptoms are a result of physiological changes in the body and as the process is reversible, full recovery is possible. Identification of links and triggers for the symptoms can significantly help a patient progress. N.B. Patients can follow the programme independently, with the support of a therapist, or as part of a group (where available) The SIRPA Recovery Programme 33
    34. 34. Cautions • Any more serious cause of the symptoms need to be ruled out, such as; cancer, infection, fracture or an auto-immune disease • People with unstable or severe mental health conditions are advised not to follow the programme unless supervised by a trained mental health therapist 34
    35. 35. • Accepting that the symptoms are stress-induced and not due to a physical cause is important for a full recovery. N.B. Sometimes having a diagnosis by a SIRPA Practitioner can help with this. • Acknowledging the underlying causes of the pain is important where the aim is recovery rather than management and can often be done simply by therapeutic journaling • Strategies can then be learned to help patients reduce the causes of self-induced stress as a result of their personality traits, learned behaviours etc. The SIRPA ™ approach 35
    36. 36. Treatment progression Educational, self-empowering and very often can be self-directed In-depth SIRPA™ Assessment (a Stress check-up to help identify links and triggers for their pain) Follow the online programme alone or with professional support (or as part of a SIRPA Recovery Programme for groups) Further support and/or refer on (Other self-empowering approach or Psychotherapy ) Books, CDs, online SIRPA Recovery Programme With a SIRPA Practitioner Support can be face to face or via skype 36
    37. 37. • Therapeutic journaling – to identify, acknowledge and gain perspective in order to let go and move on • Mindfulness and Mindfulness Meditation • Supportive self-talk • Visualisation • Some cognitive behavioural tools Some strategies included in the SIRPA Recovery Programme™ 37
    38. 38. Some evidence for a few of the treatment strategies used • Mindfulness meditation reduces stress and amygdala activation (Holzel et al., 2010) • Experience in meditation predicts a less negative appraisal of pain (Brown & Jones, 2010) • Journaling or private emotional disclosure reduced pain in people with fibromyalgia (Gillis et al., 2006) 38
    39. 39. www.sirpauk.com enquiries@sirpauk.com www.twitter.com/SIRPAUK www.facebook.com/SIRPAUK www.linkedin.com/in/GeorgieOldfield www.youtube.com/Georgie Oldfield 39

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