We hope your transition from one year to the next was smooth, or even (dare we say, and hope) a little bit fun! While we’re all probably a little battle weary we hope you’ve found more wisdom and determination in yourself than you ever knew was there. At Noigroup, we have have discovered in ourselves some extra grit and a deeper belief in what we are here to do. Noijam is just one way we can connect with you, a space where we can highlight research, share new concepts, reflect on existing ones. While it hasn’t been prolific year on noijam (quality over quantity), our intention for every edition is for it to be applicable, interesting, thought provoking, and to foster the spirit of generosity. So which of the 2021 morsels got the most nibbles? Counting down…
Number 5. New book, Pain and Perception
The last post of the year still made the top 5! There was much excitement around the release of our latest new book by Harvie and Moseley and it’s already in reprint. To celebrate our newest production we invite you to enter in a competition to win a copy of the book for yourself at the bottom of this email.
Number 4. One thing, yes just one thing
At number 4, our friend Joshua Pate and his new platform One Thing asks the question of Lorimer Moseley: ‘What is the one thing you want people challenged by pain to know?’.
Number 3. The cost of translational gaps for people with pelvic pain
The third highest read post was by Amelia Mardon, PhD candidate with the Body in Mind Research group at the University of South Australia. The findings from her systematic review of clinical guidelines for the management of persistent pelvic pain ‘clearly reinforced the idea that there are important research and practice gaps still evident throughout each step in the pathway towards optimal care and better outcomes for people with persistent pelvic pain’.
Number 2. Why therapists need a philosophy of pain
A very special guest post from three very high calibre thinkers, philosophers and clinicians – Julian Kiverstein, Laura Rathbone and Mick Thacker.
“A philosophy of pain can therefore allow for a different therapeutic relationship with their patients. Therapists can help patients to cultivate skills and capacities for living full and rich lives that creatively adapts to their pain.“
Number 1. Letter to a friend in pain
At number one is David Butler’s letter (a real letter!) written to a friend with back and leg pain, terrified she’ll need surgery. The letter included Dave’s 10 point plan to a beautiful back.
So there it is; we are proud of that broad-ranging mix!
Our Pain and Perception competition to win your own copy!
The modern science of perception has unearthed new ways to think about pain – as an experience that has multi-sensory and multi-factorial underpinnings. In this new, novel production, Dan Harvie and Lorimer Moseley, walk us through this science by interacting with illusions that challenge our assumptions on how perception actually works. Some assumptions are helpful, they eliminate over-thinking and stress – how stressful would it be to worry whether every car behind you will stop, or if water will come out of the shower head? While sometimes our friend, assumptions can also cause us to predict an outcome that is not helpful, that can prevent positive change or helpful adaptation. In the comments below, share with us a moment you have had an assumption challenged or turned around. A personal experience, a success with a patient. We’d love to hear from you. Dan and Lorimer will select a winner and you will be advised on February 1. Good luck!
With our very best wishes for a brand new year,
–Noigroup
Last week I saw a patient I hadn’t seen for a while. She had hurt her back diving into a pool. She felt a “ping” in her back and developed thoracic pain and experienced the return of an old familiar friend – right sided hip and leg pain.
When I first saw her years ago, she presented with similar right sided hip and leg pain and was terrified she would need surgery. She had had back surgery 30 years earlier for what felt like a similar pain and was convinced her back was “stuffed” and she was destined once more for the surgeon’s knife. She improved well with information about pain neurophysiology, with growing confidence in movement and with regaining trust that she in fact had a good, strong back.
Last week I saw her in my clinic, and she shared with me her latest story. After the diving incident and the onset of back pain, her mind went straight into catastrophic mode -“my backs stuffed, I’ll definitely need to see the surgeon this time”. She stopped walking and moving around. She tried to book an appointment to see me, but I was away on holiday. Next, she sat herself down and thought about some of our past conversations. She started to ask herself some different questions – “I’ve been here before and it settled down nicely with movement and relaxation”, “my physio said I had a strong healthy back, so maybe I’m not stuffed and don’t need to have surgery”, “perhaps some gentle walking and moving around doing the things I love will help settle the pain down”. She challenged her initial assumptions about the meaning of the pain and started to gently move- walking, swimming, visiting friends. Fairly quickly her symptoms started to settle down and the pain disappeared from her right hip and leg.
Her ability to challenge her original assumption of doom and gloom, allowed her to head away from adaptations that were likely to exacerbate her pain, and headed her on a more positive road to recovery. By the time I saw her she was 95% improved and feeling very confident that she was on the right track. An impressive example of someone having the tools to challenge an original assumption to achieve a very positive outcome.
About 4 years ago I was skiing in Colorado and fell and hurt my knee. I packed my leg with snow and waited for ski patrol to take me down the mountain. They bundled me, evacuated me off the mountain, and sent me to the local medical clinic about 30 miles away. I figured I sprained my knee. At the clinic, I got x-rays and was asked if I wanted pain meds (Dilaudid was on offer) which I said no to because pain was only an annoying 4/10. About an hour later, still no drugs, and doing fine. But then, I see the x-rays, doc says I have a tibial plateau fracture and I would need surgery, my pain shot up to intolerable levels (8+/10) immediately and I demanded the pain drugs. Funny, a bit of information and the thought of an orthopedic surgery immediately and drastically changed my pain perception.
Research hit me hard this year, from a half heard sentence in a podcast that I can’t remember I’ve dug up a lot of articles.
Maybe the secret sauce of exercise is not what I initially thought.
ROM doesn’t need to change after a ROM exercise
Strength doesn’t need to change after a strength exercise
Motor control doesn’t need to change after a motor control exercise
Stabilization doesn’t need to change after a stabilization exercise
…For a patient to feel a difference in their pain, function and life
I’m still trying to learn what is that secret sauce so I can leverage it
Hi NOI,
2021 was a challenge for many of us, our perceptions of what was safe to do and with whom changed often. Hidden away in social isolation was one of my most inspirational patients, someone paralysed after a car accident. She was the passenger in a stationary car at a stop sign. As so often seems to be the case the drivers of the two cars escaped with scrapes and bruises. Mrs P had a complete C5 lesion, that was in 2016.
The past year we challenged our own perceptions of what was possible for both of us.
“Let’s get you on to the floor” I said confidently but not really.
“You’re joking?” She replied in disbelief.
The rehab had plateaued out and we needed a spring forward so why not try the ridiculous.
I work independently and have a small space with little equipment, no hoists or colleagues to help. Luckily Mrs P has a good sense of adventure and humour. The first time was slapstick comic but we got down on to some mats and back up in one piece although rather flushed, ruffled and laughing. A new world had opened up too, new possibilities of movement, a change of perspective was experience, our paradigm had shifted.
Mrs P now gets down on to the tatami floor at her home by herself. Out of the wheelchair across a Bobath table, roll over the peanut shaped gym ball, with some straps to help to get back up, she is now independent to do floor work.
Since spending 2 to 3 hours per week on the floor playing with movement she has had a significant reduction in her pain and discomfort. There is also by chance a window at floor level which allows a view over her garden.
One year later we’re in the process of setting up her ‘floor world’ with various leisure activities, painting, drawing, writing, bongo drums and who knows what else…
Our goal this spring is to get on to the floor outside and maybe roll around on some grass in the sunshine.
I’d like to take this opportunity to thank you all at NOI for the education and inspiration, you’re doing some far reaching work.
The challenge I have faced with my CRPS- On 1st January ‘21 I fell and broke my left wrist.I went on to develop CRPS.By the April I had a PAINFUL 😖,purple, swollen useless hand and was in the depths of depression. I am a nurse with 37 years working in the NHS. I was so depressed I experienced suicidal thoughts. I’d been due to retire in March 22 and celebrate the end of my long run. Here I was -useless !Then I met my physio and was introduced to Graded Motor Imagery. It absolutely changed my life. I worked so hard for 5-7 hours a day. I found a strength and resolve I didn’t know I had. Now here I am , one year later with a dicky hand that does not hold me back. I’m up to 60% movement and 75% function says my physio. I AM BACK AT WORK 🎉 finishing my career the way I want to.I’ve never been so proud of myself. This therapy works. Do it ❤️Don’t be a passive observer of your pain ❤️Engage in the process ❤️ You can do it 💪
Thanks ,
Kate
My moment when my pain changed was when I attended a lecture in Jersey by Lorimer and using and educational and reflection frame of reference my pain changed. Knowing more about pain and applying it to myself helped. The session provided the just right challenge for me. These 2 factors enabled me to change my pain and increase my qualify of life. I share my lived experience with others who benefit.
Hi. I am C-IAYT Yoga Therapist and Physiotherapist. I would like to share with you a success story of a lady with CRPS. A 65 years old lady having constant pain, stiffness, and limited function in the right wrist as well as swollen fingers, has been diagnosed with CRPS and was referred by a friend and psychotherapist after she had POP for 2 months and has tried physiotherapy for 2 months. Initially the hand was much warmer, swollen, purple with red blotchy patches and shiny skin, now it is always cold, very sensitive to touch, very weak and unable to be used.
The pain was a constant 7/10 and was affecting the daily life of an active and healthy lady but also her sleep since she was very sensitive to the pressure of bed clothes. The main symptoms besides the pain, was stiffness that was worse in the morning. She was taking the maximum dose of painkillers, 4 times per day to cope with pain.
Based on the robust RCT of Moseley (2004), I addressed the CRPS with a yoga therapy program that consisted of: 2 weeks of daily yoga nidra (yogic sleep enhancing relaxation and mindfulness) focusing on the upper limbs and especially on the right arm, for the next 2 weeks I added visualisation of movements, for the following 2 weeks I added moving both arms, looking only at the unaffected one, and the last 2 weeks I added moving and watching both.
In addition I explained pain based on the book ‘Explain Pain supercharged’ and meditative elements such as appropriate breathing practices for their calming effect and chanting of positive affirmations were incorporated for empowering the client and enhancing hope.
The results were amazing and after 10 weeks she was pain free!
Assumptions, indeed. I had assumed that doctors, medical professionals all cared about helping their patients. Most do, but there is that one individual who only wants to play golf and count his money, or that one individual who does not think that patients should give them any information. That is why patient advocates are so, so important. Thank you all. Now, how about research and a cure for Complex Regional Pain Syndrome?
I was working with a patient who was dealing with chronic pain in both of her knees. She also had poorly managed diabetes, was overweight and had been off work for months due to her pain. Her goal was to get back to work where she was required to be on her feet for 12 hours at a time, often working night shifts, while she sorted out hamburger patties to be shipped to various fast food restaurants. When I first started working with her I didn’t have much hope as I assumed that her unhealthy lifestyle and the nature of her job would make it hard to relieve her of the pain that she had been experiencing for years. I thought that I would need to help her become close to pain free before she could go back to work and didn’t think that was an achievable goal in the timeframe I had to work with her. Despite my doubts, we began working together and as I educated her on self-management techniques and began working with her on a strengthening program, I got to know her better. She was motivated by more than just a job- she had a family to take care of and wanted to be able to do all the fun activities with her grandchildren such as go trick-or-treating, take them for walks, etc. She came in 3 times per week and worked her butt off the entire time, no matter how much pain she was experiencing. She eventually learned to manage her pain better and was able to build up the strength and endurance that she needed to return to work again, even though she wasn’t pain free. She taught me that you can’t make judgements based solely on external measures- if you can help someone to find their “why,” there is nothing that will stop them from achieving their goals.
Sharing my own revelation. I’d been a PT for 4 years at the time, and was a budding yoga therapist. And also someone with persistent pain for 9 years. This was prior to reading Explain Pain, Painful Yarns, GMI. Feeling more than a bit flummoxed about being a care giver who couldn’t rid herself of her own pain, I attended a symposium on yoga therapy and research.
At the conference, I attended a talk by a PT–probably about neuroplasticity or something. To be honest I don’t even recall what she talked about because what happened was so moving.
I was deep in a pain experience, continuing to be flummoxy (I know that’s not a word), distressed, sad. She took us through a guided meditation about remembered wellness in our bodies. I awoke from the moment…..pain free (at least for a moment).
Years of one experience, only to be shape-shifted in 20 minutes…my assumptions, poof!…..I wasn’t broken. I went up to her afterwards, in tears, and said “what the hell was that?”
It reminds me that sometimes words and explanation only go so far. That sometimes the shift happens in an experiential moment, when we’re still enough in mind, to notice a difference.
I can’t get over the synchronicity of landing on your blog this morning. While I read Anna Thomas’ post, I reflected on the physical pain I’ve had for over 3 years and psychic pain I’ve had all my life. I thought her patient’s story was powerful and realized that, for the first time ever, at the beginning of my yoga class this morning I actually thought to myself that I should stop s..t-talking myself and adopt a mantra with a positive message to myself – maybe I could brainwash myself into feeling strong, confident and pain free. I feel how difficult this is as I type it, but I have to try it because this is not how I want to live my life and I’ve tried everything else already!
I just want to enhance the welcome, reassuring face and listening of therapists needed when a patient in distress comes in the clinic with all the incertainties, disillusions, coming from other health professionals.
He needs information, caring, and guidance to better living
I have just had a life changing and terrifying experience. I fell 50 m down a mountain on the 11 December. It took 8,5 hours, 9 men and a helicopter to get me off the mountain and the ledge I somehow managed to come to a halt on. My son and brother were with me on the climb up Cathedral Peak in the Drakensberg mountains in South Africa. they were as traumatised as I was, perhaps even more having witnessed my fall as a piece of rock gave way under my foot on a very exposed portion of the mountain just below the summit. They heard the thump as I hit the ground 3 times in the 50 m and were convinced I could not possibly be alive. I had a totally different experience. I knew I was alive and although very sore, I was eventually going to be fine. one of the falls had seen my rib cage smack into a rock and the blinding pain that ensued made me certain I had damaged my rib cage really badly.
eventually after a 2 hour ambulance ride I was admitted to a trauma unit. a CT scan revealed a fractured scapular and a badly broken and disrupted ankle (calcaneal fracture) and many lacerations, many bone deep. No rib fractures were identified and no-one was interested in my agonising pain in my ribs which made breathing and moving extremely hard, they were far more concerned with stabilising my ankle (which they called corn flakes!) and closing my wounds. I could feel my own rib cage was remarkably distorted and I could hear and feel the bone fragments moving whenever I tried to breathe deeply. The pain persisted. I was hospitalised for a week post ORIF surgery and was discharged in a wheelchair to my family’s care (crutch walking was impossible they declared due to the scapular fracture). I struggled through the first month moving and breathing as little as possible and worrying in my own mind about my ribs, palpating them absentmindedly all the time. I worried that I would just be better and someone would say: ” these ribs should have been fixed, let’s operate now” and I would be back at square one on the healing journey. I worried that my rock climbing and yoga filled life would be inhibited by ongoing rib pain and stiffness and that my thoracic spine would cause problems for me, which would lead to disability. I felt almost no pain in my ankle, shoulder or healing wounds, my ribs were all I felt.
a month down the line, I decided to have my ribs X rayed. The report came back with 2 displaced rib fractures. I got myself 3 options on the best way to treat displaced rib fractures even in a very active person and each consultant said the same thing: “leave them, they will heal, they will hurt like mad and they will heal over 6-12 weeks”. I can honestly say that from that day onwards the pain reduced to a fraction of its pre-X ray intensity and breathing became instantly easier. the mere knowledge that there wasn’t a severe and potentially disabling problem in these displaced ribs reduced the pain. my consumption of pain medication stopped and it wasn’t long before I could walk on crutches despite them. they are still squiff and they do still hurt, but they do’t bother me much at all, because I don’t fear them anymore. I have another 6 weeks non-weight bearing on crutches so I couldn’t be more grateful.
This experience was astonishing to me! Maybe it helps someone else see that the purpose of pain is prevention of tissue damage or protection against further tissue damage.
At our first meeting my client reported 9/10 pain and had to lift her injured arm to the clinic table with her other arm. We identified that she felt most safe and at peace outside by the river, so she spent her days there doing breathing exercises, desensitization with a soft brush, nerve gliding and eventually throwing a ball for her very patient dog, who was happy even if the ball only went a few feet! After two weeks, she called her doctor and said she was ready to return to work. Her MD and I had both expected it to take a few months for this process. She told her MD that she felt I was fully committed to her healing, so she fully committed as well.
As a person living with chronic pain, the thing that has opened my eyes the most recently is just how powerful assumption, perception, and prediction actually are in shaping our entire view of, well, everything!
The output of the brain is so dependent on what input it gets from its sources, but because each person is unique, each person has a different output, and is the reason why we all need an individual approach to our pain and how we manage it.
This really brought home to me how important it is to learn more about why I (and my brain) might perceive things as they currently do, but also how I can affect and change how input is interpreted and perceived. I thought I had a reasonable handle on how I looked at things until recently; I read a book on how perception actually works and had a dawning realisation that I can affect much more than I thought I could.
My perception of how pain professionals value my feedback was also blown clean out the water recently, when my physio practice asked me to help them with developing how they manage pain patients. I never once thought in a million years that I could offer meaningful insights to professionals already knowledgeable about pain and embrace the biopsychosocial world, but here I am having regular meetings with their pain expert to help develop their services and support of people experiencing pain.
I had chronic pelvic floor pain back in 2007/2008. Could hardly sit down, wore clothes several sizes too large. After 3 years I was referred to a study combining CBT and physiotherapy. Went fantastically for myself. No pain anymore. I worked at it for a while and got to pain free. This changed my career trajectory and ended up becoming a physiotherapist! The power of the body and exercises!
Fast forward to to 2016-ish, distressing event triggering mood changes and pelvic pain. I started seeing a physio again for help but it wasn’t changing much. After a while, I started seeing a counsellor. Pain went away! All these years I thought (assumed) it was the physio that did it. And only the physio. The physical rehab and the exercises, I poo-poo’ed the CBT. Knowing my body and confidence in it had helped, I’m sure, but treating the emotion driving the physical tension/tone/pain changed the game… and my practice since then.
I am a lady in my late fifties who had a fall in my back yard around fifteen years ago. I was operated on for a microdisectomy and after a year and a half later a fusion to my lower back. I have since lived a life of chronic pain and bedridden at times. It has been a tremendous struggle back in the earlier stages just watching my life go by lying on my back just modifying my life not being able to function. I was on a cocktail of medications which were dangering my life and I was feeling very lonely and feeling very down plus depressed. I was instructed that if I didn’t make some serious changes to my life with my medications my life was in jeopardy. I made the choice to come off the majority of my medications which at the time was very difficult for myself and my family but now I am a new person. I feel much better and clear headed and my lower back pain is still there but tolerable and I’m on a very minimal drug regime. I am now working part time which really makes me feel proud and I am a much more social individual than before. I am walking regularly to help contain my fitness and I feel my family has their mum back. I hope this gives others who suffer with chronic pain some positiveness and belief that their lives can change for the better too.
Thank you for sharing storing of ‘assumptions being turned around’, I enjoyed all (even those off topic)! Special mentions below and keep them coming, I’ll be back to read others and judge with Lorimer in the coming days
@Anna – love the patient challenging their own reflexive assumptions. I reckon it’s tough to change our tendencies to think the worst. BUT, perhaps the best we can do is get good at self-questioning….
@Suz – great anecdote on the power of (danger-to-body-type) knowledge
@Ariel – thanks for a window in to your journey to find the ‘secret sauce’ of exercise. Perhaps the ways in which exercise may help are varied and individual….. but certainly biological, neurological, immunological, psychological at different times…..would love to know where you get too.
@Martin – wow, love your bold approach to help Mrs P. Reminds me of a rehab story in the book #TheBrainThatChangesitSelf actually
@Kate – Thanks for your 37+ years of service and congrats for your hard work getting back to work. We’re proud of you too!
@Samantha – ‘Knowing’ and ‘Applying’. Love that you boiled it down so simply, but profoundly.
@Brandon – Love this, Brandon. Lovely example of human potential and engaging the powers of motivation….and our tendency to underestimate people!
@Tianna – Wow, what an anecdote. If only it could be this quick for everyone!
@Cathy – Your post made me smile! Perhaps your assumption is that you aren’t already strong and awesome 😉 Just for fun this is for you (just read the summary at the start if you like): https://www.frontiersin.org/articles/10.3389/frvir.2020.00013/full
@Sue – RIVETING story Sue. Glad you’re ok. And a great example of how getting a believable explanation for your pain and some consistent advice can be analgesic.
@Clare – Thank you for sharing Clare, and glad you are helping with service development. I suspect we need more Clares.
@Karly – Great story Karly. When usually have multiple treatments at once so no doubt we make assumptions (based on our preconceptions) about which component was the effective bit. I’m sure you’re a great and broad minded physio and all the more for this experience!
I am a practicing physical therapist in Taiwan. Here is my personal journey.
I suffered from intractable neck/back pain with radiculopathy all the way down and also my shoulder for 10+ years after hit by a taxi when I was a physio student. Several MRI and electrophysiological studies confirmed multiple disc herniation with nerve compression.
I received intensive physical therapy for several years, supervised by my physical therapy professors. Which was COOL, right? I have learned and applied Pilates, motor control, and core strengthening myself (following the BEST evidences at that stage). Unfortunately, the symptoms were still struck me even when I was asleep, it stopped me from everything I liked once. I was worried about my study and future career. So I decided to receive L-spine lamninectomy and disketomy. I strongly regretted the decision because of buttock pain with limping gait right after the surgery.
Not until I learn about pain neuroscience education, I realized pain during activities doesn’t equal harm or damage. I started to bend/twist/lift my body. The paradigm shift totally changes my beliefs and daily life! I’ve read tons of articles/books and courses by Prof. Moseley, O’Sullivan, and Louw, etc.. I still have bad days sometimes but enjoy exercising and weightlifting now, even completing a marathon. Now, I enjoy my life and start helping others by MOVING the mind and body!
A while back, some of my colleagues and I were running a pain education group. For homework, we set our group the task of choosing a song that best describes or defines their pain to be shared at the next meeting. I knew one particular group member well and had a one-to-one visit scheduled with her prior to the next group.
When I arrived for the visit, she was fretting majorly over the assignment, wanting to pick the perfect song to represent her experience. This approach actually summed up the lady perfectly-she had to give 100% to everything in her life, otherwise she felt like a failure. She always busied herself tending to others needs and to all the housework for herself and her ageing father, never taking a moment for herself. As such, it was difficult to guide her towards rest and its many benefits as part of dealing with her pain. I gently tried to suggest that her song choice didn’t have to be entirely representative and that she could take creative license with her choice but she was steadfast in her mission.
Needless to say, I was floored when she showed up at the next group, proud as a peacock, and requested that we play Carly Simon’s “Haven’t Got Time For The Pain” as her choice. She found her perfect song because she listened to herself and not me. I nearly cried right there. It was a great reminder that she is the expert in her own condition; I’m lucky to even be accepted as a guide.
Being a former nurse, I have some basic pathophysiological knowledge and experience with chronic pain. It was not till a major car accident over 2 years literally flipped my experience upside down. Never had heard about the term central sensitization until my own experience with ongoing pain despite limited physical damage. I’d love to win a copy of this book so I can share the tips and tricks with fellow chronic pain sufferers and claim stakeholders I work with. It will be interesting to see where pain research heads in the next few years, especially with people suffering long COVID and other psychosocial conditions.
I´ll be short, don´t want to bore you.
Some weeks ago, I had an incredible experience with a patient with persistent back and leg pain (9 months, and some other episodes few years ago). She could only walk 40 meters, and had to stop and rest to be able to keep going, or simply decide to return home. Her life was considerably limited.
Every single movement was extremely painful (just trying a glute bridge or an assisted leg raise was the hell). After one session of talking (some motivational interviewing) and trying to understand her perspective, I gave her some very low-graded home exercises. The second meeting I couldn´t see any tiny improvement, so I decided to try GMI, starting with imagined movements, trying to focus her imagination in the places she used to go and loved, and even later, combine the GMI with her favourite music, all the while (imagination didn´t cause pain, by the way).
It just took her 4 sessions to walk five of four blocks, and her allodinya had considerably diminished, at the point I had to put her in the gym to turn up the grading. After that she was free of therapy, doing really better, and recovering a big part of her life again. She was going to try yoga again, changing some eating habits, and was so positive because of that.
It was by far, the best clinical experience in the terms of changing perception without even putting a finger on a patient, in such a short time.
The funniest part is I don´t have a clue of what really happened ! (just some hypothesis).
Thanks.