The idea that what is going on in a person’s life can have an influence on their pain, can be a difficult sell to a patient with pain.  Sometimes even for ‘painiacs’ like myself, it is hard to see the wood for the trees and stop yourself from separating out the bio from biopsychosocial.  Being mindful about our own experiences with pain as a practitioner can teach us many things that we can use  in our clinical practice.

Years ago I had low back pain.  It had been around for about 6 years, but didn’t have any real functional impact on my life.  It was there, I was distressed about it to a degree but it didn’t stop me doing anything.  I had some funny concurrent symptoms which prompted me to present for a medical review.  I had an MRI and nothing was found.  The other symptoms disappeared and the very sensible referring doctor simply told me: Just get strong.  Three simple words, combined with his confidence and the negative MRI were incredibly reassuring.  I did get strong and about 4 months later the back pain was no longer a daily problem.  Within 12 months it had almost completely gone.  Rarely, certain biomechanical stresses will tip it over into a flare up – sitting for prolonged periods and certain exercises at the gym, if I overdo it.  When this occurs, it tends to behave like chronic pain– it doesn’t have a reliable pattern, doesn’t respond well to pain medications and the pain can be a lot more intense than what you might expect for such simple stresses.

Earlier this year I was booked to go to a conference overseas.  In preparing for it, I had thought briefly about the fact that I rarely sat these days, and that the big flight, combined with 3 days at the conference was more sitting than I was used to.  I was aware that my back might get a bit sore.  Three days prior to the departure day, we discovered a large, mysterious lump on the side of  my 22 month old daughter’s head.  We took her to the childrens hospital and an appointment with a surgeon was made for the day that I was due to be leaving.    I was beside myself with worry.

We had a lot of discussion around whether I should go or not.  The tickets were non refundable and I had been looking forward to going for a long time.  It was unlikely that any scans or surgery were going to happen in the time I was away, owing to the weekend in the middle.  My husband and I decided that I should go, and could always come back early if it were warranted.

I was a nervous wreck.  I couldn’t find my passport the day before I was due to go, I wasn’t sleeping and my back was niggling – just what I needed.  Passport found, I boarded the plane for an uncomfortable 18 hour journey.  The first day of the conference I found bearable – lots of walking in between speakers, using the hotel gym and stretching out in the evening.  Day two I was miserable – jet lag had caught up, I wasn’t able to concentrate much with the presentations and the back pain was getting much worse.  That night I skyped home to hear more about the plan that the surgeon was putting in place.  There were neurosurgeons being consulted and an appointment at the childrens hospital, following a CT scan, which was to happen on the day I arrived home.  There was a suggestion that the lump was a meningocele – a protrusion of the dura, filled with cerebrospinal fluid, caused by a defect in the skull.  Things were looking serious, and my husband, a surgeon himself, who could usually talk me through my worries, was himself distressed and upset.

Day 3 was exceedingly uncomfortable. I stood at the back of the room for several of the speakers, wriggled like a 3 year old, and was distracted.  Skyping home again that night I heard that my very calm husband, who is usually very dismissive of our children’s ailments, had had a “moment” at work, shortly after receiving the referral appointment to the childrens hospital.  It was for the Childrens Cancer Centre with an oncologist, a detail he thoughtfully left out of our skype session.  Taking my cues from his level of distress, my journey home was a bit of a nightmare.  The pain was almost unbearable, sitting was really uncomfortable and with storms across the country, my flights were delayed.  I was lucky to score 3 seats on the plane and exhausted, slept through the flight.

In a blur of jetlag and anxiety bordering on panic, we took our daughter for scans and appointments, and finally to theatre for a biopsy of this mysterious and as yet undiagnosed mass.  In the happiest of happy circumstances, the mass turned out to be a haematoma that had failed to resolve, causing some reactive bony changes around it, which made it appear nasty.  The surgeon stuck a needle in it and drained it.  She was completely fine and the bony changes disappeared over the following weeks.  My back pain went away, unnoticed.

A month later I attended a three day seminar and then flew the next day to a conference.  It was a thoroughly enjoyable four days and as I sat at breakfast the next day, I reflected on the fact that I hadn’t had even a niggle of back pain. ……  I HADN’T HAD EVEN A NIGGLE OF BACK PAIN!!!!!!   Same biomechanical stress, completely different environmental setting.

I liken this experience to concept of DIMS and SIMs that David Butler and Lorimer Moseley have created for their new pain workbook “The Protectometer”, a great resource that I have already used with a few patients.  It takes what can sometimes be seen as an esoteric concept – the idea that our thoughts, environment, worries and fears can have a massive impact on our pain, and gives it a level of structure and tangibility. In short, the things that represent danger to our brain (danger in me or DIMs) will elevate our pain levels, the things that represent safety to our brains (safety in me SIMs) will reduce our pain levels.  The exercise becomes one of recognising the presence of DIMS and SIMs, reducing the DIMs where possible and increasing the SIMs.  Sometimes, even recognising that DIMs are at play, even if you can’t change them, can reduce distress about pain……. If you can see the wood for the trees!

I treated a fun and bubbly lady, who worked in a law firm, as a  patient about 5 months ago.  She had  chronic neck and arm pain and had been on the “search” merry-go-round for 6 years.  She came to see me because her manual therapy practitioner, who she had been seeing roughly 2-3 times a month for 4 years, had moved away.  She was highly distressed about her pain and fixated on the idea that there was a “cure” out there for her – that she only had to look hard enough for it.  She was very knowledgeable on the various combinations of over the counter medications she could combine with her prescription drugs to get a variable level of pain relief, and consequently was taking a lot of opioids.

Functionally, she was still employed at work but was starting to take more and more sick days off work, was cancelling social events on bad days and had stopped doing some of the things that she loved like yoga and classes at the gym.  Whilst she still regularly went to the  gym and had a personal trainer, there were dozens of “rules” about what she couldn’t do – based on cause and effect assumptions she had made about flare ups following a session at the gym.  She also had a lot of pain behaviours at both work and home – talk and avoidances that painted a picture of her being “sick” or “broken”.   As with most of these cases, there was nothing on her imaging that provided a definitive answer as to why her pain was hanging around.

Despite all of this, she was a cheery and happy person, was very motivated to get better and had a lot of insight into her thinking and understanding of her condition – I knew that she was going to do really well with a bigger picture approach.

After spending the initial consult having a really good listen to her story, including her disappointment with all the failed treatments, I introduced the idea of taking a bigger picture (or biopsychosocial) approach, as it was known to get better outcomes for achieving her goals – to get back to the gym fully, to return to yoga and for pain not to dominate her life as much as it was.  She was keen to try a different approach as she acknowledged that her journey up until now had not provided the answers she had been looking for – if anything she felt like pain was becoming a bigger part of her life.

We booked in some long consults for the following three weeks and over that time, did some pain education, reviewed her thoughts and understanding of her condition, introduced some mindfulness meditation and began to create a team around her.  We enlisted the help of an exercise physiologist to review her exercise program and challenge some of the “rules” she had around exercise, especially regarding her fear of load bearing through her arms and doing anything with her arms above her shoulders.  Together with her personal trainer they started using a graded approach to re-introduce some of the exercises she had been avoiding.  We also got her GP involved for a medication review and fortunately he recognised and agreed with our intentions, and suggested that she reduce her use of opioids.

My main goal in those longer sessions was to use a level of understanding of pain neurophysiology to separate the connection between pain and tissue damage.  With this established, we were then able to take our emphasis off chasing the pain and put it onto her functional goals – we spent a lot of time talking about what was important to her, what her pain represented to her and how it was having an impact on her life.    I then began to introduce the concept that if the pain didn’t represent damage and was unlikely to get worse, she could begin to take part in some of the things that she had been missing out on in the presence of pain.  We talked at length about the concept that the complete removal of the pain wasn’t necessary, for her to live her life the way that she wanted.

ACT and mindfulness approaches in pain are both blissfully simple when you strip them down to basics.  Provided you stick to the scope of pain and refer to a psychologist or GP if you feel that there are other psychological co-morbidities, these approaches will fall nicely under the umbrella of pain education and as a manual or exercise therapist, can fall well within your scope of practice. It makes sense for practitioners who are working with people in pain to look into some of these tools and start integrating some of the approaches in their clinical approaches.  Some great resource to start are:

• The Happiness Trap, by Russ Harris (perfect to hand over to a patient as well)
• Fordyces Behavioural Methods for Chronic Pain and Illness (2014, Main, Keefe, Jensen, Vlaeyen & Vowles)
• Acceptance and Commitment Therapy for Chronic Pain (2005, Dahl, Wilson, Luciano &Hayes)

After a brief break in sessions, my patient returned, more bubbly than normal, with a list of all the ways she had been working towards her goals.  Most importantly she reported that she had a better outlook on what her pain meant to her.  This included dropping a lot of her pain behaviours which had been defining to both her, and the people around her that she was “broken”. Ultimately this meant that she was far less distressed.  Her pain scores had dropped considerably – she still had pain, but it wasn’t interfering with her life as much as it had been.  This was reflected by a big improvement in her Pain Catastrophising Scale scores as well.

I chose not to use manual therapy on this patient because she had been so fixated and reliant on treatment prior to coming to see me, that I felt that if I used it, any gains that we made using a more biopsychosocial approach, might have been attributed to the hands on treatment, and taken away from the emphasis I was trying to create on self-management and active approaches.  Subsequently, and for a brief flare up episode we have used some manual therapy – but in a different context than what she had been previously – she now sees its as one of many tools that she could access to help her stay on track.

One of my favourite quotes that sums up a lot about these approaches is this:

“People who have something better to do don’t suffer as much.”  (Wilbert Fordyce, 1988)

You can also read this blog by Joletta Belton, who has suffered with chronic pain, but using these approaches has managed to gain a level of control of her pain and of her life.  It is very inspiring and great to forward on to patients who might be starting to gain an understanding of the concepts.

Over the weekend I was involved in a discussion on a forum site about active versus passive approaches in manual therapy.  It was posted by some very sensible people, well versed in pain science and with further training in exercise approaches.  My comment to them suggested that their understanding of  active approaches was going to be different to a lot of other practitioners, still stuck in passive mode.  I suggested that because these guys were well advanced on their integration of pain science into clinical practice, that it is easy to forget that there are large numbers of practitioners who have no understanding of these concepts and how they work in the real world – that things weren’t changing as fast as we might think they are.   Someone replied to my comment that this was not the case, as in their experience, most practitioners were on board with prescribing a stretch or two as part of treatment or occasionally recommending someone do pilates.  Job done.

It was a Saturday afternoon, I was wrangling 3 kids solo and trying to bake a cake for a four year old birthday the following day.  PLUS, I am a massive chicken on the internet.

I hate the conflict, tend to take it all very personally and it seems to be rare that a good outcome results from these often heated discussions.  Everyone thinks they are right and the lack of tone, body language and other social norms that would ordinarily govern such a discussion are lost – things tend to get said that ordinarily wouldn’t, if the discussion was face to face.  Therefore I didn’t get back on and say what was burning and bouncing around in my head as I beat butter and sugar together –       THAT IS NOT AN ACTIVE APPROACH!

All was not lost though!  Through the therapeutic mechanisms of smashing eggs and more beating, I tried hard to define what actually IS an active approach.  I believe that if we summed up the things that pain science teaches us, active approaches over passive approaches would have to be my  number one take home point – simply because it underpins everything else.  It puts the ball back in the patient’s court, gives them a sense of control and reduces helplessness. Together with education, it paves a lifelong pathway for patients to manage their own condition, instead of having to rely on someone else to take their pain away or help them out.

Further narrowing things down, I pondered that language is the most important thing when setting up active approaches.

Language helps us:

• Convey to the patient with acute pain that everything is likely to get better, that they should stay active and remain positive that things will settle in time.
• Educate the patient with chronic pain about the changes that occur within the nervous system that perpetuate a pain experience and hence separate out tissue damage from pain, empowering them to move more and be fearful less

Language hinders us when:

• Our diagnosis and subsequent explanation to the patient implies that something is wrong, broken, impaired, switched off, weak…… Eg. Your pelvis is rotated, your leg is longer, your core is weak, your cranial rhythm is imbalanced, your feet are flat, your gluts are switched off and even your neck is out (yes, it still happens)
• Our management approach implies that in order overcome these diagnosed problems, the patient NEEDS to see the practitioner in order to get resolution of their symptoms. In other words – you can’t do this on your own.

Using an active approach in manual therapy really has very little to do with what actual techniques, exercises or stretches you use.  It is about the tone of the consult from the second the patient walks in the door – creating an empowered patient who is in control of their own health.  It is a bigger picture approach and understanding of our role in helping this person on their journey.  An understanding that what we do with our hands plays a very small role in that process and respecting that the power we have with our language is MASSIVE.  This doesn’t minimise or reduce the importance of our role as manual therapists –it just changes the emphasis.

I have spent the last four days in a row sitting on my bum.  I don’t usually sit for such long times and normally my back would be in all sorts of trouble with such an unaccustomed biomechanical stress.  However, I haven’t had even a niggle of discomfort.  I am pretty sure it is because I am doing what love and pursuing the things that matter to me.  Sorry – too much psycho -babble?  I  will give it some context later.

I have had the good fortune to have been at a 3 day pain seminar in Melbourne, finishing with a final day in beautiful Adelaide for Pain Adelaide – “probably the best little pain meeting in the world” – is how they describe it, and I would have to say I agree.  In a one day, multidimensional and multidisciplinary pain bonanza, 19 presenters spoke about pain – from cultural aspects of body pain versus “self” pain, to how new technology in G coupled protein receptors might lead to breakthroughs in targeted drug therapies, and everything in between.   Here is the range of my responses to the different speakers:

• Wow! That sounds amazing.  I really have very little idea of what you are talking about, but it sounds very complicated, you are obviously very passionate about it, and I can see that some very exciting things might come out of that research. (some of the PhD presentations and receptor pharmacology information)
• You are unreal! If only we could bottle you and distribute your sensibleness to practitioners around the globe. (Peter O’Sullivan and Kevin Vowles)
• Are things really that bad? I guess they are…… Lucky we have you on the team and there is so much momentum.  Standing ovation deserved.  (David Butler) 
• Are you sure you are a Rheumatologist? That presentation was awesome (Sam Whittle on Fibromyalgia)
• Whoa – I had never thought about pain in that context. I think it is breaking my brain. Fantastic!   (Jim Hearn on Pain and the Human Condition)
• You mean you think that the data is telling us that the only things that have any effect on a patient’s pain are talking to the patient and reassuring them? Mindblowing, but at the same time not that surprising. (James McAuley, Neuroscience Research Australia)

The thing that has most floated my boat in the last few days has been Kevin Vowles’ material on ACT and its use in treating chronic pain.  The crux of the idea of ACT for pain,  is that in pursuing a meaningful life – one that taps into your values and recognises the things that are important to you, pain doesn’t have to play such a big and central  role in defining our behaviour.  It ties in beautifully with mindfulness approaches.     I will write about it in more detail in the coming weeks. For now, I am off to explore Adelaide!

Find out more about some of the speakers here:

Peter O’Sullivan : Website and this fantastic podcast

David Bulter and Co : NOI goup

Lorimer Moseley and Co: Body in Mind

Dr Sam Whittle: @samwhittle

Pain Adelaide – Keep an eye out for it for next year and save the date!  A fantastic day.

We recently found ourselves with our nearly 2 year old daughter at The Royal Children’s Hospital late on a Sunday evening.  After being triaged we joined the busy waiting room, sitting next to a man who had brought his child in to be seen for a mild viral illness.  He huffed and fidgeted enough to let everyone know that he was not happy being made to wait as his son slept beside him.  After half an hour he loudly declared “our health system is just so stuffed….” . I thought about his statement, reflecting that we were sitting in one of the world’s best hospitals (that place is amazing!), waiting to see medical staff who we trust are going to be exceedingly well trained, for absolutely no cost.  I paused for a moment, before politely suggesting to him that, to be fair, if the nurses had thought that his son was very sick, he would have been seen without delay, and that I was sure that they would take good care of them when they did eventually get seen.  He conceded and quietened down, while I continued to ponder about our “entitlement culture”.  In our very clever western society, we have this expectation that medicine will have all the answers for us – got diabetes? Take medication.  Obesity?  Lap band surgery can help.  Break a bone? We can fix that.  Headache?  Take a pill.  We get so complacent about our advances that some people forget how and why they came about, and that years ago we didn’t have such a black and white mentality that things would work out Ok.  At the extreme end of this spectrum, people might feel so safe that they might choose not to vaccinate their children.  And what happens when it goes wrong and the surgery or treatment fails to fix the broken bone completely? “They stuffed it up”  is often the idea that the patient will take away from their experience, which I believe comes from this entitlement culture – we expect nothing less than perfection.

The problem with this black and white approach is that it can set people up with some very unrealistic expectations and a poor understanding of their condition, which might lead them on to develop chronic pain.  If you happen to be the clinician attempting to lead them out of their pain spiral, getting them to move through this blame, is going to be a key component for getting better functional outcomes.  Directing their understanding of their condition towards one that fits with our modern day understanding of pain physiology is going to be the best way to help reverse the spiral.

I recently treated a middle aged man, who had chronic pain following knee joint replacement surgery, who was very angry at his surgeon.  He was adamant that it was all the surgeon’s fault because he was worse following the surgery.  On further discussion though, he revealed that the surgeon had not been emphatic that the surgery was going to be the answer to this relatively young man’s problems, and had suggested that he wait a few years and continue trying more conservative treatments.  The patient, keen for the quick fix to fit in with his work commitments, had pushed for the surgery despite his recommendations and despite further informed consent discussions that detailed the possibilities of less than favourable outcomes.  We did some pain education sessions, where we discussed in detail the changes that occur within the nervous system in the chronic pain setting.  In this case, it was also very helpful to help this man to challenge his thoughts around “fault” and “blame”, with reference to these physiological changes,  because it enabled him to take back a level of control and responsibility for his condition, which helped with his commitment to the movement rehabilitation program we started him on.  After that shift in his thinking, he seemed to make gains a lot quicker.

Pain is a subjective experience.  It is vastly influenced by many social and emotional factors such as baseline anxiety and depression levels, the context of the pain and our understanding of the condition.  Consider the difference between the athlete with DOMs following a big training session, and a person with muscle pain following a traumatic assault.  Where the athlete believes that pain indicates a certain level of achievement as a means to their reaching their physical goal, it is likely that they will view that pain in positive light and have minimal associated distress.  Their previous experience tells them that it will be short lived and is not harmful and their coaches will re-enforce this concept.  For the person dealing with pain following an assault however, a whole different picture will be at play.  Firstly it is likely there will be fear and uncertainty around what underlying tissue damage has occurred and if there is going to be ongoing issues.  Additionally, the intense emotions attached to the initiating event will be difficult for that person to separate from their pain experience.  So whilst on a nociceptive level the two events might be similar, as a lived experience, the two scenarios will be poles apart.

Different cultures have various ways of expressing and accepting pain as part of life.  Generally this behaviour is modelled by older generations to younger generations.  Where stoic cultures will tend to complain little in the face of pain and make little fuss over small injuries in children, others will verbally and physically express their pain, and the slightest sniffle in the child can be labelled as an illness and treated with much attention.  It begs the question, does the tendency to magnify a pain experience in our expression of that pain, render us more likely to go on to develop chronic pain because of the catastrophising nature of the behaviour?  Or is the opposite scenario at play, whereby the effect of being heard and having our pain validated, has a comforting  and affirming effect which disarms the hold it might have on us?  Is a support group scenario where people discuss their chronic pain a help because of the group camaraderie, or a hindrance because of it’s tendency to encourage misery and magnification?  The answer, as with most things in the pain game, probably falls into the “it’s complex” box.

The San Diego Pain Summit #sdpain brought together over 120 clinicians from eight countries. Largely made up of physiotherapist’s with a special interest in pain, it was also well represented my massage therapists, Feldenkrais practitioners, exercise practitioners and even an osteopath or two. The first event of its kind in the world, it was wonderfully put together, blending science and clinical concepts.

With my pain training coming out of Sydney University medical school, my usual ‘pain gang’ are largely medically orientated bunch, and I frequently feel that I’m having to defend my position as a manual therapist working with a chronic pain population, particularly because osteopaths are often seen as very manual technique orientated. At #sdpain it was affirming to be surrounded by people who were working in the field of chronic pain as manual therapists, confidently applying approaches such as pain education, graded movement approaches and lo and behold, manual therapy, with good clinical outcomes. I felt very at home!

Lorimer Moseley kicked off proceedings on day one with his witty, funny, engaging and incredibly relevant science and clinical information. The idolisation of the man by the group at large was evident by their engagement, the lines of people afterwards to ‘pick his brains’ and the subsequent frequent references to him and his work by virtually all of the speakers that followed. It sometimes felt like a weekend of worship at the altar of Explain Pain.

And rightly so. Moseley and his equally charming co-author, David Butler, literally ‘wrote the book’ and in doing so, started a revolution that has had a massive, world wide influence on our understanding and treatment of chronic pain, particularly in the world of manual therapy. They have lead the charge with innovative research and accessible courses showing how to apply the research clinically.

For practitioners engaging with their material, opening this Pandoras box can be both exciting and terrifying, and for many, the truth that lies in the science can make it prohibitively scary to engage with (as discussed here earlier and here by Jason Silvernail). Explain Pain helps make the transition from the dark side of a biomechanical model to the more widely excepted biopsychosocial model as pain free(??) as possible.

Jason Silvernail followed Lorimer with a beautiful, big picture overview of how getting practitioners both medical and manual, as well as society as a whole, to shift their understanding of pain, is it tough but worthwhile pursuit.

Cory Blickenstaff demonstrated how teaching patients to move within pain free ranges can help to reassure their sensitised nervous systems that movement doesn’t need to be a frightening experience.

On the final day, Eric Kruger, a US physical therapist doing a PhD in psychology at the University of New Mexico, presented ‘Pain in the face of uncertainty’. Listening to him speak, I had an urge to start high-fiving people around me, not unlike the first time I listened to Peter O’Sullivan on this pod cast whilst I was doing the grocery shopping at Coles one Sunday! He focussed around why our patient’s uncertainty about their predicament largely drives their feelings of helplessness and frustration, and how reassurance, rapport and a listening ear are more valuable than we can often imagine. He emphasised that allowing patients to express their pain is important and validating. He also strongly advocated setting expectations of flare-ups as being a normal part of the rehab process, which helps the patient to stick with the treatment approach when that inevitable first flareup occurs, rather than walking away and seeing their treatment experience as yet another failed treatment.

All of the other speakers were fantastic, and the similar themes, language and approaches that were consistently coming across in their respective modalities were reassuring. It continually demonstrated a baseline understanding that all of the speakers were operating from – that of a biopsychosocial approach played out in daily practice with every patient who walks in the door.

From a social perspective, the conference for me has been a hit! I have made many wonderful connections and have enjoyed my time in San Diego. I hope to be able to return next year and can’t recommend it highly enough.

Headaches and migraines are debilitating and costly. For people who suffer with them, it is understandable that they will want to try anything that might work. An easy fix would be lovely and pursing this is an understandably tempting option. Like most other chronic conditions however, the magic silver bullet to reduce the problem is rarely going to come from a single modality treatment such as medication or manual therapy.
Getting patients to acknowledge that there might be a mind body connection in something like back pain might be tricky. We might be able to see that there are some obvious contributors and getting that message across to the patient can be a tough but important step in making progress. However headaches is an obvious one isn’t it? It is a metaphor for stress, we even have a label for one of the more common headaches – tension type headache. It’s not always an easy sell to get this one acknowledged either. Patients will often insist that if they could just get rid of the headache, their problems would be easier to tackle or wouldn’t exist. I have been guilty of this myself – so focused on a tension headache being the cause of my heightened stress levels, chasing the quick fix with the idea that taking the headache away is the number one priority. In effect – not being able to see the wood for the trees and that the heightened stress levels are majorly contributing to the headache situation. In my case, it has sometimes taken a treating practitioner to point out this situation to me. Once this has been pointed and I have acknowledged that indeed, I am under the pump and need to address the situation, the headaches invariably go. Nothing like a personal foray into pain to help boost a practitioner’s empathy and understanding!
The science is increasingly telling the story that a bigger picture approach is the key to getting good reductions in frequency and severity of chronic headaches, as well as improving the functional losses that often accompany headaches, such as days off work.

Cognitive behavioural approaches to headaches are well represented in the literature and are acknowledged by the pain community as relatively low cost, low side effect treatment for tension type headaches and migraines.(1) A study by Paul Martin and colleagues in 2007 took 51 headache and migraine suffers and allocated them into a cognitive behavioural therapy (CBT) group, a biofeedback group and a control group. The CBT group had 8, 1 hour sessions and the intervention was found to reduce headaches an average of 68% following treatment. This was compared to a 56% reduction in the biofeedback group and 20% reduction in the control group. Furthermore, in the CBT group, the headaches continued to decrease to a 12 month follow up, whereas the other groups did not. The CBT group also had a 70% reduction in medication use.(2)

Mindfulness based approaches work really well in the chronic pain setting as part of a bigger picture approach(3). A recent study published in the Clinical Journal of Pain, looked at applying Mindfulness-based stress reduction in combination with CBT approaches in treating chronic headaches. The study demonstrated that the approach gave good outcomes for pain acceptance, pain catastrophising and helped to reduce pain interference (or functional losses to due pain). This was a pilot study but showed some very promising results. (4)

Exercise approaches for tension headache and migraine have been shown to be helpful and regular exercise is often recommended in migraine treatment. For a small proportion of the migraine population however, exercise can act, or be perceived to act as a trigger for a migraine, perhaps making them avoid exercise. A study published in Cephalgia in 2011, compared three groups of intervention for migraine sufferers – an exercise group, a medication group (Topirimate –a prophylactic medication for migraine) and a relaxation group. Good reductions in migraine frequency were seen in all three groups with no statistically significant difference between them. The exercise used was a 40 minute session of indoor cycling three times a week. Of that 40 minutes, 15 minutes was a warm up, 20 minutes was the main exercise component and 5 minutes was a cool down. It terms of risks versus benefits, this shows huge potential as it is easy to implement and has virtually no side effects, compared to some of the mild side effects seen with the medication group.(5)

So whilst we might not be able to make a big impact on these types of headaches with our hands in the longer term, we can certainly be incorporating these approaches in our practice, even if it is in the form of case management – where we oversee the treatment approaches and refer to appropriate practitioners. Alternatively you may be able to implement exercise approaches either within your clinic or together with the patient as a home exercise program. Starting patients on mindfulness meditation is a no-brainer and essentially is a free kick at goal for the results you can achieve versus the effort and cost to implement it. You can use something like the smiling mind app and website to help get things going.

You may be able to refer your patient to a psychologist for some cognitive behavioural therapy.  Our listening ears and a good referral base of practitioners in this case are the thing that is most likely going to give good outcomes for the patient. The impact that this can have should not be underestimated.

1. Rains, J., Penzien, D., McCrory, D., & Gray, R. (2005). Behavioural treatment: History, review of the empirical literature and methodological critique. Headache, 45(Suppl.2), S92-109.
2. Martin, P., Forsyth, M., & Reece, J. (2007). Cognitive-behavioural therapy versus temporal pulse amplitude biofeedback training for recurrent headache. Behavior Therapy, 38, 350-363.
3. Mars, T., & Abbey, H. (2010). Mindfulness meditation practice as a healthcare intervention: A systematic review. International Journal of Osteopathic Medicine. 13(2), 55-66.
4. Day, M., Thorn, B., Ward, C., Rubin, N., Hickman, S., Scogin, F., & Kilgo, G. (2014). Mindfulness-based cognitive therapy for the treatment of headache pain. A pilot study. Clinical Journal of Pain, 30(2), 152-161.
5. Varkey,E., Cider, A., Carlsson, J., & Linde, M. (2011). Exercise as migraine prophylaxis: A randomized study using relaxation and topirimate as controls. Cephalgia. 31(14), 1428-1438.

I seem to be seeing my fair share of patients presenting with headaches at the moment – this last week roughly half of my clinic time has spent working with patients presenting with a headache on its own, or in combination with other musculoskeletal complaints. There are a couple of things that I feel are important for breaking a headache cycle –
• The person needs to acknowledge a connection between their emotions/stress levels/current situation and how that is contributing to their headache
• They need to have some level of “body awareness” – to be able to tune into where they are holding tension in their body (jaw, shoulders, upper neck etc) and be therefore able to consciously relax that area.

Creating awareness around these areas can be a difficult task – some people walk in the door and are already on board with the ideas, telling you that things have worsened since circumstances have changed such as increased work hours or a stressful situation has reared its head. For other people, I sometimes feel like I am bashing my own head against the wall trying to get these concepts across – particularly for those who have some strongly entrenched ideas around the neck being the cause of their headache. These patients are often stuck in passive mode, believing that it is the practitioners’ job to take the headache away for them. They tend to have a cause and effect understanding about their headache which usually goes along the lines of “my neck is out/tight/sore and therefore I have a headache”. But the reality is, as discussed last time, a true cervicogenic headache is actually not that common. We will often be seeing patients with a tension type headache, who are also experiencing concurrent upper cervical pain, due to the way that the information from the head and neck are processed in the brain, particularly at the trigeminocervical nucleus.

One patient summed up the attitude that I felt I had been dealing with all week – “I haven’t got time for a headache”. A busy, self employed designer, working to some pretty tight deadlines, doing 15 hour days at the computer, sleeping in the spare room so as not to wake her partner when the insomnia was bad…………. You know the story! It took three weeks of both her GP and I saying the same things before if finally sunk in and she made some changes – we need to address the mechanical factors (time and posture at the desk), the stress levels (do your daily mindfulness exercises, make that appointment with the psychologist you have been saying you will do, schedule some down time into the diary) and for goodness sake, get some exercise! The absurdity of that statement and ironic laughs that followed probably helped to put it all into perspective for her.

So what does the literature tell us about treatment of headaches, particularly the persistent ones?
As discussed previously, a true cervicogenic headache will tend to respond fairly well to manual therapy and manipulation approaches as well as exercise approaches. A study done by Jull in 2002 (1) demonstrated that in a group of 200 subjects with a diagnosed cervicogenic headache (change in cervical range of motion, reduced control of craniocervical flexion muscles and pain on palpation of C0-C4) significant reductions in headache frequency and intensity were see in in both musculoskeletal therapy groups and specific muscle exercise therapy groups when compared to the control group. Furthermore, combining both exercise and manual therapy gave good relief to 10% more people than in the single intervention groups. Similarly a study by Haas in 2010 (2) demonstrated good reduction in cervicogenic headaches with weekly cervical manipulation, however doubling the number of treatments to two per week gave no further significant improvements.

In treating migraine headaches there is limited high quality data available regarding manual therapy interventions. Some lower quality studies demonstrated that manipulation was as effective as Amytriptyline (an older style antidepressant, often used in low doses for chronic conditions like migraine) in preventing onset of migraine. Another showed that mobilisation of the neck would have an effect on reducing migraines, but manipulation was no more effective than the mobilisation (3).

Several review articles (4,5) tell us that manual therapy is not effective for treating tension type headaches, however both reviews acknowledge that the studies included were of poor quality and therefore drawing solid conclusions about this is not possible. The tricky bit probably lies in the difficulty in accurately diagnosing a headache, given that frequently there are overlapping features of several types of headaches. See here for a reminder on the clinical features of the different types of common headaches. The answer to whether manual therapy is always the way forward is therefore going to be along the lines of how we answer this question for most chronic conditions – probably not on its own, but in conjunction with other approaches there is certainly a strong justification for its use. Manual therapists are going to be well placed to put together a management program that can combine these approaches and manage their implementation.

Mindfulness exercises, psychological approaches and exercises approaches are fairly well represented in the literature and show some really promising results in the treatment of a variety of different types of headaches, including migraines. Next time we will look at what these approaches are and how you can start using some of them in your private practice.

1. Jull, G., Trott, P., Potter, H., Zito, G., Niere, K., Shirley, D., Emberson, J., Marschner, I., & Richardson, C. (2002). A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine, 1:27(17), 1835-43.

2. Haas, M., Spegman, A., Peterson, D., Aickin, M & Vavrek, N. (2010). Dose-Response and Efficacy of Spinal Manipulation for Chronic Cervicogenic Headache: A Pilot Randomized controlled Trial. Spine, 10(2), 117.

3. Posadzki, P., & Ernst, E. (2011). Spinal Manipulation: an update of a systematic review of systematic reviews. New Zealand Medical Journal 12:124(1340), 55-71.

4. Bronfort,G., Haas, M., Evans, R., Leininger, B., & Triano, J. (2010). Effectiveness of manual therapies: The UK evidence report. Journal of Chiropractic and Osteopathy. 25, 18.

5. Fernandez-de-Las-Pena, C., Alonso-Blanco, C., Cuadrado, M., Miangolarra, J., Barriga, F & Pareja, J. (2006). Are manual therapies effective in reducing pain from tension-type headache?:a systematic review. Clinical Journal of Pain, 22(3), 278-85.

Headaches are frequent causes for presentations at most manual therapy clinics.  Headaches can be debilitating, annoying and all encompassing, be they migraine, tension type headaches, cervicogenic  or the less common autonomic cephalgias such as cluster headaches (sometimes called suicide headaches). People will frequently seek out manual therapy because when their head hurts, they also will tend to have neck pain.  Studies tell us that 64-70% of people with headache and migraine will also have neck pain ¹.

Is the neck the cause of the headache?

In some cases, yes.  In reality though, cervicogenic headaches actually make up a fairly small proportion (18%) of the headache sufferer population ².  To be classified as a cervicogenic headache (and be therefore most likely to respond to manual therapy) the headache must be precipitated by neck movements or postures and/or pressure over the upper cervical/ occipital regions, have restriction in neck ROM and have weakness in the deep cervical flexors.  Cervicogenic headaches are also typically side dominant and don’t throb³.

Typically, manual therapists tend to place a lot of emphasis for diagnosis of a cervicogenic headache on the ability to reproduce the headache with palpation of the upper cervical region.  However this is a bit of an erroneous test because we know that almost 100% of patients with either a tension type headache or a migraine will also get reproduction of their headache with palpation of the upper cervicals⁴.   This is most likely due to the phenomenon of convergence at the Trigeminocervical nucleus(TCN) , where information from both the upper three cervical vertebra and the trigeminal nerve feed into the same region in the brain.  Like other types of convergence or referred pain, the brain can’t figure out where the pain is coming from and so both can tend to be painful.  In the chronic headache sufferer, the TCN undergoes central sensitisation processes, making it more likely to interpret and pass on information of a painful nature.

The literature tells us that physical treatment for headaches tends to only give sustained benefit to those people who genuinely fall into the cervicogenic headache category ⁵ .  However, as practitioners we have all seen instances when some level of relief from manual therapy has been achieved for a headache that falls outside of these categories, including for those suffering from tension type headaches.  In these instances, we are probably having a modulatory effect on the TCN.

As an occasional tension headache sufferer, I would argue that any benefit that can be achieved from manual therapy for a non cervicogenic headache  is  fantastic and is worth pursuing – with the caveat that both the practitioner and patient understand the context of use – to provide temporary relief as part of a bigger picture of treatment.  We should not be suggesting that we can comprehensively treat all types of headaches using manual therapy alone.  As in all chronic conditions, passive approaches such as this are not the answer.

The literature is very good at telling us what doesn’t work for a particular condition, and headaches are no different in this instance.  In the next blog post we will look at some of the approaches that are known to have an effect on headache frequency, intensity and medication use.  Surely all this research has to be good for something!

1. Blau, J., MacGregor, E. (1994). Headache and the neck.  Headache, 35(2), 104-106.
2. Nilsson, N. (1995). The prevalence of cervicogenic headache in a random population sample of 20-59 year olds. Spine, 1:20 (17) 1884-1888.
3. Hall, T., Briffa, K., & Hoppa, D. (2008). Clinical evaluation of cervicogenic headache: A clinical perspective. The Journal of Manual and Manipulative Therapy, 16(2) 73-80.
4. Watson, D., & Drummond, D. (2012). Headache pain referral during examination of the neck in migraine and tension-type headache. Headache, 52(8), 1226-35
5. Bronfort,G., Haas, M., Evans, R., Leininger, B., & Triano, J. (2010). Effectiveness of manual therapies: The UK evidence report. Journal of Chiropractic and Osteopathy. 25, 18.

Exercise is an essential part of any rehabilitation approach to chronic pain. 

Our clinical experience as well as the literature tells us that it works ^1,2.

Further to this, there doesn’t seem to be much evidence to tell us which exercise works best – whether we choose motor control type exercises, graded strength based approaches or even aerobic exercises. Regardless of what exercise you choose, you are likely to see improvement in pain and function ³.

Start With Success

When we are setting someone up with an exercise program as part of a management program, it is incredibly important that we put a lot of effort into making sure that the program is going to be ongoing. 

In the event that they don’t stick with the exercise program and stop doing it before it can start to have the anticipated positive effects, the take home message for the patient is “exercise doesn’t work for my pain”.  

It becomes for them yet another failed treatment and can feed into the cycle of hopelessness that many chronic pain suffers experience.  By having a half-hearted go at exercise and failing, it may have inadvertently done more harm than good.

Engage Your Patients

Research tells us that adherence to home exercise programs on the whole is an uphill battle, with up to 70% of patient not engaging in prescribed home exercises ⁴.

Efforts to increase compliance such as involving the patient in the planning and goal setting process, formally establishing motivation and compliance, exploring the patient’s beliefs about exercise and pain, planning for and troubleshooting obstacles and setbacks and regular follow ups to check compliance have been shown to dramatically improve adherence to exercise programs ⁴.

Teamwork Makes The Dream Work

For people who haven’t got a strong exercise history, starting out with a high level of support is going to mean better adherence in both the short and long term.

Telling someone to start exercising, without much guidance or support is likely to last about two weeks – until the rain, cold, dark, sickness, increased pain or countless other obstacles rear their ugly head. 

Your Guide To Success

Specifically, to increase your chances of getting an exercise program to stick the following can be helpful:

• Establish motivation – why are you here? What do you want to get out of this?
• What do you enjoy doing? What fits in with your lifestyle? What are you likely to stick with?
• What do you understand about your pain and how exercise effects it and vice versa?
• Try to make sure the exercise is scheduled, especially for the first few months. This might mean that the person attends a class, personal training session, clinical pilates, small group training, bootcamp, crossfit etc. When it is scheduled into their diary and they are expected to attend, the chances of them turning up are greater.  This is often even further evident when there is a financial commitment attached to that session (ie. they still pay for the session in the event they don’t turn up!). If the sessions are not as individualised as something like a personal training session, getting them to create a diary entry for something like a gym class is the next best thing.
• Having a high level of supervision, particularly in the early phases can be really helpful in building confidence. This is particularly important when there is a level of fear avoidance.  If there is someone qualified who can confidently say to the client that the exercise they are doing is safe and won’t be causing damage, they are more likely to engage in the exercise even if there is some pain associated.   There is also greater chance that the exercises will be appropriately progressed and therefore you will see better results.
• For people who are struggling to see the value in, or are unable to afford these types of highly supervised sessions on an ongoing basis, I often suggest that they start with a period of 8-12 weeks on such a program and then review it. More often than not, when the review time comes around, they have seen the value in the sessions and the results that are happening. They will often be happy to continue because they are enjoying the progress they are making.  If they choose not to keep going, you have at least got a level of habit, some confidence and success, to keep going on a slightly less supervised program.
• Making a fairly direct referral to the exercise practitioner also helps with the uptake of your suggestion. If you are referring to someone that you know and trust, and can help the person to facilitate contact with that person, you can help smooth the way to the start of their journey.  When they are aware that you trust the practitioner, they will have a greater level of confidence in them too.  This works particularly well when you have your rehab options “in-house” but can also work  with some well established local networks.

Upcoming Seminars

Check out our upcoming events for details on future seminars and workshops that cover topics like goal setting and pain education.

References

1. Van Middelkoop, M., Rubinstein, S., Verhagen, A., Ostelo, R., Koes, B., & van Tulder, M. (2010). Exercise therapy for chronic nonspecific low back pain. Best Practice and Research Clinical Rheumatology, 24, 193-204
2. Hayden, J., van Tulder, M., Malmivaara, A., et al. (2005) Exercise therapy for treatment of non-specific low back pain.  Cochrane Database Syst Rev, (3). CD000335
3. Gazzi Macedo, L., Latimer, J., Maher, C., et al.(2012). Effect of motor control exercises versus graded activity in patients with nonspecific low back pain: A randomized controlled trial.  Physical Therapy, 92 (3), 363-377.
4. Beinart, N., Goodchild, C., Weinman, J., Ayis, S., & Godfrey, (2013). Individual and intervention-related factors associated with adherence to home exercise in chronic low back pain: a systematic review.  The Spine Journal, 13, 1940-1950.