Our Ask A Physio series is a collection of microblogs aimed at giving a basic understanding of some frequently asked questions. If you have an injury or are experiencing discomfort please book an assessment or contact reception for more information.


Why do we collect soo much health history & background?

We always used to hear at university that a good history is 90% of making a good diagnosis, and we really put this to the test with our online appointments over the COVID lockdowns! Of course, it is true, and even some of the things you might think are small talk (where do you work, do you have kids, what are your hobbies) give us tons of information about picking and solving your issue. We even got some interesting research over the lockdowns, showing that taking away our physical tests made a tiny if any difference in how accurate we were.

Generally, by the time we’re done taking a history we like to have narrowed things down to 2 or 3 likely suspects, which means that we don’t have to use every physical test under the sun on your sore body! That’s also why we like to run long initial appointments, a good history will often take 15 minutes or more, and a good history makes for an easy and accurate diagnosis.

HOW DO I GIVE MY HIPS & KNEES THE BEST CHANCE OF SURVIVAL?

Osteoarthritis is the medical name for the changes which happen in a joint with age. In most people, this process plays out as a natural part of aging, and is really nothing to worry about (no more so than grey hair and wrinkles!). In some people, osteoarthritis can start to become painful, and it's a pretty common reason for seeing your GP or physiotherapist. While we can’t cure arthritis, there’s plenty we can do in terms of exercise and lifestyle to manage it well. Joint replacements are often discussed as a potential treatment, but it's not just as simple as swapping out a mechanical part. It involves a pretty substantial surgery, a years worth of rehab, and the new joint will need replacing again after roughly 15 years.

In the past, we’ve always thought of arthritis as being mainly a mechanical issue, wear and tear. This has always made exercise sound a bit counterintuitive, why would you exercise on a joint which is already worn out from too much use? More recent research has found out that rather than worrying about the wear, we should be thinking of osteoarthritis as being in the same camp as things like high blood pressure, type II diabetes and heart conditions. For this reason, regular general exercise, at least 30 minutes every day is essential.

On top of general exercise, we also know that specific strengthening of your thigh, buttock and trunk muscles can take some pressure off the sore joints, and make them last longer. These can range from simple squeezing exercises all the way to weighted squats. This is where it's worthwhile checking in with a physiotherapist, too much or too little strength work will be like taking medication at the wrong dose.

Lastly, your general health and wellbeing plays a huge role in the comfort and health of your joints. Your GP is your best port of call for general check ups and pain relief. Getting a nutritionist or dietician to take a fine tooth comb over your diet is also really helpful and worthwhile. Body weight and general inflammation play a huge role in making arthritis better or worse, and even small changes to your diet can make a huge difference.

We know that people who make a sustained effort with their general fitness, strength, general health and lifestyle can put off joint replacements for years, or even get rid of the need altogether!

Compiled by our Masters trained Physiotherapist Chris Smith. To book an appointment with Chris, or read his Meet the Team profile CLICK HERE


Why am I still in pain?

In a previous blog we explained why things hurt and how the bodies' pain system works. In this blog we will explain what persistent pain is, how common it is and why our pain systems sometimes still remain active when our injuries may have healed.

What is persistent pain?

As humans it makes sense to have a pain system as an alarm to warn us when we have injured our body. The pain signals us to change our behaviour and rest in order to allow our injuries to heal. Most soft tissues within the body including muscle, ligament, tendon and bone will heal in approximately 12 weeks, and therefore you would expect that as the injured tissue heals the corresponding pain signal we experience reduces in intensity to advise you to increase what you do without coming to further harm. The trouble is this doesn’t always happen!

Infact, up to 25% of people's pain still remains once the healing should have occured. Pain that does not settle in 3 months is termed chronic or persistent pain. To understand why this occurs we need to know a little more about our bodies pain systems. Electrical signals picked up in the injured tissue by pain cells (nociceptors) are passed into the spinal cord and then up to the brain for processing. Pain science has shown us that within the spinal cord and brain 2 types of sensitisation can occur which can amplify and prolong our pain experience. These are called peripheral and central sensitisation. 

Sensitisation

Peripheral sensitisation means increased pain sensitivity to movement or pressure in the area where the injury occurred. The injured area becomes sensitive to movement and touch that would usually be non-painful. This is a normal response and helpful following an injury. However, the longer your nervous system produces pain, the better it gets at producing it. Your body learns pain! This process is called central sensitisation and occurs in the central nervous system (brain and spinal cord). Think of a sensitive car alarm going off with a strong gust of wind. The gust of wind (movement) is not dangerous anymore, but the car alarm (brain) is too sensitive. This type of sensitisation can keep driving pain long after the initial tissue healing has occurred and can go on for months and even years.

Scientists think that both genes and environment play a role in explaining why some patients develop central sensitisation and persistent pain and some do not. It is likely that the way humans perceive and make sense of their pain experience may lead to persistent pain. Our pain centres are in our brain and the brain also processes our thoughts and feelings. Stress, worries, fears and beliefs about the pain may all lead to prolonged pain. The pain can also have a wider impact on our lifestyle, jobs, relationships and hobbies, all of which can create worry, depression and frustration. These feelings can actually keep the pain system sensitised in the brain. It is well known for persistent low back pain for example that low mood, anxiety and depression and worries of long-term disability are associated with developing persistent pain.

How do I know if I have central sensitisation?

Firstly, if your pain has gone on for more than 3 months it is likely that some degree of central sensitisation may be occurring. There are some other signs also. If pain becomes more widespread and if it can be affected by lifestyle stressors easily then you may have central sensitisation. Also, if you’ve become more sensitive to stimuli that impact the nervous system. These may include movement, exercise, noise or light.

How do we help with persistent pain?

When managing persistent pain everyone's individual situation is different and will require a tailored approach. As physiotherapists we need to look at things more broadly in addition to specifically at the original injured area. Through asking further questions about lifestyle such as sleep, stress, beliefs, fears and general health we are likely to be able to suggest techniques to help calm down the pain. Techniques such as graded exercise, sleep hygiene, relaxation, meditation and mindfulness are essential to promote a calm environment for the pain to settle.

In addition it is important for patients to have a basic understanding of how pain works because once you understand why your pain remains and how common it is it can instantly make it less scary, worrying and reduce anxiety around the issue. The more you understand, the more empowered you feel to manage the pain.

As physiotherapists with holistic knowledge of pain science, psychology and physical activity and lifestyle we are well placed to treat people with persistent pain, Therefore, if you’re struggling with a persistent pain problem come in to see me or a member of our team for an assessment to see how we can help you move forwards.

Compiled by our Masters trained Physiotherapist Chris Smith. To book an appointment with Chris, or read his Meet the Team profile CLICK HERE


Understanding the type of pain I'm experiencing and what it might mean?

Today we're going to talk about pain! Although most of us don't like the sensation, pain plays a vital role in protecting us and is necessary for our survival. Pain is a universal human experience and is defined as "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage" (IASP). But what can the type of pain tell us? Can it help us to identify which tissues are causing the pain and can it guide how we target treatment? Well yes and no, it can certainly give us some clues, hence why physiotherapists spend time in your initial assessment asking so much about pain.

How does pain work?

Before we start, pain is a complex topic and the world's leading researchers are still learning more every year. Most tissues in the human body including ligament, muscle, tendon, bone, and nerve all have the ability to produce pain. The 3 main stimuli that produce pain are mechanical, thermal and chemical. For example when you overstretch and roll your ankle (mechanical stimuli), when you burn your hand (thermal) stimuli.

When a tissue is damaged, such as when a ligament is strained, sensory pain receptors (nocioreceptors) in that tissue start a process and send signals into your central nervous system, where it travels up your spinal cord to your brain. Here the decision is made how much of a pain experience to produce in the injured tissue based on many factors such as past experience, beliefs etc. This process is called nocioception.

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This is usually a good thing as a pain response prompts us to change our behaviour and allows for rest and recuperation of damaged tissue.

Types of pain

Broadly speaking pain can be classified into nociceptive pain, neuropathic pain and other pain, such as visceral pain from organs.

Nociceptive pain

This is the term for pain arising from various kinds of injury in the tissues, reported to the brain by the nervous system. This is the most common type of pain most people are most aware of - anything from stubbing your toe, straining your back or burning your hand.

This can be split further into mechanical and inflammatory pain. These types of pain can present differently and the characteristics can help in differentiating the painful tissues. For example low back pain that is present with a certain movement, but absent otherwise indicates that the low back tissues are responsible for the pain. Also, knee pain which is present only when loading the joint during walking may lead a clinician to diagnose a joint based condition such as osteoarthritis.

However, pain that is more constant in nature may have an inflammatory component. This is quite normal following a tissue injury as there is a natural inflammatory process in order to promote tissue healing. However, when constant pain starts without a tissue injury it may be that an inflammatory condition is primarily responsible for the pain. Examples of this would be rheumatoid arthritis or gout.

Neuropathic (nerve) pain

This arises from damage to the actual nervous system itself. This could be the nerves that supply the skin/muscles (peripheral nerves) or the central nervous system (brain/spinal cord). The most common examples of this are pinching or compression of spinal nerves by a disc prolapse in the spine or hitting your funny bone. Disease of the brain from stroke and multiple sclerosis can give central neuropathic pain. It's often stabbing, electrical, or burning, but nearly any quality of pain is possible making it sometimes difficult to differentiate from nociceptive pain. The presence of sensory changes such as pins and needles/numbness/tingling and weakness can differentiate this type of pain.

Pain descriptors

We are often asked if pain descriptors (such as sharp, dull, aching) can guide us to the source of the tissue damage. Research has shown this can be quite difficult and unreliable in humans, especially with nociceptive pain and the classic "feels like a pinched nerve" could just as likely be produced from a disc, ligament of joint. There are some cues as mentioned above for neuropathic pain which can be useful in guiding diagnosis. However, using the subjective pain information in addition to assessment findings is essential to making a more accurate diagnosis.

Acute and persistent pain

Most often the pain signal reduces in intensity as the tissues heal (often 6-12 weeks), however sometimes as the tissues heal the pain signal still stays heightened (in 25% of people). Pain that does not settle in 3-12 is termed chronic or persistent pain, and this is likely due to the nervous system response remaining heightened after tissue healing has occurred. This is termed central (nervous system) sensitisation and can be thought of as the volume on an amplifier being turned up too high. Or like a sensitive car alarm going off with a strong gust of wind. The gust of wind is not dangerous anymore, but the car alarm (brain) is too sensitive. Physiotherapists and healthcare professionals can use techniques to reduce the sensitivity of the nervous system and help with this persistent pain.

Pain management

The good news is whether your pain is acute or persistent it is possible to get it under control. Speaking to a health professional and having an assessment will allow a physiotherapist to understand more about the drivers of your particular pain and situation. This will enable a personalised management plan to be produced to target your pain. So if you're in pain right now make an appointment to come and see myself or one of our team who are experts in pain management.

Exercise: The Forgotten Medicine

It was once said by the US Chief Medical Officer that if exercise was a pill it would be a billion dollar industry. This is not an understatement, physical activity really is the equivalent of a wonder drug, and without the negative side effects of many of its pharmaceutical counterparts. Exercise has been demonstrated to have positive impacts on multiple body systems including the cardiovascular, gastrointestinal, musculoskeletal and neurological system.

Cardiovascular - Regular physical activity increases the efficiency of the specialised heart muscle allowing it to pump oxygenated blood to all your body tissues easier. Regular physical activity also leads to increased lung capacity, increased number of functioning alveoli in which gas exchange occurs and improved strength of respiratory muscle including the diaphragm and intercostal muscles. All this allows for improved function of the cardiorespiratory system and increased cardiovascular fitness.

Musculoskeletal - Regular physical activity can have positive impacts on various soft tissues including bone, muscle, ligament and tendon. Increased mechanical stress on soft tissue causes cells within these tissues to increase production of collagen leading to increased tensile strength of these tissues. This process is known as mechanotherapy and can be used to explain why tissues increase strength in response to mechanical load and why exercise prescription is such a key part of a rehabilitation program with a physiotherapist. Likewise gradual increase in mechanical loading can increase bone density so long as sufficient opportunity is allowed for rest and bone cell production in between loading cycles. In relation to muscle regular exercise provides a training stimulus which leads to an increase in the ability of the nervous system to recruit more muscle cells to provide a contraction, leading to increased strength. An increase in muscle size (hypertrophy) is due to increase in muscle cell size following repeated bouts of exercise, followed by sufficient rest.

Neurological - Physical activity has been associated with reduced risk of alzheimer's, dementia and improved cognitive function, likely due to improved vascular supply to brain tissue. Regular physical activity is also associated with improved mental health and reduced rates of anxiety and depression. Exercise leads to the release of various endorphins and neurotransmitter chemicals responsible for improving mood and reducing pain. In addition to the likely hormonal and chemical contribution to improved mental health with exercise, it can also improve self-efficacy and provides opportunity for social interaction with others, a factor which is important in managing mental health. Exercise also has been demonstrated to regulate appetite and sleep pattern.

Given the range of body systems on which exercise helps the human body it is not surprising that it has been shown to help in the management of various medical conditions such as obesity, Type II diabetes, stroke, cardiovascular disease, anxiety and depression in addition to a variety of musculoskeletal conditions such as arthritis, spinal pain and tendon issues to name a few.

Recommendations for exercise:
The World Health Organisation (WHO) are the global experts in managing the health of humanity. Given that lack of physical activity and preventable health conditions is seen as a crisis by the WHO, it's not surprising that in 2020 they reviewed their guidelines for physical activity. For adults aged 18-64, at least 150–300 minutes of moderate-intensity aerobic physical activity are recommended weekly or 75–150 minutes of vigorous-intensity aerobic physical activity. In addition to this, adults should also do muscle-strengthening activities that involve all major muscle groups on 2 or more days a week.

Timeframes:
Research shows that it takes on average 66 days to create a new habit forming behaviour, although this number varies widely between individuals (see here). Furthermore, in terms of fitness, after 2-4 weeks people start noticing changes in their strength and fitness when exercising. However, changes in body composition and muscle size more often take 12 weeks on average.
So, if you stick past the first month then your strength and fitness should improve, stick past the 2nd month and the exercise should become a habit. Once things are a habit they become a lot easier to maintain as part of managing our long-term health.

Type of exercise:
There are no suggestions for specific types of exercise. The key is finding something you enjoy and can stick to to make it a habit and part of your life in order to prolong and manage your health throughout your life. Get creative, do what you love! If you don't know where to start or are nervous, get myself or any of the physiotherapists or personal trainers at Auckland physiotherapy to help you. We also offer pilates classes which keep you healthy and moving and are fun at the same time. Win, win!

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