Chronic pain: What you need to know
At the end of this month, we celebrate National Pain Week. So, this month we’re going to look at chronic pain – something that 3.24 million Australians live with day in, day out. When you are living with chronic pain, life can be difficult. Getting out of bed in the morning, going to work, parenting… Pretty much everything can become very hard work. Being in pain for a prolonged period can be debilitating and can have huge impact on a person’s life.
In 2018, the total running healthcare costs relating to chronic pain across Australia topped $139 billion! And unfortunately, it is predicted that by 2050, more than 5 million Australians will be living with chronic pain. And, as research tells us, women experience chronic pain more than men. Women are generally more sensitive to pain and report more widespread and higher intensity of pain than that of their male counterparts. It is interesting though that women tend to accept their pain and get on with things, whereas men tend to become more depressed when in pain. So, man flu is a real thing!
As physiotherapists, treating chronic pain is part of our daily working life. Understanding chronic pain is complicated and requires some in-depth training. So, to make things a little easier to understand, we’ve put together this blog to help break it all down and give you a little introduction to what chronic pain is all about.
So, what is pain?
This seems like a good place to start. Pain is something us humans and other animals on the planet are fortunate enough to experience. Fortunate? Bear with us. Pain is so crucial because it is our body’s protection mechanism. Interestingly, sometimes we can even feel pain before we get to the injury stage – it can act as a red flashing warning light! Once injured, pain will hang around for a little while to remind us that we need to protect the injured area from further damage – so that we can heal. It’s probably the most state-of-the-art alarm system you’ve ever come across, and the answer is sitting inside your skull. Yes, you guessed it, you have your brain to thank for all of this :).
So, I hear you ask, ‘why are we so fortunate to feel pain?’ Well, there are a small minority of people on this earth who cannot and have never felt any pain at all. These people may have one of a group of very rare conditions called Congenital Insensitivity to Pain (CIP). Some people might think this is pretty cool, but this is a very serious condition, and many who are born with it have a shortened lifespan because potentially fatal injuries and illnesses can go completely unnoticed. People with CIP wouldn’t know they had just stood on that rusty nail, or that they have just sliced open their arm or leg. Pain is literally a lifesaver.
For ease of understanding, pain tends to be categorised based on time. ‘Acute’ pain is pain that is felt any time from injury up to the six-week mark. ‘Sub-acute’ pain (a sub-category of acute pain) is pain felt anywhere between six weeks and three months. ‘Chronic’ pain is pain that is felt for three months or longer. Let’s have a quick run down …
We feel acute pain when we fall and graze our skin, twist on the netball court and sprain our knee ligaments, or when we slice our finger with a knife when cooking. When this happens, special sensors around the injury site detect that all is not right and send a message along the nerves to the spinal cord and up into the brain. Your brain processes this information at lightening quick speed and then sends a message back to the injury site as a pain signal and you wince or yell out (and possibly curse). As time progresses over the following days and weeks, the injury heals, and the pain disappears. Along the way, your brain forms a memory of the unfortunate event. This makes you more aware and helps you to avoid similar dangerous situations in the future. State of the art indeed!
Remember the definition for chronic pain – pain that is felt for three months or longer. This pain is also sometimes called ‘persistent’ pain, because it is just that – persistent! In many instances of chronic pain, it is pain that is felt beyond the bodies normal tissue healing times. As an example, a mild to moderate knee ligament sprain takes approximately six weeks to heal. Sometimes people who have injured their knee still get pain months after the injury has healed. They have entered the realms of chronic pain. Things become more complex because by this stage there may well be involvement of different bodily systems. And, most importantly, the person’s belief about what pain is has a huge impact on their recovery. There may also be unrelated issues, such as arthritis that is impacting on recovery or hasn’t been previously diagnosed.
The development of chronic pain is a complicated process. In a nutshell, the healing of tissues has already occurred (as discussed above), yet the brain still thinks there’s a threat. This is due to changes in the nerves carrying signals to the spinal cord, and changes in the spinal cord itself. Basically, these nerves become highly sensitised and end up sending misleading information to the brain. The brain perceives this information as still threatening, and the result is ongoing pain. Ultimately your nerves are ‘tricking’ your brain into thinking you’re injured. We would like to point out that it is much more complicated than that, but this gives you the basic idea of what is happening.
It is important to understand that when someone is in pain for long periods of time, they can start to become affected in other ways. Depression and anxiety resulting from chronic pain is very common. A person’s beliefs about pain will begin to affect their behaviour also. For example, a netball player with the knee ligament injury, once playing again, may avoid certain movements due to fear of re-injuring themselves. In psychological terms, this is known as exhibiting fear avoidance behaviours, and can keep the cycle of pain going for longer than necessary.
Treating chronic pain
The longer the cycle of chronic pain persists, the more difficult it becomes to treat. Unfortunately, treatment is not as simple as applying first aid principles. Of course, treating someone’s movement dysfunctions and getting their strength and flexibility levels right are very important, but treating the resultant depression and anxiety, and educating the person on what changes have occurred in their body so they can change their beliefs about what pain is, is just as important, if not more.
Until all contributing factors of a person’s chronic pain cycle are dealt with in some way, it is unlikely the cycle will be broken. Therefore, treating chronic pain rarely comes down to just one profession or practitioner. In most cases, it requires a multi-disciplinary approach to treatment. We as physiotherapists play a crucial role, but a person may also require the services of a psychologist, their GP and possibly other specialists too. Pain medications may be prescribed by your GP to help control pain levels, but the debate on how effective strong pain medications are in the instances of chronic pain is still out.
Your physio is an expert at re-training your body to move properly and get stronger and more flexible. We will use our hands to affect your muscles, joints and skin, as well as prescribe you exercises to get you on the path to optimum movement and health. These will include exercises relating to strength building, flexibility, posture and breathing. We may also give advice on how to improve your sleeping and diet, to make sure your body is getting the correct amounts of rest and nutrition it needs to function. Most importantly though, we will sit you down and educate you on what exactly is going on with your body so that you can begin to understand it yourself and start the process of beating chronic pain. It will be a big team effort, and the results will be totally worth it.
We hope you found this blog a worthwhile read. If you would like to know more about chronic pain or National Pain Week, please visit http://www.nationalpainweek.org.au.
Afraid to laugh out loud? Incontinence help is here!
Hello ladies, it’s blog time again! To celebrate World Continence Week (17th-23rd June), we thought what better topic than the pelvic floor and incontinence. For those of you who are not familiar with this condition, incontinence is the term used to describe uncontrolled loss of urine from the bladder or faeces from the bowel. It’s a tricky problem to get people to speak out about because as you can imagine, for the majority it is quite an embarrassing thing to have to admit.
Let us assure you, if you are experiencing such a problem, you share this problem with over 5 million other Australians. In fact, 1 in 4 people over the age of 15 are incontinent, and females account for 80% of cases of urinary incontinence alone. Shockingly common right?! Well the good news is, help is at hand. The majority of cases of incontinence respond very well to conservative, non-surgical treatment and can often be completely resolved. Interested to know more? Then please read on…
Types of incontinence
It is important to know that there are different types of incontinence, and the management for each is different based on the cause. Briefly, the different types of urinary incontinence include:
- Stress urinary incontinence (SUI) – the most common form, where small amounts of urine leak due to small increases in pressure on the bladder during physical activity, or from coughing, sneezing and laughing.
- Urge incontinence – where you get an unexpected, strong urge to urinate with little to no warning. This is usually as a result of an overactive bladder muscle.
- Incontinence associated with chronic retention – where your bladder cannot empty fully, and you get regular leakage of small amounts of urine. There are many causes for this, including an enlarged prostate in men, or prolapsed pelvic organs in women, as well as medications and certain conditions, such as diabetes and kidney disease.
- Functional incontinence – where you are unable to get to the toilet, possibly due to immobility, or wearing clothes that are not easy to get off in time.
Faecal incontinence is when you have a lack of control of bowel movements and you may accidentally pass a bowel movement, or even pass wind without meaning to. This may be due to weak muscles surrounding the back passage (ladies, unfortunately this can be following pregnancy and childbirth), or if you have severe diarrhoea.
Why so many females?
In short, babies and menopause! The most common type of incontinence that we see and treat is stress incontinence. Although seen across both sexes, women are three times more likely to experience it than men. It is very common in women following pregnancy and childbirth (when the pelvic floor muscles get overstretched, and sometimes even damaged), and during menopause (due to hormonal changes).
Pregnancy, birth and menopause can affect our pelvic floor. The pelvic floor muscles sit at the bottom of the pelvic bowl, spanning from the pubic bone to the tailbone (front to back), and from one sitting bone to the other (side to side). Imagine a trampoline stretched out and attached to each bony point and you kind of get the gist. When these muscles are strong, they help to support our internal pelvic organs (i.e. the bladder and bowel, and uterus in women) and wrap around the openings of the front and back passages, allowing us to control when we decide to do a number one or two. Following pregnancy for example, they may become weak and dysfunctional, and we can lose that ability to control voiding. It only takes something as small as a cough, or an activity like jumping or running (things many of us take for granted) that may cause a person to lose a small amount of urine.
There are a number of treatment options that could help. What is most important is that you come and see us first, so we can understand the issue and figure out the best course of treatment. Some treatment options include:
- Pelvic floor and strengthening exercises
- Manual therapy
- Biofeedback (to monitor your muscle activation)
- Weight loss
- Reducing caffeine or alcohol
- Fluid altering
- Bladder training
- Quit smoking
- Surgery or other procedures
We hope you have found this blog interesting and helpful. Please join us in celebrating World Continence Week and help us to raise awareness for people living with incontinence. If you, or someone you know is looking for answers or advice on the management of these conditions, then please get in touch. We are ready to offer professional advice and/or treatment. No more leaking when laughing!
Healthy hips are here to stay
April is here, and with that comes Healthy Hips week (1-7 April), so we thought we’d write a blog about some of the common hip issues we regularly see in clinic, so you can ensure your hips stay healthy, and keep your body moving for longer.
The hip is a pretty complex joint, with numerous muscles, tendons, ligaments and other tissues attaching in and around it to provide support and movement. Because there are so many structures, it means there are lots of possibilities for things to go wrong. And therefore, lots of potential sources of pain when something does go wrong. Fortunately for us clinicians, the common things are common, and the rare things are, well, rare! This helps us to work out quickly what’s going on, so we can put you on the road to recovery.
Do I need a scan?
One common issue we are faced with in clinic, is that our patients will often come to us having seen their GP, following a scan on their hip, and have been told that they have ‘bursitis’ or ‘arthritis’, and this is what is causing their pain. This can be a little problematic for everyone sometimes, for a few reasons. Firstly, many people that have reports that suggest bursitis, or hip osteoarthritis, do not even have pain from that condition – sometimes these findings are simply incidental and have no bearing on our patient’s issues… Secondly, it plants a seed. What we mean by this is that people tend to trust what they see. So, if they see suggestions of bursitis, or arthritis, they suddenly start to believe that this is what must be the cause of their pain, rather than something else (like muscular weakness). Getting the patient to understand that their scan’s diagnosis may not be the cause of their pain (if it is indeed not the cause of their pain) is part of our job as educators of the body, and this can sometimes be difficult!
Common causes of hip pain
In our experience, the most common cause for hip issues in our clinic is muscular imbalance and gluteal weakness. Muscle imbalances are very common throughout the body, throughout the population. We all live different lives, playing different sports, having different hobbies and working different jobs. Look at an example of a desk worker who sits for their job, plays tennis left-handed, and is a keen candy-crush game addict. It’s easy to see over time how their body might develop muscular imbalance from favouring certain positions and sides of the body over long periods of time. Our bodies are rarely 100% symmetrical and can adapt extremely well, but there is always a point where it can no longer keep adapting. This is generally when you start to feel pain. Your body is telling you to do something about it. And this is where we come in!
Weak gluteal muscles are a really common problem for the general population. Why you ask? It’s because a large amount of people now sit more than move. People are more sedentary than ever. Technology is advancing and feeding our need for constant entertainment. And you can actually see it… The world is growing more obese and Type 2 Diabetes rates are continuing to grow. All this being sedentary malarkey is not good for our poor gluteal muscles. When we sit, they don’t get used, and when they don’t get used, they get weak! And they have a pretty important role to play, being responsible for several hip movements, helping to keep the pelvis stable when we walk, and allowing you to advance forward when walking, running and jumping. You see, they want to move you! Weakness in these muscles then leads to bio-mechanical changes around the hips (which spills over into the lower back, knees and ankles), and those fundamental movements suddenly become difficult to perform without major compensation and adaptation occurring. And we know what adaptation over long periods can lead to don’t we? That’s right – pain. Good… You’ve been listening!
Some of the effects of weak glutes include hip, knee, low back or heel pain, poor/slouching posture, and a change in the way you walk (your ‘gait’). If you’re a runner, you may even notice an increase in the number of blisters you are getting, due to the change in your running style (of course, you may also need new runners, so worth getting these checked too!).
What should you do?
If you are experiencing hip pain, please come in and see us… We’ll assess you to see where your imbalances are, and what is causing the pain. Whether it’s down to muscular imbalance, weak glutes, or any other cause, we’ll teach you how to put it right and get those glutes firing properly in no time.
Stress urinary incontinence – what causes it, how to treat it and how to prevent it
Running, sneezing, jumping, laughing – they should be normal activities, but for some women they bring embarrassment or anxiety. Bladder weakness, incontinence and urinary leaking are common problems, especially in women after giving birth or going through menopause. There are many causes of bladder weakness, but today, we’re focusing on one of the most common: Stress urinary incontinence (SUI).
What is stress urinary incontinence?
SUI is where the bladder leaks a small amount of urine during activities that put pressure on the abdomen and push down on the bladder, like coughing, running or laughing.
What causes it?
Stress incontinence in women is often caused by pregnancy,
childbirth and menopause. In a quick anatomy lesson, your urethra transports urine from your bladder out of the body, via a muscular structure called the urethral sphincter. The sphincter contracts to hold urine inside your body until you’re ready to go.
During pregnancy and childbirth, your pelvic floor muscles can stretch and weaken. The muscles normally support the urethra, so when they, or the sphincter muscles, are weak, they can’t do their job properly and hold your wee in. During menopause, the female hormone, oestrogen, is produced in lower quantities. Oestrogen helps maintain the thickness of the urethra lining, so sometimes with decreased oestrogen, the lining is affected, and some women experience SUI.
It’s most common with activities such as coughing, sneezing, laughing, walking, running, lifting or playing sport. Other factors that can contribute to SUI include diabetes, obesity, constipation, and a chronic cough (often linked to asthma, smoking or bronchitis).
How to treat it?
Every single person is different, so it’s always best to see your Pelvic floor physio so we can assess you and work out the best treatment plan for you. However, some common treatments we recommend to our patients include:
- Pelvic floor exercises (see below for more information!).
- Changes in fluid consumption: This could include drinking certain amounts of fluids at certain times of the day. Or it could involve cutting down caffeine or alcohol to see if they irritate your bladder.
- Healthy lifestyle changes: Quitting smoking, losing excess weight or treating a chronic cough will decrease your risk of SUI, as well as improve your symptoms.
- Bladder training: We may recommend a schedule for toileting, depending on the type of incontinence you have. This is more so used when it’s a mix of SUI and another type of incontinence.
- Manual therapy: You may have some muscular imbalances that are inhibiting your pelvic floor from working properly or are impacting on other parts of your body. We’ll assess you, and then put together a treatment plan, which may include soft tissue massage, other musculoskeletal therapies, strengthening or stretching exercises, or more.
How do I prevent it?
Remember your physios, nurses, doctors, female relatives, mum friends (and the list goes on) telling you to do your pelvic floor exercises or Kegels when pregnant? Well, that’s one piece of advice you should listen to! In fact, it doesn’t matter whether you’re pregnant or not, you should always do your pelvic floor exercises to help strengthen those important muscles. Some basic pelvic floor exercises include:
- Draw your pelvic floor muscles in and up, like you are trying to stop urinating mid-flow. Hold for 10 secs. Relax for 5-10 secs between each tightening and repeat 10 times. (Don’t actually do your pelvic floor exercises on the toilet – trying to stop while actually urinating can cause other bladder issues)
- You can add faster pelvic floor lifts to the exercise by holding for 1-3 secs and relaxing for 1-3 secs. Repeat 10 times.
- Progressing the long holds to 20 secs and then 30 secs may be a goal to reach for.
Try and make pelvic floor exercises part of your routine. For example, do them when you brush your teeth each morning and evening, and when eating lunch. There are also many more exercises to help you, including core exercises such as Pilates.
Pelvic floor exercises should not cause any discomfort or pain. If you have a history of pain with intercourse, vaginal exam or using tampons, or if you have trouble emptying your bladder or starting a wee, you should see a Pelvic Floor Physio prior to starting pelvic floor exercises.
If you’re experiencing urinary leaking, are pregnant, have given birth (at any point in your life!), or if you want help with a preventative program, please come and see us. It is always best to see a Pelvic Floor Physio to get an individual program and to be confident on correctly tightening your pelvic floor muscles. We have helped thousands of women with stress urinary incontinence over the years and would love to help you live a happier, less-anxious life, so you can laugh all you want without having to worry about incontinence!
Pelvic pain in pregnancy
You’re growing a human – a tiny person that will change your life and body forever. Of course, we expect changes and some discomfort as our body adapts to our growing belly, but seriously – this pelvic pain is another level! But what is it?
Pelvic pain during pregnancy can be from a range of things, but Symphysis Pubic Dysfunction (called SPD) is a pretty common cause. It can also be called Pelvic Girdle Pain (PGP). SPD & PGP can be explained as a bunch of signs or symptoms relating to pain in the pelvic area and lower back. It also includes musculoskeletal pain radiating to the upper thighs and crotch area.
So why does this happen? At certain stages throughout pregnancy, your body produces the Relaxin hormone, which relaxes the ligaments, producing more movement in the pelvic region to allow for expansion, not just for the baby to grow, but ultimately for the delivery of bub. This relaxation of the pelvic ligaments leads to increased joint mobility. Where the ligaments usually provide support to the joints, the muscles now have to step in and help stabilise them – they get overworked and that’s when the pain starts. Symptoms of SPD can vary widely – from mild discomfort to severe pain that can see women bed-ridden or needing walking aids.
It’s hard to say how many women actually experience SPD in pregnancy. Research suggests it’s somewhere between 4 – 84%! The variation is because of the wide range of definitions and diagnosis of SPD, as well as differing research cohort selections. However research also suggests that the incidence rate increases during the later stages of pregnancy. So what influences its onset, and how do you treat it?
Influences of SPD
While there is no way of accurately predicting which women will experience SPD, common factors that might influence the onset include women:
- who have a history of low back pain or trauma of the back or pelvis
- with an increased number of previous pregnancies
- who partake in physically demanding work
- with a high Body Mass Index (BMI)
- experiencing emotional distress
- who smoke
There isn’t one particular treatment, but common treatments include:
- Physiotherapy: Research suggests that women receiving physio treatment reported less pain in the mornings and evenings than those women who didn’t have treatment.
- Acupuncture: As with physio, acupuncture helped with pain, and functional movement.
- Pelvic support garments: Research suggests that these improved women’s ability to do things like walk and perform basic movements.
- Exercise: This can also help improve functional movement and help decrease pain, but ensure you visit your physio first, to understand what exercise is right for you, your condition and your pregnancy.
- Rest: It’s not always possible to rest completely but try to limit doing the activity that causes the most pain, avoid standing on one leg, limit weight-bearing exercises like climbing stairs or standing for long periods of time.
Pelvic pain in pregnancy is common. If you are experiencing pelvic pain, your first step is to see your physio to understand what it is and how to treat it.
In the meantime, try changing your routine by sitting down to get dressed and rotate those stilettos for low heels or flat shoes. One of the best things to try is pretend you’re always ‘walking around in a pencil skirt’ – take small steps, and when getting out of the car, slide your bottom 90 degrees and get out with your legs together. Heat might also provide some temporary relief.
To help you see an end point of your pain, know that SPD usually sporadically fixes itself after birth. And of course, holding that tiny human in your arms makes up for the grief (and you can remind them about the pain they put you through for years to come).
Women, headaches and stress
The idea of Christmas usually fills us with joy, but as we start thinking of logistics and ticking things off our mental to-do list, it can become quite overwhelming and stressful. With stress often comes headaches, so we’ve listed the most common headaches women experience at this time of the year, and what you can do to help.
These are the most common types of headaches, and about 42% of women experience these (men are 36%). On average, they start in teenage years, peaking in your thirties and then decline.
These can be triggered by:
- Poor posture
- Bright lights, prolonged reading, loud noise
- Medication overuse
- Stress, anxiety
- Fatigue, emotional upsets, depression.
You can help relieve a tension headache by:
- Reducing stress, or being in a state of mental and physical relaxation
- Leading a healthy life: Get the right balance of work, fun, rest, sleep and exercise
- Psychological treatment to help with anxieties or emotional pressures
- Manual therapy treatment, such as massage or dry needling
- Other physiological treatment such as heat pads, compress and deep breathing
- Over-the-counter medication such as aspirin, paracetamol or ibuprofen.
Migraines can be pretty severe, and there are many types. They are usually one-sided and often accompanied by sensitivity to light, sound or smell, nausea, vomiting or cold hands. Some people also experience migraines with ‘aura’ which may include visual disturbances or numbness in the arm or leg. They can last from part of a day to three or four days and affect about 15% of Australia’s population.
It’s shown that your susceptibility to migraines is normally inherited (now which side of the family do you blame?), and there can be certain triggers (different for everyone), which include:
- Dietary triggers: Some common ones include missed, delayed or inadequate meals, caffeine withdrawal, certain alcohol, chocolate, citrus fruits, aged cheese and cultured products, monosodium glutamate (MSG) and dehydration.
- Environmental triggers: Common ones include bright or flickering lights, bright sunlight, strong smells, travel or flying, weather changes, loud sounds, going to the movies or overuse or incorrect use of computers.
- Hormonal triggers: Three times more women suffer from migraines than men, with the difference being most apparent during reproductive years. Some common ones include your last menstrual period, menstruation, ovulation, oral contraceptives, pregnancy, hormone replacement therapy and menopause. We’ll go into more detail about this below.
- Physical and emotional triggers: Common ones include lack of sleep, oversleeping, illness, back and neck pain, sudden, excessive or vigorous exercise, emotional triggers such as excitement or arguments, and relaxation after stress (known as a weekend headache).
There is no cure for migraines, but medication or alternative therapies might help. Alternative therapies include physio and massage, as well as many other areas like aromatherapy and meditation.
Hormones and headaches
Women get more headaches than men, with the difference noted most during the reproductive years, as mentioned above. There are three main areas to hormones and headaches:
- Migraine and menstruation: The ratio of migraines in children is 1:1 female to male. During reproductive years that ratio changes to three females to every one male. While there are many opinions as to why this is the case, most experts do agree that it’s mainly to do with a fall in oestrogen that triggers a migraine. Migraines associated with PMS (pre-menstrual syndrome) may improve with over-the-counter medications such as evening primrose oil, vitamin B6 or magnesium supplements. Always check with your doctor before taking vitamin B6 as it can have toxic side effects. Doctors can also prescribe other medications. Think about keeping a headache diary so your doctor can better understand the relationship between your cycle and headaches/migraines.
- Migraine and contraception: The effect of hormonal contraception on migraines is varied – some women get migraines when they start contraception, sometimes it makes them worse, and sometimes it has no effect. Generally speaking, a high dosage pill tends to increase the frequency and intensity of headaches, however a small number of women reported an improvement when they started taking the pill. Talk to your doctor about the best way forward.
- Migraine and pregnancy: Migraines don’t put pregnancy at risk, but they can be a concern, especially if it occurs for the first time. Studies suggest that 60-70% of migraine sufferers feel an improvement in their migraines during pregnancy – especially during the second and third trimesters. If you’re getting migraines during pregnancy, consult your doctor as many manufacturers don’t recommend their medication. After giving birth, many new mother’s (3-40%) suffer from headaches, migraine re-starts, or may get a migraine for the first time. However, if other headaches occur, see your doctor, as they could be related to a number of other medical issues that may need investigation.
- Migraine and menopause: Many women find that their migraines worsen leading up to their last period, and shortly after. Those who may not have noticed a link with their menstrual cycle might start developing regular monthly migraines. Some women choose to undergo Hormone Replacement Therapy (HRT), which replaces oestrogen that the ovaries can no longer produce. In theory, this should help migraines, but alas, the reality might not reflect this! HRT can both relieve migraines and aggravate them. Research suggests oral HRT is better for women who suffer migraines, but always talk to your doctor.
There are so many different types of headaches, and treatment varies from medication to manual therapy and physio. Whatever you’re experiencing, consult your doctor, or get in touch with us – we help many women with their headaches, and would love to help you too.