Hello, I'm Paul Evans and welcome to Airing Pain, a programme brought to you by Pain Concern, the UK charity that provides information and support for those of us who live with pain. This edition has been funded by the generosity of Pain Concern supporters and friends and by an educational grant from Grunenthal. The way the water almost responds to us and responds to the little changes we make, it's almost like being with a very benevolent friend because it's really given me something that I can do for myself, which is beneficial in terms of pain management, almost no matter how bad my back has been at times. I'm able to at least go and glide and stand up and feel better for it. And I'll be taking the plunge to find out just how responsive the water is to me later in the programme. But you'll know by now that one of our aims on airing pain is to answer questions you've put to us at Pain Concern. We have an advisory board of leading health professionals and experts in pain management to guide you. But do remember that whilst we believe the information and opinions on airing pain are accurate and sound, based on the best judgements available, you should always consult your health professional on any matter relating to your health and wellbeing. He or she is the only person who knows you and your circumstances and therefore the appropriate action to take on your behalf.
Well, Paul Cameron's one of our experts. He's a pain specialist, physiotherapist and a PhD research student at the Centre of Primary Care at Aberdeen University. He also delivers the community-based Rivers Pain Management programme in east of Fife. Here's his first question. I'm 20 years old and have been diagnosed with dehydrated discs. I'm currently on a lot of medication and have been for the last two years. I've done physio, epidurals, acupuncture and I've recently had a massive flare-up. I'm in so much pain I just don't know what to do. I use TENS machines and heat pads. Nothing works. Paul? That would be your typical, I suppose, complex patient caught in the chronic pain cycle, if you like. Obviously, I don't know that patient's specific details, but in general I would say that, you know...
What you've painted a picture there is of a chronic pain patient, someone who is very anxious now, is in a lot of pain, has flare-ups, worries about their future. Catastrophising, we would call that, possibly. And we would approach that in a way that would be looking at that person's self-management, looking at a way that they can progress their life. I mean, they're only 20 years old, and they have a whole life ahead of them. And if they get caught in that cycle of thinking that there is no future for them, there's no way ahead, it's just going to be a life of pain, then you can imagine, I can only imagine what that must be like, and I can imagine it would be terrible. So for that 20-year-old, we would certainly be looking at ways to, again, using all the professionals involved in a pain team, for example, and the GP.
to minimise their pain as much as possible. And that's firstly through adequate pain control. Secondly, it would be about getting them moving as well and actually educating them. And we find that education of patients is a huge thing because you do get a lot of terminology expressed by patients and usually there's a lot of misconceptions, there's a lot of worry. They've heard things like crumbling discs, wear and tear. We dispel those myths and we explain exactly what these things mean. And we also educate them in the actual strength, for example, of the spine, the strength of the spine, just how mobile it is and all the structures involved and what we mean when we're talking about things like dehydrated discs and what that means for the future as well. And all those things combined, I would say particularly...
The education allows the patient to progress, I think. It allows them to remove the fear and reduce the anxiety. And through the reduction of anxiety and the increase of movement, and we're not talking about running a marathon, we're just talking about movement, then we do find that the patient's pain can reduce to a point where they can function better. And that allows them to start living with the pain without them being controlled by the pain. You use the word catastrophizing. Now, I know what a catastrophe is. So what do you mean by catastrophizing?
Where a patient, or anyone, may be told, for example, a diagnosis that they have wear and tear, or they have a flare-up, and their response to that flare-up is that, well, that's it, their life's over. They have to give up work. They're not going to be able to work again. They're not going to partake in the sports that they enjoy ever again. They turn that element of symptom, internalise it, and catastrophise. And it does start to affect their whole life in that way. So, somebody tells me I have a bad knee, I think. That's a wheelchair at the very best, housebound, my life is now over. Imagining the very worst, instead of how things could be good.
Yes. A practical example may be, for example, a person who enjoys golf and then has a flare-up of a back pain and they give up golf completely. They don't think about reducing the number of holes they play. They don't think about going down to the driving range. They don't think about the social side that they enjoyed in the clubhouse. And they withdraw themselves into the house and that is their life. They've removed themselves from something they very much enjoyed. That would be catastrophising.
So you can see how those sort of thoughts can not just affect the pain, but can affect the whole life, the social circle, the friends or family. So it's a big element to them. And for that particular patient you mentioned, 20 years old, with a whole life ahead of them, and actually equally, a 90-year-old thinking exactly the same way, it's not a good place to be. Many thanks, and we'll be returning to Paul Cameron to answer more of your questions later in the programme. Now, don't forget that we can't talk about specific cases. But you'll remember him saying an increase in movement can reduce pain.
Well, swimming is often recommended as being beneficial to people with chronic pain conditions. However, as in all exercise activities, swimming with poor technique can result in strain of muscles and joints. Daphne Wood of Pain and Abel swims to help manage her own chronic pain. She's a qualified teacher of the Shaw Method, which applies principles of Alexander Technique to swimming. So, speedos in hand, I met her at the Ozone Health and Fitness Club in London's King's Cross and Bloomsbury Holiday Inn to find out what kinds of persistent pain conditions her swimming lessons could help with. Whatever doesn't need any.
Sort of acute treatment, really. Some people come as part of rehabilitation, so following surgery or accidents. Others who would perhaps have been to something like a pain management programme and have been advised to do exercise. but perhaps find a high-impact exercise difficult, or who just want to enjoy swimming as part of pain management? Well, from my point of view, I've had fibromyalgia for about 22 years. I have a lot of aching, a lot of pain. I was a very good swimmer, a very strong swimmer. I tried to swim, and it's a boom-and-bust scenario. I enjoyed it too much, it's going too well, and I suffer afterwards.
Perhaps you can help me get through this. Yes, I think one of the things that, even without seeing you in the water, I would say that the general sort of pain management principles apply to swimming as much as anything else, that you need to pace up slowly. And so after today's lesson, which will be quite gentle, you need to look at how you felt for a couple of days after that. And if that seemed fine, then continue at that level for a while. The problems I get with swimming...
Keeping my head above water because I need to breathe, I get a lot of strain in the back of my neck and my shoulders. That's a crucial thing that we'll be looking at today because part of my approach is about applying principles of Alexander technique to swimming. I believe that the relationship between your head, neck and back is crucial for effective movement. And if you're holding your head out of the water and tightening the muscles at the back of your neck, that has an adverse effect on movement. Also, if you're trying to float with your head out of the water, it means that you tend to sink because your head is above pushing your body down. So there's not really any way around learning to negotiate putting your head in the water, which is in fact a lot easier than most people.
and many people who come for lessons are in fact really annoyed to find out how easy it was, and it's been this kind of mystery. Should I tell you what we'll be doing before we get in the water? Yes, please. Two things to remember. The one is to attempt never to hold your breath when you put your face in, and the other thing is to blow out gently through your mouth whenever your face is in the water. So what we'll be doing, we'll be standing over there in the pool, feet firmly on the ground. You'll start an outbreath from before you put your face in, and we'll work on trying to keep the outbreath continuous until you back out of the water.
I'm not afraid of getting my face wet. The point I was making was that you have to come out to breathe sometime. Yes, and that comes later in the stroke. The way we work is that, initially, I work on people being comfortable just walking in the water, putting their face in, and then learning how to glide, so that you can have a strong sense of, even if you forget what to do with your... arms and your legs, what to do with a stroke, you would be able to stand up and take another breath. And then once the sort of anxiety about what do I do if I run out of breath or forget what to do with my arms and legs, once that's delayed, then you kind of relax and can think how to move your arms and legs. Before we met and when we'd arranged this, I said to myself, I don't need Daphne to teach me to swim. I've been doing this for 52 years. What I need Daphne to do is to teach me not to swim so much.
Right, yes, that's a lot of what I do. One of the crucial things that people need to learn, and I think that probably has bearing on those of us who tend to have sort of strain and things, is when to use effort and when not to use effort. It's really important to know, for example, in front crawl, you press back for a bit, but then you let your arm go. And that release doesn't only give some relief to the muscles and joints, but it also allows the effort to happen better. Or in breaststroke legs, if you pull your legs back in a tight way, you can't...
kick back nearly as well as if you start with relaxed legs. So that sort of stroke by stroke is something, but in terms of swimming less. A huge amount of what I'm doing is about paying attention to each stroke rather than I must go and do my 20 lengths. And when you do that, you begin to notice the difference it makes, for example, if you hold your hands differently in a softer way. And the swimming then becomes a process of discovery and exploration and you learn things and you come out and you know more about yourself than when you went in. So it's not just that you tick it off because you've done your 20 lengths. It should actually be quite enjoyable and experimental. Come on then, let's do it. OK, let's get in. You'll need your goggles. Yes, please.
Daphne Wood of Pain Enable. Now, whilst I run off and get my goggles, let's try and get some answers to a few more of your questions from physiotherapist Paul Cameron. Actually, swimming may be relevant to this next questioner, who says that his doctors have told him that he'll be in less pain if he loses weight. Why? Right, OK.
Obviously, again, not knowing that particular patient's circumstances, I would say that, well, obviously, a loss of weight is healthy for a number of reasons, if you're particularly overweight, not just for pain reasons, for other health reasons as well. If we are talking about particular joint pains, then yes, that could relieve some of the weight off the joint, and obviously anything that may relieve some weight off the joint may reduce or help reduce the pain in a joint as well. It's a very difficult one to say, really, because there's a lot of people who are overweight with no pain, and you wonder why. They have no pain if just losing weight was the answer. I would say that, yes, weight may be a consideration for people who have overweight with joint pain and it may help them. There's no guarantees, but certainly for an overall health perspective, yes, losing weight and being that little bit healthier and happier with it possibly may actually help reduce the pain anyway. I suppose, you know, we don't know what sort of weight this person is, although I'm sure this applies to thousands of people, maybe me as well. The laws of physics say that if I have a problem with my knees and I'm carrying five stone extra on them and possibly my centre of balance...
has shifted forward because of my enormous gut, then the laws of physics say something has to give. Yeah, I would agree. So the caveat to that would be that you don't gain weight overnight. So it's not a sudden change for your joints. And equally, you don't lose it overnight either. So again, it wouldn't be a sudden change for your joints. And none of these things are quick fixes. They're just one element of our...
pain management, or a whole scenario of pain management. So yes, excess weight may cause excess strain on a joint, which may, and I say may because we don't fully understand everything about the pain mechanism, so it's difficult to say yes for sure. But certainly we do have patients who lose weight and feel better for it. And if we were to use those patients as an example, then yes, losing weight may help. Here's quite a complex question from a correspondent. I'm 47 and my knees are causing me agony. X-ray and MRI have revealed nothing. I'm taking six to eight painkillers a day, which make me tired and irritable, but help with the severity of the pain. I suffer from joint pains too, mostly in the mornings. Rheumatoid arthritis has been ruled out.
And they're saying I have osteoarthritis. And if so, I'd just have to live with the joint pain. However, it's my knee that's unbearable and mostly on the outside. A specialist is contacting my GP to recommend stronger painkillers! I'd appreciate some advice.
The first thing I wouldn't do is talk about specific medication anyway, but I would advise that particular patient to return to the GP and have that discussion about their pain control. They have mentioned some side effects they feel they're getting from their pain analgesia, and obviously that would be an area that a pharmacist or a GP would be an expert in those areas, so they're the ones that really should be sitting with that patient and having that discussion. I would advise that to any patient who's worried about medication. Yes, we have a limited number of pain medications, to be honest, and research has always been carried out to try and improve that, but that doesn't mean that there isn't scope for change and there isn't scope for allowing a patient to be a bit more finely tuned with their own pain medication because everyone moves one differently. But again, it would be a conversation to have with your GP or a clinical pharmacist who'd be able to assist with that as well. Physiotherapist Paul Cameron. And if you'd like to put a question to our panel of experts or just make a comment about these programmes, then please do so via our blog, message board, email, Facebook, Twitter, or even good old-fashioned pen and paper. All the contact details are at our website, and that's at painconcerned.org.uk. And from there, you can download all previous editions of Airing Pain, along with a host of information of how to manage your pain. Now back to the pool. We're suitably goggled. I'm ready to take the plunge with Daphne Wood of Pain and Able.
What I'd like to start with is just walking to as deep as you're comfortable with left arm forward, right leg forward and then swapping over. In other words, opposite arm and opposite leg. This is partly about arriving in the pool, getting your body to obey your brain before we start the more complicated things. So it's quite simple, but in a way it just helps us both catch up with ourselves. Being aware of how you swim and swimming with good technique can really be an effective way of helping manage chronic pain. And it may be that there are people who do swim, but they swim holding a lot of tension or they keep their heads out of the water, something like that. Because people who can swim, swim naturally, most of them have been swimming for most of their lives. They have picked up habits of the best way to swim for all of those lives. That's right, yes. And some of those are based on...
focusing mainly on getting across the pool, ideally without taking a breath or purely on speed, which is fine and I'm not knocking that sort of swimming for people who don't have any difficulties. But if people do start to experience increased pain, for example, after swimming, maybe knee pain after doing the breaststroke or shoulder pain after doing front crawl, then there are things that we can address to make the swimming more satisfying and more beneficial. OK, we don't have a go now at the breathing. Are you OK about that? OK, if you can put your goggles on, please.
Lean towards the wall, leaning into the wall with your fingertips under the surface of the water. My chin is just above the water line. And I'm going to nod my head. In fact, I can stop talking as well. I'm just going to nod my head and put my face under the water. Not your whole face yet until you get used to it. The crucial thing is to keep the outfit continuous. You were concentrating while I was in the water with me breathing correctly and breathing underwater. What's the purpose of that?
We started with the breathing because if you're not able to put your head in facing the bottom of the pool and negotiate the breathing easily, you won't be able to get a good floating position in the water. If you have to hold your breath in order to put your face in, that creates quite a lot of tension. And what most people do then is hold on for as long as possible and come up gasping. Sometimes they judge it right and it works. Sometimes they get water in and then they cough and splutter. So we do that first.
standing by the side of the pool so that there's no other factors that you're worrying about. Your feet remain firmly on the floor so that you can give all your attention to just keeping the out-breath constant as you roll your face into the water and come out still blowing out and then take another breath. After that, once you can prioritise the breathing, then we can start working on legs coming off and keeping the breathing going. It doesn't sort of just keep going down. No, that's right. There's a point where it seems to be pushed up a little bit. Yeah, it's not because my head is too full of eight. No, most people tend to do this, it's so fine. OK, try that again and just sort of feel how it's quite a strong pushing up, really. All shore method teachers have had all the traditional sort of swimming teacher training. I've had an additional one-year training in applying Alexander technique to swimming.
Forget about the swimming for a minute. What is Alexander technique? It's difficult to sum it up, but through Alexander lessons, you become more aware of your habitual ways of moving, holding your body. So it's partly awareness of habits. It's a recognition that the way we think and feel affects the way we move. Another one of the principles is about not end gaining, not just focusing on the end of the pool, but paying attention to each stroke, the means whereby we get to the end of the pool.
a rather elusive concept called direction, which on dry land you would be thinking up. What do you mean by thinking up? Thinking up. It's just a sense of looking at runners and thinking, is there attention on going up or on going down? And you can actually get a sense of that if you look at people running. Another example of going up that I experienced was in...
a very grey English winter when I suddenly got given an air ticket to go to a nice sunny country. And I noticed that my walking changed. I just did literally get that sort of more bounce in my step. The prospect of going somewhere sunny changed my mood and changed the way I moved. And that was in a sort of upward...
which is like the opposite of depressed. I think there's reasons why there are these words in our culture. The way it was explained to me when I went through a course of Alexander Technique was that thinking up is like having a hook at the back of your head from which your body suspends and comes into alignment, but not you pushing your head up. Exactly, yes. That's really good. It brings together both the thinking up and the fact that you don't actively push yourself up. It's something that by thinking or the awareness of it allows it to happen.
about direction now. In swimming, the going up translates into going forward. A lot of good swimming is thinking about what you're doing, and in particular in the light, we're going to experiment now on thinking of sending your arms and head forward. So don't worry about your legs or whether you're floating. Just think of going forward, forward, forward between your arms and head. You're teaching me how to actually use my body shape, my natural body shape, to do all the work, minimising the use of my muscles. That's an interesting way of describing it. I mean, what we were certainly working on is seeing...
How much can be achieved by doing very little in water? Simply by leaning forward, thinking forward through your arms and thinking of your head going forward and adjusting the position of your arms so that you get a good, buoyant experience in the water. That didn't require any pushing off or kicking or anything, and you were able to then get some momentum and go forward in the water. To me, that's not swimming. No. That's being in the water. Yes.
You swim by, first of all, becoming comfortable in the water, knowing that you can manage the breathing, knowing that you aren't holding unnecessary tension. We looked, for example, at how the position of your arms affects the strain or the degree of strain in your lower back, how your head position can really make a difference to how your neck and shoulders feel. So we get a good foundation laid, which is being able to breathe comfortably, glide, stand up, realise that the water is supporting you, have some experience of buoyancy. Once that's all... taken care of then you can give your full attention to how do I need to move my arms and how should I kick my legs you aren't battling with survival at the same time and I think it's really important to explore buoyancy and to know what happens when you do very little in water to know that you can float and then from there move on to learning a stroke and the interesting thing that I found was that you by systematically going through different parts of my body feel like my head my breathing my legs my hands the angle of my hands and the water you made me notice what my muscles were doing and how changing position
could alter the way those muscles were working. Exactly, yes, yes. And you see, those kind of observations that you made come much easier when we reduce how much you're doing. It's unlikely when you're aiming for the end of the pool that you pay much attention to those rather subtle things, but which are really going to affect how your body feels after a good swim. I think it's time to just look at how you get stand-up, because...
There's something very wise in the back of our heads which won't let you float comfortably unless you're very clear about how you're going to get your feet back on the ground and how you're going to point. Now, the reflex way people often do it is to snatch their head out, okay? If you do that, if you come up head first from the horizontal, you're immediately tensing all these muscles. You can hear it even in my voice. And you feel as though you can't breathe.
In terms of pain management, people who come to you, how do you assess what they can do and what they can't do? Often they will come for their first lesson having not been in the pool for a long time. But as you saw in the first lesson, the approach is very gentle. It's quite challenging. If anything, it's more mentally demanding and it's more about their awareness of trying to think of what you're doing with your breathing and your feet and your arms. It's more that than physically needing to swim up and down. So very often the physical side of it isn't that taxing. And then we would certainly speak the next time about how they felt after that. And there's always a...
at the beginning of the lesson to sort of look at any issues that have arisen. Sometimes just the joy of being in water means that somebody will then go to an aquaerobics class after my lesson and say, well, I felt dreadful, you know. And in fact, it's just been that they've gone on and done a lot more. But I've rarely had any sort of big problems in terms of pain after the lessons. If anything, the relief of being able to move and the kind of movements we do often leaves people feeling more relaxed and sort of in less pain. What I found today is that I could actually go to my pool.
and use the water therapeutically and for enjoyment without having to crease myself. Yes, and that's brilliant. If you found that today, then I'm delighted. And I'm delighted too. So that's Daphne Wood of Pain and Abel. She's based in London, and you can get more information about her lessons at her website, which is painandable.com. No gaps there. And there are teachers of the Shaw Method throughout the UK, details of which can be found at artofswimming.com. Again, no gaps. Artofswimming.com. The last word to Daphne. A lot of our...
habitual ways of approaching life don't work in water. It's very often that on a day-to-day basis I've thought that trying hard was the way to succeed. In water it really doesn't work and over and over and over when people do less, try less, allow things to happen, allow the water to support them, that's when the actual good swimming results. So water also is this wonderful medium which can give us another sort of sense of life and how things happen and take away some of the pressure of trying hard and things having to hurt and be difficult to do us any good or to succeed.