Recently the government released a document on a nationwide strategy on pain management. Pain (especially chronic) is prevalent, yet misunderstood. There’re many current flaws leading sufferers to be neglected, ultimately leading to non empirical options such as opioid use. In regards to Opioid use, we now have strong evidence that it leads to poor outcomes. The national strategic plan is a thirty-two page document. So I will iNform you on the relevant key points from an exercise physiology perspective.
Key point one:
Chronic pain from a medical perspective was not classed on its own as a specific condition. When seeking a team care arrangement (TCA) from a general practitioner (GP) you would have to have an accompanying comorbid condition to be eligible, which is a sadistic oxymoron. A comorbid condition such as type two diabetes mellitus for example. Secondly, living with chronic pain is terribly difficult without the appropriate resources and social support. Along with access to evidence based care which is lacking in some states in Australia. The aforementioned strategy is advising to include chronic pain as a specific medical condition. With eligibility to access a TCA which is fantastic news! And which brings me to my second key point.
Key point two:
Team care arrangements (TCA) are medical resources for certain populations whom are eligible for five appointments with an allied health practitioner through the Medicare benefits scheme (MBS). The premise of the five appointments is to access support and guidance to manage and optimistically ameliorate one’s chronic condition. Now, allied health professionals have been stern over the years that five rebatable appointments are well below par to make any inroads and psychophysiological change. It was only recently due to the COVID-19 pandemic that a mental health care plan was extended from ten appointments to twenty via the MBS. And most would argue that twenty appointments with a psychologist for a complex psychological issue is only minor at best, however is a good start. It is proposed that ten appointments will be issued with the aforementioned strategic plan which again is progression albeit insignificant to guide and implement real change.
Don’t get me wrong, I’m an optimist. When you’re in the field of chronic pain you see suffering, you empathise deeply and you require more time and resources to help.
To gain access to the national strategic plan for pain management. Readers can access via the painaustralia.org.au page.
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Although pain is advantageous for protection and survival. Persistent pain carries no real biological purpose – yet is sadly highly prevalent in the population. I’m not going to dwell on epidemiology. I want to tie in nicely the importance of clinician collaboration as an excellent prophylaxis for acute (and persistent) pain, whilst also discussing a Cochrane review on the lack of evidence of NSAIDs (nonsteroidal antiinflammatory drugs) for the acute management of low back pain.
What are Cochrane reviews?
Cochrane reviews are excellent resources for clinicians (and the general public) to access high quality evidence with iNformed recommendations. Cochrane reviews (or collaborations) involve clinicians/researchers who have excellent experience and knowledge in a specific field. They gather all the relevant research papers on the topic of research (low back back and NSAIDs in this case). They extract all the relevant papers that meet a specific criteria and make recommendations based on the overall evidence.
The reason why I spent a good paragraph on the aforementioned is that the Cochrane library can be accessed by anyone! Therefore, anyone can seek and critically evaluate a medication (like a NSAID) for example. You can also look at the evidence (for the acute use of low back pain) and come to an evidence based conclusion. As a clinician, providing evidence based care is important for your health and well-being. We call this evidence based care the Science-Practitioner model.
Ok! I’ll provide you a quick synopsis of the paper.
Van Der Gagg and colleagues found: When using a qualitative (self reported) scale for reports in pain reduction, the authors found no statistically meaningful benefits for the use of an NSAID in acute low back pain. A previous Cochrane review in 2014 by the same group came to the same conclusions for the analgesic paracetamol for acute low back pain. These are important implications, as medication may be one’s first choice approach to decrease symptoms. However, with what’s been written and known empirically, what is the best approach to improve symptoms of acute low back pain?
The current evidence suggests that empirical pain education along with graded specific exercise correctives are the current gold standard for the management of acute low back pain. Pain education allows the individual who has pain to better understand it, whilst the clinician being thorough in their examination providing reassurance, and safety to move. We clinicians call this the biopsychosocial model. As the schematic below shows, this is an intricate interplay between tissue, one’s thoughts and feelings, and the environment (potential threats and safety’s).
My premise in this blog is to not overwhelm you with information. More so that there’s evidence out there for you to access. Along with clinicians whose duty of care is to iNform you on the aforementioned publications, and devise an appropriate treatment plan to improve your symptoms. The team at Move For Better Health can guide you safely through your acute pain, whilst collaborating together (Physio, Exercise Physiology, Psychology, Podiatry, Nutrition/Dietetics) in our disciplines with great communication and decades of combined experience.
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Stop! Now check you are breathing… or, are you holding onto your breath?
Breathing, which I’ll define as diaphragmatic breathing is incredibly important for many areas such as the management of blood pressure, reducing muscle tone and most noteworthy (and a collaborative of the two aforementioned), activating your parasympathetic nervous system. Now you all know that I’m a huge neuro-nerd! However, for the practicality of this blog I will only touch the surface of the parasympathetic and sympathetic nervous system.
So what is your parasympathetic and sympathetic nervous system?
Crash course in endocrinology!
Your parasympathetic nervous system is what’s known as your ‘rest and digest’ system. A relaxation system let’s say. Your sympathetic nervous system is your ‘fight, flee and freeze’ system. And although a neat sounding alliteration. The sympathetic nervous system should only be called for during short bursts of stress (such as physical activity, complex problem solving). However, when called upon more-so and on a regular basis the sympathetic nervous system can have a downstream effect in compromising the immune system (sickness), all the way down to-your genome (RNA damage).
So you can see that being more parasympathetic over sympathetic is important! And what is an excellent prophylaxis for the parasympathetic nervous system? Diaphragmatic breathing! That’s right! I don’t have to go all spiritual on you’ll here. Just your breath!
Let’s get practical!
1. Sit in a comfortable chair, or lie supine (on your back).
2. Make sure you’re not distracted!
3. Rest your hands gently on-to the side of your ribs.
4. Inhale for a count of two seconds through the nose by breathing into your hands (notice how your ribs expand).
5. Hold the end of the two second inhale for a further two seconds (deliberate breath-hold)
6. Exhale through the mouth for the count of four. (You should notice that your ribs draw back inwards somewhat.
7. Repeat five more times.
8. Note how you feel?
Fingers crossed you’re feeling perhaps a sense of ease? Slightly calm and relaxed? A bit more mental clarity? Even a wry smile?
So there you go peeps! I didn’t use the word meditation once (this time). I simply guided you through how to breath diaphragmatically, inducing a parasympathetic response. A neat tool to use throughout ones day! Recommended when there’s an accumulation of unease.
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*Disclaimer: if you are prone to orthostatic hypotension, or vertigo (BPPV). Please be mindful when standing or arising from a lying position following diaphragmatic breathing. Or consult with your GP or EP if you need-so.
My previous blog discussed admitting to my grief along with finding practical ways to contract skeletal tissue throughout the day. I want to build on from my previous blog, discuss routine and the importance to establish one during these times.
Whether inadvertent or not, you’ll have some form of routine. Routine maintains a strong sense of order and control which is definitely not obsessive or compulsive. More so, having your morning routine structured, along with a neat and organised environment decreases time wasting and increases efficiency.
When my routine was initially disrupted there was a sense of entropy which bought on a feeling of unease. I am now almost three weeks into my new morning routine. I’d like to share with you all what my morning now looks like. This may or may not provide some useful strategies to implement into your day. However, I am being a little bias to suggest that one or two of my morning rituals are very helpful! And of course evidence based!
Here we go:
4:30 am – arise
4:35 am – caffeine
4:40 am – Coronacast on RN (staying iNformed) along with a short stoic meditation podcast to increase my focus and drive for the day.
4:55 am – Twenty minutes of stretching for specific muscle groups that are restricting my mobility. Each stretch is timed with a countdown to enhance efficiency and maintain structure.
5:15 am – Four sets of 40-30 single leg calf raises (my calf’s are weak!) and I have Raynaud’s phenomenon.
5:25 am – Thirty minutes of guided meditation using the Ten Percent Happier app. (My morning meditation is working on good intentions for the day along with prolonged exhaling)
6:00am – Shower, dress, floss and brush my teeth.
6:20 am – Check emails and social media (social media time is restricted, which I’ll elaborate on)
So the above is now my new morning routine. I realise that not everyone is going to have the time that I have to dedicate to this. However, I strongly advocate that by creating calmness and stillness which ultimately is called mindfulness, you will greatly enhance mood, reduce blood pressure, increase creativity and so forth for the day ahead. Lastly, I found great benefit by delaying checking my emails and social media accounts until all of the aforementioned had been completed. I found that I was spending inappropriate amounts of time on social media trying to feel connected. When on reflection I was feeling more disconnected, whilst wasting time and thus not being productive. You may have noticed that I haven’t included any physical activity. I am exercising in the afternoons now. However, a brisk morning walk is highly valuable and a mindfulness activity in its own right!
In conclusion, if your routine has gone awry as mine did? I encourage you to plan and structure a productive routine to start your day. You won’t regret it!
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So, I’ve finally accepted what psychological researchers are calling the current state of affairs as grief. My routine is methodical. Dealing with change and uncertainty like many is difficult. My life is based on alarms, timers and proclivities. For the last week or so my circadian rhythm has been awry. The gym that I go to has temporarily closed. My time-restricted fasting has been more of a challenge, and I’ve had to meditate and journal my way out of regular unease. As you can see my routine has been disrupted by this change. This is not great for a creature of habit, introvert and perfectionist! However, finding routine can manage change.
So now that I’ve accepted the grief. I need to be proactive moving ahead. I require a new routine. Now that I am sitting more, and self-isolating at home I need to move regularly. As I write this blog, my one-hour timer on my iPhone goes-off to remind me to get up and do fifteen pushups with a resisted powerband. This neat little ‘timely’ reminder is what I’ll discuss with you’ll now.
Tuesday’s for me used to be a little like the following. High intensity intervals on the bike for twenty minutes before work in the morning followed by upper body resistance training and high intensity intervals on the rowing machine in the afternoon following work.
To do my best to mimic the aforementioned, this is what i do now. I know that I have a very large hill to climb on my road bike this afternoon. I’ll use this opportunity to ride hard up this hill, to get-in my high intensity interval! Secondly, as previously mentioned I have a hourly timer set. This is reminding me to get up and perform fifteen pushups with a resistance band. The resistance band (as the name suggests) is trying to replicate a pushing exercise I’d typically do on Tuesday’s (Bench press). So far I’ve already done sixty pushups. With the goal to hit one hundred by the days end.
By still having a routine, and changing what I can control. Instantly I feel more at ease and grounded.
If the above resonates with you and you’re self isolating at home, there’s a plethora of objects to safely use around the home to still accumulate load as one would at their gym.
More so, being guided through this process via Telehealth, and a home based program may bring more ease, a sense of control and routine back in one’s life.
We can help you with this!
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