What happened when I met a rock-star physiotherapist!

Regular readers of my blog will know that one of my pet topics is how do you know which Health Care Professional (HCP) to go to? How do you work with them for a good outcome? And how do you know when to run out of the appointment and never return to that person again?

My lumpy rehabilitation journey has allowed me to build up a larger-than-average sample of interactions, create a picture of myself as a ‘failed patient’ after two years of never managing to succeed on two successive weeks of physio exercises, and now I am delighted to say that my quest has led me to meet a rock star physio (and actually succeed!) So I wanted to tell you all about it…

How did I find him?

Part of spending months and years incapacitated has led me to want to really understand what is going on for me physically. So I have attended every single free seminar/webinar/TED talk etc online that I can find related to recovery. It has been fascinating and illuminating.

Paul Hobrough has written two books (‘Running Free of Injuries’ and ‘The Runner’s Expert Guide to Stretching’) and is so famous that even my Mum has heard of him. Initially I thought this is because he is based in Northumberland (where my parents live), but actually it is because he has a great common-sense column in one of the national newspapers! I heard him speak on an England Athletics webinar and when I heard that he was doing tele-medicine appointments, I had to give it a go….

Sharing the history

After years of being in and out of treatment rooms, I think that I have my history giving down to a pretty good delivery. It is definitely a learned skill that requires years of practice and improvement before graduating to professional patient level, but I hate the oral tradition of history taking. Here’s why:

  1. All HCPs are pressed for time, so when you have a complex history (as I have) I have seen the panic start to rise in their eyes and them start to look for straws to grasp at – which means that landing the holistic overview of the situation is hard. And any glancing contact with something that they have been taught is a red or amber flag leads to them jumping in with an early diagnosis and potentially the whole appointment and interaction is derailed as you either succumb to a snap-judgement that you think has already been investigated, or you try to have a respectful debate with someone who is (and wants you to know that they are) so much more of an expert than you are.
  2. In my experience the majority of HCPs are very bright, studious people with a strongly introverted approach to life. This means that they are brilliant at really thinking deeply about issues and working out great solutions – but only if they are given the time to do this. Hence the extrovert’s style of iterating through oral history-giving has to be bad for them. Additionally, they need time to consider how they are going to share their views back with you (the patient), so that you can understand them.
  3. From a patient point of view, there are times when I am in such a mess that I can barely string a sentence together let alone a complex history under time pressure. Because pain makes you live in the moment, it can be hard to step out of the moment and give a balanced overview at that point of time.

This is why I always email my history over before an appointment. Almost every time I have done this the HCP has pre-read it and come in with questions (only one did not – they proceeded to read it aloud in the appointment and then lecture me on what a pathetic specimen of a human being I was for not understanding what was needed – for a whole hour without me getting a word in edgeways – that was an appointment where I should have stood up, paid and left).

What was the difference that a rock star physio made?

Here’s the parts that blew me away:

  1. EMPATHY: Paul created instant connection between us by making a very humble joke about his presentation at the seminar that I had attended. I went from being very nervous to laughing in seconds, and I also understood that the ground rules were that it was OK for me to ask anything – which completely changed the power dynamic in the appointment.
  2. DIAGNOSIS: In the first 5 minutes he not only summarised his diagnosis of what the issues were, but also how he thought I understood them – he repeated back to me the language and things that I had said in my email.
  3. UNDERSTANDING: We then spent another 5 minutes where I was able to question him about this more – and I felt like I was having a personal medical masterclass, where he simply and clearly laid out medical theory, practice and levels of certainty in lay language that genuinely made sense to me and where it was also OK for me to say where I did not fully understand it.
  4. REFRAMING: Within this he completely reframed my expectations. I saw the medical process as me vs pain – with success as elimination of pain. He got me to talk about triathlon racing and the normal types and levels of discomfort in training and racing.  From there we agreed that it was about control, pacing and self-management of pain – which seemed so obvious (but was a new insight for me).
  5. GOAL-SETTING & OWNERSHIP: As we got to the midway point, he moved me into goal-setting. At the time I was in the split mentality of “I want to return to Ironman Triathlons but think that will be impossible – and my day-to-day is governed by so much pain that I often cannot walk to the corner shop”. He gently nudged me to explore a goal that I thought was an impossible ask, and he saw as a very viable 3-month goal. It was so exciting!
  6. DETAILED PLANNING OVER 3 MONTHS: Then he moved into explaining to me the specific movements that were going to be challenging, how to dose them in, what signs would show that it was working and what would show that I needed to regress the progress. He was completely unapologetic that it was a lot of work – that even writing the excel sheet with the programme on was a lot of work – but even that was exciting to me. I wanted to be a part of this and I was completely signed up to whatever work it took.
  7. SETTING UP SELF-MANAGEMENT: So having specified the programme in detail, he delegated me to write it and email it to him for review and any feedback/changes within the next 3 days. I did, but he had explained it so clearly within the appointment that no changes were needed.
  8. TRANSMITTING CONFIDENCE, BELIEF & HOPE: Then he wrapped up with the ‘piece de resistance’. He said “I back my opinion and experience and I really think that with this plan, you can make this goal in 12 weeks. But it won’t be easy – I think that you will have a number of setbacks – and we’ve talked about what it looks like when you need to regress, how to monitor symptoms, how long to rest it and how to move forward again each time. I also accept that no-one can truly know what is going to happen and in the event that in 12 weeks this really hasn’t worked then there is another more interventionist path that we can take, that has good scientific evidence behind it and has worked for a lot of people.” In that closing minute he had imbued me with his sense of confidence, belief in the plan, readiness for setbacks and knowledge that even this plan was not the end of the road – so there was always hope. If I was summarizing it as a mantra it would be ‘you’ve got this!’

What happened next?

I followed the plan – it happened 100% as Paul said. It was hard work, it took patience and tracking. I had set-backs and had to follow the approach that we had talked about. I doubted at times, but always thought back to his confidence to reassure myself and follow the exact detail that we had agreed. In 12 weeks I hit the goal that I had only dared to dream could be possible.

All from one 30-minute appointment – where an incredibly intelligent and kind man with a wealth of knowledge gave me the keys to the castle, to unlock so much of my misery.

I haven’t seen Paul since – and I feel bad that I only paid him for that one appointment. I can only reassure myself that by not clogging up his agenda with more he has been able to change so many more lives for the better.

Thank you Paul.

And breathe (out)!

One of my goals for 2021 has been to get back to blogging. I think that it is fair to say that everyone has found the last year tough, and that there are still some hard yards to travel. But the outlook is so much better with the amazing work of the scientists to get to vaccines.

There has been a theme recently that seems to pop out at me from so many diverse areas that I wanted to learn more about it. And the theme is breathing! It seems to be a part of every aspect of life, from how to lose weight, to how to manage difficult situations, to getting to sleep and staying well. But is all of this an over-promise?

I became very conscious that I personally had stopped breathing much deeper than the top of my ribs because the pain of moving my ribcage was substantial. This was such a contrast from the deep belly breaths that I used to take when I was doing sport that it was striking. But since my activity levels had dropped so much, these little sips of air seemed enough, and they just made it all hurt a bit less (or so I thought!)

But reading this book – Breath from James Nestor – opened my eyes to the fact that breathing is just so important. And especially important in engaging the parasympathetic system, which we need for healing. And that actually it is the out-breath that is the most important part for engaging that.

It’s a fabulous book, with well-explained examples and analysis. Some of it is pretty mind-blowing! Who knew that we have a Nasal Cycle across each day where we use our nostrils differently and then switch?!

And if we are not already standardly nose-breathers, then the importance of grooving that habit!

But it led to me deciding to work on how I was breathing. Across many months and multiple times across each day (rather than just when I was struggling to get to sleep). So I thought that I would share the journey that helped me to find some of my favourite exercises – in case they are helpful for others.

  1. I started by training my body to let air into my rib cage and to expand the diaphragm down into the stomach space – and to do this in different positions. So I would lie face-down on the floor, with a little ‘fist pillow’ to hold my head straight but nose off the ground, and I used the sensation of my body on the floor to feel the air coming into my ribcage and also my stomach expanding and then the opposite when I breathed out. Over time I played with the order of the chest vs stomach expansion (to give the body a sense of control, and even playfulness, with the breathing).
  2. Then I started to use the breath as a signal to my body to release. So in my physio exercises, I would start with a minute of deep breathing exercises. And in each of the rehab exercises, at the point of maximum stretch, I would then look to do 3-5 deep in- and out-breaths, counting to 5 on the way in, 3 at the top, and 7 on the way out. I’d feel the breath impact on the tissues as they settled into the most difficult parts of the rehab exercises.
  3. I also discovered the Box Breathing app on the phone. Box breathing has been made famous by the military as a technique for creating calmness, focus, and readiness – even under the most extreme conditions. The technique is simply that you use the same count for breathing in, holding at the top, breathing out, and holding at the bottom. You have to focus on it and work on control. Over time you can increase the count. (The app counts out loud for you and also gamifies the amount of work that you have done on improvement).
  4. By now I had started to get a little bit hooked! So I started investigating all of the different breathing techniques from yoga. I had done a few in my weekly yoga class before my injury and with the help of YouTube, I rediscovered these and more.

There are a whole selection of videos on the site related to the book: https://www.mrjamesnestor.com/breath-vids

So 6 months on from my hilarious ambling through breath in every context, what have I actually integrated into life?

I have to admit that I have not stuck to all of those complex techniques, although I tell myself that if I do get back to yoga classes again then I would embrace them with enthusiasm.

But I have:

  • Become very focused on the benefits of breathing with movement to manage the pain in my body – and found T’ai Chi as the tool that brings me the most success here.
  • Kept the daily discipline of ‘resets’ in the day where I take 3 minutes to do some box breathing before starting something new. Whenever I go to get a drink, I use this as a cue for one of these breathing breaks.
  • Made the 5-3-7 pattern the start and consistent focus in my rehab exercises, as the way that my body can absorb the challenges of these movements and not fight back with fear and tightness.
  • Used a deep sighed out-breath and then 3 deep, slow breaths as my step into calmness when I notice the mental or physical signs of stress creeping up on me (the shoulders coming up towards the ears, the tight feeling in the pit of the stomach or an increase in my heartrate as I anticipate what might happen next)

I’m interested in whether breath management has been a part of your rehab journey, and what your experiences have been with it?

Why going to a Pain Clinic can be a really good step to recovery

When the physiotherapist mentioned going to a Pain Clinic, everything about it that I could find suggested to me that this was a last resort – a place that you go once you have lost every last vestige of hope that you can get better and just want to manage the pain to try to find a way to get through the minutes and hours of an agonized existence. And talking with a number of other people in pain, this perception is very common, and none of the things that I could find online change that view.

However, the reality was so very different, and this is why I wanted to write this to help others to get the help that they need faster.

They never dismiss your pain

I can imagine that one of the challenges for Health Care Professionals is when they have to admit that something is complex and they don’t really know the answer. The downside of this is that thousands of people every year are dismissed by comments and inferences that imply that the pain is ‘all in their head’. You only need to take to Twitter or patient forums to hear the things that people have been told (or at least how they have interpreted comments from Doctors and Physiotherapists).

At the pain clinic, dealing with serious pain is their ‘thing’ and they are overflowing with compassion, knowledge, support and genuine interest in your pain. This alone is a huge relief, when you have been spending months battling to get people to listen the symptoms and take them seriously. It feels like getting into a comforting, warm bath! Plus they have models and simple explanations that help you to make sense of how your life is unravelling and what you can do about it.

One model that was enlightening for me was the ‘pain triangle’ that they said was universal in serious pain – where the relentlessness and intensity of it makes you feel helpless and hopeless, and your incapacity and reliance on others then drives feeling worthless. Then each point of this ‘helpless, hopeless, worthless’ triangle reinforces the other points, dragging you lower and lower until you can find something to break out of the vicious cycle.

They really want to get to the root cause

The next bit of brilliant news at the pain clinic is that they profoundly believe that your pain has a cause and that with work, they can find it. I felt that there was almost a detective vibe – where they are searching for the cause with different clues, hypotheses and points of evidence. They listen intently to every clue that you can give them, weighing it and thinking about what it could mean in a medical sense.

The pain clinic felt different. How? Well, I sometimes joke that when you see a consultant, they only have the 3 N’s (kNife, Needle or Nothing) and physiotherapists only have the 3 P’s (Poke, Push or Pray). This is of course brutally unfair and negates all of the knowledge and complexity of what they do, but as a patient it can reflect the outcomes and the lack of transparency in the process where they have the knowledge and you are just left with the problems. But, in the pain clinic, it felt like there was a logic in the way that they assessed the total body and looked at the interactions of different body parts. This is especially important when there are different body parts involved or overlapping conditions that come under two different surgical specialties because it leads to a lack of clarity about where the leadership and ownership sits between the different specialties once you are an out-patient. Whereas in the pain clinic it is all assessed together and at the same time (almost like you are one person with all of the parts of your body connected!)  

They take a multifunctional approach

The other brilliant bit is that all of the different disciplines work together and talk to each other in the pain clinic. This is so different from life as an out-patient and even as an in-patient, when even when you try to get the physiotherapy and surgical side to align behind one treatment plan and talk with each other, one party always resists it (even if you promise to sign GDPR releases, volunteer to manage the phone call within your appointment and volunteer to step outside if there is something that they want to discuss without you present).

At the pain clinic they have a common goal to reduce and eliminate your pain, and they each bring their own specialist skills to this team goal. It feels like a sports team, with everyone rooting for each other and working hard to get a result. As a patient, you feel in good hands.

This team support is important. If there was one tip that I would give to Physiotherapists in the out-patient context it would be ‘don’t comment at all on any previous physio that the patient has had’. I have seen nine different physio’s through the path of my pain and universally in the first stage (when they ask you lots of questions about what has happened and what you have done before), every single physio has critiqued what the previous physio has done with very negative tones and criticism. This really does not help! We cannot turn time back and I have already decided to change physio to see you, so there is no need to justify why you will be better. It makes me (as the patient) feel vulnerable and scared, because it makes me wonder if I allowed the ‘wrong’ treatment to be given to me (even though there was no way that I could have had the knowledge to make this judgement). And when you have seen as many as me, you start to build a picture that there is no common view of best practice and that there may be a lot of snake-oil sales people in the physiotherapy profession who maybe have not kept up-to-date with best practice. I hope that this is not true, but is a clear impression that the criticism of others can generate.

So my advice for patients is to seek out a group who work together across functional boundaries with your wellbeing as a patient as their over-arching goal.

When should you go to a Pain Clinic?

There is not really a clear view on when to go to a pain clinic, and again you can get a lot of contradictory advice. The textbooks says that pain is considered to no longer be ‘acute’ and to have become ‘chronic’ after 3 months, although many GPs seem to operate on 6 months.

I also think that there is a lot of pressure on the resources of the pain clinic (and there is a really long waiting list for it – over 9 months in our area). My hunch is that this leads to a tendency to hold off from a referral to the pain clinic until it has been a very long and serious issue. If you have health insurance, there are also private pain clinics, although you will need to have a look at the terms of your policy to see whether this is covered and what the referral process is.

I would suggest that for the reasons above a pain clinic may be especially helpful if:

  • You have overlapping conditions that make you feel that you are falling through the gaps
  • You are not making any progress and need a different approach
  • You are reaching a point of despair

I wish you the very best of luck – you are not alone, and there is a brilliant team somewhere who can help you! Stay strong in order to find them and start to move forward.

Recognising other bloggers who have cast helpful light and perspective on my own challenges

It has been quite some months since I last wrote a blog. The back end of last year was a hard road of trying to get the pain medications to the balance that made the basics of getting through the day possible, and working out how to shrink life to the things that I could get through. Then facing up to the surgeon’s persuasion that a tenth surgical procedure was the best way forward.

Through this time I struggled to find a way to share my experience in a way that I felt could help others.

Plus, I have to say that I found various bloggers and communities who are sharing their experiences and I felt were sharing a lot of the things that I had been searching for over the last two years.

So I wanted to blog to share links to some of them – in the hope that this is helpful for people reading it.

Joletta Belton – My Cuppa Jo (www.mycuppajo.com)

Jo shares her experience of over a decade of pain stopping her ability to work as a firefighter and to run and pursue the sport and life that she loved. She has gone on to do a huge amount of study about posture, musculoskeletal issues and pain, now sharing this with others in her beautiful and inspiring blog posts and also as a patient advocate at international conferences.

Tina – Living Well Pain (www.livingwellpain.net)

Just as Jo has pioneered the path in Canada, Tina has done the same in the UK. Tina’s accident was over two decades ago and she shares her experience of how to live well with persistent neuropathic and musculoskeletal pain with lots of practical tools and advice from her own experience. These come in the form of blog posts on specific topics and most recently as a patient advocate, she has written a guide for patients called ‘Making the most of Physiotherapy’.

Pete Moore – the Pain Toolkit (www.paintoolkit.org)

Pete attended a pain management programme in 1996 and since then has dedicated himself to sharing the best information and knowledge with both patients and clinicians across the globe dealing with persistent pain, especially back pain. He has a great website and has written a number of excellent guides on pain. Most recently he has set up a monthly Pain Toolkit Online Café on Zoom, where anyone is welcome to digitally ‘pop-in’ and chat or listen to others working with similar issues to their own.

Barbara Babcock – Return to Wellness (www.returntowellness.co.uk)

Barbara’s experience of her own neurological illness and also caring for her husband meant that she saw up-close-and-personally the life-changing impact that a serious health issue can have. This led her to use her coaching experience to restore emotional wellbeing and look positively towards the future. Her blogs and self-help tools help across: managing the health issue, reclaiming emotional health, reclaiming relationships, returning to work, reclaiming meaning & purpose in life, reclaiming hobbies & interests and support for carers and supporters.

Jo Moss – A Journey through the Fog (www.ajourneythroughthefog.co.uk)

Jo is bed-bound as a consequence of the health issues that she suffers from. She writes her blog to give other people in the same position a bit of hope. She says “My life isn’t easy, but it is worth living. I may cry a lot, but I also laugh a lot. I may get depressed, but I’m also optimistic. No matter how bad things seem right now, they will get better. You can take back control and give yourself hope for your future”. Her blog is frequent, searingly honest and brutally insightful on topics that others may shy away from.

Sheryl Chan – A Chronic Voice (www.achronicvoice.com)

Sheryl lives and blogs from Singapore, living with multiple lifelong illnesses. Her blog sets out to help other sufferers with a toolbox, but more widely to raise awareness of long-term illnesses from a number of perspectives and encourage empathy amongst all facets of society, and not just healthcare. Her blogs are frequently very practical, covering both the physical and the emotional challenges with equal frequency.

The Princess in the Tower (www.princessinthetower.org)

This site has a number of useful resources for learning about chronic pain and how to manage it and reduce it. The blogs focus a lot on the emotional impact, and ways to manage this.

Then, I also discovered some really useful communities:

HealthUnlocked (www.healthunlocked.com)

This is like a medical version of Facebook and there are different groups that you can sign up to. One of the groups is Pain Concern (a charity that also have a helpline that you can call and lots of other support tools that you can access at www.painconcern.org.uk)

Anyone can post a thread and expect to get genuine responses from others. The tone is universally helpful (in my experience) and can get some good insights. Obviously, this is not professional healthcare advice, so it needs to be seen in that context.

The Injured Athletes Club on Facebook

This community was set up by Carrie Jackson Cheadle and Cindy Kuzma to go with their book ‘Rebound: Train your mind to come back stronger from sports injuries’. They moderate and facilitate the group to get to a mix of being able to vent about challenging times, ask for advice/perspective and celebrate progress, with ‘Winning Wednesdays’, Monday Motivation and Friday Feeling themes running most weeks.

I hope that you find some of these inspiring and helpful, just as I did. If you have others that you think are excellent, then do share!

Why I asked for my money back on the FAI Fix

The FAI Fix was recommended to me by a friend of a friend. It was developed by two Personal Trainers (PTs) in the USA – Shane and Matt – who both had significant hip issues and manage to overcome pain, impingement and poor Range of Movement (RoM) without surgery – although they do admit that this has taken up to a decade of daily work! It comes with a number of success stories on the website: https://www.thefaifix.com/ and is supported by some really excellent YouTube videos and emails that made me really feel that Shane and Matt understood the issues and challenges of hip pain, and also explained the anatomy aspects of it really clearly.

However, when I was thinking about signing up for the programme I could not find any impartial reviews of how people had got on with the programme. And I saw tweets and messages of others looking for the same. So I thought that I would write about my experiences in order to support others.

The programme

There are 2 levels of the programme. The basic one is the FAI Fix Basic for $129.95 USD – a one-off payment that then gives ongoing access to the exercise library. There is then a further payment to do the more advanced programme for athletes who want more hip movement (eg powerlifters). But they are clear that this is a much smaller group, and is a progression from the first programme once you have resolved the pain in your hips in usual daily activities.

On the homepage, they explain their TSR system – Tissue Work, Stretching and Reactivation. This is a common (and well-proven) structure for many rehab programmes:

  1. releases with the foam roller, ball, knobbler etc to release the overactive muscles
  2. stretching to lengthen the tight muscles
  3. reactivation to activate and strengthen the underactive muscles

It is impressive how much more RoM you can get by doing targeted muscle releases before stretching that area.

There are a minimum number of tools that you need in order to be able to follow the programme – a foam roller, a strap (which could be a belt from a dressing gown), a lacrosse ball (or small, hard ball – there are different levels of hardness in therapy balls and the idea is that you progress) and possibly a ‘knobbler’:

The tools! The ‘stick’ was an optional extra, and the blue one is the ‘knobbler’ – but most of the programme could be done on the floor in front of a mirror with the foam roller.

When the programme link arrives there are 13 tests which are meant to narrow down which of the 5 key muscle groups is the issue. Then there is a TSR exercise set for each muscle group and a 6th workout that is a combination across muscle groups.

My experience with the programme

In advance of signing up for the programme, I was uncertain whether it was suitable for me given that I was 6 months on from hip arthroscopy surgery. However, I got a response that looked like it was a response from one of the 2 PTs reassuring me that it would be suitable – although looking back, I now think that it was probably compiled from a series of standard paragraphs.

Working through the programme is quite intense – the diagnostic exercises take quite a lot of set up and checking the form and RoM in front of the mirror. If you or someone in your family are not quite experienced in Personal Training and muscle groups it would be quite difficult to work through. And the challenge for me was that the tests were not discerning for me – all of them were painful and all of them had less-than-ideal RoM, so it was hard to diagnose where to focus.

I diligently followed the programme daily for 4 weeks. The good news is that I did see an increase in my RoM, but no reduction in the pain before, during or after the exercises. Therefore, I followed the process to get advice from Shane and Matt. I wrote a summary of how I had interpreted the 13 tests and what I had been doing, but got only a 2-line response from someone other than them telling me that I needed to choose just one muscle group and focus on that, but no further details on how to make that choice or how to better understand the diagnostic tests (given that all were painful and low RoM).

I followed the advice for another 4 weeks and then got in touch again, but did not get any response this time. In the meantime, the general emails from them changed. In the first couple of weeks, they had been bits of advice and case studies which were definitely motivational – especially on fixing the body through movement rather than surgery. But after that, the emails continued to come 3-4 times per week, but were now trying to sell more stuff (tools, personal coaching, other programmes etc). 

So, I decided to ask for my money back (which in-line with their no-quibble money-back guarantee they refunded immediately – although interestingly they did not ask for any feedback on what had worked and not worked, or why I was asking for my money back).

My summary

The exercise video library is good (there are probably 50 exercise variants covering the 5 muscle groups), but I would suggest that the money is much better spent with a Movement Trainer who specializes in Corrective Exercise and can really help you to diagnose which are the problem movements and then focus a personalised programme on just what you need. This should actually start to address where you have the pain and monitor development and progress you see with the exercises, in order to then make choices on how to progress.

That said, the overall message that you can make progress on your hip pain without surgery is profoundly supportive. Plus there is a strong sense of realism in the sense that they are clear that it will take work and time.

Good luck with getting to the bottom of your hip pain and finding the key to unlocking the pain.

My experience with hydrotherapy

I have not blogged for a while whilst I have been trying new things, doing lots of research and trying to make progress on reducing my pain and increasing my ability to cope with day-to-day tasks and activities. It has been an interesting voyage where I have become clearer that there are many paths to recovery – and no-one has the universal answer, so you have to try lots of things! With this in mind, I thought that I would share in a few blogs over the coming weeks some of my recent experiences.

Hydrotherapy was one of the things that was suggested after each of my surgeries. It is 45 mins drive to the nearest hydrotherapy pools and there are none in my local authority area. Plus you have to have a medical referral form and go through some extra checks to get access, so it all took a bit of organising. But I think that is was well worth it, as I think that it reduced pain in the short-term and had an incremental improvement in the Range of Movement (RoM) in the scar tissue and the affected muscles.

What is hydrotherapy?

The hydrotherapy pool is kept at 37 degrees Celsius, which consistently feels very pleasant and after 30 mins of doing structured exercises feels positively hot!

It is about shoulder depth and about 10m across, so it is easy to get the benefit of the water resistance as well as the immersion.  There is also easy access, including a hoist so that you can get in and out even when your body is not working well. Given that there is only space for a small number of people, it is key to reserve the slot and be there changed and ready in time.

You can work with a physio in the session, but once you have a routine it is relatively easy to work through the exercises on your own. There are ‘weights’ made from floats to create additional resistance by pushing them down in the water and inflatable ‘noodles’ for support.

How is it better than a normal pool or hot tub?

I had tried both the normal pool and hot-tub, and would say that the hydrotherapy pool is much better.

Doing my exercises in the pool was hard work (remember that 1 litre of water is 1kg – so there is lots of weight in the water resistance), and the cooler water temperature that makes it suitable for swimming means that there is not the therapeutic benefit of the muscle release that helps with RoM and probably with the pain reduction too.

I had also used the pool to try a little aqua-jogging with the float-belt (as shown in the photo). This is used a lot by elite athletes when they have injuries and it is claimed that you can keep 80% of your running fitness if you put the same hours in at the pool. This should work really well for lower limb injuries where you need to keep the muscle memory, but avoid the impact (especially in stress fractures and some soft-tissue overuse injuries). But given that for me the inflammation affects the movement pattern, I found that it was too tough at this stage.  

The aquajogging float belt clips around you to keep you upright without your feet touching the bottom of the pool (you need a pool deep enough for this!) and you can add difficulty by holding a waterbottle in each hand and changing the amount of liquid in it for more difficulty.

The hot tub is useful for me for the muscle release and for managing some of the pain. But it is not deep enough or large enough to do all of the exercises, so it is not as good as the hydrotherapy pool. I think also that the 30 mins slot, where everyone else is also working on their exercises, brings a level of focus that really helps.

Did it make any difference?

My own experience was that it was a very supportive environment – everyone there is working on getting better and is very willing to share what they have had success with.

In terms of the physical impact, the warmth definitely had a positive impact in terms of reducing pain for a few hours (just like hot water bottles etc when at home). My understanding is that this is not universal – some people find that the pain is reduced with cold, others with warmth.

Plus, I found that 30 mins of hydrotherapy definitely improved RoM for a period of 24-48 hours and if I did it 3 times per week, I saw real progress on my land-based exercises. That said, it was positively hard work – after 30 mins the combination of the temperature and the hard work was very tiring and I was keen to get out and have a nice drink of water! And the travel on top made it quite a bit harder. So, I would say that if you have a hydrotherapy pool nearby, do make use of it in your recovery and rehabilitation.

Another self-help technique for back pain – the McKenzie method

I had lots of people getting in contact after my blog earlier this week on back pain, so wanted to quickly share this additional technique that has brought relief and recovery to many. I hope that some of you find that it helps.

For a lot of people (especially runners and cyclists it seems) back pain comes and goes episodically. For most the issue is a disc bulge (most people over 25 or 30 years-old seem to have them to some level), and the disc bulge moves slightly, compressing one of the 4 key nerves at that lumbar vertebrae level and sends white-hot pain, pins & needles and/or numbness down the leg, sometimes with symptoms in the bum cheek or hip as well.

Each nerve has a role for areas of the body and internal organs. If you are interested in understanding the link between the level of the spine (which vertebra) and the body, have a look at the spinal nerve chart: https://millerchiropracticclinic.com/spinal-nerve-chart/

A lot of people have found great relief through the McKenzie method

First of all, take this simple self assessment – answering yes or no to each of the questions:

  1. Are there periods in the day when you have no pain? Even 10 minutes?
  2. Is the pain confined to areas above the knee or above your elbow?
  3. Have you had more than one episode of low back pain or neck pain over the past few months or years?
  4. Do you feel worse during or immediately after prolonged bending or stooping; as in making beds, vacuuming, gardening, concreting, etc?
  5. Do you feel worse when sitting for prolonged periods or on rising from the sitting position, ie after watching TV or working on the computer?
  6. Do you associate your pain with any one particular activity but are generally pain-free when not engaged in this activity?
  7. Do you feel worse when inactive and better when on the move?
  8. Does your low back feel better when lying face down? (You may feel worse for a minute before the pain subsides, in that case, the answer to this question is yes).
  9. Does your low back pain feel better when you are walking?

The McKenzie Institute claims that if you have answered yes to more than 4 questions, your chances of gaining benefit from the McKenzie method is very good.

They say that if you answered yes to 3 or fewer, then you may require specialised assessment and treatment.

The McKenzie method is built on gentle spinal extension exercises

The theory behind the method is that most discs bulge out backwards, and therefore gentle extension exercises encourage the disc to change shape with more of the disc-matter at the front and take the pressure off the nerve that it is compressing.

Robin McKenzie’s book ‘Treat your own back’ is inexpensive and practical – giving a do-it-yourself plan for relief of lower back pain through postural changes, ergonomics, and simple exercises. It also provides a clear understanding of the causes and treatments of persistent back pain.

One last key tip

I think that anyone who goes to a physiotherapist with back issues is given spinal extension exercises. But I am not sure that everyone talks about technique, and it is really important. If you simply move into the spinal extension, then all of the muscles in the lower back shorten as you peel up. But if you engage your abdominals (especially the deep Transversus Abdominus) and then do the back extension, then the same muscles go into extension due to the reciprocal inhibition of the muscle pairing with the abdominals. This is what you want.

Do topical treatments work?

When the problems are joints and muscle cramps, there are a lot of topical treatments that are marketed at you. But should you use them?

I am not medically qualified, but I have tried a lot of them out and read a lot of labels, so here is my layperson’s view:

There are probably two underlying reasons that you are looking at topical treatments:

  1. For pain management
  2. For localised healing

These two things are linked by the need to reduce inflammation – key for the early stages of healing, and inherently linked to localised pain.

I think that there are better ways to get to pain reduction?

Many of the medicated creams and patches are delivering ibuprofen or a similar drug. These are strong drugs that can have a major impact on your organs (especially if you are not well hydrated). So my recommendation is that if you need that pharmaceutical, take it orally and monitor the dose carefully. Trying to understand the dose from cream or patch is much harder.

Some help pain relief by delivering warming, or heating component via a chemical reaction. Temperature management is a great way of helping the body with pain. But personally, I would prefer to do it with a wheat bag (for heat) or an ice pack (for cold), rather than a chemical reaction.

But massaging the scar tissue with a suitable substance seems a good plan

It is universally agreed that massaging the scar tissue is key for helping the healing of scar tissue. And massaging in nutrients that are going to help seems like a good plan. Although it should be noted that every substance can have side-effects, so you should read all of the labels and look up the potential side-effects so that you know what to look out for.

Whether these are crushed Epsom salts in olive oil (for the Magnesium – to sedate the nervous system and draw out the toxins from the muscles). Or a magnesium sulphate spray or cream for the same effects (but a more expensive price tag! Reflecting the convenience of not having to crush the salts in a polythene bag with a rolling pin and mix in the oil!).

I also realise that there are different views. I love to read the blogs from Paul Ingraham on painscience.com and this one on Epsom Salts is apparently one of his most read:  https://www.painscience.com/articles/epsom-salts.php . I think that he does accept that some things can cross the skin, but is sceptical on the impact of magnesium sulphate. You can read his blog and decide for yourself (and indeed if Epsom Salts in the bath works for you – who cares if it is a placebo effect if it works for you?)

Or maybe Aloe Vera or Arnica-based creams/patches to reduce the inflammation and support the next stage of healing. I have to admit that I prefer the creams – as the patches do not encourage the massaging, and this is really important for the benefit to the scar tissue. Additionally, with the creams you see and control the dosage a little more – which is not so clear with patches.

Probably the best option is a skincare product with vitamin D (like Bio Oil) to moisturise and care for the scar tissues when you massage them. And always make sure that you put a high factor sun cream on the area for any exposure to the sun, as the new skin is very vulnerable.

When the pain goes down the leg or arm

The challenge of a lot of the nerve-based cramping is that the pain in the muscles put into continuous cramping can be completely debilitating. Massaging in muscle-relaxing gels or creams can help to reduce this secondary issue, although obviously, it is short-lived as it does not address the nerve issue that is causing the cramping.

Oral muscle relaxants do work, and again may be a better treatment for the issues (depending on how bad the symptoms are).

Overall

So in summary, I am not sure whether the topical treatments are the best way forward, as I think that a clearly dosed oral approach may be better. But for sure you need to find the skincare product that encourages you to massage the scar tissue to keep helping it to remodel properly. And a high factor suncream to protect the tissues in the sunshine.

Should I be taking painkillers?

Pain is such a difficult topic and in all of the people that I have asked, no-one is really able to give any clear answers. I have written some other blogs on pain itself. In this blog, I wanted to explore the topic of when to take painkillers. It is the question that I have asked every single medical practitioner that I have come into contact with and not really got any consistent or clear answer.

So here is my summary.

Pain as the protector

Pain is there for a reason – it is there to protect our tissues from damaging actions. So taking painkillers in order to be able to ‘push through’ and walk/sit/stand or even do more energetic actions is likely to be a bad thing. The physiotherapists generally seem to sign-up to the ‘listen to your body’ school of understanding the pain signal.

When we are trying to release the tension in over-active, tight muscles with stretches/releases, there are some tricks like using the contract/relax form of stretching that uses the inverse stretch reflex, or activating the antagonist muscle during the stretch to use reciprocal inhibition to enable the muscle to ‘turn-off’ and stretch.  But if the releases and exercises (to activate the under-active muscles) hurt such that you have trouble adhering to the physiotherapy regime, then the GPs seem often to recommend taking enough painkillers to get through these in order to support recovery.

Pain as the problem

When pain stops you sleeping and leaves you in a permanent state of stress (racing heart-rate, perspiring etc), then this is clearly a problem for your body as well as coping with life. For the body to have any chance of healing, it needs the parasympathetic nervous system activated (the one that goes with calm and balance), not the sympathetic nervous system (the fight-or-flight system). Therefore, if you are not sleeping or not reaching a state of calm, then it would seem necessary to take enough painkillers to manage this situation. Certainly the osteopaths and chiropractors seem to subscribe to this view of management – ideally without synthetic drugs, but definitely calming the system and getting it out of the hyper-vigilant or over-alert state that it can get into. Homeopaths will also suggest treatments that can help here.

Which is fuzzier – pain or painkillers?

A lot of painkillers seem to leave you feeling mentally very fuzzy and unable to focus and concentrate, but pain can also leave you feeling like the world is a long way away down a dark tunnel. So you need to find the type and dosage of painkillers (or none) that give you the best effect physically and mentally. Obviously, painkillers are more effective if you take them over a period, so taking them as the pain comes on, rather than when it is totally unmanageable will help – which I know is sometimes easier said than done.

Drugs are not the only solution

Research that shows that pain is worse when we are low and lonely, less active or less busy and feeling less good about ourselves. For some great explanation of the science behind pain check out these brilliant and simple explanations of understanding and managing pain at  https://www.retrainpain.org/

There are also all sorts of mental and physical techniques that you can try and see what works for you and your situation. There is no simple solution that works for everyone.

But what about the question of if/when to take painkillers?

You need to find what works for you. But I think that the principle of listening to and understanding your pain, and then recognising what you need to give your body in order to manage the pain and the recovery is really important. Painkillers may have to be a part of this, especially in the early stages, but the quicker you can get to other, more sustainable, solutions the better it is likely to be for your body.

I hope that you get out of pain soon. I know just how exhausting and enervating it is.