Transcript – Programme 24: Exercise and Managing Pain
How swimming can help manage pain, and a Q&A session with physiotherapist Paul Cameron
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Paul Evans takes the plunge with Daphne Wood of Pain and Able to find out more about how swimming combined with the Alexander technique can help people with persistent pain conditions. Physiotherapist and Pain Concern expert advisor Paul Cameron answers listeners’ questions on issues from dehydrated spinal discs to losing weight to reduce pain.
Issues covered in this programme include: Exercise, swimming, the Alexander technique, awareness of habit, dehydrated spinal disc, weight loss, joint pain, catastrophising, flare-up, osteoarthritis and breathing technique.
Paul Evans: 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’s supporters and friends and by an educational grant from Grünenthal.
Daphne Wood: 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 has 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 am able to at least go and glide and stand up and feel better for it.
Evans: And I will be taking the plunge to find out just how responsive the water is to me later in the programme. But you will know by now that one of our aims on Airing Pain is to answer questions you have 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 is one of our experts. He is 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 the East of Fife. Here’s his first question: ‘I am 20 years old and have been diagnosed with dehydrated discs. I am currently on a lot of medication and have been for the last two years. I’ve done physio, epidurals, acupuncture and I have recently had a massive flare up. I am in so much pain, I just don’t know what to do. I use TENS machines and heat pads – nothing works.’ …Paul?
Paul Cameron: 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, what you have painted a picture of there is a chronic pain patient, someone who is very anxious now, is in a lot of pain, has flare ups, worries about the future – ‘catastrophising’, we would call that possibly. We would approach that in a way that would be looking at that person’s self-management, looking at ways they can progress their life – they are only 20 years old – they have their whole life ahead of them and if they get caught in that cycle of thinking there is no future for them, there is no way ahead – it is just going to be a life of pain. I can only imagine what that must be like and I imagine it would be terrible.
So for that 20 year old, we would be looking at ways to, again, using all the professions involved in a pain team, for example, and the GP, to minimize their pain as much as possible and that is firstly through adequate pain control. Secondly, it’s about getting moving as well and actually educating them. We find that education of patients is a huge thing, because you do get a lot of terminology expressed by patients and usually there are a lot of misconceptions, there is a lot of worry – they have heard things like crumbling discs, wear and tear and we dispel those myths and explain exactly what these things mean.
We also educate them in the actual strength of, for example, the spine, the strength of the spine – just how mobile it is and all the structures involved – and what we mean when we are talking about things like dehydrated discs and what that means for the future as well. All those things combine and I would say particularly the education allows the patient to progress, I think. It allows them to remove the fear and reduce the anxiety. Through the reduction of anxiety and the increase of movement – we are not talking of running a marathon, we are 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 pain, without them being controlled by the pain.
Evans: You use the word ‘catastrophising’. Now I know what a catastrophe is, so what do you mean by catastrophising?
Cameron: Catastrophising is 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 ‘well that’s it’ – their life is over, they have to give up work, they are not going to be able to work again, they are not going to be able to partake in the sports that they enjoy ever again… They turn that element of the symptom, internalize it and catastrophise and it does sort of affect their whole life in that way.
Evans: 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?
Cameron: Yes. A practical example may be, for example, a person who enjoys golf and then has a flare up of 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 club house; and they withdraw themselves into the house and that is their life – they have removed themselves from something they very much enjoyed. That would be catastrophising.
So, you can see how those sort of thoughts not only affect the pain, but affect their whole life, their social circle, their friends or family – so it is a big element to them. For that particular patient you mentioned, just 20 years old with their 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.
Evans: Many thanks and we will be returning to Paul Cameron to answer more of your questions later in the programme.
Now, don’t forget, we can’t talk about specific cases, but you remember him saying that 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 strained muscles and joints.
Daphne Wood of Pain and Able swims to help manage her own chronic pain. She is a qualified teacher of the Shaw method which applies principles of the Alexander technique to swimming. So, speedos in hand I met her at the Ozone Health & Fitness Club in London’s Kings Cross at the Bloomsbury Holiday Inn to find out what kinds of persistent pain conditions her swimming lessons could help with.
[Background sounds of swimming pool]
Daphne Wood: 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 the high impact exercise a bit difficult or who just want to enjoy swimming as part of pain management.
Evans: Well, from my point of view, I have 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. [Wood: Right.] I try to swim and it’s a boom and bust scenario. I enjoy it too much, it’s going too well and I suffer afterwards. [Wood: Right.] Perhaps you can help me get through this.
Wood: Yes, I think one of the things that I would – even without seeing you in the water – is say is that the general 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 would need to look at how you feel a couple of days after that and, if that seemed fine, then you continue at that level for a while.
Evans: The problems I get with swimming are 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.
Wood: That’s a crucial thing that we will be looking at today. Part of my approach is about applying principles of Alexander technique to swimming, so, I believe that the relationship between your head, neck and back is crucial for effective movement and if you are holding your head out of the water and tightening muscles at the back of your neck that has an adverse effect on movement. Also, if you are 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 is not really any way around learning to negotiate putting your head in the water, which is in fact a lot easier than most people believe. Many people who come for lessons are in fact really annoyed to find out how easy it was and that there has been this kind of mystery. Shall I tell you what we will be doing, before we get in the water?
Evans: Yes, please.
Wood: OK, two things to remember: 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 will be doing, is standing over there in the pool, feet firmly on the ground, you will start an out breath from before you put your face in and we will work on trying to keep the out breadth continuous until you back out of the water.
Evans: I am not afraid of getting my face wet. The point I was making is that you have to come out to breathe some time.
Wood: 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. Then, once, the sort of anxiety of ‘what do I do if I run out of breath or forget what to do with my arms and legs’ – once that is allayed, then you can relax and can think of how to move your arms and your legs.
Evans: Before we met and when we had 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.’
Wood: 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 strain and things – is when to use effort and not to use effort. It is 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 breast stroke 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 am doing is about paying attention to each stroke, rather than I must go and do my twenty lengths. And when you do that, you begin to notice the difference it makes, if, for example, if you hold your hands in a softer way – 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 is not that you just tick it off because you have done your twenty lengths – it should actually be quite enjoyable and experimental.
Evans: Come on then, let’s do it.
Wood: OK! Let’s get in. You’ll need your goggles.
Evans: Daphne Wood of Pain and Able. Now whilst I run off and get my goggles, I want to try and get some answers to a few more of your questions from physiotherapist Paul Cameron. Actually, swimming may be relevant to this next question – he says his doctors have told him he will be in less pain if he loses weight – why?
Cameron: Right, OK. Obviously – again, not knowing that particular patient’s circumstances – I would say that, obviously, loss of weight is healthy for a number of reasons, if you are particularly overweight – not just for pain reasons but 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 reduces weight of the joint may reduce or help reduce the pain in a joint as well.
It is a very difficult one to say really, because there are 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 is maybe a consideration for people who are overweight with joint pain and it may help them – there are no guarantees, but certainly from 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.
Evans: I suppose – we don’t know what sort of weight this person is, although I am 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 am 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.
Cameron: Yeah, I would agree. So a caveat to that would be that you don’t gain weight overnight, so it’s not a sudden change to your joints and equally you don’t lose it overnight either, so, again, it wouldn’t be a sudden change to your joints either. None of these things are quick fixes – they are just one element of 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.
Evans: Here’s quite a complex question from a correspondent: ‘I am 47 and my knees are causing me agony. X-ray and MRI have revealed nothing. I am 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 morning. Rheumatoid arthritis has been ruled out and they are saying I have osteoarthritis and, if so, I just have to live with the joint pain. However, it’s my knee that is unbearable and mostly on the outside. A specialist is contacting my GP to recommend stronger painkillers!! I’d appreciate some advice.’
Cameron: The first thing I wouldn’t do is talk about specific medication anyway, but I would advise that particular patient to return to their GP and have that discussion about their pain control – they have mentioned some side effects they are 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 is worried about medication.
Yes, we have a limited number of pain medications, to be honest, and research is always being carried out to try and improve that. But that doesn’t mean that there isn’t scope for change, there isn’t scope for allowing a patient to be a bit more finely tuned with their own pain medication, because everyone will respond differently. But, again, it would be a conversation to have with your GP or a clinical pharmacist, who would be able to assist with that as well.
Evans: Physiotherapist, Paul Cameron. And if you would 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, painconcern.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 – where, suitably goggled, I’m ready to take the plunge with Daphne Wood of Pain and Able.
[Background sounds of swimming pool]
Wood: What I would like to start with is just walking to as deep as you are 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 is quite simple but in a way it helps us both catch up with ourselves in the water.
[back in the studio]
Wood: 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 or something like that.
Evans: 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.
Wood: 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 experiencing increased pain, for example, after swimming, maybe knee pain after doing the breast stroke or shoulder pain after doing front crawl, then there are things we can address to make the swimming more satisfying and more beneficial.
[Background sounds of swimming pool]
Wood: OK, we are going to have a go now at the breathing, are you OK about that?
Evans: Yes, yes.
Wood: Put your goggles on please. Lean towards the wall, leaning into the wall with your fingertips underneath the surface of the water.
Evans: My chin is just above the water line.
Evans: Now I’ll nod my head. In fact, I’m going to stop talking as well [laughing]. I’m just going to nod my head – do I put my face under water?
Wood: Not your whole face yet – until you get used to… the crucial thing is to keep the out breath continuous.
[back in the studio, absence of background swimming pool sounds]
Evans: You were concentrating while I was in the water with me breathing correctly and breathing under water – what was the purpose of that?
Wood: We started with the breathing because, if you are 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 are no other factors that you are 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 on and keeping the breathing going.
[Background sounds of swimming pool]
Evans: So what I was doing there, I was just let my head float?
Wood: Yes, yes, could you feel that it doesn’t just sort of keep going down? [Evans: No, that’s right.] There is a point where, it is pushed up a little bit.
Evans: Yes, yes, it’s not because my head is too full of air [laughing].
Wood: No, most people’s heads do this, so you are fine [laughing]. Try that again, just sort of feel how that is quite a strong pushing up really.
All Shaw method teachers have had all the traditional sort of swimming teacher training. I have had an additional one year of training in applying Alexander technique to swimming.
Evans: Forget about the swimming for a minute, what is Alexander technique?
Wood: It is 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-gaming: 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. And there’s a rather elusive concept called direction which on dry land, you would be thinking up…
Evans: What do you mean by ‘thinking up’?
Wood: Thinking up – it’s just the sense of… looking at runners – and thinking is their 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 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 direction which is like the opposite of depressed. I think there are reasons why there are these words in our culture.
Evans: 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.
Wood: Exactly, yes, that is 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.
[Background sounds of swimming pool]
Wood: I am going to talk a little bit about direction now. In swimming the going up translates into going forward. A lot of good swimming is thinking about what you are doing and in particular in the glide. We are going to experiment now, thinking of sending your arms and head forward so don’t worry about your legs or whether you are floating, just think of going forward, forward, forward with your arms and head.
[back in the studio, absence of background swimming pool sounds]
Evans: You were teaching me how to actually use my body shape, my natural body shape to do all the work, minimising the use of my muscles.
Wood: 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 and that 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 then to get some momentum and go forward in the water, yeah.
Evans: To me, that’s not swimming.
Evans: That’s being in the water.
Wood: 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 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 is all taken care of, then you can give your full attention to ‘how do I need to move my arms? 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.
Evans: And the interesting thing as well that I found is that by systematically going through different parts of my body, if you like – my head, my breathing, my legs, my hands – the angle of my hands in the water – you made me notice what my muscles were doing and how changing position could alter the way those muscles were working.
Wood: Exactly, yes. And you see those kind of observations that you made come much easier when we reduce how much you are doing – it’s unlikely when you are 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.
[Background sounds of swimming pool]
Wood: … that’s lovely. I think it’s time to just look at how you stand up because there’s something very wise in the back of our heads which won’t let you float comfortably unless you are very clear about how you are going to get your feet back on the ground and how you are going to breathe. Now, the reflex way that people often do it, is to snatch their head out, OK? If you do that, if you come up head first from the horizontal, you are immediately tensing all these muscles, you can hear it even in my voice and you feel as though you can’t breathe…
[back in the studio]
Evans: In terms of pain management for people who come to you, how do you assess what they can do and what they can’t do?
Wood: 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 the awareness of trying to think about what you are doing about 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. Then we would certainly speak the next time about how they felt after that and there’s always a chance at the beginning of the lesson to look at any issues that have arisen. Sometimes just the joy of being in water means that somebody will then go to an aqua-aerobics class after my lesson and say ‘I felt dreadful’. And in fact it’s that they have just gone on and done a lot more. But I have rarely had any 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 in less pain.
Evans: 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.
Wood: Yes, that’s brilliant and if you found that today, then I’m delighted.
Evans: And I’m delighted too. So that’s Daphne Wood of Pain and Able. She’s based in London and you can get more information about her lessons at her website which is painandable.com. And there are teachers of the Shaw method throughout the UK, details of which can be found at artofswimming.com. The last word to Daphne:
Wood: A lot of our habitual ways of approaching life don’t work in water. Very often, on a day to day basis, I have thought that trying hard was the way to succeed – in water it really doesn’t work 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 succeed.
- Daphne Wood, Pain and Able
- Paul Cameron, Pain Specialist Physiotherapist, NHS Fife.