Getting the best of Christmas

5 top tips if you suffer chronic pain

If you are suffering chronic pain, here are 5 tips to maximise your festive spirits and joy. You can decide upon your approach and give it your best by following some simple principles.

1. Make a plan

What is your picture of success? How do you want Christmas to be? What can you focus on that would make it memorable for the right reasons?

The questions we ask ourselves, we will always answer. So, make sure you come up with ones that self-encourage, helping you to focus on what you want, rather than what you do not want.

Think and act like the person you want to be

Make a plan each day, prioritising the key moments, punctuating them with rest and recovery time. You can share your plan with those you’ll be sharing the day with so that everyone is on board. Of course, the best plans do not always turn out the way we want, so we need to be flexible. However, if we try to stick to it in the best way that we can, often made easier by writing it down, then we are doing all that we can to be successful.

2. Motion is lotion

This is a way of nourishing your body (tissues — muscles, joints, tendons etc.). The key is to be consistent through the day. In essence, the movement is ‘pumping’ blood and hence oxygen into the tissues as well as removing the build up of toxins (that cause sensitivity).

The brain is embodied, and needs movement to survive — the brain needs a body. Pretty much everything that we do requires movement. Anything that gets in the way of the movements necessary to meet our needs will raise the perceived threat value. As many readers will know, pain is well-related to perception of threat and the state of the person, and poorly related to the tissue state.

Move to groove >>> any movement is a good movement!

A simple way of using ‘motion is lotion’ is to move and change position every 15-20 minutes, and then stand up and move around every 40-60 minutes. These are ball-park figures and it is important to work out your own need for movement. Further, you may like to use prompts and reminders until this becomes a habit.

3. 3 breaths

As often as you can remember (use reminders for this as well), stop and pay attention to three full breaths. Notice the moment when you first breathe in, the sensations in your body, and as you breathe out, the sense of letting go.

Attention is one of the skills of being well. A famous study was entitled, ‘the wandering mind is an unhappy mind’; in other words, the more we can pay attention to what is really happening, the happier we feel. Paying attention to your breath is a simple way to develop this skill.

Notice how you relax and muscles ‘let go’ as you breathe out. This is because on the out-breath, the parasympathetic nervous system is more active. This branch of the autonomic nervous system is responsible for all the important healthy functions behind the scenes: digestion, sleep, energy, anti-inflammatory activity and more.

5/5 breathing >>> count slowly to 5 as you breathe in, and count slowly to 5 as you breathe out. Continue for a minute or two, or longer

We have no direct access to our biology. It is in the dark, so to speak. However, there are one or two things we can choose to take control over to an extent. Breathing is one, with all the benefits that come with the innumerable practices that have been ‘breathed’ over the centuries.

A further use of the 3 breaths is when you feel tense, pain, frustrated, angry, upset or any other emotional state. Notice how when you pay attention to the breath, those feelings ease. This is because you have stopped fuelling them with the thoughts.

4. Meaningful connections

We need each other. We are design to connect and share and be generous. Have you noticed how your feelings change when you do something for someone else, no matter how small or insignificant that it may be? In fact, it is the little things, consistently, that make the difference, especially in a relationship.

How great does it feel to be with people who care about you, and you care about? Notice how that feeling builds when you pay attention to it (re-read the bit on attention above if necessary). Become aware of those great feelings and sensations in your body when you merely think about a special person.

Even when you don’t know the person you are encountering, can you make the connection meaningful by passing the time of day, and smiling? Of course you can! This can become the way you do it; your style.

Watch other people interact, share and be kind to each other. You will change state and feel it. Pay extension.

One way of connecting is by touch. Again, by design we have a system dedicated to light touch that is a direct way of soothing another, showing care and concern and evoking a healthy biological response. This is also a simple way for a partner to share a moment with you.

The key to feeling the effects, is to be present. This is the only moment, right now…it’s gone, and here is another…gone, and so on. Being present means that you can pay attention to what is actually happening, rather than being embroiled in the mind’s wanderings. To be present is also a skill to practice.

5. Smile. Just because you can

Notice what happens when you bring on a gentle smile. A soft upturn of the corners of your mouth. You can choose to tie this in with the now well-known practice of gratitude. The (biological) state of gratitude is one of the healthiest and an ‘antidote’ to suffering states.

Before the practice, it is important to acknowledge that all states are normal and part of the spectrum of feeling states. We need all of these states of course, as they communicate a need.

What are my needs right now? This is a great thinking tool, as you step back from being caught up in it all, and realise what it is that you need to do in this moment: move, breathe, eat, re-frame a thought etc.

What are my needs right now?

To practice gratitude is to become aware of something in your life that you are grateful for. There are many things that we can chose. Of course, whether they become apparent depends on your mood. A handy mantra here is: for a good mood be grateful, in a bad mood be graceful.

Practice: think of a moment in your life when you felt truly grateful for something. Focus your full attention on this memory, re-living it using all your senses, noticing which senses amplify the feelings. Is it the sights, the sounds, the feel? As you continue to focus on the feelings as they arise in your body, notice how they build.

Moment to moment noticing of things to be grateful for and those that bring you joy is a practice; a skill. For instance, you can decide to approach the day by looking out for things that make you laugh or smile. Then you practice.

The fact of the matter is simple in principle. The challenge is to keep focused and pay attention to what is really happening in the face of the many distractions. It is to realise that we live out a story that can appear to have been written for us. There’s some truth here in as much as we are fed beliefs from a young age, many of which are wrong, yet can limit us as we grow. Realising that you do not have to continue with the same story if it is full of suffering, is the first step to moving onward. Many don’t realise their potential, feeling that somehow, this is it. Not true. Is it time for a new story for you?

What will be your story from now?

And so, what will be your approach? How are you going to do Christmas? How are you going to do life? What is your picture of success? What principles must you follow each day to get those little wins on the way forward? Make a plan, get the right support and encouragement around you, and go for it. Each person is a miracle when you think about how we came into existence and how we are designed to grow and serve a purpose.

Merry Christmas.

Why keeping in touch with your body is important

Body painting

This is a short blog about why keeping touch with your body is important

The body, your body, is always there. It is always changing and updating, but in essence a constant feature of the present moment.

The mind however, goes off. It travels forward and back at a whim so it seems. But reality is only here and now, the rest is just in thought. However, each thought, each feeling, each sensation and each movement are all embodied. They are also embedded within a context, an environment and a society.  The mind simply cannot be considered in isolation.

This in mind so to speak, means that what we focus on governs how we feel. Our emotional state is a biological state, orientating us towards a particular experience, to meet a particular set of needs. What is interesting is that when we focus our attention on the feeling itself, if it is a state of pleasure or joy or any other positive feeling, it grows. When we focus on a negative feeling such as anxiety or anger, what happens? Well, you can either try it or wait until the end to discover the answer.

The whole person

Regular readers will be familiar with my writings on the whole person. In short, the premis is that it is always the person as a whole who has an experience. For example, I feel pain in my hand rather than my hand is in pain. The importance lies in the need to address the person to successfully address pain. As I tell people I see, the biology of pain (and there is nothing specific to pain) is largely not where you feel it.

To feel oneself then, requires a completeness. A wholeness that needs both body and mind to be in the same place at the same time. Only when the two are together as one are we truly present. In our world where we learn early to escape the body from horrible feelings, emotions and sensations, this can seem like the thing to do. We are encouraged to drink, smoke, take drugs, buy something new and distract. Except trying to avoid and escape results in on-going suffering instead of facing and transforming. We cannot escape suffering in life. It is part of life. But no-one teaches us how to suffer. To know how to suffer is to reduce the impact and overcome the cause(s) of one’s suffering.

A simple practice

One simple way to be whole, and to connect and re-engage with the body is with the body scan. This is where you pass your attention through your body from top to bottom. You notice without judgement, with acceptance of what is, and an openness to all experiences and sensations. In so doing, you are whole, which is the true person.

The awareness, or check-in as I sometimes call it, is a way to address our biological needs. Checking in, I am aware that I need to move, to stretch, to drink, to eat, to scratch, to go to the loo etc etc. Without this bodily awareness, I miss the cues and conscious feelings of need states. And to miss out on the basics can add up over time. Place stress on top and soon our bodily systems are in survive mode, increasingly interpreting sensory information as possibly dangerous. What do we feel then? Headaches, body wide pains, irritable bowel, fatigue, poor concentration, low mood, anxiety and more.

Make a commitment

So what can we do?

We can decide to commit to a route of wellness and practice certain skills each day to build. Without wellness life is even more of a challenge. Part of being well is being present and we can only do so with body and mind together. Each moment is made up of our perception, action and cognition. They are inseparable, yet each adding something distinct the the richness experience.

If you like, now, you can sit or lie and pass your attention through your body to see what is what. Remembering of course, impermanence. Things are always changing, otherwise life would not be possible. So notice the ever changing biology at work. You can spend a minute or a few minutes or an hour. That’s the beauty of checking in. It is easy, and you can do it anywhere, anytime.


This is one of many practices and tools from The Pain Coach Programme

Talking pain with Pete

Pain Coach + Pain Toolkit getting together to deliver the RIGHT messages about chronic pain

This is the first of a series of conversations about pain. Pete’s 5 question challenge:

  • how did you get into pain?
  • what about people looking for a quick fix?
  • what questions should patients ask me?
  • is social media useful?
  • what is the future for pain management?

A series of chats coming soon. Enjoy!

Pain in Spain

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Keynote at the Congreso Fisio 2018

IX UMH Physiotherapy Congress 2018, Alicante

There were several remarkable things about the UMH Physiotherapy Congress in Alicante last week, which I will share below. Before though, I want to state that without doubt, the organisers created a meeting that universities around the globe should seek to emulate. This was a conference that was professionally co-ordinated, filled to the brim with great and varied content, smoothly run, and was attended by an enthusiastic, passionate, sizeable group of 420 professionals and students. The success emerged from the co-ordinated efforts of many individuals, in particular Sergio Hernández Sánchez, Ellana Mckerrell and Roser Bel-lan Roldán.

I was delighted to be asked to speak to over 400 people at the main conference and then run a Pain Coach Workshop for professionals. This was an opportunity to share some of the latest thinking about the global problem of pain, and ideas about how we can go about driving social change together. On reviewing the statistics, it appears that the chronic pain numbers are slightly lower in Spain compared to the rest of Europe (16.6% and 20% respectively). Despite the mild difference, this still represents a major public health issue that needs urgent attention, with the costs estimated at 1.5% of GDP.

“The pain in Spain is mainly on the plain”

This was a conference of the highest quality. The topics, the speakers, the logistics, and the atmosphere were second to none. And what is so remarkable is that the conference was planned, organised and run by the physiotherapy students from UMH. This was as professional as it could be, and therefore the Congreso was a great success as far as I was concerned.

The Pain Coach Workshop was an UP (Understand Pain Social Enterprise) offering, allowing me to work with twenty five professionals who were keen to build on their knowledge and skills for chronic pain. The participants kindly shared their experiences and insights about chronic pain in Spain, and together we worked through a ‘lite’ version of the Pain Coach day.

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Pain definitions from the 5 minute challenge

With a handful of English speakers, we had a fantastic translation team, who really made the workshop happen. They were brilliant as we got into the rhythm of exchanges. In the three hours we looked at the vehicle of coaching as a means to deliver skills and knowledge, together with always seeking to get the best from both the individual and the clinician. From there, we considered a range of practices including those that seek to build wellness, address sensorimotor adaptations, reduce threat and sensitivity and to encourage people to live their best lives, whatever their circumstances. The emphasis of the Pain Coach is upon realising the choices we have in life and how we make the best ones to achieve success and results. The philosophy that runs through the programme is based upon knowledge, wisdom, and compassion.

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Translation in action at The Pain Coach Workshop

This was an important trip for several reasons. Firstly to make new friends in Spain so that we can build upon the successes and create future events that benefit individuals and society. Secondly, we have identified a need that we can meet together with education, encouragement and enablement at both the undergraduate and professional levels. And thirdly, we can tap into the passion that was so clearly expressed in the opening ceremony by Roser and Sergio, to move forwards in a positive and productive way.

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For information about keynotes and Pain Coach Workshops, please contact us: painphysiolondon@gmail.com

The Shape of Pain ~ a show about the pain of CRPS and relationships

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“One woman attempts to articulate her experience of physical pain. Pain with no apparent cause. Also, she’s met someone, and they want to make this work. Words and an original sound score combine to create an explosive dialogue about love and perception. An experiment in how we talk about pain – and if we ever do that in a way someone else can understand.” China Plate

To briefly set the scene, this is a one-woman show that attempts the most challenging of tasks, to communicate pain. For many years, I have listened to people as they try to describe their pain, providing an open forum for them to use their own words, descriptions and illustrations. Of course, none fully capture the lived experience and so we must acknowledge this limitation whilst absolutely validating what the person says. Carefully documenting the language, phrases and comparisons, we must treat the narrative with care and compassion, listening deeply and equally observing how the words are delivered—gestures, facial expressions and subtle posturing.

And so, The Shape of Pain seeks, in an experiential manner, to get over to the audience what it is like to be in pain of a chronic nature as a feature of complex regional pain syndrome (CRPS). For those who are unsure, CRPS can be a painful condition of an extreme nature. There are other signs and symptom as well, which out of necessity define it. There are many painful problems and we must be able to differentiate to deepen our understanding through enquiry. The Budapest Criteria set out to do just that.

For me, it was a remarkable performance by Hannah McPake, delivering the narrative with authentic emotion, seeking to engage the people in the room. I am not a theatre critic so I can only comment on the technical aspects as an amateur, so I will stop there. However, as a clinician with a purpose to drive social change with regards chronic pain, and as a member of the audience, I was somewhat torn between the two. Flitting in my (embodied) mind, just as when we were invited to explore our perception of the Necker cube, I was critically appraising the way pain was being described, then drawn to the sensory experience of being present and back again.

In a conversation afterwards with some of the people who had watched the play, there was a feeling that we had definitely had an experience. You are not simply sitting and watching. You are absorbed by force—the sounds, the stage, the lights, the performance, and the projection of the script on the panels, which to me represented the imprisonment that some perceive and describe as their sense of agency is seemingly squeezed from them. In the discussion group, we all appeared to subscribe to the idea of pain having a shape. Job done!

Knowing that people suffering with particular sensitivity, and that is not just those with CRPS, will react protectively as their brain predicts a possible danger, means that the play would likely be provocative of pain. This point is made clearly in the script, which you can purchase, and a reason for an actor playing the part because of the effects of the words. Many people have told me, usually when prompted, that watching someone move, thinking about movement, certain smells, sounds and other ‘stimuli’ bring on the pain. When you understand pain, you know why this happens and how very real it is, together with changes in the sense of size of the limb, perception of the world and the sense of self.

Chronic pain is the number one global health burden. There are huge financial costs for society to bear, and immeasurable suffering for individuals. With the numbers of people affected by what we can safely say is a public health issue of major concern, you would expect a play such as The Shape of Pain to be sold out in a sizeable theatre as society tries to gain a grip on the problem. The question at large is why, with the costs in the billions each year and the impact on social function, is there so little accurate and impacting coverage? Most articles describe pain in the wrong way, the ‘old way’, which is distinctly unhelpful at best, and at worst keeps people thinking the wrong way. At the moment I have no answer to that, but instead focus energies upon delivering the right messages and the latest understanding to those in need.

The Shape of Pain is a significant contributor to the narrative of the most impacting of pains. A main feature of the tale is relationships. That of the person embodying the pain with the pain, the person in pain with a loved partner, the person in pain with the audience, and all of these vice versa. Undoubtedly, with pain lurking and then dominating ‘me’, there is impact on relationships. We are social creatures and relationships are important for our health, whilst also being the source of great suffering if we are not careful and nurturing. It can be more challenging to nourish a relationship if you are suffering pain persistently, as the Shape demonstrates frankly, but equally one can gain strength.

I will not capture all the angles within this short blog. Yet I hope to transmit several key messages of hope whilst fully applauding the team behind this play. They have created a brilliant piece of intimate theatre in which you cannot fail to feel deeply engaged as you run from emotion to emotion until the rather disquieting, darkened end, which is wholly appropriate. However, in a selfish way, I am pleased that the venue is smallish and intimate, because you feel so much more ‘in the room’ with the character.

On hope, there has been great advance in our understanding of pain, primarily from the getting together of neuroscientists and philosophers. This has resulted in better questions, with new insights for answers that are most helpful in describing pain to people so that they can give meaning to their lived experience. From there, this understanding informs many practices and tools that can be used to manage the painful moments, and overall seek to improve one’s life with a clear direction and steps to take. We are designed to change, impermanence making life viable, with each moment unfolding as fresh and new. This in mind, we can choose an approach, establish our purpose and pursue it in the best way that we can.

Here are 5 facts about pain (there are many more):

  1. Pain (a subjective feeling state) and injury (objectively observable and measurable) are not the same and they are not well related
  2. Pain is part of the way we protect ourselves
  3. There is no pain centre in the brain. And there are no pain signals or pain chemicals. We have systems that have a role in protection and survival — e.g./ nervous system, sensorimotor system, immune system
  4. Pain is an inferred state that motivates us to take action to address a need in our body or our world
  5. Chronic pain does not ‘start’ at 3 months. The reasons why someone experiences on-going pain are more to do with prior life experiences of protection, genetics, early uncontrolled pain at the time of the incident and perhaps gender. There are and will be many more factors.

A brief summary of the modern approach to chronic pain

As I have said, the first step to successfully managing pain moments and carving a new way forward, is to understand your pain. This is how any programme should begin, with practical knowledge and ‘know-how’. To get results, we have to shift our thinking and approach as much as using the new and necessary practical tools and actions each day. This does not mean ‘you’ have to change as a person. Instead, you are encouraged to use your existing strengths and successful styles (you will have had many successes in life, overcoming challenges) to focus on your desired outcome and the steps to take.

There are specific exercises that need to be practiced in a dedicated manner, just like learning a musical instrument, general principles to follow to gradually engage with chosen and loved activities (getting into flow), and thinking tools to focus, create calm and build wellness, our greatest buffer to life’s ups and downs. The Pain Coach Programme contains all of these components together with many other tools and practices to draw upon to embody and live a meaningful life. There is not any single practice, instead an approach that embraces what we know about being a conscious human being.

Managing the painful moments with increasing skill transforms these episodes into opportunities to head in the chosen direction. Like learning to sail a boat, we learn a great deal when the waters get choppy, and we may even capsize! But then we can focus upon rolling the boat over again and setting sail towards that desired outcome. This may happen over and over, but we can choose an approach steeped in doing our very best as we seek to master ourselves. The principles of mastery certainly apply here. In facing these challenging moments as they arise, we create new habits, replacing those that do not work, but always in line with what we want to achieve. Stringing these together with the skills of being well and specific training, we can build a foundation of understanding, compassion (especially self), and know-how that can be built upon.

This is truly an exciting time as our learning gathers pace. My role and purpose is to be a conduit and distill the great work being done by many across the globe, into tangible and practical tools that each and every one of us can use to get the best results.

The Shape of Pain is on now at The Battersea Arts Centre (where I had some delicious potato wedges in the cafe!) until 10th March. If you are interested in pain or dramatic theatre or both, this is definitely worthwhile seeing. Note though, if you are a pain sufferer, it may be evocative for some of the reasons outlined above. In knowing this though, you may choose to go along for the ride.


For further information, contact me at painphysiolondon@gmail.com

A story of learning

Funny colorful signpost to different countries around the world

This patient wanted to share her story to inspire others. She travelled to London from her country in Africa to find answers to her pain problem.

Overcoming a pain problem requires understanding that informs practices you use each day, through the day, whilst living life the best way you can. In other words, you may have parameters to work to right now, but these will grow as you develop and build wellness, together with the specific exercises and strategies you use to get better. It is a learning process. Nothing happens in isolation as we are all on a timeline with what is happening now impacting upon the next moment and so on.

Many people do not realise or actualise their potential. We have much more ‘say’ in what happens than is commonly thought. Understanding, awareness, patience and compassion are all key ingredients for gathering insight into what is really happening now, the best actions to take and how to carve out a way onwards that is meaningful.

This is the work of overcoming pain by addressing the needs in ourselves and our lives concurrent with building wellness (resilience, outlook, attention and generosity).

Here are her words:

Hi everyone, my story begun in October 2016. I woke up one morning partially ready to go to work and I noticed a slight pain in my butt, I thought nothing of it and went to work. The next day I was limping but I still ignored the pain because I had a lot of things to take care of at work. What would they do without me in the office? duh… absolutely nothing. The pain kept increasing and within a week I was paralyzed by pain and completely immobile. The pain was so severe in my left leg that moving any other part of my body (eyes and mouth excluded) caused excruciating pain, so I had to lie still. I still get emotional thinking about the day I was taken to the hospital, because the pain was so bad I had several blank moments I fought against because I didn’t want to faint and cause more injury. It was tough but we made it to the hospital eventually.

At first the doctors thought I was suffering sciatica but after a couple of days they saw that the medication did absolutely nothing for me except put me to sleep for long hours. So, I started a series of tests, blood tests, scans, x-rays and MRI all of which were very traumatizing because of the pain and the village it took to help me from one point to the other. Eventually I was diagnosed with transverse myelitis. It was a probable diagnosis, they still weren’t sure.

In the beginning of this whole situation I thought it was something that a pill and a day of rest would cure but as time went by and the pain kept increasing I thought death had come for me. yes, I did feel as if I was going to die but I wasn’t ready so I found myself soliloquizing continuously about my dreams and how I was looking forward to the future. I even remember getting upset for a moment at God for giving me all these dreams and then letting death stand in my doorway before I achieved any of those dreams. A whole day of both internal and external positive speech got me to the point of utter believe that no matter what happened I was going to live.

Weeks passed, the pain was more manageable but I was still bed ridden. For someone who is independent and very private; it was quite devastating to lean on people for every single thing. I mean I am extremely grateful for my mother, she was there from the beginning to the end but it was gut wrenching when I couldn’t sit on my own because my back muscles couldn’t hold me up, so I had to be held like a child or when I couldn’t even brush my teeth or feed myself or lay on the bed myself or bathe myself.  Like I said before, I am extremely grateful for everyone that took care of me but it did not change the fact that it was extremely difficult to see myself in that position; but as time went on I learned to see all the little things we all take for granted when we have complete health and accepting help became easier for me but not without the overflow of gratitude for all other things good. Indeed I learnt to be grateful for everything no matter how little, which was very important in my recovery journey.

Four months passed, I was better and using a walker to get around. I was discharged from the hospital but things did not progress further. I almost panicked wondering if I was ever going to walk on my own again but I didn’t allow myself enter that rabbit hole. Eventually my parents brought me to London for further medical treatment, to see if there was anything the doctors back home missed and after another round of tests and scans I was directed to a Rheumatologist and a Physiotherapists (Richmond Stace).

During my first meeting with Richmond Stace I quickly understood that this was not a physical fight; it was more mental than physical. “The fact that there is pain doesn’t mean that there is injury” he said, these words changed my life because from then on I started to try myself. I developed the courage to believe I could not just walk again but run and dance and do everything I loved to do before I became ill. Some days where extremely harder than others but my self- speech helped me through those days. If I had an emotional issue I could not overcome on my own, I spoke to Richmond about it and he would tell me what to do; it made me understand that I didn’t always have to internalize everything but since I’m the kind of person who doesn’t really like talking to others about my innermost thoughts I found a way that always helps and that is journaling. I don’t write every day but I write when I am battling something that won’t just go away; and it helps every single time.

The days went by, I kept doing my exercises and mental imaging, some days I would think I was getting better and others made it look as if I was going back to square one. I read a lot, everything I read was kind of like an expansion of the things that Richmond was teaching me and it was a wonderful blend. The time for us to go back home was near and I was able to take at most five painful steps a day. I remember the day my mother booked our tickets back home, she requested for assistance and it upset me so much because it made me feel as if I was not going to get better before we go back. I was going to go back home still using the walker and nothing was going to change but things did change. Two weeks before we went home, I got up one morning, looked at my walker which was always beside my bed and ignored it without realizing that I was ignoring the thing that helped me get around; I got up with very minimal pains, I walked to the sitting room and never looked back. I screamed for my mum and the moment she saw me walking with only two legs, she fell on the floor and began to cry. It was a very emotional day but all was not over.

I was walking by myself, every one including my doctors where very happy for me but what I did not realize was that I couldn’t jump back into my usual life. Richmond gave me exercises to do but I decided to take the exercises further and I tried to run a short distance. Guess what? I couldn’t run at all. I tried to jump and it was painful as hell. Walking around for more than an hour was so painful I felt like using a walker again. I got very upset because I felt that I was going to look healthy and not be completely healthy. I was still going to need a wheelchair at the airport, look for the elevator or escalator wherever I went. I was so upset that I cried for a whole hour in the bathroom and when I was done I cleaned my tears and did the exercises Richmond told me to do in the first place and I haven’t stopped since.

So, I have come to the end of this long story and these are the lessons I have learnt so far.

1) In all things give thanks

2) Help is good, no man is an island. Accept help and be grateful for it

3) Read, knowledge is power

4) Meditate, it is the best medicine

5) Visualize your health goal

6) Persevere

7) Do what your doctor says especially if your doctor is Richmond Stace

8) Laugh, laugh as hard as you can. It’s better to laugh than to cry

9) Never ask. “Why me?” and if you do, your answer should always be “because I am special and highly favoured”.

Am I able to run now? Nope, am I able to dance? Just a little but I can jump without pain and I can walk for three hours straight without pain. I am not there yet but is anyone ever “there”? and besides what is “there”? Where is “there” anyway? I have come to believe that this life is a journey and as long as I am happy in each moment and doing the things that will improve me then “there” for me is actually now. I hope this encourages you to keep pushing for something better.  Your life is your life, only you can do the things it takes to be better.

Signing out! Anonymous.

UP Workshop in society for society

Richmond Stace ~ Specialist Pain Physiotherapist & Pain Coach
Richmond Stace

On Monday I will be delivering an Understand Pain Workshop in Newport. This is one of the UP social initiatives, whereby when I run a Pain Coach Workshop for clinicians and other professionals, I the run one for the people locally for free. It is a 1 for 1 model.

There are several avenues that I am pursuing to drive social change and a new understanding of pain: The Pain Coach Workshops for clinicians, Understand Pain Workshops for the people in society, and 2 free places for local undergraduates at each Pain Coach Workshop (see some recent comments by a student about the day).

Both the workshops and my clinical work is informed by the latest thinking in pain science and associated fields, delivering the pinnacle of understanding in a practical way. As with any problem, when we understand it, it is no longer a problem but something we must transform using tools that work. As an example, last week I spent 3 days in the company of some of the greatest contemporary thinkers about consciousness and life. Pain is arguably the best example of a conscious experience, and hence understanding this is a key aspect of understanding pain. For those of you who are interested, this included Dan Dennett, Karl Friston, Andy Clark and Anil Seth. In the room though, were many brilliant brains (whole people!).

Brilliant brains!

The basis of a workshop is that people leave with practical skills and a working knowledge of pain so that they can go about implementing and integrating these into their life. I am an avid believer in living life as a main purpose. What I mean by this is that many people suffering chronic health and pain will put their lives on hold and await a change. The science and I argue that the way to get back to living, it to actually get out there and live. Of course there are ways to do this and the purpose of the workshop is to show people how they can; emphasis always on the word ‘can’.

It is worth noting that the Newport workshop (call 01633 820321) is for anyone suffering chronic pain. There are also specific workshops for conditions, for example complex regional pain syndrome (CRPS). There is a CRPS workshop on Tuesday in Bath — see here

You can keep up to date on events and read blogs and tips by following me on Facebook (click on the ‘like’ button), Twitter and signing up to my blog here.

Whether you are a clinician who works with people in pain, a professional such as a lawyer or case manager, a patient or carer, I hope to see you soon!

RS

Ellen’s final blog before the 1/2 tomorrow

RP

Running Blog Take 3

10/09/2017

So this morning, after work, I got home and decided to go for a run. I felt good and knew I was going to aim for 5km and depending on how I felt when I got to the end of the 5km I might try to go further.

Unfortunately I did not come back with the same positivity that I left with. The first five minutes of the run was good however after that every time I stepped down on my left foot, it felt like someone was stabbing a sharp knife through my kneecap. I managed to run the 5km however came back crying. When I got back, both my mum and dad were around but I did not want to show to them that I had struggled so I just said I needed a minute and went up to my room. I had to strip off as my brace was too tight round my leg and then my running trousers were making my knee more sensitive. I managed to calm myself down enough to stop crying but just felt defeated, which then led on to me feeling like I had bitten off more than I could chew with signing up for the half marathon!

About 5 minutes later, my mum came up to check on me. I wiped the tears away but she could tell something was wrong! I could not help but break down, telling her my worries about not being able to complete the half marathon and letting all the people who have sponsored me down. For some reason the thought of my future life was also upsetting me.

Ever since I’ve had my CRPS I have always had goals to get to the end of. At 15 it was my GCSE’s. At 17 it was my A Level’s. At 20 it was finishing University. With all of these focuses, thinking about my long-term life never really happened but now at 22, in full time work, there is no end goal. This means its more about thinking of moving out, meeting someone, having children things like that and also knowing that I might be suffering with CRPS for the rest of my life. I know that life could be as good as any life I was going to have before CRPS but the thought of living with pain everyday for the rest of my life is still absolutely frightening and upsetting.

CRPS UK charity for complex regional pain syndrome

My mum has never really liked to talk about this aspect of the CRPS because no one wants to think of their child being in pain for all their life but today she listened then did what my mum is so amazing at. Distracting me, and pulling the real me back out! We chatted like mother and daughter do and started giggling and the pain finally subsided. Today was a bad run, but I am sure even Mo Farah has bad days!!

12/09/2017

This week really has not been good so far! After Sunday, I took it easy yesterday hoping not to make it worse. I hardly did anything all day but still had stabbing pain through my kneecap still. I went to bed at my normal time however could not get comfortable and so could not sleep. After an hour of laying in bed I gave in and took some painkillers. However even these didn’t work and so 30 minutes after I’d taken the ibuprofen, my knee flared up. It was a short one but where I was drained from all the pain during the day already, the flare up made me feel extremely lightheaded. Within 2 minutes of the flare up settling down, I had layed down and basically passed out. One wake up in the middle of the night and then I was up for work as normal this morning!

I wore my big metal brace all day to support my leg while I walked, which meant I could get through work and then also drive to my physio appointment. I do not like wearing the brace as it draws attention to my issue, which I cannot stand but what I cannot stand more is feeling sick because of having to take so many painkillers. Wearing the brace means I do not have to take pain killer throughout the day so it is the lesser of two evils! Luckily I do not loose my freedom anymore when it flares up as last year I got an automatic car, which means I can drive without using my left leg, and so means I do not suffer pain when driving anymore!

At physio I spoke to him about everything I had spoken to mum about on Sunday and he reminded me that each day is different and so I will never know what the future will hold so what is the point in worrying about it! With regards to the running he reminded me that a week ago I ran 7 miles. No one forced me, my determination did it so my determination will be what gets me round the half marathon! He told me that this last month before the run, needs to be more relaxed and I need to focus on getting myself to the start line, rather than the finish line! This gave me a boost and the confidence I needed to carry on running, just once my leg is 100% better!

UP understand pain

14/09/2017

So at the beginning of the week, dad told me he was not going to set up his own fundraising page, and instead he was going to ask all his friends to donate to my page and then he would match whatever I make! This morning he emailed the link to my fundraising page out to his friends and my goodness have I been overwhelmed by emails telling me how much people have sponsored me! The amounts keep getting bigger and bigger and my target of £500 had been doubled within a few hours and the sponsorships just keep on coming! Means I definitely cannot back out now because thinking of what that money can do within both CRPS UK and UP makes me jump for joy! Although think Dad is starting to regret saying he would match whatever I make!!

18/09/2017

So from a week after my last run tonight I finally felt strong enough to put my trainers on again and try to go out running! I had a vague aim of where I wanted to get to for my run but knowing how bad the last week had been I knew that setting a proper aim might make it worse so I just needed to go out and do my best. As I was getting ready my four-legged running partner, Cooper was staring at me, begging me to take him with me. Knowing the companionship, even from a dog, might make the run easier, I took him with me!

We both got into our rhythms and just kept on running. Cooper is really good because he quite happily just trots alongside me and does not get too distracted, which means I do not have to worry about keeping him on too tight a lead, which would affect my arms while running. What always amazes me about him is that if for some reason my normally breathing pattern while running gets disrupted he immediately looks up at me to check on me! He is a really good running partner as he can run exactly the same as me but also check on me!

We kept running and running and when we got back home, I had the biggest smile on my face as we managed to run 4 miles in 45 minutes! There was a little bit of pain but that seemed to be coming from the ill-fitting brace rather than my actual knee. With this in mind I have ordered a new support, which is more open so is not too tight and will not make my leg quite as hot while running! I cannot wait to get back out at the end of the week!

21/09/2017

I was expecting some backlash pain after my run on Monday but I felt nothing. In fact I felt better than ever! My new brace also arrived and I was desperate to try it out however today was gym day, so the running would have to wait! With it being so close to the run, my personal trainer thought it would be best to just work on stretching out my legs properly and working on general fitness. With having to have a week off, I thought I would be puffed out within 5 seconds of lifting a weight however surprisingly I was fitter than ever! I skipped the most I’d ever done, I lifted the largest weight I’d ever done and I did the best pull ups I’d ever done! I thought the week off would slow me down, however it seems it’s just made me stronger. I feel more ready than ever for my run, which is now on only 17 days away!!!

23/09/2017

I was desperate to try out my new brace and I felt I needed to try out running a long distance again. I decided I was going to try running a 10km although Dad is away so was worried I might struggle a bit without any company to keep me going. I had a plan of where I was going to go in my head however did not completely set the route as I never do, to reduce the risk of any pain. When I set out I just thought I would try my best, whether it would be small or long.

Every run I have previously done from home starts the same way, by going up a steep hill onto the main road I run along. Previously I have never been able to run all the way up this hill, normally get half way up before I start puffing however today I ran and ran and ran and then was at the top. Before I had even started the proper run I had the biggest smile on my face because I had managed to get up the hill! It gave me such a boost and so the main run began. I changed the route in my head as soon as I started, as I wanted to make sure I was as comfortable as possible. My first part of my run was only about 1km so I went slow and steady and used it as my warm up.

My new brace was incredible and so I had hardly any pain, which meant I got into my rhythm really quickly and still had the biggest smile on my face! It was getting warm but my breathing was under control so I was still feeling comfortable! I got to the point, which I originally decided would be turning around point as I was going to do, two laps but I was then worried if I turned around the pain would start so I carried on. I ran down a road that was very up and down but I was still running by the time I got home. I was so happy with myself however still wasn’t sure how long I had managed to do! I got my phone out to check and I had run 10km and felt like I could have kept going! It was hard but it was also such a boost!! I finished my run today, really excited for the actual thing!

29/09/2017

It’s been a quiet beginning of the week as I did not want to do too much with the race day getting closer and closer. However today is the turn of my last proper gym session before the real thing! The main focus was overall body strength and all was going well until the second round of dumbbell presses on my right side. As I pulled the weight up, the left hand side of my back too a big stab. I dropped the weight and sat down. I hate when my condition becomes obviously within a public place as it makes me so nervous, which then makes the pain worse. However my personal trainer was very good, letting me sort myself out before getting me to carry on but move onto something else, which would not be as irritating. We did lots of different backstretches, which dispersed the pain so I still walked out normally. I was so happy about this as I had also planned to go for another long run with Dad tomorrow and I really did not want to miss that, as I knew how important it was! I may not have worked out as hard as I wanted but I feel today was more of a success with the fact that even with some stabbing pain, I could carry on!

30/09/2017

Work went way too quickly this morning. My nerves about going out for my first ever 16km run was at its maximum. I went to meet Dad at the office and was so nervous I could not even speak to him; I just wanted to get going to see what I could do.

We set off both feeling good, except for a massive stitch that I had in the left side of my abdomen. The first 5km seemed to go so quickly. I think this was because for the first time I actually spoke to Dad while running. I’ve never done it before because I was always worried about disturbing my breathing. I’ve worked on my breathing rhythm so much that now it just comes naturally and I do not focus on it. This made me feel better about talking to Dad, and when I did start talking to him, it brought me straight away from any aches I had.

We ran pretty much all of the first 12km however as we started our last 4km loop, Dad began to suffer with some pain within his legs. This meant we did a mixture of walking and running but that was fine as my pain was starting to get worse so it also gave me a bit of a break! I am so determined to run this half marathon that even when I have been in agony on training, I do not stop and I do not say anything because I feel I can just keep going, even if that makes the pain worse. So actually Dad needing to stop was a bit of a benefit as it made me take a break and let my body settle a bit.

We made it to the last 1km and now Dad had to keep me going as my hip felt like it had completely dislocated. I was running, if you could call it that considering I was limping, all the way to the end! Even when Dad pulled up with cramp I continued to the end. I got into the office and thought I was dying, but then I looked over at Dad and he looked exactly the same as me so I felt a little better! Now I know I can run 16km, I feel a lot more confident about next week as now it is only the last 4km that will be new! I cannot believe in 8 days I will be running the real thing! It has come so quick but I am so excited for it now!

02/10/2017

So unfortunately the happiness and excitement of Saturday’s run was not long lived. After going to the cinema Saturday night, I suffered a flare up, which was a bit of a knock back. It has always been normal for me to be left in pain after the cinema so adding the pressure of the run on top of that, meant I was not surprised when it happened. People always think I am strange when I just accept the flare ups, but if I do not accept them, I cannot move on and get on with my life each day. That does not mean they do not still frustrate me and upset me every single time but I left myself feel those feelings then I carry on.

I carried on, on Sunday, doing my horse in the morning then going to work and although it was hard, my will power keeps me going. The afternoon was not so easy, the pain got worse so I knew it was time to ask for help. I asked someone to look after my horse and luckily I did as I then suffered a second flare up. Having double flare ups in the space of 24 hours does not tend to happen to me anymore so I try not to dwell on them but it is hard as you feel like you are being knocked down twice!! However once the second flare up was out the way the aching lifted a little, just enough that I could smile again.

I thought the last few days would make me more nervous for the run however all its done is make me be more realistic. I have just accepted that I will probably be in a lot of pain after my run if not suffer a flare up, but that’s okay because it would have been for a good reason and maybe just this once, the pain would be worth it.

04/10/2017

I agreed to go and see the personal trainer to discuss my nutrition for the last few days before the run and also to stretch myself out properly before the run. I never knew stretches could be so painful!! Everything ached and twinged as the personal trainer helped stretch me out. However afterwards I felt so good and loose. Felt like I could go run a marathon, which is luckily because I’m running half in 4 days!!

We spoke about the best things to eat on the day and to eat before hand and I was so glad he said I didn’t have to eat beetroot as every runner had told me that I needed to have a shot of concentrated beetroot on the start line, but I hate beetroot!! He said it might be an idea to have some jelly babies in my pocket during the run to give me an energy boost when I need it, however I then remembered that on my Duke of Edinburgh I ate jelly cubes and so that was it, I was taking jelly cubes to the run with me!

I cannot believe how quickly the run has come around. I am both excited for not only getting myself this far but also for the possibility of the actual day and also nervous about letting people down. People have been so generous donating to me and I really will put my best effort into running it on Sunday! Let’s hope I make it to the start line!

RS: I am sure you will! All the hard work has been done now — a very positive approach taken, inspiring many.

 

Helena’s story

An excellent story of achievement from Helena

image1

A story of courage, perseverance and a ‘can-do’ attitude to life

My name is Helena, I am 20 years old and from London.  I developed CRPS in my right leg as a result of a kayaking accident in 2013.  My CRPS deteriorated very rapidly and suddenly in February 2016 leaving me in a wheelchair.

I missed kayaking a lot and I was bored of being stuck in the house. So I started researching Paralympic sports which is when I came across para or adaptive rowing.  So in September I had a taster session at the Royal Docks, I enjoyed it so much that I was introduced to the Royal Dolphins and London Youth Rowing (LYR). The Royal Dolphins are a very small disability rowing group coached by LYR. Over the coming months my condition slowly started to improve and within a few  of months of starting rowing I was waking unaided although still in pain.

The Royal Dolphins compete in the Great River Race every year and I was quickly asked if I wanted to join the crew for this years race. I was in two minds my head was saying no my heart was saying yes. After deliberating the idea I said yes.

So on the 9th of September I completed the Great River Race. The race is London’s  river marathon and is 21.6miles down the Thames from Millwall Dock to Ham in Surrey.

We started at Greenwich  pier where our boat (called a Cutter) was docked.  The river was very rough and we were towed by our safety boat to near Millwall Dock, this is where we started our journey, passing a large ship which marked the start line. The bridge count began, there was 29 bridges between us and the finish.

The first big landmark was Tower Bridge and it was amazing to go under such a historic bridge. We rowed at a steady pace and soon enough we were going past the Houses of Parliament and Big Ben.

Battersea Bridge marked the halfway mark and by this point my CRPS leg was starting to complain. I kept moving my leg trying to get comfortable. I was determined that this was not going to stop me, there was no way I was letting my crew down.  Knowing we were halfway the  adrenaline started pumping through my body and I had a burst of energy.

This burst of energy  got me all the way to Chiswick Bridge, we had been rained on and we were now starting to tire. My CRPS leg was going all kinds of colours, my foot was swelling slightly and my lower back was killing. We kept up the steady pace as we needed to get as close to Ham as we could before the tide changed.

Unfortunately the tide changed a few miles from the finish, the water all of a sudden felt heavy and we we were having to row harder to keep the boat moving. By this point the surroundings were very rural and there were not many people around.

There was a sigh of relief when we eventually went under Richmond Bridge, the last Bridge! We all came together and rowed the best we have ever done, over-taking several crews who had gone  out too fast. We could hear the tannoy at the finish party and the gun went, we had finished!

It was the hardest but most amazing thing I have ever done. It has only just sunk in what I achieved. If you are a CRPS sufferer reading this, if you take one thing from it, let it be this, you can do anything with CRPS, you’ve just got to adapt!

You can follow Helena on Twitter here and her blog here.

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CRPS Cork 2017 Day 2 Observations and onwards

IMG_0455
Cork 2017

Does technology do it? 

There can be a place for interventions in a rounded treatment programme for CRPS. However, like drugs, they do not give the individual the opportunity to learn about and transform their pain. Instead it is an attempt to change the symptoms without addressing the reasons. In other words, a short term, possible fix. It is understandable why someone would go for that option. The responsible clinician will ensure that the person continues to work upon their practices together with the interventions and drugs. ‘Is this what really happens?’ is the question.

Technology is advancing all the time and hence in society is perhaps an implicit expectation that a ‘machine’ will solve the problem. Clearly interventions have not solved this problem, the numbers of sufferers are ever-climbing. I am not sure that they ever will be more than an occasional contributor because the only way a person can really create a meaningful life is by doing just that.

You get back to living by living, not waiting for something to happen or for someone to do something to you. There maybe parameters to work to and practices to practice, but engaging with what you expect of you and your life is the way to gain success. Drugs and interventions may be useful along the way, but not as the main thrust. To offer such a way forward is not giving the person the opportunity to reach their full potential.

To offer drugs and interventions as the way forward is not giving the person the opportunity to reach their full potential. Only by understanding their pain will the person see their own potential to get better

We should be keeping an eye on the balance of funding for research. Is there the necessary funding for study of the condition versus funding for possible interventions and technology? Who is providing the funding? This was an interesting and relevant observation from one of the speakers.

What about the immune system?

The mid-morning session was of interest to me. I find the immune system fascinating as one of the important systems that play a role in protecting us. What goes on in the immune system in CRPS? Are we seeing an over-inflammatory response in people who suffer the condition? How have they been primed and how has their neuroimmune system learned to protect and heal over the years? Dr Andreas Goebel and Professor Frank Birklein delivered very good scientific talks on the topic, offering their insights into the relevance (see links to articles below).

“So what?”

There is a search for sub-types so that treatment can be tailored for these categories. The question is whether we can ever reduce the immeasurable number of variables that constitutes an individual with their unique story into a sub-type? Whilst studying the microbiology of inflammation in CRPS may deliver some important insights into parts of the condition, we must maintain a picture of the whole and remember the person. Chemicals, receptors, signalling pathways are all fascinating (I do love looking at them) but the patient can rightly say: ‘so what?’. There must always be relevance for the person: “What does this mean for me?”.

So what is the relevance? If we can understand these pathways and the role of inflammation, develop ways of determining their influence and how this manifests as the lived experience, we could possibly develop pharmacological treatments that help. Again, this does not replace the need for the person to learn about and transform their lived experience but it could help. It appears we have a long way to go. Additionally, is the fact that any agent that has an effect upon the immune system is likely to have other effects, often unwanted. Chatting to a rheumatologist, she made it very clear that extreme caution is needed in using an ‘auto-immune’ approach to treat CRPS because of the possible side-effects.


Here are some of the studies that are relevant and were referred to:

Complex regional pain syndrome: An optimistic perspective

Inflammation in cold complex regional pain syndrome

CRPS: evidence for warm & cold subtypes in large prospective clinical sample

A prospective, multisite, international validation of the CRPS Severity Score

Association of catastrophizing with interleukin-6 responses to acute pain ~ https://www.ncbi.nlm.nih.gov/m/pubmed/18778895/

Cutaneous immunopathology of long-standing complex regional pain syndrome

Treatment of Longstanding Complex Regional Pain Syndrome with Oral Steroids

Genome-Wide Expression Profiling of Complex Regional Pain Syndrome

Local anaesthetic sympathetic blockade for complex regional pain syndrome

Increased prevalence of posttraumatic stress disorder in CRPS

Autoimmunity contributes to nociceptive sensitization in a mouse model of CRPS


The posters presentations were punchy, which is exactly right. It is a skill in itself to keep to your allocated time, allowing all speakers to tell the audience about their work. With the advent of TED talks and this becoming the accepted way of presenting your point, it keeps the delegates on their toes and fresh for the information.

Janet Bultitude won the poster competition for her work on the spatial elements of CRPS.

The afternoon was completed with a discussion about amputation and whether this should be a treatment option for people with resistant CRPS. This could have been a highly emotive subject but in fact there was a very sensible and reasoned conversation. Examples were given when amputation was necessary, e.g. when the limb was gangrenous, including Victoria Abbot-Fleming from Burning Nights giving an account from her perspective as a double amputee. Just as Day 1 was rounded off with real experiences, this was true of the second.

With final comments and thanks from Dr Dominic Hegarty, the feel was certainly one of achievement. The conference met its expectations in the main, drawing an international crowd, a host of top names and talks that covered the ground. For me though, there was a missing ingredient: the actual people whom we have been discussing, those suffering CRPS. This is a consistent omission at conferences and one that I feel misses a great opportunity for important conversations.

SIP 2017 ~ chronic pain is a societal issue
SIP in Malta 2017

At the SIP 2017 conference in Malta there was equal participation in all areas, including the working groups, by all delegates: patients, patient representatives, clinicians, policy makers, MEPs, scientists and charities. All contributed meaningfully so that the complete story was told with equal contribution. Opportunities and possibilities resulted in positive work being done at the conference, rolling onto action in Europe. Sadly, on return to the UK there was no change. No-one I spoke to had even heard of SIP let alone the work. We are embarrassingly behind.

Change is inevitable, but which way?

Undoubtedly, there is positive work being done in the UK but is it fragmented. Despite having organisations such at the British Pain Society and the Pain Coalition, again most people have never heard of them and have no idea what they do. When I say people, I mean those that need those organisations to function: patients and their families. There is little point in having societies and working groups if the beneficiaries are not receiving answers to their ‘so what?’. This must change. The change will occur in society and has started. This is the reason for UP, to drive such social change because this is where the problem of pain is embedded.

Returning to CRPS, one of the distinct points to come from the conference is indeed the complexity. With different research groups looking at different elements, of course we must draw it together to explain the 1st person experience: pain, altered body sense, altered perception, altered emotions, altered cognition, altered movement, sensitivity, the ‘what it is like to have this’, what it is like to look at my limb that is part of me but does not feel it and much more. In 2011 I wrote a blog entitled ‘It feels weird‘, one of the features of CRPS that is often described to me by patients. Frequently they would tell me that no-one had listened to this before and hence they were nervous about telling me until they understood that I wanted to hear about it!

We are complex. As I have already said elsewhere, there are innumerable variables that make each moment unique and within that our experience is unique and we are unique. You cannot wholly control for that reality. However, I believe that there is great hope and that includes using all of the work we have heard about over the past few days. There was frank honesty about what is known and what works as well as what hasn’t yet. Perhaps the complexity of existing is the reason why and we may not have answers anytime soon. But, and this is a BIG but, that does not mean that people cannot get better. They can, You can.  We don’t fully understand consciousness yet but this does not stop us from experiencing and manipulating it. Pain is one of the best examples of a conscious experience together with love, and as we get to grips with this, we will understand pain more and more.

People can get better

Pain is one of the defining features of CRPS. To understand pain means that the person realises and actualise their potential. Pain is characteristic of the person and hence unique to them. To change pain, which we can, we have to change, which we can. Each person has great potential that is often untapped. We have opportunities and possibilities when we are open, learn and use practices to steer ourselves onward in a chosen direction. We begin by asking ourselves ‘what do I want?’. The answer to this is not ‘I don’t want pain’. Think about what you want, not what you don’t want. This is the beginning.

I would love to know how CRPS Cork will inform practice as from the following Monday morning. It is unlikely we will ever really know, but this is the real measure of success. How will this conference have an impact upon society and the people suffering CRPS? Now that would be an interesting question to answer.

Onwards.