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Survival of the safest: The protective nervous system Part 3.

By Sudi de Winter

In this series we are looking at pain as a protective survival response. Without pain, our life expectancy is greatly reduced. We have evolved with survival as our priority, which outweighs happiness and comfort. Unfortunately, our pain response sometimes becomes exaggerated and unreliable when we develop chronic pain.

In part 1 and part 2 we discussed what chronic pain is and how it develops. In this blog, we look at how to treat it. In my experience of working with chronic pain, treatment broadly falls into four overlapping stages: finding the right support, reframing the pain, reconditioning your body and trusting the process.

Several years ago, I had a lower back disc injury resulting in leg nerve pain. I initially noticed tingling and some odd sensations after some weightlifting, which progressed into a deep, burning ache that turned into chronic pain.

After several months, I went for an MRI, which confirmed nerve compression from a lumbar disc. As I have seen many patients with debilitating pain from similar injuries, this only alarmed me further.

Regrettably, I did not seek the right support.

1. Find the right support

There’s nothing more confusing or frustrating than receiving different messages about your pain or how to treat it from multiple therapists. If you have a multi-disciplinary team supporting you, you want them to be on the same page – or you could end up juggling conflicting treatment strategies.

The first step is therefore to seek out a practitioner who has a strong interest in chronic pain and an understanding of modern pain science.

A good practitioner will first take a comprehensive history, performing a thorough examination and further investigations if necessary. Importantly, they will rule out pathology and structural damage as the primary cause of pain.

Successful treatment of chronic pain relies on you being actively involved in your recovery. You are in charge. The therapist is really just a facilitator for change.

With the right support and information, you have the power to treat your own pain ultimately, you’re the one who will produce changes in your nervous system and body.

In contrast, passive interventions are things that are done to you. Be wary of practitioners who explain your pain through pathology that they propose to ‘correct’ solely with treatments like manual therapy, dry needling, surgery, injections or medications.

If you have had chronic pain for many years you will know that passive interventions such as these are not effective in the long term.

How can you find a good practitioner? Websites and practitioner profiles are a good way to learn about a therapist’s approach to chronic pain. Look for anything demonstrating their knowledge of pain science and preference for an active approach.

Prior to your first appointment, have a think about your beliefs, expectations and concerns regarding your pain, and be honest with your practitioner about these.

Ask for resources backing up the therapist’s assertions. It is good to see material from academics in the field of pain science to reassure you that their approach is legitimate and that you are receiving the best standard of care under evidence-based medicine.

My personal story with pain dragged on and eventually led me to further my understanding of chronic pain. I came across Alison Sim an osteopath with a Masters in pain science who delivers excellent education ( This led me to the Neuro Orthopaedic Group and their incredible text, ‘Explain Pain’ (

Once I began reframing my knowledge of my pain I felt like I was heading in the right direction.

2. Reframe your pain

Gaining a new understanding of where your pain comes from and why it persists – in other words, reframing ­– is vital to treatment and will form the foundation of your recovery.

Your chronic pain, although it is physically real and debilitating, can be understood as an unhelpful protective reaction in response to perceived threat, rather than a sign of genuine danger or tissue damage (for more on this refer to part 1 and part 2)

Truly knowing and accepting this is the key part to treatment.

The function of pain is to alarm us in order to provoke a protective reaction and make us seek safety. However, the more scared we are of our pain, the more we inform the nervous system that the situation is very serious and deserves yet more vigilance and protection. This potentially increases our sensitivity.

This negative spiral can be avoided by reducing fear. This happens as we notice more about our pain patterns, triggers and inconsistencies, and bring awareness and acceptance to our experience of pain.

Have you noticed that your pain levels are triggered by non-physical loads (things like stress, fatigue, hormonal fluctuations and illness)? Do you feel like it comes on for unexplained reasons?

Your practitioner should help you to become aware of such triggers and patterns. It is common for pain flare-ups to happen when stress, fatigue, illness and hormonal fluctuations occur, rather than due to tissue-based load alone. This shows that the body’s perception of threat and signalling of danger are not always accurate.

You may also notice that your pain changes location and quality –another indicator that your nervous system is not perfect at discriminating or discerning threats in a precise way.

Our conscious thoughts and beliefs influence our unconscious pain response. Awareness training, or mindfulness practice, will build your skill in watching both your thoughts and bodily reactions, which can be very helpful during this hard process of reframing your pain.

With my leg pain, I greatly reduced my exercise loads (too much in retrospect – I became overly avoidant). I have always used exercise as a tool for maintaining mental health. When I lost this outlet I started a mindfulness practice, which I believe, helped me a lot.

When my pain flared up, I noticed my reaction, reflected on what was happening in my life, and weighed this up with my new understanding of my pain. This led to a new acceptance of my pain and when and why it was happening, reducing my fear of it.

You might not feel like you’re able to accept your pain right away. But even being aware of pain is a helpful step. As we decrease our fear and resistance, we loosen its grip over us and build resilience.

Returning to my personal example. I held a belief that the physical nature of my work (manual therapy) was bad for my injury and pain. Indeed, my pain was worse at work.

However, one day I realised that my leg pain was increasing when I arrived at work but before I had commenced any manual therapy. This greatly challenged my beliefs. I realised I had created a negative association between work and my pain. Unsurprisingly, my body reacted to this belief by increasing its protective response when I entered my work place.

Simply by becoming aware of this association, my pain immediately reduced.

Over time, we can come to understand and change our beliefs. We can recognise what makes us feel safe and what actions or contexts are threatening, and we can build awareness and lower our resistance and fear. All of this will help to rewire the nervous system from an unhelpful, overly sensitised state to a more stable and reliable system. Ultimately, this reverses chronic protective pain in the long term.

3. Recondition your body

From here, you are ready to set physical goals with your practitioner. Alongside rewiring the nervous system, proper treatment for chronic pain will address any physical deconditioning and build your tissue capacity.

What would you most like to return to doing? What does your condition stop you from doing? What activities are you most fearful of?


If you have been suffering for a long time, it is likely that you are physically deconditioned from avoiding activities that have provoked your symptoms or that you simply believe are bad for you. Re-conditioning, building strength and restoring movement are key.

With my disc injury, I realised I had become fearful and avoidant of forward bending. For example, I would dry my legs after a shower by raising each foot so I didn’t have to flex forward.

Therefore, one of my rehab strategies was simply to get comfortable with bending forward when drying my legs! It worked, and with various progressions I eventually made it back to more challenging forms of mobility like yoga.

One man I saw had experienced severe pain from a car accident 20 years earlier. When I first met him I was struck by how rigid and upright he was. His fear of movement was obvious, and he held a strong belief that relaxing and moving would flare up his pain.

It took time to convince him of the false association he held between movement and his pain, but after recognising and working through this belief, he was ready to start physically reconditioning.

Learning how to breathe deeply, relax his posture and stop bracing was the first priority. From there, we slowly increased his range of motion with bending and twisting movements. He was then even able to start gym training and weightlifting.

His pain levels reduced markedly but have not completely abated. However, he is able to function much more freely and has resumed activities he enjoys.

The reconditioning process can look very different for each person. Start slowly and think long term. Set achievable progressions.

One of the best things that you can do is to violate your own negative expectations. This means doing something you thought you were unable to do without causing a flare up. This builds confidence and decreases fear, breaking the cycle of pain–fear–avoidance–deconditioning–pain.

In doing this, not only are you reconditioning the body physically, but you are continuing to rewire your nervous system.


4. Trust the Process

Expect some flare-ups along the way.

After all, we are trying to reverse neuroplastic changes that have developed over months, years or decades.

Therefore, setbacks are understandable. The body has become expert at protecting you and you are actively challenging its safety mechanisms and parameters. But every setback is an opportunity to increase your resilience. Try to be mindful, stay calm, keep moving and return to the foundations of understanding your pain.

This is simple, but far from easy. You will need support, patience and courage. The path is different for each one of us. Therefore, address the threats that seem most relevant to you with priority.

For some people this will mean prioritising psychological support. For others it may be getting guidance for exercise, diet or medical management. Some people may need a bigger team around them if they have more serious medical, physical or mental complications.

As a practitioner treating patients with chronic pain, I refer to psychologists, personal trainers, doctors and other practitioners as needed.

The goal of this treatment approach is to rebuild confidence, capacity and perception of safety and to decrease perception of threat and danger.

This may seem overwhelming, especially if your pain is complicated by other diseases, hardships or constraints.

But sometimes, it does not take much.

A friend of mine finally came to see me after a 10-year history of sciatica and a history of lumbar disc injury. He does heavy work and he wanted a new set of MRI images to see if the structural damage had worsened.

Instead, I talked him through the treatment process we have outlined here and sent him away with some further pain education resources, a proposed mindfulness practice and some strength and mobility exercises.

A week later he returned and despite not having done any of his homework, his pain had miraculously resolved. This particular man has a strong mindset and I believe he was able to change his pain merely through reframing his understanding of it. Moving from a belief that his pain was an indicator of disc damage and deterioration, to an understanding that it really represented an overly sensitised nervous system was all he needed.

In the years since, he has been to see me a few times for acute episodes of lower back pain. These have resolved quickly, and together we marvel at how his chronic pain story came to a resolution merely through a new understanding of his pain.

Survival of the Safest: The protective nervous system. Part 2

By Sudi de Winter

Why does our body develop chronic pain, chronic fatigue and anxiety?

First, let’s recap. In Part 1 of this series, I talked about pain and fatigue as protective mechanisms.

We are genetically wired for survival as our number one priority. Happiness and comfort come a distant second. The more we are exposed to threat – or even just perceive a threat – the more sensitive our protective mechanisms become. The threshold lowers.

This is a function of neuroplasticity. Neuroplasticity, put simply, is the brain’s ability to change itself.

Here are some positive examples of neuroplasticity in action:

  • London cab drivers display significant growth in a part of the brain called the hippocampus, which is the memory center of the brain. As they learn the thousands of streets around London throughout their career, the hippocampus enlarges and these drivers display remarkable powers of map recollection.
  • Learning to ride a bike. Training strengthens connections in the visual, sensory and motor cortexes of the brain, which are responsible for these reactions and movements.

And some negative examples:

  • Soldiers exposed to danger and trauma may develop PTSD. The more severe, the more likely post-traumatic stress will occur. The amygdala, the brain’s main fear centre, demonstrates increased activity in people with PTSD
  • Children raised in threatening/dangerous environments are more likely to have developed sensitised and protective nervous systems as an adult (presenting in a variety of mental and physical health problems). Again, the amygdala (and other limbic system structures) are likely overactive.
  • Addictions/habits. Expectations of chemical rewards can be programmed into our brain.

Let’s get back to chronic pain, chronic fatigue and other weird, persistent responses.

Why do people in relatively safe environments, seemingly without traumatic history, develop these conditions?

If we can accept that these conditions are manifestations of exaggerated protective responses, we can begin to understand how they may come about.

Homo Sapiens have been around for over 150,000 years. But think how much our environments and culture have changed in just 200 years. In 1817, we did not even have steam trains. Just over 150 year later, we put a man on the moon. Nowadays most of us spend the majority of our day seated and looking at screens. So much change, with so little time for humans to adapt.

Although, the Sabre-tooth tiger, food and shelter are no longer our biggest concerns, there are so many more environmental, occupational, social and financial stressors that our brains may perceive as threats. And as I’ve noted already, the mere perception of threat can trigger as big a protective response as a live and present danger.

I have noticed that when I see a magpie flying near me I automatically flinch. This is not just because they are the mascot for an evil football team, but mostly, I realize in hindsight, because I have been swooped several times cycling. My brain has physically changed to react more protectively when I see these savage beasts!

Mass media, marketing and advertising set both conscious and unconscious expectations for us that we can never live up to. Therefore, our perception of ourselves may always be under threat in terms of body image, material wealth and social status. In daily life, most of us are simply unaware of the subtle stimuli that may be setting off danger signals in our subconscious minds and causing our protective mechanisms to kick in.

With the onset of pain, anxiety or fatigue, the background accumulation of such threat response could play a part.

These chronic responses in the body are physically real and genuinely debilitating. They are no one’s fault. Episodes may have an overt trigger (trauma, injury, stress or illness) or manifest without apparent cause.

Our understanding of the immune system is increasingly pointing to its importance in stress and protective responses. 70-90% of the cells in the brain are called glial cells. These are immune cells!

Chronic pain and chronic fatigue are likely to strongly involve hyperactivity of immune responses. Viral infections often seem to trigger the onset of chronic fatigue syndrome, and sometimes even chronic pain. But the same goes for physical traumas and psychological stresses.

However, I believe this immune connection will become clearer in coming years. Hopefully this will shed light on the countless, enigmatic auto-immune diseases, like lupus, rheumatoid arthritis, ankylosing spondylitis, coeliac disease and type 1 diabetes.

When trying to understand an individual’s chronic pain or fatigue, getting their whole story is vital. Trying to identify some of the pieces to their puzzle that we can change or understand, whilst knowing that there will be genetic, hormonal, and immune idiosyncrasies that we cannot fully comprehend, or change.

Nonetheless, there is hope. Becoming aware of subtle threat perceptions and reframing how we see these chronic conditions form the foundation for an effective approach to treatment.

So how do we use neuroplasticity to reverse these unhelpful conditions? Stay tuned for part 3!

Survival of the Safest: The protective nervous system. Part 1.

By Sudi de Winter

Anxiety, chronic fatigue and persistent pain. I obviously now have full command of your attention with these sexy conditions!

But given the complexity, functionality and brilliance of the human body, I have long asked myself, why is the body capable of producing such unhelpful responses?

Evolution 101: traits that make us safe are more likely to get passed on. Therefore, traits that enhance our survival chances are always going to be become dominant.

Animals of all sorts have different survival mechanisms. Chameleons can change colour to camouflage themselves from predators. Echidnas have spikey exteriors to physically shield themselves. Koalas live in trees out of harm’s reach.

Humans have highly evolved nervous systems that alert us to threats within and outside our bodies.

Individually, we possess remarkable resilience through our nervous system and its coordinated work with our immune and hormonal systems.

The human nervous system (brain, spinal cord and peripheral nerves) is incredibly well adapted for survival. We experience:

  • Thirst – to protect us from dehydration
  • Cold – to warn us when our environment is becoming dangerous
  • Fatigue – to rest when sick or in need of recovery
  • Pain – to alert us to potential threats
  • Anxiety/fear – to alert us to threats in many different contexts

Mostly, these responses are incredibly useful and essential for survival. Yet sometimes they go haywire.

Unfortunately, happiness and mental comfort come second to these crucial survival processes. If our nervous system unconsciously deems that we are not safe, protective measures are taken.

The body sometimes gets it wrong. It starts producing an exaggerated protective response that is unhelpful. This exaggeration can be a temporary amplification of intensity (think headache/migraine/acute neck or lower back pain) or can also develop into a more persistent pattern of symptoms (eg. chronic pain).

Sometimes a patient will barely be able to walk in my door due to a recent onset of crippling lower back pain. This presentation often has nothing to do with tissue damage, but merely an extremely efficient, and debilitating, protective response.

I liken it to a fire alarm going off in an office building. Everyone is evacuated and 10 fire trucks arrive at the scene. After a full investigation, it is concluded that some burnt toast set off the alarm.

When pain, fatigue or other protective responses persist, this can be another another sign of an overly sensitive nervous system. Chronic fatigue syndrome, fibromyalgia, chronic pain, anxiety and insomnia. These conditions may all be examples of a protective nervous system that has gone into protective overdrive.

In these more persistent scenarios, it is more akin to a quieter alarm bell going off continually, with an annoying fireman (I am picturing Fireman Sam) coming in to check on our safety daily.

Why does this happen?

Stay tuned for part two.

Dancing – good for the mind, body and soul.

By Amy Lawton

We all know dancing is great for our bodies, encouraging cardiovascular health, getting us moving in different ways and adding to musculoskeletal strength and conditioning. But did you know about it’s positive effects on the neurological system and mental health? It is even being used to treat Parkinson’s Disease, as well as memory disorders such as dementia.

Dancing requires complex mental co-ordination, using both the motor and sensory systems, and music stimulates the reward centres of the brain so when we dance it results in widespread use of our neurological system in a pleasurable way.

Research has shown dance to decrease anxiety and boost mood more effectively than other physical outlets.

TIP: choose a song that makes you happy every day, shut your curtains so your neighbours can’t see, close the doors so you don’t get interrupted and let loose!

During dance, an area of the brain called the cerebellum which is responsible for co-ordination amongst other things, is also stimulated which can lead to improved balance and decreased dizziness.

TIP: tai chi is another great form of exercise which helps with balance and co-ordination.

Brand new research from this year has shown that the biggest predictor of future dementia is a sedentary lifestyle. However, it also showed is that it’s never too late to start. Even following the onset of dementia an increase in physical activity leads to improvement in memory.

TIP: learning a choreographed dance leads to an even stronger improvement in your memory- simple dances can be found on sites such as you tube or if not choose an iconic music video or get creative and make up your own.

Dance has many positive effects on us, not just for fitness but for balance, memory and mood. There are no limits as to how you can incorporate dance into your life, from an African or tap dance class to dancing in your bedroom, only your imagination can limit what you can do!

Should you exercise when pregnant?

By Lucy Hodgson

Ive heard a lot of people say that labour is like a marathon. This implies a certain amount of cardiac fitness is required. I always had this is in mind when I became pregnant, thinking cardiac fitness should be my main focus for a healthy pregnancy and labour. But then, a good friend of mine said she wished she had more strength when it came to her labour, and indeed her recovery.

There is an awfully strong focus when women are pregnant on their labour and how it will go. Whilst important, this is a relatively short part of the whole journey, which also includes pregnancy, and then looking after a newborn, infant, toddler, child etc.

Regular exercise, including strength work, is a great way to prepare your body for the changes associated with pregnancy, and will help with your recovery and the ongoing demands placed on your body. During my own pregnancy I completed regular pilates training, running (up to approx 24 weeks) and rode my bike every day. Whilst there are no guarantees, regular exercise should help prepare your body for labour.

Pregnancy is an extremely dynamic state, meaning the loads and demands on the body are ever changing. Some women (approx 20-50%) do experience pain, particulary around their pelvis and low back. This is not something to be scared of but equally should not be considered normal. Women should seek early advice. Often changing simple movement patterns and postures, getting some treatment, and improving general strength can alleiviate these symptoms, enabling a more comfortable pregnancy. 

We are often asked about exercise during pregnancy. During pregnancy it is safe and advisable to continue to exercise at the level you are used to for as long as you can comfortably do so. Think of Serena Williams competing at the Australian Open during her first trimester!


If you are new to exercise, build up at a moderate pace, avoiding high impact activity. There are, however, a few things to consider specifically when pregnant.


– high intensity sports with risk of collision or falls
– extreme temperatures i.e. hydrotherapy pools or bikram yoga
– lying on your back for prolonged periods of time (most yoga and pilates classes will offer alternative postures)

STOP if you experience –

– vaginal bleeding
– nausea or vomiting
– feeling faint or light-headed
– strong pain, especially from your pelvis or back
– reduced movement of your baby.

There are a few conditions with which you should avoid physical exertion; including –

– your waters have broken (ruptured membranes)
– uncontrolled high blood pressure
– pulmonary or venous thrombus
– low lying placenta (placenta praevia) in late pregnancy
– intra-uterine growth retardation
– incompetent cervix
– uterine bleeding
– pre-eclampsia.

If you do experience any pain during your pregnancy, early interventions are the key. Women often think that pain is a normal part of pregnancy but left unchecked it can become debilitatating, especially if this is not your first pregnancy and you are already trying to wrangle another child. As the body prepares itself for labour, the ligaments do become softer allowing more motion to occur. Exercise, particularly well targeted strength work, enables the muscular system to better control and stabilise general day to day movements.

Overall, regular exercise and strength training has many benefits during pregnancy. It helps your body adapt to the changes associated with pregnancy and readiness for labour. It also helps with your overall health and well being, and prepares you for the new loads and demands that will be placed on the body (and the mind) as a new parent.

But what do you do, when pregnancy is finished?

After pregnancy the best thing you can do in the early days is to focus on your pelvic floor. Daily!

For more things you can do as a new mum – stay tuned.

Running injuries… ‘Loads’ better.

By Sudi de Winter

A systematic review of 17 high quality studies showed that, at any time, 19-79% of runners are experiencing injury. If we assume injury incidence is somewhere in the middle of these wide ranges, the numbers are very high. No wonder running gets a bad rap.

Why do I always get injured?

Most running injuries are due to tissue overload. Each tissue; bone, muscle, joint, tendon or ligament, has a certain capacity to withstand force applied to it (load). Usually with running, we load our tissues within in a tolerable limit, rest, recover and run again uninjured.

Sometimes, however, we load a tissue too much or too frequently, without giving it adequate time to adapt. The result is overload and grumpy or injured tissue. A stoic runner can even develop bone stress fractures if they continue to run through symptoms and signs of bone stress reaction.

It is also important to consider overall load history. If someone has taken up running later in life and does not have much experience with sport and physical activity, their tissues and bones will not have developed the same capacity as the lifelong sportsperson. It may seem obvious, but these people will be more vulnerable to injury.

The good news is that the body is incredibly good at adapting, and, if done carefully and slowly, even the most sensitive person with complex injury history, can build up their running to surprisingly high loads and volumes.

The problem is that there is no one size fits all. Many people will find couch to 5km programs overload them. For many runners I advise taking double the recommended time. Rest and recovery are crucial. For someone with a sensitive system and complex pain/injury history (eg. a chronic fatigue individual), they may need to take much more time to adapt and even more care with a supportive, holistic approach. The key is that each running program needs to tailored to the individual and their story.


It’s all about balancing load with capacity.

What can I do to better manage loads, adapt quicker and increase capacity?

Relative to other sports, running is not particularly high impact. This is especially true at low to moderate speeds. However, running is extremely repetitive. Particularly if we always run on the same surface, the same route at the same speed with the same technique again, and again.

If we are injured, or we just want to be smarter about training, it is clever to mix up these training variables to reduce overload. This might mean

  • running on different surfaces
  • introducing variation to your runs eg. interval training, hill training, long/slow runs, tempo runs and really easy recovery runs
  • try different routes, trail runs
  • get some running retraining or gait analysis to learn different running techniques
  • running in different styles of footwear

Aside from load management and load variability, we can influence a body’s capacity to withstand load with strength training. If we train the muscles best adapted for running, we can absorb running loads more efficiently with these muscles, thus taking loads off the passive structures like the joints, tendons and ligaments.

How important is running form?

There is no one ‘right’ way to run…


Priscah Jeptoo won the silver medal in the marathon at the London Olympics with funky running technique.

However, we have enough understanding of the gait cycle and biomechanics to appreciate how different running strategies and techniques will manipulate and shift loads around in the body. This is why running retraining and gait analysis can be very useful for the injured runner.

The answers are often simple.

The merits of running are huge. Countless studies cite its mental and physical health benefits and implications for increasing life expectancy. And no, it is not bad for the knees. A massive study, showed less arthritic development in runner’s knees compared to non-runner’s knees.

I often walk to work along a popular running track. It is a real pleasure to watch the myriad of different shapes, sizes and running techniques these people have. I think about changes I could make to their running and remind myself.. “if it ain’t broke, don’t fix it”! Nearly everyone can run if they wish to and the answers to staying healthy are surprisingly simple. The main message is avoid doing too much too soon. The body can adapt to running loads beautifully if given time.

I love when someone wanting to run tells me they are unable to run or have been advised to avoid running. It is satisfying to get them back on track and running with confidence. Running is not dangerous. We just need to be smart, patient and take a simple load management approach.





Keep calm and carry on. An interview with Alison Sim discussing chronic pain and chronic fatigue.

Alison Sim is an osteopath with a Masters degree in pain management. Alison works predominantly in the area of chronic pain and runs education courses on different topics about pain.  She has also presented at international conferences.

Sudi – Is chronic pain becoming more prevalent?

Alison – No, it is not becoming more prevalent. I think it is picking up more attention due to the rise in opioid use and the focus that health systems and the media have been paying to this issue. It is just increasing the  awareness – which is a great thing! Chronic pain rates still sit at around that 20% of the population mark, whether that’s in the West or in the East. 1 in 5 people, or 1 in 4 people, depending on how you look at it and how you define chronic pain.

Sudi – For people who are in acute pain (new pain), what is the message to them to help them prevent developing chronic pain?

Alison – Seeing a good health professional who is up to date with pain science is really an important first step. If they can assess you and reassure you that you are likely to recover, you will feel much more relaxed about having an injury or pain. Knowledge is power. Then the trick is to keep calm and carry on. If you are not as worried about it you are less likely to be checking in on it. This seems to be an important part of the recovery process – knowing that you are safe. Once you have this in mind, it is important to stay active, get back to work, hang out with your mates, keep doing stuff. Negative beliefs, worrying thoughts, anxiety, stress, activity avoidance are some of the main risk factors. The best thing we can do as practitioners is to look at people’s beliefs and help them come to a better understanding of their pain, that fits more with a modern, scientific understanding of pain. If we can help people to understand that pain is multifactorial, and not always just due to tissue damage (without them just thinking we are saying it’s all in their head), it tends to relax things.


Sudi – For people that do have persistent pain, and have come to an understanding that it is not due to tissue damage, what pathways do you recommend to help them move forward?

Alison – That is a tough one Sudi! Maybe that is the key message. There is no ‘go-to’ and it is very individual. There is not one easy pathway. For some people it might be that they need to move more. For others, it may be they need to see a psychologist to treat underlying, long-standing depression. A medication review could be part of the process for some. For others, it might be putting 3 or 4 strategies together.

Sudi – Prognosis-wise, what’s the good news and what’s the bad news for people in chronic pain?

Alison – That is a really good question. When you are trying to tell people this message, that they need to step off the merry-go-round, that they need to stop looking for that quick fix, that they probably need to embrace a bigger picture approach which involves meditation, exercise, not being so focused on their pain – it can be  such a confronting message and people might have trouble relating to that idea.

Prognosis-wise, I don’t talk about what the stats say, and I don’t talk about whether people are likely to get ‘better’. I focus more on what do they want to do, goals and function, rather than getting pain-free. Getting rid of the pain should not be the goal, although that may be a by-product. It is more about accepting, and living well. Pain or no pain. People are used to fighting pain. And it is society’s way as well… ‘pain is wrong and we have to do something about it’. So it is a hard message to get across.

It is about how we define success. This is really important, and it’s a conversation we need to have. Set our expectations. What are we looking for? If we establish that someone’s goal is to get rid of the pain, we have work to do to change their mindset and expectations- to help them to focus on getting back on track and doing the things that are important to them.


Sudi – Pain is a protective response. Fatigue is a protective response. From your understanding, could chronic pain and chronic fatigue be similar in their physiological causes?

Alison – From my research and my understanding, that is what I have arrived at. From a neurological and social understanding there are some profound similarities. Unfortunately, the fatigue community is about 20 years behind the pain community. Instead of coming to a multi-disciplinary and multi-modal approach, people have gone looking for a medical ‘cure’. In the pain community, we have accepted that there is no biomedical cure, as we cannot necessarily identify it. So we focus on function. The fatigue patient groups seem to be really disappointed that the gold standard treatment is symptomatic treatment, meaning trying to gradually increase exercise and load tolerance. The impression that they can give is that they see this approach as not good enough because symptomatic treatment is not fixing the cause. They are still at the stage of  ‘if we can find what’s wrong then we can use a medication to fix it’.

It is such a debilitating and frustrating condition that it is totally understandable how this situation has come about. You can understand how someone would be really focused on wanting to find a cure. Unfortunately though, at this stage, these symptomatic interventions are the best that we have and they can be really effective for some people. Like treating people with chronic pain, it is really important that people understand that there will be times during the treatment process that they are worse, and that it is a slow process with ups and downs. If people can be well supported with this understanding and also supported and reassured in those bad days or “flare ups” it can help them to stick with the approach and get back to having more energy to live their life.

But yes, it is a really interesting area, and there are many similarities between the two conditions.


A big thank you to Alison Sim for her time and the interview!

Can your back ‘go out’?

By Sudi de Winter

No. This is the simplest, and most honest, answer.

People often explain their pain as ‘my back has gone out’. This would imply a structural deformation, like, for instance, a shoulder dislocation. A shoulder dislocation is a medical emergency that often requires relocation under anaesthetic and can have long-term implications.

Perhaps if you have suffered severe trauma you could dislocate a spinal segment. This would be a catastrophic injury, likely paralysing you. Luckily the spine is incredibly strong and resilient, and this would need a huge amount of force to create such a scenario.

However, acute, disabling back pain often occurs without trauma, and the trigger maybe something as trivial as putting your socks on, bending, turning, or just getting out of bed.

In all of these scenarios there is very little force going through the body and, indeed, we have probably achieved all of these actions thousands of times without injury or pain. So, it can be assumed we have not structurally damaged our body when these painful events occur.

A clinician’s first priority in addressing any pain is to rule out true pathology and tissue damage like infection, fracture, dislocation, ligament or muscle tear, tendon injury, hard neurological signs, cancer etc. If these more serious conditions can be excluded, then the pain can broadly be placed in the category of non-specific pain. Meaning that there is no specific pathology. This is a broad church, as the vast majority of presentations manual therapists see fit into this category.

So what causes non-specific pain?

Let me share a personal experience. Several weeks ago I was putting my socks on when I experienced sharp lower back pain and dropped to the floor. Trying to rise off the floor or later from a seated position or bending was restricted and painful.

A world of pain.

The pain was intense and certainly did its job in alerting me to a possible threat. But as this has happened many times before, and I had known it to resolve over several days with treatment and other strategies, I knew I was dealing with non-specific pain, and not with tissue damage.

The trigger in this situation was very clear, and yet, surely something as trivial as bending to put socks on should not pose a threat to my body.

I thought back on the days and weeks leading up to this event. I had been sick the week before. I had been under stress with several things. My four-year had just started kinder and, with the transition, his behaviour had been challenging. I had been wrestling with my kids the days before and landed on my back a little awkwardly. These were just some of the conscious threats that I could identify. Yet, there would be many more unconscious factors that my body was processing on a cellular or systemic level.

My point is that anything that may be interpreted at a conscious or unconscious level as a threat may contribute to the sensitivity of our system in protecting us. Sometimes this protection occurs on a physical, or musculoskeletal level, as pain. Once triggered, this pain reaction may well cause local physical changes in muscle, immune cells (inflammation) and nerves.

The response is designed to protect our bodies by alerting us to potential threat and limiting further movement. The problem is that this reaction can sometimes be devastating and debilitating in response to very little, or no, credible threat. Meaning, the body gets it wrong.

However, the pain and physiological changes are as real as if you had broken a bone. Getting a treatment at this point will help calm things down. Moreover, understanding the nature of non-specific pain is likely to reduce stress and further improve recovery time.

I would explain my experience with an analogy. Putting my socks on was the ‘tip of the iceberg’ that we can clearly see above the water. Yet what is in the body of the iceberg, hidden below, may be just as important.

Diagram - May 2017

All possible threat/danger messages are unconsciously changing the tide level in this analogy. Fortunately for me, putting my socks on is nearly always an easy function! Meaning the tide is high enough for me to smoothly sail over this imaginary iceberg. Annoyingly, it seems impossible to accurately know when the water level drops to high alert. There are just too many unknowns.

The good news is that these experiences are not harmful and do not represent true danger or tissue damage. Usually we will recover from these events fairly quickly with the right management and an understanding of non-specific pain.

How we respond to them though is crucial. If we feel like we are the Titanic catastrophically hitting the iceberg, we will only further ramp up our pain response.

titanic 2

The problem is that pain provides the perfect environment for anxiety to flourish and each time we encounter it we may find it hard to believe that there is nothing structurally wrong.

Seeing a good health practitioner to rule out more serious injury is a crucial start. Manual therapy can help calm down a protective reaction. Developing rehabilitation strategies including mobility and strength is a good next step. Developing a path to increase capacity, movement and load tolerance will improve confidence for the future. Yet it is also important to identify and address other factors that may be sensitising your system (i.e. stress, fatigue, psychological, immune and hormonal factors etc.). This is a holistic and preventative approach.

The reason I feel strongly about this approach is that if we are told something is ‘out’ and all we need to do is ‘put it back in’, it is disempowering and encourages a passive, and indefinite, approach. Changing our understanding of pain to a more scientifically-informed perspective can lay the foundation for an empowered, active and sustainable approach.

Do you clench your jaw or grind your teeth?

By Sudi de Winter

If you have ever heard someone grinding their teeth during their sleep, and just how loud it is, you will have some idea how powerful the jaw muscles can be.

Man pulling car teeth

Jaw clenching and grinding (called bruxism) falls into two categories: awake and sleep bruxism.

The causes of this disorder are not fully understood, but stress and psychosocial factors are strongly associated with these conditions, particularly the awake form.

Bruxism, if present, is an important factor to address in jaw pain and TMJ disorders. However, the evidence does not point to any definitive, effective treatment.

If bruxism is causing excessive tooth wear, dental intervention is suggested, often for prescription mouth devices to prevent tooth wear at night.

If anxiety, depression or psychological factors are thought to be associated with bruxism, psychological support is also recommended.

Assuming that bruxism is due to a subconscious mechanism when awake, and an unconscious mechanism at night, we may want to direct intervention to our habits during awake times.

Becoming more aware of our jaw tension and habits will form the foundation for a mindfulness approach.

I recommend a guided TMJ meditation as an exercise to become more skilful in this awareness, and to help relax the powerful jaw muscles. The idea is that if we can become more conscious of this subconscious pattern, helping to change our habits during the day, there will be an affect in reducing the unconscious pattern during sleep.

There has not been any research into this, but practising some meditation and becoming more aware of our awake habits certainly cannot hurt!

If you suffer from bruxism, you might want to try our guided, 10-minute, TMJ mindfulness exercise.

I suggest practising this formally each day (or night before you sleep), and also trying to check in with jaw as may times as you can throughout the day. See if you can run your tongue between your teeth. If your jaw is clenched, think soft tongue, soft eyes and smooth brow. Perseverance is the key. Hang loose!

sleeping baby

Maximising placebo.

By Sudi de Winter

Imagine this scenario. Your child is running down the hall, trips and lands headfirst.

Now consider these two different responses.

I saw you trip and fall. It will be alright. Let me kiss it better.


Oh my God! You banged your head. You could have killed yourself! 

crying child

We all know these contrasting approaches would produce different reactions in the child. The first reaction is an example of placebo and the second could be described as the opposite effect, nocebo.

However, you may not appreciate the physical and chemical changes occurring during these events.

A common misconception about placebo is that it is merely a non-specific, psychological effect occurring in the suggestible person. Yet incredible research over the last two decades has transformed our understanding of these placebo phenomena.

Professor Fabrizio Benedetti is a pre-eminent placebo researcher and his work has demonstrated the specificity in various placebo effects. For example, if someone is given opioids for three days (conditioning), and then on the fourth day given a placebo, the brain will produce its own opiates from its own ‘drug cabinet’. These endogenous opioids will use the same pathway as the conditioning opiates.

Yet if someone is conditioned with cannabinoids (a different class of drugs – one example is cannabis) and then given a placebo, the brain will produce its own cannabinoids and light up that pathway. The same placebo effect specificity is seen with aspirin conditioning, some immune suppressants, some hormones and many other drug systems. Even in Parkinson’s disease, if patients are conditioned, sham electrical brain stimulation will create a 200% increase in dopamine, and motor function will markedly improve, albeit temporarily.

Basically, once the body has learnt a response, it is capable of mediating that same response solely through the power of expectation and ritual (pill, injection, procedure etc.).

These are conscious placebo effects, as the power of expectation is crucial. Interestingly, if someone is given an active drug through hidden administration, its effect may be greatly diminished compared to the patient who is aware of and expecting drug administration.

There are also examples of unconscious placebo effects. For example, if someone takes a round, white pill and knows it is a placebo there may be physiological effects occurring in various drug pathways, regardless of the person not expecting any effect. In this case, the ritual alone is enough to trigger chemical mediators.

In fact, the more complex the ritual, the greater the placebo effect. Surgery has been described as the ultimate placebo due to its elaborate machinations. White coats, important surgeons, anaesthesia, and sharp knives. Sham knee meniscal surgery trials (anaesthesia and incision only) have produced superior outcomes to the actual meniscal surgery.

Studies have also shown more expensive, brand name medication to be more effective than cheaper, generic versions (for example, Nurofen versus ibuprofen). Here, marketing complicates the ritual and expectation picture. The other day I bought a brand name, specifically due to this! It’s madness!

Health care practitioners must juggle placing ethics and honesty first and yet attempt to not completely demolish placebo effects.

As Fabrizio Benedetti says, “Our words alone move a lot of molecules around in the patient’s brain.” Next time my kid falls, I’m going to maximise the placebo by using the most effective child placebo: kissing it better!

happy child

Further reading:

Cure: the science of mind over body. Jo Marchant – Very accessible and entertaining.

Placebo effects. Fabrizio Benedetti – More clinical, in-depth look into the science of placebo.

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