A Practical Guide to Persistent Pain Therapy

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The Voldemort Effect: A Guest Blog by Jack Chew

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It’s not news to anyone aware of my podcast, previous blogs or twitter feeds that I’m quite the fan of ‘stirring the pot’, and that my contrarian tendencies often walk me into glorious and inglorious disputes and debates. Some bear fruit and progress ensues, others quickly descend into snide remarks and a dozen emojis… But recently, I’ve clashed with colleagues who are my usual allies over one particular topic; one that I refer to as ‘the liberal use of language’. 

To clarify from the off, I loathe the suggestion that ‘the pendulum has swung too far’ when it comes to professional and societal understandings of pain, function and more broadly, human health. BUT, I am certainly concerned about the tactics being used by some ‘thought leaders’ and their followers as they try to move beyond the ‘hurt equals harm’, tissue-centricity that remains commonplace. This concern is related to their apparent willingness to implement whatever strategies they like to achieve this goal; at times this includes the overlooking of both logic and evidence. 

To simplify a little, I’ll focus specifically on what I see as a self-induced phobia of talking about human anatomy. An example to set the scene: 

A 30 year old laborer was assessed by a therapist following an injury at work. He was in a tight corner lifting breeze-blocks that would normally require assistance but instead, he tried to wiggle it out of the space alone. He did so with a flexed and rotated spine then felt sudden back and leg pain which he had not experienced before. A few weeks have passed with little resolution, he is now off work and, as is the nature of modern society, every friend, family member and shopkeeper’s dog have given their take on diagnosis and proposed solution. Fortunately (ish) he has seen his GP who has prescribed some medication and advised him to avoid bed-rest. His social consensus diagnosis of ‘slipped-disc-trapped-nerve’ is neither supported nor refuted by his doctor but fortunately (ish) he was encouraged to see a local Physiotherapist. 

4 weeks later, subjective assessment by said Physio reveals significant concerns regarding work, sport, general ADL function and what the future might hold for him. All of which are completely legitimate and sensible concerns when efforts are made to view the problem through the patient’s eyes, especially in light of his current education regarding pain, injury and bioplasticity. Objective assessment reveals certain directional and positional preferences, tenderness in the lower lumbar spine and buttock, a positive straight leg raise but fortunately, no sign of significant neurological compromise such as myotomal weakness, reflex changes or overt sensation loss. 

Now it is far beyond the scope of this blog and far beyond the reach of my current patience to discuss exactly how this patient should be treated and managed. Instead I will draw a line in the sand here and say that in my opinion, any failure to explain the likelihood of this man having had a disc injury that is affecting a nerve root is nothing short of dishonest. 

How we go about doing this is where the conversation gets interesting of course, but any purposeful avoidance of the words that the patient brought to the conversation, is linguistic gymnastics that are very likely to make you (as well as the team, company and profession that you represent) look like idiots. 

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We now treat discussions with patients regarding anatomy, tissue physiology and structural injury with kid gloves. While our good intentions make us sensitive to the contemporary understanding of pain, and keep us from labeling disruption of structure as the only causal factor in pain experience, I argue that we are beginning to do society and our profession a gross disservice. 

And so to my naming of this blog and the suggestion that many in the MSK industry are succumbing to what I call ‘The Voldermort Effect’. 

Odd as the comparison may sound at first, failure to discuss structural injury, at least initially, in the terms that the individual has come to understand it, is doing the same disservice that members of the magic community did by refusing to mention Voldemort’s name in JK Rowling’s Harry Potter books. By refusing to label him, they prevent an open and honest discussion from taking place about possible solutions. And that is where mainstream Physio reformers find themselves today with regards to morphological and patho-physiological lexicon. The idea that we must avoid words that are well established in society due to fear of mortally wounding patients is rank hypocrisy that patients are very likely to see through. 

How does this sound?: 

“Your body is strong and robust with a wonderful capacity to adapt to the stresses and strains placed upon it. It will adapt regardless of your age and given the right stimuli, it is amazing what biomechanical and morphological quirks it can accommodate. 

But your mind will latch irrationally onto words, regardless of the context in which they are discussed. Because unlike your body, your mind is invariably fragile and so we mustn’t take any chances.” 

This ‘new-age dualism’ is bound to push patients back towards the pseudo-truth-tellers who, through ignorance and/or laziness and/or profiteering, will continue to attribute cause of pain to specific tissues. 

‘He who shall not be named’ came back with a vengeance and the denial of his existence facilitated his reincarnation. Similarly, the failure to discuss anatomical structures in a patient’s own familiar terms is bound to give fuel to our nemeses and thwart the progress that we all dream of. 

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I must point out that I have landed on this analogy through my interest in Liberal Democrat MP candidate; Maajid Nawaz who makes the same comparison to President Obama’s inability to name recent acts of global terrorism as ‘Islamic Extremist Terrorism’. I welcome you to draw the parallels between our causes, as always, I have my take, but most importantly it would be unfair of me to not mention his influence on my use of the term. So if you’re interested, this short clip explains his own use of the analogy very well: https://www.youtube.com/watch?v=6BQWqFyRpFQ 

And yes, I’m suggesting we should talk about structures regardless of presentation and duration of symptoms if that’s what the patient wants to talk about. Because patients kind of matter in the whole ‘getting better’ process, right? The merry dance that some clinicians have found themselves doing to avoid certain words is very impressive, but the notion that a therapist would be admired for opening their explanation of assessment findings with ‘well, pain is emergent and we’ve come to understand that every person is influenced by biological, psychological and social factors’ makes me shudder and genuinely fear for the future sanity of my soon to be burnt-out colleagues. 

I’ve long banged the ‘mind your language’ drum across all media, but I would suggest that I’ve been misunderstood if it has been thought that my mission is police language in an oppressive manner. 

Mainly because words are just words. 

Many are aware of the brilliant research of Ben Darlow and others regarding the impact that language can have on patients; and I am not for a second countering this work, since I have long promoted it. However I feel that a simple but intellectually dishonest interpretation of such work has infected the minds of many well-meaning reformers who seem to attribute power to words that they simply don’t have. 

Words are just a series of letters. Letters are just a series of lines. It is our history, culture, language, consciousness, emotional maturity and many more factors that have led to some words having more meaning and connotations attributed to them than others. Forgive my over-simplification here but it is through this complex sociological process, coupled with complex individual biological and even metaphysical processes that some words can sometimes influence beliefs. 

(This is what makes language so incredibly interesting, but I won’t assume that anyone is nearly as geeky as I am about the topic, so I’ll skip a chapter on linguistic theories… this time.) 

But I can’t help but prioritise a plea for recognition of the widely respected concept that it is when words influence beliefs and when beliefs influence behavior that we should be most interested. Because these processes of influence can be demonstrably affected by our interactions, and therefore the impact that we have on any individual’s life. 

I agree that clumsy use of jargon and structural reasoning has clearly demonstrated that we can have deleterious effects on these processes, but the answer is surely not to kick back so hard against it, as to stop using words altogether?! 

How about we instead aim for honesty? Human pursuit of truth is an incredible thing so why not aim for delivery of our very best guess at that moment in time? 

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This approach means that using the term ‘crumbling’ to describe a spine remains off the table, because it’s dishonest. But using the terms ‘bulge’ or ‘fracture’ surely can’t have such deep-rooted negative connotations that they mustn’t be uttered in case they do irreparable damage, even when they are immediately placed in context? 

Failure to talk about Voldermort did nothing to contribute to his existence and if anything, it fuelled the fear and mystery surrounding his power. We are seeing language being policed in all walks of life contributed to by ‘social justice’ movements and a new wave of Marxists suggesting oppression where it doesn’t exist. So instead of inventing our own brand of ‘political correctness’, could we instead reclaim the words, reframe them, attach reassurance to them, add humour to them, laugh at our historic mistakes and drive a process in which we are honest with our fellow human beings about what we think is going on at any given time? 

In a recent in-service training session with the brilliant IPOPS band 6 team, we discussed the concept of individuals and groups being happy to promote or condone dishonesty if they perceive it to be in the ‘right direction’. This is a dirty tactic that we surely can’t succumb to at an N=1 level in clinic. 

We all have our favorite topics attached to our specific agendas, especially on social media. The ease of the retweet to support our general narrative is something than no-one is immune from. But at a clinical level at least, a push for balanced honesty is surely the only way to stop the swinging pendulum of patient education becoming a wrecking ball. 

In a nutshell: think hard, be critical, be reflective and then say what you want!* 

*Including about this piece! 

Chewy

Physiopedia Interview

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Last week I had the great pleasure of chatting with Rachael Lowe from Physiopedia about pain education. I hope you find our chat helpful and thought provoking. 

Thanks for watching.

Bournemouth 20th & 21st August 2016

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I am delighted to announce a Know Pain course in Bournemouth

on Saturday 2oth & Sunday 21st August 2016


For more details about the course, please click the link below:

Know Pain Bournemouth


The course will be held at

Physiotherapy Department

The Royal Bournemouth Hospital

Castle Ln E, Bournemouth BH7 7DW

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Special Promotion!

20% discount (£220) for multiple bookings of 2 or more people.

Email mike@knowpain.co.uk and quote KPBOURNEMOUTH20 to

take advantage of this offer.


There is limited availability for this event so make sure you 

reserve or book your place early.

Click below for the booking form:

http://knowpain.co.uk/course-dates-2/course-bookings/

The 12 Know Pain Tips of Christmas

The 12 Know Pain Tips of Christmas

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So, it’s that time of year again. You’re working out how many kilos of Brussel sprouts to buy, whilst simultaneously planning a festive season to rival Santa’s workshop! Christmas is not the easiest time to consider your health and fitness, so here at Know Pain we’ve put together 12 handy tips to help you stay on Santa’s nice list.


Top Tips

1. Ready for winter? Preparing for bad weather can prevent a lot of trips & falls. Keep paths clear and buy grit salt to melt ice.

2. To help prevent falls check there is still tread on the soles of your shoes and slippers. Also check the rubber grip on walking sticks.

3. Keep moving! Make walking and stretching a regular part of your festive period.

4. The days of ‘No pain, no gain’ are gone. If it hurts to do exercise, then it’s the body’s way of saying “I shouldn’t be doing it that hard!” Hurt does not always mean harm so it’s important to get moving at a comfortable level. This applies to all activities (wrapping presents, shopping, cooking…the list is endless!).

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5. Physical activity is good for the mind, body and soul. Daily exercises will boost your fitness, mood and decrease stress levels. Motion is Lotion!

6. Tense your bottom muscles every time you steal a chocolate tree decoration! When it comes to exercise, little and often is the motto.

7. Don’t make exercise a chore. Exercise is your playtime – whatever you do make sure it’s fun!

8. Exercise is for life and not just for the young…you are never too old.

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9. Use your home gym! We all have gym equipment at home. For example, try repeatedly sitting & standing from a chair. Think…what does this part of my body do & then gently move it!

10. When watching TV – get up and walk around when the adverts come on. It’s important to change your posture regularly. You wouldn’t keep your finger pulled back for a long time. Your spine, knees & shoulders are no different.

11. Nothing changes if nothing changes! Think of something in your life that you’d like to change. Now make a list of the pros & cons of making that change.

12. A journey of 1000 miles begins with a single step…if you are attempting activities that are new to you…remember – Start easy & build slowly!


 

Have a wonderful Christmas & a Happy New Year!

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#selfmgt TweetChat 11th November 20:00 GMT

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Following the excellent discussion during our first TweetChat, Pete Moore and I have arranged another TweetChat at 20:00 GMT on Wednesday 11th November. This provides a great opportunity for people in pain and healthcare professionals to come together to discuss the issues that matter. 

For more information about this event, please click the link below:

http://www.paintoolkit.org/news/article/pain-toolkit-selfmgt-tweetchat

#PainTalk 8pm UK Time Wednesday 16th September

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At 8pm Uk Time on Wednesday 16th September, myself & Pete Moore from Pain Toolkit will be hosting a one hour TweetChat (#PainTalk)

to discuss 4 hot topics about pain management.

This online event is free of charge and is open to everyone.

Pete and I would like people in pain and healthcare professionals to consider the following 4 questions for the #Paintalk discussion…

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More information can be found by clicking the link below:

http://www.paintoolkit.org/news/article/tweetchat-paintalk-with-myself-and-knowpainmike-16th-sept-8.00pm-uk-time


We look forward to welcoming you to #PainTalk

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Beyond Words

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No matter which sense we use, most attempts to express our perceptual experiences fall short of the mark through words alone. Think about how people express their love for one another or how they attempt to describe the experience they have when drinking Merlot. 

Here’s an extract from an article in The Telegraph newspaper which highlights this point beautifully. The following words are those of J. Ray. As the newspaper’s wine buff, Ray felt obliged to provide a counterargument to the scientific discovery that wine buffs talk rubbish… 

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“How does one describe what scrambled eggs tastes like, or smoke smells like, without comparing them to something else? So it is that we wine lovers might describe a wine as tasting of truffles, leather, game and rotting veg. Well, dammit, that’s what old red burgundy often resembles. It certainly doesn’t taste of grapes.” J. Ray 

With it’s idiosyncratic and cluttered complexity, pain is very much alike in it’s desire for creative expression.

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Here’s an interesting read on the subject…

Finding a visual language for pain: 
http://www.clinmed.rcpjournal.org/content/2/6/570.short

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The French artist Henri Matisse (above) notes that, “Creativity takes courage.” I lose count of how many times I use this quote when teaching healthcare professionals. If we are to help people in pain to make sense of their distressing experiences, we must encourage them to step outside of language and explore other means of expression. Without this, we squander opportunities for empathy and therapeutic connection. 

So next time you find yourself sat in front of somebody in pain who looks like one of the faces you see below when you ask, “What does your pain feel like – sharp, stabbing, achey?” or, “How would you describe your pain on a scale of 0-10?”, it is time to get seriously playful and embrace creative practice.

Don’t forget that large dose of courage!

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FURTHER LEARNING

To hear more about the use of imagery and metaphor when helping people make sense of pain, listen to my podcast chats with Jack Chew and David Pope by clicking the link below:

http://knowpain.co.uk/resources-2/podcasts/

Also, you might like to test your metaphor knowledge by taking the metaphor challenge here:

http://knowpain.co.uk/resources-2/the-metaphor-challenge/

Finally, this wonderful presentation by Dr Deborah Padfield is a must watch:

 

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A vet’s approach to fear, pain and mobility

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I was delighted when Dr Marianne Dorn, a veterinarian and physiotherapist, got in touch to discuss her work with me. Having listened to my Physioedge podcast with David Pope (http://physioedge.com.au/pe-035-know-pain-mike-stewart-part-1/) Marianne was keen to discuss her experience of working with distressed animals and has kindly written a guest blog to share a vet’s approach to fear, pain and mobility.     

Healthcare professionals who work with fellow human beings regularly encounter behavioural and linguistic displays of vulnerability from people in pain.  Ben Darlow and colleagues recent work – Easy to Harm, Hard to Heal: Patient Views About the Back (2015) (http://www.ncbi.nlm.nih.gov/pubmed/25811262), reveals such displays. 

This characteristic vulnerability that so frequently accompanies pain led Louis Gifford to the formation of his Vulnerable Organism Model. In his 2005 editorial for the Physiotherapy Pain Association’s News publication entitled, The sickness response and the vulnerable organism – When you’re low you hurt more easily (https://giffordsachesandpains.files.wordpress.com/2013/07/issue-19-editorial-vulnerable-organism.pdf ), Louis suggests: 

“The notion of a ‘vulnerable organism’ should provide a management opportunity – with the underlying goal for the patient to feel strong, confident and fit and the goal for the therapist being to help get them there. A simple change in mood may be enough – it’s surely a common clinical observation!”

Whilst there are obvious distinctions between human and other animal responses to pain experiences, there are also some striking similarities that highlight our need as healthcare professionals to provide reassurance through the detection of vulnerability, and through skilled verbal and non-verbal communication. This includes touch!

Therefore, it gives me great pleasure to introduce Dr Marianne Dorn’s guest blog.  

 


 

A Vet’s Approach to Fear, Pain and Mobility

Working in the UK as “The Rehab Vet”, I help restore comfort, confidence and mobility to dogs and cats referred to me with all kinds of orthopaedic and neurological issues. I am forever searching for strategies to understand and help my canine and feline patients, and so was interested to hear Mike’s views on the Physio Edge podcast.

One point that he brought up was the link between fear, pain and reduced mobility in his human patients. Now this is also a key concept for my small animal patients – so I just had to get in touch with Mike and share something of my experiences from the veterinary field.

Many pets feel anxious at times, even if their family and health-carers have the best intentions. This is particularly the case in those experiencing chronic pain and/or mobility issues. Just getting around the house and, for cats, negotiating home territory, can become frightening. For dogs, fear of slippery floors and steep steps is a very, very common problem. Unfortunately, visits to the vet clinic cause many of these animals yet more stress for all kinds of reasons.

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Above: Just getting around the house can be stressful for an older animal

 

Before they can begin to feel confident, dogs and cats need to take their own time to “sniff out” the situation. They check for olfactory cues and look about to read the body language of people and other animals when they find themselves in a new situation.

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Above: dogs take time to sniff for clues when they meet someone new…

The typical hurried approach within the vet examination room can come across to the animal as quite frightening. Having worked for many years as a general small animal vet, I’m aware that this can be a tense environment, with vets and vet nurses constantly completing tasks against the clock and always ready for the next emergency to come through the door. If the animal reacts to this stress by turning away or wriggling, then they’ll be firmly “held down” or “held still” for examination, and this restraint makes the pet even more frightened.

There’s a further problem for the painful animal who visits the vet clinic. How, as vets, can we know exactly where the animal is hurting? Careful observation and history-taking is extremely useful. But the quickest method is to put the pet through a series of pain tests and, as vets, this is what we have been taught to do. So, for example, a dog that is lame on his right front leg will be firmly restrained while the vet pokes and prods each structure in that limb and manipulates each joint every which way. When the dog flinches or yelps in pain then we have an answer.

Every vet that I have met clearly loves animals, and most are kind, generous people. Vets hate the idea of putting any animal through pain or fear. However, these firm restraint and rapid pain-testing methods are standard practice.

I do notice high muscle tone and awkward postures in frightened dogs and cats. Animals already suffering from musculoskeletal pain will go home feeling worse after a stressful experience, and it is likely that fear may contribute to chronic pain syndromes in pets.

Here are just some potential causes of anxiety for the animal at the clinic:

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Subjectively, I get the impression that animals feel less painful once steps are taken to remove the real and perceived threats. Pain-scoring in animals is difficult. I’m going by subtle changes in their posture and body-language and in the way that they react to being touched. What’s more, animals become ready to move in a more balanced and efficient way once the perceived threat has gone. There’s a close connection between fear, pain and mobility.  

Things I do to reduce the patient’s fear include positioning myself really carefully when working with them, Tellington Ttouch techniques and careful attention to flooring and to any restraints.

Taking enough time over each session is also helpful. Animals are so used to being manhandled at the clinic that to have a veterinary professional help them into a comfortable position and then just sit quietly with them must come as something of a relief. This also gives me a chance to talk to the owner about how they are coping and to discuss the home care regime.

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With plenty of time allocated to each session, I have a better chance of locating any painful areas without forcefully restraining the patient. Initially, I get clues from watching the animal walk, turn, stand and change position. Then I settle the animal into a relaxed position and use my fingers as gently as possible to assess the neck, back and limbs for discomfort, watching for subtle flinching, muscle twitches or gentle behavioural signs (e.g. for dogs, repeated lip-licking) to show that I’ve touched a sore spot.

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It’s all very well reducing the stress in the clinic, but what about at home? An important part of my job is to teach owners ways in which they can use their own hands, body position and voice to make their animal feel more comfortable. I also explain something of the animal’s body language to his or her owner, and suggest how they could respond to it. Home visit check-ups offer the opportunity to assess the home and garden environment for causes of stress, from slippery flooring to awkwardly-positioned bedding.

Frightened animals tend to adopt a tense body position, ready for a panicky “fight or flight”. This posture varies between individuals, but often involves a dramatic tightening of the neck and shoulder muscles. Not only is this muscle tightness uncomfortable, but standing like this does not lead nicely into efficient, pain-free movement.

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Above: Frightened dogs adopt tense body postures

Many painful pets already have tight shoulder and neck muscles, and stress tends to make this even worse. Rather than scaring them so that they practise their tense fight or flight posture, I help them into functional, efficient positions during the examination and while I talk to the owner. To allow for this approach, I do take a whole hour over each session, and have the luxury of treating most of my patients in the comfort of their own home.

So, should vet clinics be avoided? That’s not the case at all! The standard of veterinary care is constantly improving, and vets do wonders in diagnosing and treating dogs and cats. However, do choose a vet clinic carefully. A good practice will not only excel from the clinical point of view, but will also have staff who are ready to listen and to address these quality of life issues in a practical way so that, each time you visit, you and your pet can go home together feeling that bit better.

 

Dr Marianne Dorn BVM&S PGCert SART MIRVAP MRCVS

The Rehab Vet, Herts, UK

Website: http://TheRehabVet.com

https://www.facebook.com/therehabvet

Twitter: @therehabvet

Choose Movement!

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As the cult movie Trainspotting once taught us, life is about choices. Our modern world is full of them. What colour sofa to buy? How big should my TV be? Tea or coffee? Whether to change the bed clothes today? Chicken or fish? The list is endless! 

Amid the myriad of choices we encounter, the decision to increase our activity level is all too often overlooked. It’s easy to see why this might be. For millions of people, long hours at the office, family responsibilities and countless deadlines all take precedence over regular physical activity.  Some of this has to do with the modern day perception of what “exercise” is. Much of it has to do with how our societies have embraced technology over movement. For many, exercise equates to pounding the pavements with sweat dripping from every pore. I’ve lost count of how many times people recoil at the thought of heading to a gym. 

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If we are to stand any chance of reducing the global epidemic of persistent diseases that relate to inactivity, we need to change people’s perception about movement and make activity a normal, fun and engaging part of everyday life. This is why the work of people like Dr Mike Evans (http://www.evanshealthlab.com) and Ann Gates (http://www.exercise-works.org) is so important. 

Dr Mike has launched a much needed campaign called Make Your Day Harder. It’s a simple message. As societies we sit far too much. We need to find little, helpful ways of moving more often. This needn’t involve a triathlon, just something small that means something to you. Check out the Make Your Day Harder website (http://www.makeyourdayharder.com ) for further information and some typically engaging and creative ideas from Dr Mike.

Speaking of engaging and creative ways to encourage people to move more here’s a superb video from the Stockholm subway: 

During my recent trip to Singapore, I had the great pleasure of working with the staff at the Khoo Teck Puat Hospital (https://www.ktph.com.sg/main/home). Prior to running my Know Pain course in Singapore, I was shown around the hospital and was hugely impressed by their innovative use of simple, positive health messages to encourage people to be more active. Here’s a few examples:

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As you can see, it doesn’t take much to get the right message across. So ask yourself: How could you do something similar in both your home and workplace?

I really do wish that I’d considered my choice of footwear for that last photo. Oh well, give me an affordable, positive health message over a mild fashion faux pas any day! 

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A Practical Guide to Persistent Pain Therapy

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