Chronic pain is debilitating to individuals and to our economy, yet most treatments are based on the assumption that it is due to a physical cause. Once it is recognised that chronic pain is caused by our brain and central nervous system as part of a protective stress-processing response, then as this process is reversible, full recovery is possible. SIRPA Ltd was set up to train health professionals to integrate into their own work the pioneering SIRPA approach, where the emphasis is on recovering from chronic pain, rather than management. www.sirpauk.com

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Recovery from chronic pain
Georgie Oldfield MCSP
www.sirpauk.com

2. Georgie Oldfield MCSP
Physiotherapist & Founder of SIRPA Ltd
‘Stress Illness Recovery Practitioners Association’
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3. Learning Objectives
To understand:
•The concept of stress-induced chronic pain
•How SIRPA’s approach can help patients suffering
from chronic pain recover based on this understanding
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4. Hippocrates
“It is more important
to know what sort
of person has
the disease than
the disease the
person has”
460 BC – c. 370 BC
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5. New interventions for LBP needed
European Spine Journal : Review article
Volume 16, Number 11 / November, 2007 Pages 1776-1788
‘Effect sizes of non-surgical treatments on
non-specific low-back pain’
Conclusions: ‘The effect of treatments for LBP is only small to
moderate. Therefore, there is a dire need for developing more
effective interventions.’

6. Current confusion

7. Anomalies
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• Symptoms often don’t match the diagnosis
• The onset of pain is often after doing
something completely innocuous or
something the patient normally does with
no problem
• The onset of pain can often not be linked
to any physical incident e.g. they wake up
with it.
• People with postural, structural or
biomechanical ‘abnormalities’ often
recover, despite these remaining
unaltered
• Chronic pain is often non-specific and
medically unexplained.

8. 79 year old lady with 4 week h/o severe back
pain and bilateral leg pain with numbness,
resulting in her inability to walk unaided
“Widespread degeneration
throughout the lumbar
spine with almost total
effacement of the
epidural and CSF signals
at the L4/5 level,
confirming subtotal
spinal block”
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9. 79 year old lady with 4 week h/o severe back
pain and bilateral leg pain with numbness,
resulting in her inability to walk unaided
Questions to consider:
•Why had she only had pain for 4 weeks, yet
this sort of spinal degeneration takes
decades to develop?
•How was she able to recover fully within 6
weeks with very gentle treatment, despite
her spinal degeneration remaining
unaltered, such as the stenosis?
•Why was she able to remain pain free if the
spinal degeneration was the cause of her
symptoms? - see later

10. Signs versus symptoms
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Pain can be present whether or not a physical
abnormality/problem is present.

11. Common Anomalies
No Pain? Pain?

12. Research into MRI scans of
people without back pain
1) The Journal of Bone and Joint Surgery, Vol 72, Issue 3
403-408, 1990 SD Boden et al
Conclusions: About one-third of the subjects were found to have
a substantialabnormality (57% in the over 60s)
2)New England Journal of Medicine: Vol 331; 69 – 73, July 14th
1994, No. 2 Maureen C Jensen et al
Conclusions: The discovery by MRI of bulges or protrusions in
people withlow back pain may frequently be coincidental
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13. Research into MRI
scans of the spine (2)
3) Ann Rheum Dis. Vol. 62: 371-372 (2003 ) Centeno and
Fleishman ‘Degenerative disc disease and pre-existing spinal pain’
Conclusion: “Degenerative disc disease, as seen on imaging, is not
a painfulcondition.”
4) The Journal of Bone and Joint Surgery (American)
83:1306-1311 (2001) David G. Borenstein et al
The Value of MRI of the Lumbar Spine to Predict Low-Back Pain in
Asymptomatic Subjects’ A Seven-Year Follow-up Study
Conclusions: The findings on magnetic resonance scans were not
predictive of the development or duration of low-back pain.

14. Pain versus
Posture/Structure/Biomechanics
The fall of the postural–structural–biomechanical
model in manual and physical therapies: Exemplified
by lower back pain
Findings – There is no correlation between pain and
posture, structure or biomechanics of the spine.
by Eyal Lederman
CPDO Online Journal (2010), March, p1-14. www.cpdo.net
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15. UK National Regulation
Display Screen Equipment EEC Manual Handling
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16. Back pain and RSI
The number of people developing Back pain
and RSI continues to rise, despite the
introduction of these national regulations in the
early 1990’s. These regulations are addressing
the widespread current belief that there is a
physical cause for these conditions.
But what if they aren’t physically induced?
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17. Work environment
and back pain
Work and back pain: a prospective study of
psychological, social and mechanical predictors of
back pain severity. Christensen J O et al.
Eur J Pain. 2012 Jul;16(6):921-33
Conclusions: The most consistent predictors of back
pain prevention were found to be decision control,
empowering leadership and fair leadership

18. The role of physical and
psychological factors in
occupational low back pain
Occup Environ Med 2000; 57: 116 – 120 (February) Anne-
Marie Feyeret al New Zealand 1999
Conclusions: Other than a history of LBP, pre-existing
psychological distress was the only factor found to have a pre-
existing influenceon new episodes of LBP
N.B. This could have included stressors such as; exam worries,
relationship issues etc

19. • ‘No stress, No whiplash’ (Castro et al., 2001) and demolition
derby drivers have less chronic neck pain (Simotas & Shen,
2005)
• Hauser et al. (2011) report there is a significant association
between sexual and physical abuse in childhood and
fibromyalgia. Work place bullying was also found to increase
the incidence of newly diagnosed fibromyalgia (Kivimaki et al.,
2004)
• Higher percentage of back pain in adolescents with mental
health problems (Rees et al., 2011)
Evidence linking
stress to pain
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20. Emotional & physical pain
• Physical and emotional pain have been shown to
trigger the same areas of the brain
Kross et al. ‘Social rejection shares somatosensory representations with physical pain’.
Proceedings of the National Academy of Sciences in the USA. 2003, 23: 15280 – 15283
• The emotional brain is activated by fear and worry,
which cause pain pathways to become more
pronounced
Bailey et al. ‘Treatments addressing pain-related fear and anxiety in patients with chronic
musculoskeletal pain: A preliminary review’. Cognitive Behaviour Therapy. 2009, epub.
August 20, 2009
Asmundson G et all. ‘Understanding co-occurrence of anxiety disorders and chronic pain: State
of the art.’ Depression and Anxiety. 2009, 26: 888-901
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21. The concept underlying
the SIRPA approach
• Physical and/or psychological symptoms
become the escape mechanism for
unresolved emotions when they build up
and for which there is no other outlet.
• The symptoms are part of a protective,
stress-processing response, which is
automatic and unconscious.
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22. • Current Life stresses/responsibilities
• Childhood, or past, ‘traumas’ or pressures
• Self-induced pressures due to; personality traits,
learned behaviours & beliefs e.g. being overly analytical
or self critical, the need to please/be good/perfect etc,
and/or the belief that they have a ‘weak/damaged’
back/neck/shoulder etc
• Being constantly on the go, overstimulation, overwhelm
& lack of time to ‘defuse’
Underlying causes of
psychophysiological symptoms
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23. Are you saying the pain
is all in the head?
Symptoms are a result of unconscious and automatic
responses in the brain and central nervous system when the
emotional brain has been triggered.
NO!

24. Emotion
Neuropeptides (molecules of emotion) flood the body and brain
Stimulate the emotional brain e.g. the Amygdala
The Hypothalamus triggers physiological changes via the
Autonomic Nervous System (ANS)
Basic Neurophysiology
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25. The ‘fight and flight’
response is a
survival/protective
response to a
perceived ‘threat’.
Physiological changes
occur via the ANS –
and is automatic and
unconscious.
The Stress Response
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26. Modern stress/threats
Are mainly psychological
However………….
Our perceived stress is only 10% due to what happens to us
(physical or psychological) and 90% how we deal with it.
i.e. psychological - self-induced stress
e.g. ruminating over things or over-analysing. Being self
critical, a perfectionist, a people-pleaser, a ‘coper’,
conscientious etc

27. 79 year old lady with 4 week
h/o severe back pain & bilateral
leg pain with numbness
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If you remember this lady, her pain came on just before her
daughter left for a month’s holiday in Australia.
For an elderly person this was a huge stress. She was fearful
of being on her own and also having strangers (Home Care
staff) coming into her home each day, but she bottled up
how she felt because she didn’t want her daughter to worry
about her.
The symptoms were protecting her from falling apart emotionally and/or
having to deal with these ‘dangerous’ emotions.
She recovered after offloading her fears , getting used to the new staff and
then as she was improving, her daughter returned home. There was no further
need for her symptoms to ‘protect her’.

28. Symptoms protect
A GP had been unable to write for
months. During an in-depth
assessment it turned out he had not been
able to write since he collapsed (while
writing) and had to have life-saving heart
surgery
N.B. He could type all day and had no
other problems with his hand at all.
His brain had associated his nearly dying with writing, so the unconscious ‘stress
response’ would cause his hand to “go dead” to protect him from this ‘life-
threatening’ activity. Recovery was swift with simple, self-empowering
strategies.
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29. Case study: 6 month
exacerbation of chronic LBP
MRI results: ‘massive disc protrusion at L5/S1, compressing both
S1 nerve roots and causing marked central canal stenosis’. (see
slide 11)
Symptoms: bilateral constant sciatica, pain was scored from 6 –
10, (with 10 the maximum) plus numbness laterally over both
ankles and feet.
Signs: Reduced Lx ROM, loss of bilateral ankle reflexes and
minimal strength in left plantar flexors.
Pain Medication: Gabapentin, Dihydrocodeine, Diclofenac,
Paracetamol 29

30. A&E with
intravenous opioids
This lady’s nerve pain
pathways had become learned
and during the previous 6
months she had been unable
to sleep for more than 20
minutes at a time.
The following slide shows a
graph she completed herself
during her recovery while
following the SIRPA Recovery
Programme.
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31. 31

32. 3 years later
Still fit and healthy 3
years later and
bouncing on a
trampoline.
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33. No exercise, drugs, hands on therapy or surgery
The symptoms are a result of physiological changes in
the body and as the process is reversible, full
recovery is possible.
Identification of links and triggers for the symptoms
can significantly help a patient progress.
N.B. Patients can follow the programme independently, with the support of a therapist, or as part
of a group (where available)
The SIRPA Recovery Programme
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34. Cautions
• Any more serious cause of the symptoms need to be
ruled out, such as; cancer, infection, fracture or an
auto-immune disease
• People with unstable or severe mental health
conditions are advised not to follow the programme
unless supervised by a trained mental health therapist
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35. • Accepting that the symptoms are stress-induced and not due to
a physical cause is important for a full recovery. N.B.
Sometimes having a diagnosis by a SIRPA Practitioner can help
with this.
• Acknowledging the underlying causes of the pain is important
where the aim is recovery rather than management and can
often be done simply by therapeutic journaling
• Strategies can then be learned to help patients reduce the
causes of self-induced stress as a result of their personality
traits, learned behaviours etc.
The SIRPA ™ approach
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36. Treatment progression
Educational, self-empowering
and very often can be self-directed
In-depth SIRPA™ Assessment
(a Stress check-up to help identify links and triggers for their pain)
Follow the online programme
alone or with professional support
(or as part of a SIRPA Recovery Programme for groups)
Further support and/or refer on
(Other self-empowering approach or Psychotherapy )
Books, CDs, online SIRPA
Recovery Programme
With a SIRPA
Practitioner
Support can
be face to
face or via
skype
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37. • Therapeutic journaling – to identify, acknowledge and
gain perspective in order to let go and move on
• Mindfulness and Mindfulness Meditation
• Supportive self-talk
• Visualisation
• Some cognitive behavioural tools
Some strategies included in
the SIRPA Recovery Programme™
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38. Some evidence for a few of the
treatment strategies used
• Mindfulness meditation reduces
stress and amygdala activation
(Holzel et al., 2010)
• Experience in meditation
predicts a less negative appraisal
of pain (Brown & Jones, 2010)
• Journaling or private emotional
disclosure reduced pain in
people with fibromyalgia (Gillis
et al., 2006)
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39. www.sirpauk.com
enquiries@sirpauk.com
www.twitter.com/SIRPAUK
www.facebook.com/SIRPAUK
www.linkedin.com/in/GeorgieOldfield
www.youtube.com/Georgie Oldfield
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