Speech recognition software

What is it? It's software you use to dictate into your computer instead of typing with a keyboard. You can write in most programs with it, but it works particularly well in Microsoft Word. You can also use it to partially replace a mouse, depending on which version you get.

Does it work? I find that it helps me use a computer for longer without getting as much pain, but because it works imperfectly I still have to use the keyboard and a mouse a bit, so it's not as effective as not using a computer at all.

Who does it work for? People whose pain is set off by using either a keyboard or a mouse or both. This is likely to include people with RSI or wrist or finger problems and possibly also elbow and shoulder or upper back problems if these are exacerbated by using a computer. The questions to ask yourself are: do I end up in more pain if I use a computer? Are the problems due to my keyboard and mouse use or due to my chair or just the fact I'm sitting down? If it's due to using the keyboard or mouse, speech recognition software could well help. Obviously it won't cure any pain, but it might prevent you from getting computer-related pain.

Who doesn't it work for? People whose pain is not caused by using a keyboard or mouse. That probably includes most people with neuropathy, migraines etc. If you have neuropathy in your hands or arms that make it harder to use a keyboard or mouse for you, speech recognition software might also be worth considering, whether or not it has any impact on pain for you.

Where can I get it? From the Internet or from within your computer in the case of Windows 10. I have only ever used Dragon Naturally Speaking. I've heard that this is the best software available, although in my experience it still has a lot of room for improvement and people with pain problems and disabilities are clearly not its primary market, as it sometimes increases the number of ways in which you need to use a mouse to use it between versions, whereas if it cared at all about people with disabilities it would try and let people who can't use a mouse use it. You can get Dragon from Amazon or directly from the manufacturer, Nuance. I suspect you can also get it from anywhere else that sells software.

How much does it cost? Dragon is available in several versions. Because it is still a far from perfect product, I reccomend buying the latest version (Dragon Professional Individual or version 13 as at the time of writing). Within that, you will be given a choice between Dragon Home, currently £73.18 on Amazon; Dragon Premium, currently £109.94 on Amazon; Dragon Professional Individual, currently £279.99 on Amazon, or Dragon Professional (Enterprise), currently £699.99 on Amazon and definitely not necessary for any purposes other than for a large corporation. Nuance, the manufacturer, periodically seems to do offers. These are sometimes better value than the equivalent version on Amazon, but sometimes still more expensive.

Which version do I need? It depends where your problem is. If you just have a problem with using a keyboard but not a mouse, then Dragon Home is very probably enough for you. You can use it in US or British English (or Australian, Canadian or, I think, Indian English) and you can add your own vocabulary using vocabulary editor. You can also use Dragon's built-in commands. What you can't do is create your own custom commands (which better enable you to use it to replace a mouse) or use it in spreadsheet programs.
If you need to use it to replace a mouse, then I recommend Dragon Professional Individual, because you can use it to create your own custom commands. For instance, I have set up Dragon to copy the text I have selected then open up an Internet browser, go to Onelook then paste the copied text into the blank field and press enter (i.e. to look up a word or words I have highlighted in Onelook) when I say "Onelook". To do this, you will need to be able to look up the necessary keyboard shortcuts (I use Google to do this) and add the commands in Dragon's command browser. You need to be fairly confident on a computer to do that, but if reading that you think "I can probably look up all the bits I need to know", then you are almost certainly right, you are confident enough on a computer to be able to do this. Please note that I haven't succeeded in entirely replacing a mouse or keyboard with Dragon. If you absolutely had to, you might be able to, although if you can't even touch a mouse, you'll probably have to regularly call someone over to restart Dragon for you when it crashes, as it's not the most stable program in the world, and also you'll need the patience of a saint, as some of the things you'll need to do are rather cumbersome and fiddly. I actually use Dragon Professional Individual in conjunction with a special kind of mouse (also a far from perfect solution, but better than not having it from a pain perspective).
Here's Dragon's features matrix of what is and isn't included in each version. Some parts of it are easier to understand without an IT degree than others.

Is there a cheap/free version?  Yes. Windows 10 comes with free speech recognition software included. To find it click the magnifying glass icon in the task bar to bring up the search box, or if you have a search box in your task bar, just go straight to that. Type: speech recognition software. Windows will then guide you through what you need to do to set that up. Because I owned Dragon Professional long before Windows 10 came out, I've never actually tried the Windows 10 version, so I'm not sure what its limitations are. You will definitely need a desktop microphone or headset microphone to use it, but then you'll also need one for Dragon. Some hard copies of Dragon come with a free headset. The one you use for Skype may well be fine. Roughly speaking, the better your microphone, the better the speech recognition software will work, because the easier the software will find it to understand your words (and believe me, you'll find it misunderstands you a lot even with a superb microphone. I've actually accidentally learnt new commands when it misunderstood something I said). The same applies to your computer's sound card, the better your sound card the better the software is likely to work.

Is there any evidence for it? Not as far as I'm aware, only the anecdotal evidence of me saying I'm in a lot less pain when I use it instead of a keyboard and mouse and less pain still when I don't use a computer at all.

Is there anything else I should know?  Yes. You will either need to use it in a room of your own (for background noise reasons and because you're talking quite a lot of the time) or in a room with people who don't talk much themselves, but can cope with you talking to the speech recognition software while they're working. It's unlikely to be able to hear you well enough against the background noise in a busy room with lots of people talking. In a room with no one talking except me I always found it rather embarrassing to use and I also worried I was distracting others from their work. If you do need to use it in a loud room, you've got a better chance with a headset than a desktop mike.
Dragon is not designed to work with all programs. It is optimised for Microsoft Word. Whether it works in other programs is potluck and Dragon's support staff won't be able to tell you in advance whether it will work or give you any support if it doesn't. If you need to use a particular program and you want to use Dragon instead of the built-in Windows 10 software, your only option is to buy Dragon, try it and take advantage of the 30 day moneyback guarantee from Nuance if it doesn't (if buying from another seller, you'll have to check in advance if they offer that). The dictation box may help with some programs. This enables you to dictate into it then transfer the contents to any program, including ones where dictation doesn't work. But for others it is too fiddly, slow and frustrating. The dictation box works well in a program where you don't need to add any formatting and can add large chunks of text at once, it works badly anywhere you need to add a sentence or fewer words or numbers at a time and/or you need to add formatting.
Also, you'll need to get into the habit of using it. I use it for work and I find I only use it in my work software and not for anything else because I'm not in the habit.
Make sure you get a hard copy of it on disk. My experience of it is that it doesn't download properly and the version you download won't work properly. I've no idea why that is.
Finally, I've only ever managed to get two types of help out of Dragon's customer support: they've explained what the features in their features matrix mean and how to buy various products, aside from that they only explain why nothing else I ever ask is anything they can help with or anything other than my problem. Basically, if you're not trying to use Dragon with a Microsoft program (ideally Word), then they can't help you (and it does indeed work rather badly and inconsistently with browsers, for instance).

 Was it worth the money/effort? For me, definitely. I wouldn't be able to do my job without it (well, not and sleep as well, and the excrutiating pain would probably be rather distracting). If you have Windows 10, I think it's at least worth getting hold of a headset and giving the built-in Windows 10 speech recognition software a go. If that works for you, but has limitations, it is probably worth investigating whether Dragon might be an improvement.


Do you use speech recognition software? Which one and would you recommend it? Have you got any tips?

Cognitive behavioural therapy (CBT)

What is it? It's a form of talking therapy that can help you manage your problems by changing the way you think and behave. It focuses on how your thoughts, beliefs and attitudes affect your feelings and behaviour, and teaches you coping skills for dealing with different problems. It combines cognitive therapy (examining the things you think) and behaviour therapy (examining the things you do).

Does it work? CBT cannot cure your physical symptoms, it can only help you cope better with  them. It may reduce the level of disability you experience because of the pain without reducing the pain or it may just improve your mood. Studies suggest its impact is only likely to be small to moderate, but reliably better than no treatment at all.

Who does it work for? Because it's about changing your thinking and behaviour, not treating your pain directly, it can work for people with any type of pain. However, its results will vary from person to person, and given that some reviews of trials conclude it works best on mood, it may work best for people who experience low moods because of their pain.

Who doesn't it work for? Not everyone who tries CBT benefits. I wasn't able to find evidence which predicted in advance which people were more or less likely to benefit from it, although if you already have a positive mood most of the time and/or have already optimised your thinking, behaviour and coping strategies, you may not get additional benefit. The question here is whether you have genuinely already optimised your strategies, or whether CBT ideas and exercises could give you additional help.

Where can I get it? Clinics of pain education (COPEs) tend to offer it as part of their services. In theory you could be referred for CBT directly by your GP, but given the current financial constraints on the NHS, some or all GPs may be unwilling to refer patients directly for NHS treatment, although they may be able to recommend a CBT therapist for you to see privately. Alternatively, a register of all the accredited CBT therapists in the UK is available here. It is worth checking if the therapist you are thinking about seeing knows about using CBT to treat chronic pain, as treatment of pain is not the commonest use of CBT and it's possible that pain treatment differs either slightly or a lot from treatment of other problems. According to Wikipedia, you can also get CBT in group sessions or in computerised form (e.g. an app) or by reading self-help materials.

How much does it cost? If you can get it on the NHS it is free. If you have to pay to see a therapist privately, according to the NHS website the cost is usually between £40 and £100 per session, sessions are generally 30-60 minutes. WebMD says you will probably need between 8 and 24 sessions plus possibly booster sessions for chronic pain.

Is there a cheap/free version? You can buy a book on CBT and apply the techniques from there. I haven't tried any books, but Overcoming Chronic Pain:A Self-Help Guide Using Cognitive Behavioural Techniques gets 4 stars on Amazon and only costs £7.49 on Kindle, from £2.99 used or from £7.11 new. If this book includes exercises, it may help to get a friend or family member involved to encourage you to complete all the exercises, for instance checking up on whether you have done the exercises, as it is all to easy to simply stop reading a book or skip the exercises.
Alternatively you can get free CBT apps for your phone. Look up CBT in the Google Play Store or iTunes. Most of these are aimed at depression or anxiety and none at pain, but some seem to be more general CBT information, and in fact some of these techniques are likely to also apply to chronic pain anyhow. Also, if your pain is causing you depression or anxiety, then these apps are particularly appropriate.
I've briefly tried Cognitive Styles CBT Test, which tests your tendency to think in a way that CBT thinks will be to your benefit or detriment. Despite passing most of the test with flying colours and getting roundly praised, I found its assumptions about what some of my answers meant irritating. On the other hand, I have quite a long history of finding this sort of thing irritating, so I suspect I'm not the ideal target, and if you're less irritable than me it may give you some useful areas to think about. I also tried CBT Thought Record Diary. I liked this a lot better, and filled in my first diary entry about my irritation with the previous app. I found this helpful (it actually dissipated my irritation), but I have existing knowledge of CBT thinking styles and errors due to my reading and listening interests. I think you need this knowledge to use the app well. You could gain these by reading a book or even just by reading information such as this about them on the Internet. Please note though, that this only enabled me to decrease the length of time I spent irritated at the previous app, it gave me no help whatsoever for my pain (although perhaps if I had used it on a pain-specific negative emotion it would have worked for that). You may or may not be able to adapt a non-specific CBT diary to your pain issues - although irritation at medical professionals and treatments offered that completely fail to understand my situation is actually part of my pain problem and something I think most people with chronic pain are likely to face, so you can certainly try it for that.
According to Wikipedia, NICE recommends computerised CBT for mild to moderate depression, but doesn't recommend a specific product or anything specific to pain. You might be able to access this via your GP if your GP deems it suitable for chronic pain or you also have mild to moderate depression. I'm not clear if the NHS has any computerised or Internet-based CBT available that is suited to chronic pain and I was only able to find apps for smartphones available to the public and did not come across any other software you could buy (search size: lazy - I googled it and never got past the first page).

Does the individual practitioner matter? Yes. Studies of of psychotherapeutic treatment show that the top determinant of outcome is whether or not the patient likes the therapist, so find a therapist you like - even on the NHS you have the right to request a different therapist. Also, I find that some people's explanatory styles are likely to be a better match for the way you learn and understand than others. I find it really hard to get help from someone who I dislike or someone who explains things in a way that's meaningless to me. The same applies to books that are written in a manner that doesn't work for how I think and/or irritate me.

Is there any evidence for it? Reviews suggest CBT holds its own compared with usual care or no treatment at all for pain-related problems, with small to medium effects on pain intensity, catastrophising and mood, and small effects on pain-related disability and activity interference (not doing things because of pain). This conclusion and the reviews I looked at come from this paper by researchers at the University of Washington. The paper reviewed studies and reviews on the impact of CBT on chronic pain, but was not a systematic review so may be subject to bias and omission, but it does have a focus on statistical significance, which is something I approve of (statistically significant findings = reliable findings). I didn't look for any further trials. To be frank, when I present evidence, I am usually only presenting what I can find by trawling the Internet for 60 minutes or so, so this is no worse than that (proper systematic reviews take a lot of time and are usually done by professional researchers).

Here's my summary of what they found with links to the original reviews and meta-analyses:

CBT for chronic pain in general:
A 2012 Cochrane review  concluded that, compared with treatment-as-usual or wait-list control conditions (wait-list controls = people who do not get treatment until after the trial), CBT had statistically significant (i.e. we can trust these findings) but small effects on pain and disability, and moderate effects on mood and catastrophising, after treatment. By 6 to 12-month follow-up, however, the only significant effect was for mood. Compared with people getting other treatment, CBT was not superior for pain or mood outcomes.

CBT for chronic back pain:
A 2007 meta-analysis of 22 randomised controlled trials of psychological treatments for chronic back pain indicated that psychological interventions had positive effects on pain, pain-related interference with activities, health-related quality of life and depression compared to various other treatments or non-treatment. CBT was found to be better than not receiving treatment for improving the intensity of pain after treatment but not for health-related quality of life or depression. A 2010 Cochrane review of behavioural treatments (including CBT) for chronic low back pain, which included 30 randomised controlled trials, concluded that behavioural treatments were more effective than usual care for pain after treatment but no different in intermediate to long-term effects on pain or functional status (i.e. what you can and can't do). There was little or no difference between behavioural treatment and group exercise in improving pain and depressive symptoms over the intermediate to long term. However, for most of the comparisons there was only low or very low-quality evidence, and there was no high-quality evidence for any comparison (i.e. the evidence wasn't very reliable).

CBT for headaches:
A 2007 review of behavioural treatments for headaches described CBT-based interventions (relaxation, biofeedback and cognitive therapy) as reducing headache activity 30%–60% on average across studies. These effects surpassed those of other treatments/non-treatment and were typically sustained over time, including years after treatment.
According to this review, biofeedback interventions are commonly used in treating chronic headaches, either as a stand-alone treatment or in conjunction with other CBT techniques.

CBT for chronic oro-facial pain:
A 2011 Cochrane review of psychosocial interventions for chronic oro-facial pain concluded that CBT, either alone or with biofeedback, resulted in long-term (more than three months) improvements in pain intensity, depression, and pain-related activity interference; however, the authors called for more rigorous studies to substantiate these conclusions, saying that there was weak evidence to support the use of psychosocial interventions for chronic oro-facial pain and although significant effects were observed for outcome measures where pooling was possible, the studies were few in number and had high risk of bias.

CBT for rheumatoid arthritis:
A 2002 systematic review found that psychological interventions may be important adjunctive therapies in the medical management of rheumatoid arthritis, but that psychological interventions may be more effective for patients who have had the illness for shorter duration. A 2010 systematic review, noted that comparative analyses revealed that interventions utilising more self-regulation techniques reduced depressive symptoms and anxiety significantly more than interventions utilising fewer such techniques and also that depressive symptoms were reduced significantly more among recently diagnosed rheumatoid arthritis patients than among those with long-standing rheumatoid arthritis.

CBT for fibromyalgia pain:
A 2010 analysis found cognitive-behavioural treatment to be significantly better than other psychological treatments in short-term pain reduction. Higher treatment dose was associated with better outcome. Publication-bias analyses demonstrated that the effect sizes were robust. The results suggested that the effects of psychological treatments for fibromyalgia were relatively small but robust and comparable to those reported for other pain and drug treatments used for this disorder. Cognitive-behavioural therapy was associated with the greatest effect sizes.

Are there any negatives? CBT takes time and effort (and if you have private sessions also a lot of money). Its effect is only likely to be small to moderate and it may not work for you at all. You may access it in a way that irritates you or isn't meaningful to you and you may have difficulty applying information from a book or keeping going with the exercises. I also dislike the impression I sometimes get from medical professionals that because CBT can be used for pain and may reduce disability levels, this implies that part of my level of disability is due to my attitude and that CBT can reverse disability or prevent further disability (this is far from proven) and that they want me to change my attitude through CBT instead of dealing directly with the disability or problem I currently have. This may actually be an example of mind-reading on my part, and CBT suggests I should test this assumption by checking with the medical professionals if this is really what they mean or if they are just out of ideas and CBT is the last weapon they have left in their arsenal and we're now down to things that only have a small impact on my mood instead of genuinely improving my pain or disability levels. Overall though, given that CBT ideas even help me investigate why I dislike people suggesting CBT to me so much, I'd say it's worth at least knowing what the thinking errors or cognitive distortions that CBT tries to deal with are, and if you think it is something that could be helpful to you, then pursuing it further, whether that's simply by reading a book or by other methods.

Anything else worth knowing? It's drug-free and may improve your mood and therefore your life in general. Also, if you like this method of trying to understand how your thinking and behaviour affect your well-being (or if you like the idea in theory, but dislike the way CBT is presented), you may also like to try reading the book Buddha's Brain.

Was it worth the money/effort? For me it is unlikely to be. According to WebMD my belief that it is unlikely to help me and will at best provide a small effect – probably on my already generally positive mood – means it's even less likely to work for me than for someone who believes it will work. I generally agree with the idea of avoiding the cognitive distortions CBT talks about, but actually I wasn't particularly prone to those in the first place, and suffer practically no anxiety and mainly already have a positive mood (admittedly with spots of temporary irritability), so the effects it's most likely to have (effects on mood) aren't in an area where I need much help. I also have a tendency to test out what I can and can't do and what the pain cost of doing those things is for me. It is possible it could have additional benefit for me and I have decided to give it a fair chance and complete the programme if the next clinic of pain education I'm booked in for offers it. I'm even thinking about buying and reading that book I found when researching this post. On the other hand, for me it definitely wouldn't be worth paying the over £1000 a private course of sessions could easily run to.

Have you tried CBT? Was it successful for you? Did you have to believe in it first to get the benefits? What benefits did you get? Were there any unexpected bonus benefits? Can you recommend a particular app or book? Or did it not suit you, and can you identify why that was?

Osteopathy

What is it? Osteopathy is a system of treatment used primarily for musculoskeletal problems where the osteopath uses massage, manipulation, stretching and other phyical techniques. NB Osteopathy is not the same as American osteopathic medicine, despite the fact that providers of that are also sometimes referred to as "osteopaths" in America.

Does it work? It very much depends what the root of your problem is plus some other variables that seem not to have been identified yet (see the section on evidence). In particular, trials have looked at its efficacy for low back pain.
I couldn't make up my mind whether it worked for me. As a solution for my problems it at most lasted a few months and I sometimes got worse for a few days after treatment (even with exceedingly gentle treatment). This happens sometimes with osteopathy, and is not considered a problem (I agree with that, I think it's only a problem if you get worse for a few weeks or months or if you are consistently worse after it with no subsequent sign of improvement to beyond the state you were in to start with). I also often felt marvellous (for me) for an hour or so after treatment. My problem was that beyond the occasional marvellous hour, it wasn't clear whether I got better than I would have been without treatment or whether time would have healed me anyhow. For some people, it will hopefully be more obvious than it is for me.

Who does it work for? People with musculoskeletal problems, including postural problems. Trials have focused on people with low back pain. See above and the section on evidence.

Who doesn't it work for? There's no evidence that it works for anything that isn't a musculoskeletal problem. According to NHS Choices, some osteopaths claim to be able to treat things other than musculoskeletal problems, such as headaches, migraines, painful periods, digestive disorders and depression, but there isn't enough evidence to support this. If you have one of these and want to try an osteopath anyway, I recommend setting yourself a target before your first visit for the minimum you're hoping to achieve by when and at what cost for it to be worth the money. If it doesn't improve you to the minimum level you need, then stop. If the osteopath says you will need more treatment than you were hoping for it to work, work out what minimum result you would need to see for that to be worth it and if you don't achieve it, stop.

Where can I get it? Personal recommendation is always good. Alternatively, the Institute of Osteopathy has a website you can use to find one. Osteopaths are regulated by statute in the UK.

How much does it cost? According to the General Osteopathic Council, fees typically range from £35 to £50 for a 30 minute session. I have typically been recommended to have courses of weekly sessions - I think generally about 6-8 - followed by less frequent follow-up sessions to keep my body working right (e.g. every 6 weeks). I'm not sure how typical that is, but I have the suspicion that it is rare to be recommended only a single session. Your osteopath may want to see you for longer for your first visit when they assess your problems (and charge more for that session).

Is there a cheap/free version? In some areas you may be able to get osteopathic treatment on the NHS. If you have health insurance, that may cover it. Otherwise, as far as I'm aware, no, there's no cheap or free version.

Does the individual practitioner matter? I think so, as the osteopath's decisions on how to treat you will be based on their only personal knowledge and experience. As with most other jobs requiring a skill, it seems likely that some will be better than others, but I don't have any personal experience where I could say "osteopath A was definitely better than osteopath B".

Is there any evidence for it? Yes, but it's a bit mixed. Some trials show positive results, others show no improvment beyond the placebo effect. Also, some trials don't differentiate between osteopathy and other manipulation treatments, such as chiropractic and physiotherapy. I found the trials referenced in this section in this 2013 pdf from the National Council for Osteopathic Research.

No better than placebo:
A meta-analysis of 39 randomised controlled trials showed spinal manipulative therapy (which includes but is not limited to osteopathic manipulation) had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises or back school. Results for patients with chronic low-back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results. Looking specifically at osteopathy, a randomised controlled trial of 91 participants and a 1985 controlled comparison of osteopathic manipulation with other treatment showed no clear benefit to osteopathy above placebo.

Better than placebo:
One small (40-patient) single-blind randomised controlled trial tested osteopathic manipulation against a control treatment known to work (chemonucleolysis) for patients with sciatica/symptomatic lumbar disc hermiation. Patients reported a 12-month outcome that was equivalent to chemonucleolysis, but showed a significant improvement compared to it in pain and disability in the first few weeks

A randomised trial known as UK BEAM looked at the impact of exercise, manipulation, and manipulation followed by exercise, each together with best GP care compared to GP care alone on chronic low back pain. After 3 months, they found an improvement with just exercise, a slightly greater improvement with manipulation and an even greater improvment still with manipulation and exercise. But "manipulation" here means a package of techniques representative of those used by the UK chiropractic, osteopathic, and physiotherapy professions, where the manipulation was applied by either a phyiotherapist, an osteopath or a chiropractor, so although this does speak in favour of osteopathy as one of the manipulation techniques involved, it doesn't differntiate it from physiotherapy or chiropractic. Also,  you couldn't tell in advance who was going to benefit.
This randomised controlled trial showed that an osteopathic manual treatment regimen met or exceeded the Cochrane Back Review Group criterion for a medium effect size in relieving chronic low back pain.
Are there any negative side effects? It's not cheap and you can have an adverse reaction to it. This study shows that headache, stiffness, discomfort and fatigue were quite common after manipulation (it didn't look at osteopathic manipulation specifically). However, it also noted that they were usually mild and short-lived. My own personal experience is that I sometimes feel worse immediately after or for a few days after osteopathy, but I've never felt worse for longer than that (and I have a particularly fragile body). Please note that I have always explained to osteopaths that I'm unusually fragile because of hypermobility syndrome and then they've left out any techniques they thought weren't gentle enough for me.

Anything else worth knowing? It's drug-free, which is great. My experience is that if your level of fitness (including in particular muscles) is poor, they will sometimes ask you to do exercises that you can do at home as part of your treatment.

Was it worth the money? I'm not sure if it was for me. I'm glad I tried it, but I'm not convinced it was a particularly good fit to my problems. The evidence suggests to me that it may create an improvement for some people, but not for everyone, and unfortunately you can't currently predict in advance if that will be you. I'd say that doesn't mean you shouldn't try it at all, but you need to think about what would represent a level of success worth the money to you.

Have you tried osteopathy? Was it successful for you? What signs did you recognise that by?

Buddha's Brain by Rick Hanson

What is it? It's a book by Rick Hanson exploring the neuroscience behind the contemplative teachings of Buddhism and how you can harness it to rewire your own brain for greater well-being. Its subtitle is "the practical neuroscience of happiness, love and wisdom". It's not specifically aimed at people with chronic pain, but when I read it I found that a lot of the ideas in it applied well to pain. It may also help you better understand meditation and mindfulness (two things I found much harder to do before reading the book, although I have to confess I'm still no master now).

Does it work? It's another one that won't get rid of your pain, but it contains ideas you may be able to use to help you deal with and/or reduce its emotional and mental impact, such as the concept of the first and second dart.

Who does it work for? It can work for any kind of pain because it doesn't tackle pain itself, only the way you experience things (including pain). I reckon whether it will work for you depends on whether the way it's written speaks to you and explains it in a way that's meaningful to you. I like a scientific, evidence-based approach, so I like that about it. Because it's examining a religious tradition, it may also work for people who like a spiritual approach. My experience has been that some books work for me, some really don't, and this one did.
 
Who doesn't it work for? If your religion (or lack of religion) mean that you are uncomfortable learning the teachings of Buddhism (even though no belief in Buddhism is required or promoted), then this book probably isn't for you. Also, if you already apply all these teachings, then it might not have anything to add. Other than that, you're just running the risk that the way it's written won't be meaningful to you or explain things in a way that enables you to apply them.

How much does it cost? As at the time of writing, the prices on Amazon range from £4.99 from an audio download to £8.65 for a used paperback to £10.44 for a Kindle copy to £13.48 for a new paperback.

Is there a cheap or free version? You might be able to borrow a copy from a library. There's also an app available from iTunes for iPhone and iPad for £3.99. I haven't tried the app, but the principle sounds good.

Is there any evidence for it? I'm not aware of any trials looking at the impact of reading Buddha's Brain on chronic pain. Buddha's Brain itself presents evidence for pretty much everything it says and goes through how neuroscience says Buddhism's contemplative teachings have an effect.

Are there any downsides? You have to read the book and some of the suggestions aren't easy to apply and some take up quite a bit of time. But there are quite a wide range of suggestions and some of them are easier to apply than others, so hopefully you can find at least one that works for you.

Are there any other upsides? It's drug-free and has no side effects.

Was it worth the money and effort? I'm glad I bought it and I'm glad I have the information. It's improved my understanding of what's going on in my brain and also my understanding of things like mediation and mindfulness. Even though I still haven't cracked meditation and do slip back into bad habits, I have useful, practical information that I didn't have before I read it.

 
Have you read Buddha's Brain? Did it work for you? Have you tried the app? What do you think? Do you have any books that you can recommend?

Good sleep hygiene

What is it? It's a set of principles worked out by researchers to try and get you the right amount of sleep for your needs. This website has distilled it into twelve principles for you, or you can get your information on what to do from trusty old Wikipedia. Or there's this one  or just google "sleep hygiene" and look for a website that describes it in a way that works well for you. One tip I've picked up along the way, but never tried is that jigsaws make a good thing to do if you've gone to bed, but are failing to fall asleep (providing you don't use too bright a light). Basically, you are looking for something that's absorbing, but not so captivating you want to stay up doing it even after you start feeling sleepy. Another top tip from my own personal experience is that if you go onto or increase your dose of meds that make you tired and/or sleepy, then you should reassess your bedtime and/or getting up time, as meds can change the amount of sleep you need.

Does it work? It's another one that won't get rid of your pain, but, if it succeeds in getting you more sleep (and you were getting too little before), your pain's likely to reduce. There's research that says people are more sensitive to pain when they haven't had enough sleep.

Who does it work for? People whose pain is affected by the amount of sleep they get (probably everyone) and who are able to improve the amount of sleep they get using the principles.
 
Who doesn't it work for? People already getting the perfect amount of sleep every day, people whose pain is completely unaffected by sleep and people who are unable to get any additional sleep despite applying the principles.

Yes, but I'm not sleeping enough because of the pain. Yeah, me too. And even with the sleep hygiene tips and amitriptyline, which increases my ability to go to sleep and stay asleep, my sleep is still disturbed by pain and I still often don't get enough. But as far as I can tell, the sleep hygiene tips do help me get more sleep than I would without them (even if sticking to them is sometimes a real nuisance). It's worth a trial run to see if the benefits outweigh the nuisance of the lifestyle modifications you need to make.

How much does it cost? Nothing. It's free, unless you have a lot of modifications you need to make to your bedroom to make it conducive to sleep, in which case, that's the cost.

Is there any evidence for it? There's evidence such as this that people are more sensitive to pain if they haven't had enough sleep. The same article mentions a study that proved that extending sleep length reduced pain sensitivity, albeit on a small sample size. Interestingly, this review of the literature says that sleep impairments are a stronger and more reliable predictor of pain than pain is of sleep impairment.
Rather less encouragingly, this article says though epidemiologic and experimental research generally supports an association between individual sleep hygiene recommendations and sleep at night, the direct effects of individual recommendations on sleep remains largely untested in the general population. Worse, I found this article that says sleep hygiene is normally not enough by itself to treat severe, chronic insomnia.
I suspect what we've got going on here in sleep hygiene is a mixture of theory-based medicine (as opposed to evidence-based medicine) and a collection of things individuals have told doctors worked for them. Basically, there's certainly not any evidence that these recommendations are bound to work for everyone. But there is evidence that lack of sleep is a problem for pain, and the sleep hygiene principles seem to be the best non-medical ideas currently available for increasing sleep. If they're not enough for you, you might also like to try amitriptyline, as, in addition to being used for chronic pain, it also has a sedating effect.

Are there any downsides? Good sleep hygiene involves lifestyle changes. Some of them are pretty minor (like getting up and doing a jigsaw if you can't sleep), but others are pretty major, like going to bed and getting up at the same time every day (what do you do if you usually need to be up at 7 am for work and need to go to bed at 10 pm to get enough sleep for this, but your usual social life involves drinking alcohol and/or staying up till 11 pm or midnight or later?). It's an extra imposition on a life that already has more difficulties and compromises than other people's because of chronic pain.My compromise is to do it, but make some modifications or not bother on some days because otherwise my social life would be even more limited than it already is. I still haven't worked out whether it's best to get up at 7 am on days after I've stayed out late, so I definitely don't get enough sleep, but don't get out of the routine or whether it's better to sleep in late, get enough sleep and risk changing my sleep pattern  - my body already tends towards a 25 or 26 hour sleep cycle as it is.


Are there any other upsides? It's drug-free and has no side effects.

Was it worth the effort? It's something I constantly debate. I do do it. Or at any rate, my alarm goes off at 7.15am every day and I try not to go back to sleep after that (which is difficult with my amitriptyline) and I try to go to bed at 10 pm or earlier. My current dose of amitriptyline means that I'm usually too tired to stay up longer and actually if anything I need more than the 9 hours of sleep I usually get. Without amitriptyline I probably only need about 8 hours a night, on the other hand, without amitriptyline it takes me much longer between going to bed and going to sleep, so my bedtime might not be quite as different as you'd think. Definitely my pain is worse when I have less sleep or am more tired and sleepy, but I find the bedtime and getting up time part of good sleep hygiene a real burden, as it is hard to juggle work, socialising and the 9 hours of sleep amitriptyline makes me need. Overall, my current judgement is still that it's worth the impositions.
 
Which principles of good sleep hygiene do you use? Does it work for you? Do you have any tips or workarounds?

Know your triggers

What is it? It's an approach I use to help me deal with my own pain. What I do is keep an eye out for what triggers my pain and then see if it does so consistently. I use this knowledge to make decisions about whether to avoid the thing or do it anyway and deal with the pain. I tend to cut out things I don't care much about entirely (like skipping or cycling) and restrict the amount I do of things I do care about or find ways to minimise the part that cause me problems (like gardening in shorter bursts and without digging and travelling on public transport to meet up with friends and trying to find more local things to do), so that I only have a limited number of nights I have to take extra meds or can't get enough sleep each month.

Does it work? It won't get rid of your pain, but it might help you reduce and control it. It might also help you better understand why you have pain on one particular day and how you can avoid getting as much pain on others and make conscious decisions about your preferred trade-off between doing things you want to do and minimising your pain. Remember, knowing something is a trigger for your pain doesn't mean you have to cut it out entirely. With knowledge comes power.

Who does it work for? People whose pain is affected by what they do or by the world around them.
 
Who doesn't it work for? People whose pain is completely unaffected by all environmental influences. This is actually unlikely to be anyone, as doctors keep telling me that everyone's pain is affected by the amount of sleep you get and stress.

How do I do it? When I'm in more pain than usual I start with the question: have I done anything differently today or yesterday? Here's a list of factors that I've heard medical professionals mention as pain triggers:

• not getting enough sleep
• stress/emotional distress
• (women only:) the point you're at in your menstrual cycle

Quite often we have no control over these factors (although I'll be writing more about strategies for managing sleep, stress and your menstrual cycle in later posts), but I find even knowing that I'm feeling particularly bad today for one of those reasons helpful, as if there's a reason I've got bad pain today (or have even had it for several of days), it's reassuring to know the trigger is unlikely to last forever and that this isn't necessarily a sign of a permanent deterioration.

Here's a list of things I've found trigger my pain:

• cycling or skipping or exercise that mimics these, but not exercise in general
• walking for more than 20 minutes (but usually only my knee pain and not one of the pains that stop me sleeping)
• consuming milk that isn't lactose-free (gut symptoms)
• digging the garden and topiary, but not planting things, providing I take regular breaks
• sleeping without a pillow under my knees
• having a laptop on my lap (my left thigh strongly objects to the pressure)
• using a mouse
• standing around for more than about 10 minutes 
• sitting or lying in less than optimum positions
• travelling on buses, trains or tubes for more than 20 minutes
• travelling on public transport at all in winter
• driving for more than about 60 minutes
• being a passenger in a car for more than about 3 hours
• cleaning the bath
• painting the walls or skirting

Notice how specific these are. I could just have concluded that exercise sets me off and avoided all exercise and I could have just concluded that dairy in general (or worse, all the usual food suspects including gluten, wheat, nuts and fish) set me off (I do actually also have a problem with nuts and fish, but not with every single one of the usual suspects plus also with some really unexepcted foods).

What actually happened was that I noticed that I was consistently having bad hip and lower back problems after I'd been exercising. I tried cutting out exercising as a whole (actually I went on holiday and didn't bother to exercise) and noticed that I was much better. But instead of permanently cutting out all exercise, I cut out the bits I suspected most (ones that involved my hips and lower back) and kept going with the rest, then noticed how I felt. After that I kept adjusting and kept adding things back in or cutting more things out until my pain felt no different or only minimally different after I'd exercised (I don't count normal pain after exercise here and fortunately I can feel the difference). I also concluded that contrary to government advice, I was better off doing my major exercise in only 2 long sessions per week rather than a smaller number of smaller sessions, so I only get 2 to 4 days of pain after exercise instead of 3 to 7, as I really don't like coping with that most days on top of my usual pain. The trick is to think "how can I do this differently? what are my other options?". Some of them might be worse for you, some of them will hopefully be better. Also, you may be able to work on some of your movement-based or postural triggers with physiotherapy, the Alexander Technique or just by generally strengthening the muscles that are causing the problem with exercises.

Your specific pain triggers will probably be different from mine, and some things that make my pain better might make yours worse (for instance you might be better off exercising in small sessions everyday rather than in 1 or 2 big sessions a week). But knowledge is power. Once you know what is going to put you in pain, you have a choice between avoiding it or choosing to do it anyway. You are under no obligation to minimise your pain. The trick is to live the best life you can with the cards you've been dealt.

Other tips:

• Don't beat yourself up if you can't work out some of your triggers. Some of them are really hard to work out and I sometimes realise mine months later after a lifestyle change has made me realise something I wasn't aware of was triggering pain (cycling was one of those because I'd previously not had a problem with it). I'll probably never work all of them out.
• A pain diary might help, especially to work out if your menstrual cycle is involved. My pain is extremely complex and fluctuates a lot throughout the day. I am, however, usually able to answer the question was today a red day (awful, struggling to cope), an amber day (lots of problems, far from a good day, but definitely not a red day) or a green day (no major problems, felt pretty OK) so I suggest keeping a paper record and rating your pain 1 = green/good day, 2 = amber/middling day, 3 = red/awful day. If you're a visual person you could use colours or  make a bar graph. You can compare this to your menstrual cycle or other things going on in your life.
• Once you have a suspect, change only that about your life and see if you notice a difference. Reintroduce it after a week or two as a double check.
• If your suspect is quite a big thing (e.g. exercise in general or food in general), see if you can narrow it down by reintroducing one thing (or one set of things) at a time. If you find a trigger within a set of things, it's even worth re-introducing one of those things at a time, because the aim is to have as many safe things in your life as possible and as few things it's best to avoid as possible.
• If it is possible, don't replace the thing you are cutting out with something else that isn't normally in your life. For instance, don't replace milk with rice milk or soya milk if you don't normally consume those, as if you continue having a problem you won't know if the thing you excluded (milk) wasn't the problem or if you have a problem both with the thing you excluded (milk) and the thing you replaced it with (rice milk). Just because many people have problems with thing A but not thing B doesn't mean you don't have a problem with both or neither or just thing B.
• Sometimes we can get a placebo effect from our brain's beliefs. This means you might cut something out that is completely neutral for you, but the placebo effect might mean you improve anyway. Actually, if you can benefit from the placebo effect this is great and realistically it probably doesn't matter if your body actually gets pain from cycling or your brain produces a placebo effect from you not cycling. Just try not to get to a situation where you only eat cabbage and water and move your left arm only on Tuesdays with a full moon. Try and be as specific as possible and cut out only the bare minimum, and if you have cut a lot out try reintroducing things occasionally (I regularly reintroduce milk that isn't lactose free whenever I have a cappuccino at a cafe, my guts let me know I still have a problem with it  every time).
• My pain onset is often delayed. If you're like me, everything you did in the 48 hours before the pain started is a suspect. Some things are obvious. For instance, I currently have pain in my thigh under my laptop. This happens consistently. What's less obvious is that my thigh and hip also typically experience more pain later in the day or at night after I've done this, often with a pain-free gap in between. Why, you may be asking, do I currently have a laptop on my knee? Laziness and choices. You don't have to choose to minimise pain every time, but I certainly wouldn't do it all day every day.

How much does it cost? Nowt. It's free.

Is there any evidence for it? I seriously doubt it. It's not something medical professionals I've met have encouraged, although it could just be that my googling skills were lacking. Remember, the fact that I say it works for me is only anecdotal evidence (which is a very poor level of evidence indeed). But also remember that there being no trials doesn't mean it doesn't work, it means there's no evidence either way.

Are there any downsides? It is possible that if you follow this advice that you'll end up paranoid and anxious and that the expectation of pain from an activity will in itself be enough to create the pain without any other stimulus from the activity itself.
I'm not generally an anxious person and I prefer living in a world where I get more predictable pain and make conscious choices about whether things that increase my pain are worth doing anyway and planning for easy days on days I expect an increase in my pain (for instance because of the time of the month). It also means I can manage my meds better. Because opiates stop working for me if I use them regularly for several months, limiting the number of days on which I need them to sleep is really useful for me and means I don't have to worry they're going to stop working.
However, everyone is different, so if you find that looking for triggers seems to be making you more anxious or making things worse, it's a good idea to stop doing it. Also, if you can't stop beating yourself up about not finding every single trigger, consider yourself exempted from carrying on. If this isn't making your life better it's not worth doing.
The other downside, even if this approach is generally successful for you, is that you can end up avoiding a lot of things and it can be very frustrating, and bring home to you the difference between your life and a healthy life.


Are there any other upsides? It's drug-free and has no side effects.

Was it worth the effort? It's not actually much effort for me (apart from the pain diary, which I confess to not ever having successfully kept for longer than a week and a half). I find myself doing it without much thinking about it. On my bad days, my brain quite often finds its way to the question "why?" and I find it much less distressing to answer the question "why today?" than "why me?".
 
What are your triggers? How do you work out what your triggers are? Does this approach work for you or does it make you feel worse?

Pillow under your knees

What is it? A pillow (or two) under your knees when you're lying down on your back, for instance to sleep. I find a firm pillow (or better still two) is much better for this than a soft one. Also, if you're lying on your side, switching the pillow(s) to between your knees can also help.

Does it work? Yes, if your pain is musculo-skeletal pain in your lower back or hips or thighs (or even pressure-sensitive pain in your heels). The theory is that having pillows under your knees while lying on your back takes the strain off your lower back by altering your posture and where you're putting the pressure. Likewise, having a pillow between your knees when you're lying on your side can improve how your body distributes pressure and take pressure off problem places. With the pain in my heels, I find that sometimes they're very touch sensitive and having two pillows under my calves when lying on my back allows me to hang my heels over the edge and not touch the mattress, thus alleviating any pain from pressure on my heels. It's also possible that changing where the pressure is when you're lying down like this may help muscle or skeletal pain on other areas, so might be worth a try.

Who does it work for? See above.
 
Who doesn't it work for? People whose pain isn't musculoskeletal and/or isn't at all affected by their posture or where they feel pressure.

Where can I get it? Anywhere they sell pillows - the Internet, bed shops, shops that sell bedding such as supermarkets or Argos or Wilko's.

How much does it cost? Free if you already have spare ones, otherwise the price of a pillow, such as this pair for £10 from Asda. Plus pillowcases if you don't already have spare ones, such as this pair for £2 from Asda. You don't need fancy, expensive pillows for your knees, although based on my own experience I do recommend getting firm ones. Alternatively, if you consistently sleep on your side, you may prefer a full-length body pillow like this one from Argos for £13.99, which already comes with its own cover. I don't think this would work for me, as I need to regularly change positions (including mixing up whether I'm lying on my side or my back) to sleep through the night, and a body pillow would make that harder, but if you consistently sleep on your side, this could be a good answer for you.

Is there a cheap or free version? You really don't need fancy pillows or attractive pillowcases, so if any of your family or friends is throwing pillows out and even pillowcases with largely aesthetic flaws, those would be fine, providing the pillows' level of firmness suits you. You could also use cushions instead if you needed. Rolled up towels or clothing are a reasonable emergency solution (for instance if you are staying somewhere with no spare pillows), but I can't recommend them as a long-term solution, they're not nearly as effective or comfortable.

Is there any evidence for it?  I couln't find any. The nearest I could get was an article saying an expert recommended sleeping with a pillow between your knees. If there's evidence either way, my search didn't find it, which means I couldn't find any proof that it's any better than placebo, but also I didn't find any proof that it isn't. The best I can do is tell you that not having a pillow under my knees means I'm significantly more likely to wake up with severe pain in my lower back in the morning. Me telling you this is only anecdotal evidence, so barely better than no evidence at all, but I can't see anyone bothering to do a trial, so this and the fact some experts recommend it is probably about as good as you're going to get. I suggest trying this for yourself with spare pillows or cushions if you have them, and considering buying dedicated pillows if it works and you need to. I noticed it worked for me on the basis of the following:

• with leg pillows I largely avoid severe lower back pain the next morning
• I don't wake up with my lower back in a position that is painful to get out of (I think the fact this happens to me without leg pillows may be a hypermobility syndrome thing)
• I think I find my position while lying in bed less painful (although not pain free)
• I think I may wake up in pain less often during the night (my pain fluctuates anyway and it's been years since I had to sleep without leg pillows, so I'm not 100% sure on that one, but I think it may well be the case)

Are there any downsides? Every now and then I get my leg pillows tangled in the duvet and have to sort this out in the middle of the night, plus the cost of the pillows. Plus, the bed looks like the princess and the pea sleeps there in the morning.

Are there any other upsides? It's drug-free and has no side effects.

Was it worth the money? Yes, absolutely, I actually get quite worried about what sort of state I'll be in the next day if I don't have access to proper knee pillows for any reason. It does, however, only save me from pain I would have gained during the night. It certainly doesn't solve all the pain I went to bed with or guarantee a pain-free night or a pain-free day the next day.

Do you use leg pillows? What level of firmness works best for you? Do you use a body pillow and would you recommend it? How did you work out if they were helpful for your pain or not?