Understanding Chronic Pain

Kieran is passionate about helping people get out of chronic pain and back to what they do best.

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Kieran is a chartered physiotherapist, registered nutritional therapist and corrective exercise specialist who specialises in helping people in chronic pain get back to what they do best.


Kieran is fascinated to understand the causes of someone’s pain. From here he puts together a plan using physiotherapy, exercise, nutritional therapy and education to help you get back to what you do best.


Kieran is based at the Bowskill Clinic, 4 Duke Street, W1U 3EL near bond street tube station. Where patients are unable to attend the clinic he can do home appointments.


To find out more about Kieran see his bio here


To ask Kieran a question or book an appointment;

call 07830160323

email kieran@kieranmacphail.com




Manipulation and Chronic Low Back Pain

Clinical prediction rules based on clusters of signs and symptoms have been proposed to identify responders to MT (Cleland et al., 2007). Flynn et al (2002) performed the following manipulation with the symptomatic side down. This was identified by pain on forward flexion, most pain on sacral sulcus palpation, the patient’s description of most painful side or a coin toss if neither of the previous provided a direction of preference!

They assessed 11 variables and found 95% success when these five conditions were met; <16 days of symptoms, >35°of internal rotation in one hip, hypomobility with lumbar spring testing, FABQ work subscale score <19, and no symptoms distal to the knee. Perhaps this could be refined further by not performing the technique if a coin flip was required. The clinical prediction rule has been validated with a follow up. (Childs et al., 2004).

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Kalauokalani et al (2001) conducted a randomized trial of 135 patients with chronic low back pain who received acupuncture or massage. Before randomization, study participants were asked to describe their expectations regarding the helpfulness of each treatment on a scale of 0 to 10. After adjustment for baseline characteristics, improved function was observed for 86% of the participants with higher expectations for the treatment they received, as compared with 68% of those with lower expectations. Furthermore, patients who expected greater benefit from massage than from acupuncture were more likely to experience better outcomes with massage than with acupuncture, and vice versa


Kalauokalani, D., Cherkin, D.C., Sherman, K.J., Koepsell, T.D. and Deyo, R.A., 2001. Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects. Spine, 26(13), pp.1418-1424.

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Visceral Manipulation & Chronic Low Back Pain!?

Guillaud et al (2018) conducted a systematic review on the accuracy of visceral osteopathy diagnosis and treatment. The systematic review for treatment identified six studies, with four deemed high risk of bias. The two studies that were included were one on low birth weight infants with negative effects and Panagopoulos et al’s (2015) RCT of physiotherapy plus visceral manipulation or placebo visceral manipulation for chronic low back pain. This found no benefit at 6-weeks for NRS, but at 1 year there was benefit, but no change in disability and patient specific functional scale. Guillad et al (2018) scathingly conclude that there is no evidence for the reliability or efficacy for visceral osteopathy. Which is technically accurate, however, Panagopoulos et al’s (2015) findings are interesting, and surely with refining which patients respond to such an intervention there could be real benefit here. How to do this is difficult. There are huge issues. There are no gold standards to compare assessment and treatment to. These need to be identified first before assessment and treatment can be done. This is an area in its infancy that needs to be opened up to the scientific method and not cling to pseudoscientific excuses to avoid clarification in developing the most efficacious approach.

Guillaud, A., Darbois, N., Monvoisin, R. and Pinsault, N., 2018. Reliability of diagnosis and clinical efficacy of visceral osteopathy: a systematic review. BMC complementary and alternative medicine, 18(1), p.65.
Panagopoulos J, Hancock MJ, Ferreira P, Hush J, Petocz P. Does the addition of visceral manipulation alter outcomes for patients with low back pain? A randomized placebo controlled trial: does visceral manipulation alter low back pain outcomes? Eur J Pain. 2015 Aug;19(7):899–907.

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Fuentes et al (2018) conducted an interesting four arm trial on Interferential, sham interferential, with a good therapeutic alliance and poor therapeutic alliance. Each session was thirty minutes. In the good therapeutic alliance during the first 10 minutes, each participant was questioned about his or her symptoms and lifestyle and about the cause of his or her condition. Therapists were encouraged to listen actively by repeating the patient's words and asking for clarifications, tone of voice, nonverbal behaviors such as eye contact, physical touch, and empathy. For example saying, “I can understand how difficult LBP must be for you.” The therapist then stayed in the room during the entire treatment and during the measurement of outcomes. During this time, verbal interaction between the therapist and participant was encouraged. Finally, at the end of the session, a few words of encouragement were given. In the poor therapeutic alliance group, interaction was limited to about 5 minutes during which the therapist introduced herself and explained the purpose of the treatment. Participants were told that this was a “scientific study” in which the therapist had been instructed not to converse with participants. After setting up the interferential the therapist left the room and returned 15 and 30 minutes into the treatment to be present when the tester arrived to conduct outcome assessment. Mean differences on the post intervention NRS were 1.83 cm active interferential and poor therapeutic alliance, 1.03 cm for sham interferential and poor therapeutic alliance, 3.13 cm for the active interferential and good therapeutic alliance, and 2.22 cm for the sham interferential and good therapeutic allliance. Mean differences on PPTs were 1.2 kg, 0.3 kg, 2.0 kg, and 1.7 kg respectively. Thus therapeutic alliance was more effective at reducing NRS and pressure pain thresholds than the interferential. ...

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6 days ago

The Low Back Pain Algorithm; Kieran Macphail

Pain education as recommended by Nijs and chums back in (2011). How do you do it?

First education session
The first educational sessions are suggested to last one or two 30 minutes sessions and be based around sections 1, 2 and 4 from the book “Explain Pain” (Butler and Moseley, 2003). The treatment rationale should be explained, patients should understand the mechanism of central sensitization. Therefore education of the central sensitization model relies on deep learning, aimed at reconceptualising pain, based on the assumption that appropriate cognitive and behavioural responses will follow when pain is appraised as less dangerous (Moseley, 2003).
Nijs et al (2011) suggest acute nociceptive mechanisms are explained first and are then contrasted with central sensitization processes. The education is presented verbally (explanation by the therapist) and visually (summaries, pictures and diagrams on computer and paper). During the sessions patients are encouraged to ask questions and their input should be used to individualise the information.

Home work
Patients should receive an educational information booklet about the neurophysiology of pain and be asked to read it carefully at home. Patients with central sensitization often have neurocognitive impairments, including concentration difficulties and impairments in short-term memory (Nijs et al., 2010), they can forget a number of aspects of the verbal education. Therefore providing the same diagrams and information provided in the education sessions, written information that can be read afterwards is a valuable and essential part of the intervention.

Second session
Before the second education the patient is asked to complete the neurophysiology of pain test. This is used to test the reconceptulisation of pain and guide the session. Next, the therapist discusses the existence of sensitization in this particular patient by giving the patient insight to somatic, psychosocial and behavioural factors associated with pain. This is followed by i.e. discussing with the patient how information provided can be applied during everyday situations. Nijs et al (2011) suggest this can be done with the Pain Reaction Record.
Nijs et al (2011) suggest that after these sessions, treatment such as stress education or exercise can be conducted. It should be explained to the patient how these treatments will further contribute to decreasing hypersensitivity. From then on the therapist should continually check the patients understanding and continue to help the patient reconceptualise pain where appropriate.

Butler, D.S. and Moseley, G.L., 2013. Explain Pain 2nd Edn. Noigroup Publications.
Moseley, G.L., 2003. Joining forces–combining cognition-targeted motor control training with group or individual pain physiology education: a successful treatment for chronic low back pain. Journal of Manual & Manipulative Therapy, 11(2), pp.88-94.
Nijs, J., Van Houdenhove, B. and Oostendorp, R.A., 2010. Recognition of central sensitization in patients with musculoskeletal pain: application of pain neurophysiology in manual therapy practice. Manual therapy, 15(2), pp.135-141.
Nijs, J., Van Wilgen, C.P., Van Oosterwijck, J., van Ittersum, M. and Meeus, M., 2011. How to explain central sensitization to patients with ‘unexplained’chronic musculoskeletal pain: practice guidelines. Manual therapy, 16(5), pp.413-418.

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1 week ago

The Low Back Pain Algorithm; Kieran Macphail

I think the poor Piriformis gets very unfairly blamed. So this anatomical study fits my bias nicely.

Natsis et al (2014) found of 294 limbs of caucasian cadavers examined 6.4% had anatomical variants of the sciatic nerve passing through the piriformis.

Natsis, K., Totlis, T., Konstantinidis, G.A., Paraskevas, G., Piagkou, M. and Koebke, J., 2014. Anatomical variations between the sciatic nerve and the piriformis muscle: a contribution to surgical anatomy in piriformis syndrome. Surgical and Radiologic Anatomy, 36(3), pp.273-280.

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