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How a physical therapist helped me through my lowest point, Part 8

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This is the eighth post in an ongoing series.  If you would like to start from the beginning, click here.

The last post in this series was the hardest to write, and that’s why, of course, it took me so long.

I was just starting to get a handle on things by my sixth visit. I had gotten brave enough to use the elliptical trainer at home for short periods of time, and was starting to go on short 45-minute hikes. I was no longer afraid of every little ache and pain in my body, but I was holding my breath; afraid it was too good to be true, that one little thing would change and all the pain would come rushing back.

This is the point at which Tim told me my next visit would have to be my last. He said he had done his best asking for extra visits from the insurance company, but they had finally put their food down with this next one.

He reassured me that I already knew everything I needed to know, but promised that I could email him if I had any questions.

Despite all my fears, everything was fine for the next few months. I increased my time on the elliptical trainer, and started going for longer hikes. I knew that if something started to hurt, I would ask myself, “Is this really dangerous?” But I didn’t even seem to really need to– most of the pain was gone, and the pain that I did have didn’t seem to snowball out of control like it had in the past.

Except for my knee.

Knee pain was actually the original reason for my referral to physical therapy. Chondromalacia patella, or inflammation of the cartilage under the kneecap, was the diagnosis I’d gotten from my orthopedist.

But Tim had viewed the knee pain as part of my overall problem with a revved-up nervous system. He told me that chondromalacia patella was sort of a “catch-all” diagnosis, and sometimes doctors just gave that diagnosis when they didn’t know what else could be causing the problem.

So he hadn’t done anything specific to treat the knee. Once he’d seen the 20 X’s I’d marked down on the form that asked where I had pain, he’d switched immediately over to a chronic pain/nervous-system mindset, and had treated me with the protocol he’d learned for that.

I believed Tim of course, because he had helped me more than anyone else ever had. But the fact of the matter is that, even though he was right about the other 19 X’s on the paper, he was wrong about the knee.

I didn’t want to freak out and rush back to the orthopedist, of course. I had taken a leap of faith in trusting Tim when he told me the pain in my back and my ankle was safe to ignore, and I didn’t see why the knee should be any different. I didn’t want it to be different. I wanted everything to be fixed; I wanted to be cured. After years of wandering from specialist to specialist, I wanted my problems to have one answer.

Much of Neil Pearson’s teaching focuses on not beating yourself up mentally, on not forcing yourself to keep going through a pain that doesn’t melt away with the “Is this dangerous?” dialogue. This is, of course, precisely what I did.

I tried to rest my knee, but it didn’t seem like there was any amount of rest that could make it better. I tried ice, and I tried Advil, and I tried to just forget about it. I heard my parents’ voices in my head from all the years of unexplained pain and injuries before: You worry too much. You dwell on things. Why do you have to get so intense about exercise? Just relax.

But ignoring my knee didn’t make it better. In fact, it got worse and worse, rapidly, until even the act of lowering myself down onto a chair was painful. It was high time to admit I had another problem; one that changing my perception of pain couldn’t fix.

So I went to a second orthopedist. Sure enough, I had chondromalacia patella, and it was worse now because I hadn’t treated it. It was bad enough for the inflammation to actually show up on an X-ray, which, I learned, not everyone’s does. But luckily, it wasn’t so bad that I was likely to have permanent damage or need surgery. I just needed to go back to physical therapy, and actually treat it this time.

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For a while, I wasn’t sure whether to include this last part of the story. After all, I really believe so strongly in the potential of this approach to help people with chronic pain, and I hate to end this series on any kind of a negative note.

But it’s important to remember that nothing is a silver bullet; that just because one thing might fix 95% of our problems, it won’t necessarily fix that last 5%.

For this approach to truly help a patient, it has to be implemented in a setting that allows for the type of injuries that won’t go away just by fixing a revved-up nervous system.

The therapist should be looking for two kinds of pain: the pain caused by a revved-up nervous system when nothing is physically wrong, and the kind of pain caused by particular biomechanical issue that needs to be treated. In fact, it’s pretty likely that both will exist in any chronic pain patient, since chronic pain usually develops after a person has been through some sort of extreme injury or medical event.

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You might have noticed from my other posts that I harbor a lot of anger and resentment towards the medical professionals whose judgmental attitudes and lack of compassion cost me months, if not years, of normal life when I was younger.

But to be honest, I don’t really blame Tim. He was doing the best he could in an extremely limited setting. He was attempting to implement an approach that he didn’t have a ton of experience with, and that most pain management specialists in this country still even haven’t heard of. And he was going up to bat against both a billing department and an insurance company who didn’t have any idea what he was doing.

I mean yes, technically, he shouldn’t have told me to ignore the orders of my orthopedist. But I know from my own experience as a patient that physical therapists often fill in the gaps left by a physician who was rushing, or who didn’t really care.

And I also know from my own experience working at the mental health agency that everything is different when you’re actually on the job. It’s easy to have the right answers when you’re a student; when you have time to sit and think and put the pencil to the paper and write the right thing.

It’s a whole different story when you’re actually in the field; when patients and coworkers and bosses are all asking something different from you. When you have too much to do and not enough time to do it in; when you’re trying to help a patient as much as you can before her insurance company cuts her off.

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The reason I decided to include this part of the story is that this approach to physical therapy has the potential to help people even more than I was helped. I am so incredibly grateful for the help I received, and I don’t mean for this to be a negative thing.

Instead, I am excited. What would happen in a setting where the physical therapist had all the time in the world and didn’t have to rush? If he knew he wasn’t the only one who knew about this approach to pain management, and didn’t have to feel like he was going out on a limb or deceiving the insurance company by explaining pain concepts to a knee patient?

Of course, I don’t mean to make it sound like there aren’t already great physical therapists out there who are already doing all of these things. I know from all of the reading I do online that they’re out there; I just haven’t been their patient.

I’m just excited about all of the potential there is to build on what I learned in my experience, which–even with its limitations–changed my life.

***Photo Credit: Elliot Cable on Flickr***

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How a physical therapist helped me through my lowest point, Part 7

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**If you are new to my blog and would like to start at the beginning of this series, click here.**  

From the elliptical trainer, we moved on to some very gentle weight lifting and core exercises.

For reasons neither Tim nor I understood, the hospital he worked at had recently made the decision to get rid of all of its weight-lifting machines.  (Who does that?).

So, he explained, we weren’t going to be able to do the full range of exercises he would have prescribed to me a few months earlier.

But he did have me lifting some very light free weights.  During some of these exercises, I would sit on an exercise ball while I lifted, to strengthen my core at the same time.

I also used the arm bike, which I absolutely loved.  It was so freeing to feel all of my back muscles working, in a way that would have been much too painful for me months earlier.

The main purpose of these exercises, however, wasn’t strength-building.  The real purpose was to give my nervous system the chance to experience using my muscles, in a way that didn’t increase pain.

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Many of the researchers/writers I read regularly talk about the importance of making a patient feel safe, so his or her nervous system doesn’t feel like it needs to be on guard during an appointment.

Sometimes it is necessary to push through pain in physical therapy.  When my father was in physical therapy after having surgery on his knee, his PT stressed how important it was for him to regain as much flexibility as possible before scar tissue took over.  He would stretch my dad’s leg out as far as my dad could stand it, and use very painful techniques to break up the scar tissue that had already formed.

But when the number one goal of treatment is to calm a wound-up nervous system, it’s important not to cause even more pain during an appointment.  You want the patient to feel totally safe, and not pressure him or her into doing exercises that he or she has apprehensions about.  As long as the person is afraid, even a little bit, his or her nervous system is going to conclude that it needs to stay in protection mode, and it’s not going to relax.

I know I’ve said this in previous posts, but I’m going to stress it one more time: what was so important about my treatment with Tim was that he had taken the time to really talk to me about my exercises, and whether they were safe or not, before actually asking me to do them.

It was a transformative combination: having new information about how my nervous system worked, as well an environment where I felt safe to try new things at a pace I was comfortable with.

It really did work.  I started finding I was able to do a lot more when I was on my own between appointments.  I started going for little walks again, amazed that the same pain that had once built up so quickly was now a quiet murmur.

I started using the elliptical trainer at home.  First I started with ten minutes, as Tim had urged me not to overdo it.  But then I would add one minute on, then two minutes, and then one day I did eighteen.

I started driving to some of the nature trails that are near my house and just getting out of the car and walking, trying not to overthink it.  Instead of watching and waiting for the pain to start, I tried to keep my mind empty and light.  If pain signals entered my mind, then I would focus on them and ask myself “Is this dangerous?”  And I tried to be ok with the answer, whatever I decided the answer was that time.

I didn’t allow myself to push through something that really hurt, because Tim had made me promise not to.  But the amount of time I could walk before it started to hurt became longer and longer.  My walks went from no minutes to five minutes to ten minutes, to fifteen, until on the day of my last appointment I had just gone for a forty-five minute hike.

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Top photo courtesy of tinydr on Flickr.

Botton photo courtesy of Boston Photo Sphere.

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How a physical therapist helped me through my lowest point, Part 6

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**If you are new to my blog and would like to start at the beginning of this series, click here.**  

Part 6: Re-adjusting my concept of what is “dangerous.”

When I was running long-distance in high school, I’d really pushed my limits.  Pain didn’t scare me as much as my irrational fear of gaining weight and not training hard enough.  I had rarely let pain stop me, and on more than one occasion, I had paid a price for that refusal.

As a freshman, I had partially torn my hip flexor off of my hip bone during a cross-country race.  I’d had some pain in the few days before the race, but one mile in, endorphins had taken over, and I felt no pain.  Then, as I sprinted down the finish line, my right leg completely gave out beneath me, and I’d had to hop across the finish line on one leg.  After that, I was on crutches for months.

Then, while training for track during my junior year, I’d developed compartment syndrome.  I’d had pain and a feeling of “deadness” in my calves for weeks, and I continued to push it.  Running was the only thing that chased the dark clouds of depression away, and I was excited about the fact that, once track started, I was going to be in amazing shape.  Instead, by the end of the season, I was barely able to walk.

After these injuries, I’d sworn I was never going to let anything like this happen again.  How could I have been stupid enough to ignore all the warning signs?  My body had tried to tell me again and again that it was a bad idea, and I hadn’t listened.  So I promised myself I’d never ignore it again.

But now, in physical therapy, Tim helped me to realize that maybe I’d gone too far in the opposite direction.  There was a big difference, he said, between pain in someone who’s running 40 miles a week, and pain in someone who is basically sedentary.

My nervous system was functioning differently now, as a result of the physical traumas I had endured.  It was as though my body was looking at pain through a magnifying glass.  A little muscle spasm that I might have ignored in the past was now debilitating.

I might have the same amount of pain now, just walking down the sidewalk, as I’d had running at seventeen.  But, Tim explained, I wasn’t subjecting my body to anywhere near the same amount of forces.  I might have the same amount of pain as I’d once had running, but it didn’t represent the same amount of “danger” to my body.

From running, I had learned that the way to respond to something that was agonizing was to stop and rest.  If something hurt that much, it must be on the verge of rupturing, of tearing… tendons were about to come unattached.  Right?

Wrong.  I was doing what anyone in my situation would do—taking the information my nervous system gave me at face value.  But Tim helped me to see that, because my body had adjusted its “criteria” for causing me to feel pain, I needed to change my own “criteria” for evaluating that pain.

Things just weren’t as dangerous, Tim promised me, in someone with my level of physical activity (or lack thereof) as they were in a long-distance runner.  I might be feeling a muscle spasm that hurt just as much as a pulled muscle when I was running, but– given the fact that my nervous system was revving everything up, and that I was not subjecting my body to anywhere near the same amount of forces– it was nowhere near as dangerous.

Tim urged me to stop thinking of pain as a sign that something was ripping or falling apart.  Those types of injuries were definitely possible when I was running a 5K race, or pounding down a track at 5:30 mile pace.  But they were simply not possible in a generally-healthy twenty-five year old who went for a walk a few days a week.

It seems obvious now, but of course, pain is specifically designed not to let us ignore it.  There’s no way to tell, based on sensation alone, whether or not a painful sensation is safe to ignore.  Pain doesn’t come with labels saying “this is inflammation in your joint” and “this is an overworked muscle.”  It all just feels dangerous.

What I love about Neil Pearson’s approach is that it in no part blames the person with pain for what has happened to him or her.  Instead, he suggests that the person in pain ask him or herself, “Is this really dangerous?”

Pain is designed to draw our attention to something, to make us change our course of action.  But that doesn’t always mean that we have to stop using that part of our body completely.  Sometimes, our nervous system just wants us to focus on something; to give it the attention it deserves; to make an educated guess about what is needed.

Maybe it means we decide to only walk for five minutes, instead of ten.  Maybe it means we promise ourselves that we’ll schedule that doctor’s appointment as soon as we get home.  Maybe it means we promise our aching neck that we’ll get a massage soon.  All of these things can actually have an effect on reducing pain.

When you stop and focus on what your body needs, it stops trying so hard to get your attention.  I’m not saying that this is a miracle cure and you’ll never feel pain again.  But you might find that the pain becomes manageable.

When your body sends you pain signals, it wants you to answer the question, “Is this dangerous?”  Your body doesn’t have all the answers; something that’s painful might not always be harmful.  It just means your nervous system thinks it might be, and wants you to find out for sure.

This is why something as simple as scheduling an appointment with a doctor you trust might actually reduce your pain.  Your body wanted you to answer a question, and you took a proactive step towards getting that answer.

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Of course, I probably wouldn’t have made as much progress if I had tried to use this approach on my own.  It really helped to have someone else there with a lot of expertise who could help me make an educated guess about what was really going on in my body.  I was completely terrified by the concept of trusting my body, and it really helped to be able to ask Tim what he thought the pain meant.

I trusted him because, well, he took the time to earn my trust.  He didn’t have me in the gym trying to do exercises on my very first day.  Our first four visits were all spent talking about the information in the Neil Pearson lectures, and about my past experiences with injury and exercise.

I’d had many other physical therapists in the past who’d expected me to just get up and do all sorts of exercises right away.   Based on my diagnosis, they said, I “ought” to be able to do all sorts of things.  And when I would refuse, saying I was scared, it would turn into a conflict.  I’d either end up doing the exercises, which would of course increase my pain because I was scared, or I’d get a lecture about how I had to listen to this person if I really wanted to get better.

Tim didn’t ask me to do any exercises until the fifth visit; only after he’d spent the previous four reassuring me that there were, in fact, a lot of exercises I could do safely, and that my body was capable of handling much more than I thought.

He started out by having me walk on the treadmill.  The first day, I only did five minutes.  The next visit, I did ten.  Of course, I was apprehensive, but the important thing was that I didn’t feel like I was being forced to do something.  I knew it wouldn’t turn into some kind of huge conflict or battle of wills if I needed to stop.

From there I gradually progressed to other exercises.  I had been terrified to use the elliptical trainer, although up until the pain became debilitating it had been my favorite machine.

One day Tim convinced me to get on for just three minutes.  Just to see how it felt.  “Is this dangerous?” he asked.  “No.  No way this is dangerous for you, in just three minutes.”

Three minutes ended up feeling so great that I ended up doing ten.

To be continued in Part 7!

**Track meet picture courtesy of oscarandtara on Flickr.**

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How I’ve (Mostly) Made Sense of My Issues

Of course, I’m not saying everything is perfect now.  But I’m definitely way better off than I was a few years ago, and a lot of that has to do with how I’ve changed my perspective on pain.

Two important ways in which my thinking changed:

1) Understanding that not all pain comes from a physical injury.  This helps cut down on the cycle of fear.

We grow up thinking that pain must automatically mean we are injured.  However, pain is actually a lot more complicated this, especially in the case of someone whose body has been through some sort of trauma.

(I have written a lot about this in past posts, so I am not going to focus on it as much in this one.  But if you are new to my blog, definitely check out my page on “Calming Your Nervous System” for more!).

2) Learning as much as I can about the body.

The more I learn about the structure and function of the body, the more surprised I am at all the things doctors and other people don’t tell you.

The best thing you could possibly do is take a real, official anatomy and physiology class.

Don’t make the mistake that I did, when I was younger, in thinking that you can learn from just anywhere.  Don’t just try to pick things up anecdotally from your acupuncturist or massage therapist, or even physical therapists.  It’s just not the same.  They might tell you what they think you need to know, but they are practitioners, not educators.  I spent so much time in physical therapy over the years that I thought I knew a lot about the body, but once I took actual college courses in the subject, I realized how much there was that I didn’t know.

Start at the bottom; put in the time and pay your dues.  Learn about the body from the cellular level up.  Memorize the names of bones, the locations of muscles, learn the paths of the major nerves.  It gives you a sense of mastery, and helps you feel more connected to your body (in a good way, not in a focusing-on-the-pain-more way).

The best part is, when you are caught in a cycle of chronic pain, when your body’s “alarm bells” seem to be constantly ringing, knowing more about the body can help you turn down the signal.

Pain is a dynamic interplay between the body and the brain.  The body can send signals up to the brain, to determine if action needs to be taken.  The brain can also send signals down to the body asking for more information, if it wonders if the body has been hurt.

When you have a chronic condition, knowing more about your own anatomy can help turn down some of those alarm bells when they start ringing.

Here is an example from my own life:

A few years ago, when I first began to have knee issues, there was one night where I experienced extreme, stabbing pain in one leg.  The pain didn’t make any sense to me—it ran in a diagonal line from the outside of my upper thigh, across my leg, to the inside of my knee.

At the time it really freaked me out.  I had no idea what could cause pain to run in such a diagonal pattern.  I thought the muscles of the upper thigh ran in a strictly vertical direction.  Since it wasn’t a muscle, I thought it, must be some kind of serious problem involving a nerve.  Maybe it was even a pinched nerve in my lower back.  I burst into tears, took a ton of Advil, and waited desperately for my next physical therapy appointment.

Now I know that there is a muscle that actually does run diagonally across the knee, along the exact same path that the pain ran that night.  The sartorius muscle runs from the outer thigh to the inner knee.  It acts at the hip, raising the leg forwards and out to the side, as well as rotating it outwards, and it helps to bend the knee.  It is also the longest muscle in the human body.

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Photo credit: Wikipedia. http://en.wikipedia.org/wiki/Sartorius_muscle

If I had known this back then, I probably would have reacted to this situation completely differently.  I would have known there are muscles in the upper thigh that run in other directions straight up and down, and wouldn’t have assumed it was a nerve.   Even if I didn’t remember the exact name and location of the sartorius, I would have known what section of my textbook to flip open to for a refresher.

Of course, to go back to point #1, it also really helps to understand that just because the pain is severe, it doesn’t necessarily mean the condition is severe.  A muscle spasm like that one can be extremely painful, but it isn’t really “dangerous.”  It’s just a sign that the muscle is overworked and you need to rest it, ice/heat it, and get a massage.

I know that now, and I’m sure I have had muscle strains in the years since then that have been just as severe.  But none of them have set off the same “alarm” bells, and I’m sure that part of that is because, on some level, my body has made peace with the idea of muscles being overworked and needing to rest.  I’m not talking about a conscious process.  It’s something that probably happens below the level of conscious thought, where signals from the spinal cord enter the brainstem.

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Photo credit: Zillafag http://www.flickr.com/photos/zillafag/

My conscious mind is not as anxious about random shooting pains because a) I’ve had them before and everything turned out fine, b) I now realize that muscle pain can run in all kinds of crazy directions, and c) muscle pain is not dangerous.  When those same pain signals begin to enter my conscious mind, I simply am not as afraid as I used to be.  In the past, when I was more frightened of the pain, my brain would send a cascade of chemicals back down my spinal cord, telling my nervous system to “turn up the volume” on the signal.  Now, it doesn’t, at least not as much.

Of course, my life isn’t perfect now.  I still have some physical issues (I am planning to write a post soon on my ongoing issues with the sacroiliac joint).

But I just don’t seem to have the same overblown, five-alarm-fire response to pain that I used to have.  I think my physical issues are probably worse now, in an objective sense, thanks to the sacroiliac issues that I’ve had for the past two years.

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My nervous system, a few years ago. Thanks to songglod http://www.flickr.com/photos/22643708@N06/

But I am actually in less pain than I was a few years ago, where I went from doctor to doctor, only to be told that nothing was wrong, and it’s largely because I helped to calm my nervous system down.

It’s not that I’ve learned to block out pain, or anything crazy like that.  I’m not saying I have no pain. I’m just saying that now, I have the pain response of a normal person (or close to it) rather than the extreme, overblown pain response of a few years ago.

It’s not that I had a problem with anxiety, as so many doctors were wont to think.  It’s that my nervous system was giving me a lot of very “loud” input, and I didn’t have any way of determining which signals might be okay to “tune out.”

There’s a big difference between trying to ignore pain that you think could be a sign of something dangerous happening in your body, and deciding in a calm, rational manner that you are pretty sure you know what’s causing the pain, and that it is not a sign of immediate danger.

The first of those options will only make the pain louder.  Pain is there to protect you and get you to change your course of action when your nervous system thinks you might be in trouble.  Trying to push through the pain and going about your business as usual will only make the pain worse.

But pausing and actually focusing on the pain, deciding you have a reasonable guess as to what’s causing it, and what to do to make it better, can make the pain go quiet.  Or, at least, quieter.  But you have to really believe that you are safe, for this to work.  You can’t think there might be some hidden cause your doctors have missed, that part of your body might be falling apart.

And it’s ok if that’s what you do think.  It is certainly a valid position to be in.  Sometimes there is no simple answer.  I am not telling you you should be able to use the thought process I’m describing here all the time, or implying that there’s something “wrong” with you if you can’t talk yourself out of being scared.  That is the exact opposite of what I’m saying.

I’m just telling you that, the more you know about the body in an objective sense, the easier it will be for you to make sense out of it when the body gives you subjective input.   In my own life, the more I learned about anatomy and physiology, the less scary pain became to me, which in turn meant there were fewer alarm bells going off.

It isn’t the answer to everything, but learning about these subjects might be the answer to some things.

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How a physical therapist helped me through my lowest point, Part 5

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**If you are new to my blog and would like to start at the beginning of this series, click here.**

In some ways, the “cure” wasn’t a magic bullet.  I do have some pain, and in some ways my life hasn’t really changed.

But in other ways, it was like magic.  Finally, I had an answer for my pain—a real answer.

For so long, I’d been told by various doctors and physical therapists that the answer had something to do with my mental health.  That I was depressed, or anxious, or afraid to move.  That “something bad had happened to me a really long time ago,” and my body was using pain to express my unconscious thoughts about it.

Perhaps there was a grain of truth in some of those things. I hadn’t exactly had a happy adolescence, and I was deeply afraid of the kind of injuries that had forced me to stop running.   I didn’t necessarily identify with the person in the picture they were painting—I didn’t consider myself to be particularly depressed, or troubled.  But these issues loomed large in my past, so it wasn’t too much of a stretch to imagine that maybe they were still affecting me more than I consciously realized.

I had wasted years, since the first person told me at nineteen that he didn’t think there was a concrete medical reason for my pain, wondering if psychological issues were to blame.  I was never completely on board with this theory, but I also didn’t have a better explanation.

For years, every health professional I saw would eventually tell me he or she didn’t understand why I was in so much pain.  “You have some issues with muscle tightness and posture” they would tell me.  “It’s possible you still have scar tissue left over from your surgery.  But I see other patients with these issues, and you are in more pain than all of them.”

Then each of them would proceed to give me some kind of advice.  Most of them were kind, and very well-meaning.  “I think maybe you should talk to someone about this.  I’m not really qualified.  Maybe you should see someone who has been trained how to help people with depression, like a psychologist.”

I called this conversation “The Talk.”  Every time I saw a new doctor or physical therapist, I knew it would come up eventually.

Sometimes I would be upfront about it at the first appointment: “I’ve been told there might be psychological reasons for why I’m in so much pain.” Other times, I would experiment by not saying anything, seeing how long it took for the person to reach this conclusion on his or her own.  Sooner or later, almost everyone did.

I was in college for most of these years, and as a result, I had access to hundreds of well-respected academic databases requiring a paid subscription.

I spent hours pouring over the literature on chronic pain and depression; anxiety and depression; anxiety and chronic pain. Fibromyalgia and chronic pain.  Somatization disorder.  Conversion disorder.  The relationship between chronic pain patients and patients with irritable bowel syndrome.  Which therapeutic interventions had been shown to help.

All of it left me feeling like shit.

I just didn’t identify with the kinds of mental health issues these articles would discuss.   In a way, maybe I would have felt more optimistic reading these articles if I actually considered depression to be one of my cardinal issues.

Now, let me be clear: there is nothing wrong with being depressed, or having any other mental health issues.  I have several close friends with mental health issues, who rely on psychiatric medication to live their lives.  There is nothing wrong with that.  There is no shame in it.  Mine is not the story of someone who really is depressed, but just doesn’t want to admit it.

My problem wasn’t depression, it was pain.  Perhaps I would have felt more optimistic reading these articles if I actually felt I had clear-cut case of depression, which might improve with medication and therapy.

I had met with therapists from time to time, over the years.  The medical professionals I would see kept sending me to various people, and, agreeable young woman that I was, I would always agree to go and meet the next person.

But we never got anywhere.  Sometimes the therapist and I would agree that I might have a mild case of depression, but we never had the kind of huge psychological “breakthrough” that the doctor or physical therapist who had sent me there had hoped I would have.   Often times in therapy, the conversation would turn back to pain, and the therapist’s own experience with back or neck pain.   In the end, the therapist would usually just refer me back to physical therapy.

Over the years, whenever I wasn’t too occupied with coursework, I would think about depression and anxiety.  I wondered if it was possible that I was more troubled than I actually felt.

In retrospect, this was a completely pointless use of time, and of course it made me feel worse.  How can it be a good thing to insist to someone who doesn’t feel depressed that she spend time talking to other people about whether or not she might be depressed?  Why dwell on hypothetical negative emotions when you don’t have to?

But there was really no talking to some of these doctors.  Even the most sympathetic could not be swayed.  It was practically at the level of religious belief for some of them: if there is no concrete medical reason for a patient’s pain, then she must have mental health issues.  There was just no way around it.

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That is why the Neil Pearson lectures blew my mind the first time I watched them.   It made so much sense right away—how could anyone have a discussion about pain without discussing the functions of the nervous system itself?  All these doctors I had seen had focused only one aspect of the nervous system: the neurotransmitters of the brain.

But there were other aspects of the nervous system that were worth discussing.    The peripheral nerves, the things that sense mechanical damage, temperature, and chemical signals.  The dorsal horn of the spinal cord, where sensory information enters and travels up to the brain.  The relationship between the brain and the spinal cord, and how, somewhere along the way, your body can decide whether it needs to know more about what’s happening in your body, or whether it’s safe to tune those signals out.

Nowhere in the lecture did Mr. Pearson bring up the subject of depression.  Not, I am sure, because he had never learned anything about the relationship between depression and chronic pain.  But because there was a better explanation out there, one that did not require a diagnosis of ill mental health.

What had happened to me wasn’t some freak occurrence that had happened only to me, as a result of some psychological trauma I couldn’t even remember.  It was, instead, the result of normal processes of the nervous system being altered a little bit by physical trauma, which of course I could remember, and which made sense to me.

How was it possible that none of the doctors or physical therapists I had seen before had known this information?  I wish I knew.  I don’t really have a good explanation, except for that all of the decent research on pain science is very recent, whereas psychologists have been studying depression and chronic pain for over a century.   Some of the theories people were using to diagnose me, I realized, hadn’t changed very much since the days of Sigmund Freud.  It seemed that many of the research studies on depression and chronic pain had been based off of some of these same assumptions.

I am really hopeful that in ten to twenty years, the “conventional wisdom” about the causes of chronic pain will be a bit more modern.  I really hope that, someday, the kinds of things I learned in physical therapy will be taught, not as optional continuing education courses, but as part of the required curriculum in medical, physical therapy, and occupational therapy schools.

To be continued in Part 6!

*****

Top Photograph: Don’t worry, I don’t understand everything that’s going in this photograph either.  But it seems a hell of a lot more scientific than simply making the assumption that a patient is depressed.  Thanks go to Open Michigan.

Second Photograph: I love when I randomly find awesome things like this on Flickr.  We should all trust in our nervous systems. Thanks go to Cliph for the image.

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How a physical therapist helped me through my lowest point: Part Four

This is the fourth part in a series about an amazing new approach to physical therapy for chronic pain patients.  To start from the beginning, check out Part One, Two, and Three.

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For the first few visits, all Tim and I did was talk.  He didn’t have me in the gym doing exercises like all the other patients I walked by on the way in.  Instead, we sat in a quiet area and talked about what I had learned in the Neil Pearson videos.

What I learned is that pain is so much more complicated than we think.  When I first learned about the nervous system in high school biology, I was taught that nerve impulses travel through the spinal cord to the brain, where they are interpreted.

simple nervous system

This is a very simple model, and on a basic level it’s true.  That is how nerve impulses get to the brain.  But when it comes to the experience of pain, there are many additional factors.

Normally we think about the nervous system as a one way street, where signals are only travelling to the brain. But what I learned from Tim is that the experience of pain is a lot more complicated.  Our brains are constantly evaluating input from our nervous system, trying to sort out which signals are important for us to know about, and which aren’t.

Our brains are filtering our experiences all the time, determining what is and what isn’t important for us to know about.  After all, it wouldn’t make sense for us to be aware, on a conscious level, of every little thing that’s going on in our bodies.  We don’t need to feel, at all times, the sensation of clothing on our backs.  We don’t need to wake up out of a deep sleep just because there is a blanket touching our legs.  Our brains filter out information all the time, so that we can focus on more important things.

On the other side of this equation, the brain can actually “turn up the signal” on something it thinks we need to know about.  If a part of your body hurts and you try to ignore the pain and go about business as usual, your brain will make that pain louder.  It isn’t doing that to be annoying; it’s trying to protect you.

Lorimer Moseley tells a revealing story about the time he was walking in a nature preserve when a stick brushed against his ankle.  He had once been bitten by a poisonous snake in that same nature preserve, also on his ankle.  He freaked out and fell to the ground, writhing in excruciating pain.  He told his friends to call for help, thinking he needed to get to a hospital as soon as possible.

A few moments later he looked at his ankle and realized there were no bite marks.  There was, instead, a stick lying on the ground next to him with a sharp point.  He was then faced with the awkward task of telling his friends he was wrong, that there was no snake, that he’d freaked out over nothing.

This is how the nervous system works.  It is not meant to be “accurate.”  It is meant to protect us.

When Moseley’s nervous system felt the stick scrape his skin, it knew that the last time it felt those sensations, there had been great danger.  It also knew that not only was he outside, but he was walking in the exact same nature preserve where that same danger lurked.  His nervous system decided to tell him about the dangerous thing that had just happened to his ankle, and it told him about it loudly.  This is how the nervous system works; it decides how much danger we are in based not only on physical sensations but also on context.

Normally when we notice these little idiosyncracies of the nervous system, we are embarrassed.   These little errors in judgment can make it seem like we’re crazy, or overly anxious or neurotic.  But this is how the nervous system works.  It is not meant to be “accurate,” it is meant to protect us.   Even when our nervous system doesn’t have the whole story, it fills in blanks as much as possible, taking our fears and beliefs about the situation into account.

In people with chronic pain, the body’s protective response has gone haywire.  It’s as though the nervous system’s threshold for action has been lowered, and things that didn’t seem dangerous before now seem very dangerous.

It’s like we’re Lorimer Moseley walking through the nature preserve, all the time.  The difference is that Moseley’s case was a singular event based on coincidence: the stick brushed up against him in the same place that the snake had bit him, and he was walking in the exact same park where he had encountered the snake before.  While Moseley’s experience had a concrete end, every day chronic pain patients encounter “sticks” that our bodies interpret as “snake bites.”

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The good news is that, because the nervous system takes our conscious beliefs about pain into account when making judgments, we can actually affect how it reacts to various stimuli.  (I want to be very clear here: we do not cause chronic pain with our thoughts and beliefs.  This is an oversimplification, and it’s also insulting).  But the nervous system does pay attention to context when deciding how dangerous something is.

In his lectures, Neil Pearson says that when your pain starts to get worse, you should ask yourself “Is this really dangerous?”  An increase in pain is a sign that your nervous system has decided whatever you’re doing is dangerous.  But is that really the case?  If you’ve been living with pain for a long time, it might not be.

This is where your conscious thoughts and beliefs can play a role in breaking the cycle of pain.

I had lived with pain for so long that my view of what my body could and couldn’t do had gotten very warped.  I felt pain every time I tried to walk, or lift something, or go up and down stairs.  I thought my body was weak, that there was something fundamentally wrong with it, and every time I pushed myself it seemed to get worse.

Tim helped me to recognize that the pain I felt was not necessarily an accurate barometer for what was wrong in my body.  The reason I had a setback every time I exerted myself, he said, had more to do with my nervous system freaking out than the fact that I had actually pushed my healthy twenty-five year-old body to its limits.  When my body began to hurt, I was to say to myself, “There’s my nervous system again.  Freaking out.  But that doesn’t mean anything is wrong in my body.”

Tim and I talked a lot about how the body works, and how I wasn’t going to hurt my back, or my legs, or my ankle just by doing basic things.  Because one of my major complaints was back pain, we talked about the anatomy of the back, and how my MRI showed I didn’t have any serious pathology.  Tim promised me that my body was so much more capable than I thought it was, and that once I could help my nervous system calm down a little bit, I would see that.

We also talked about what kinds of things would produce pain in a person whose nervous system wasn’t freaking out.  It honestly really helped me to have a trained physical therapist to bounce ideas off of.  I trusted Tim.  If he told me the pain I felt was likely coming from my freaking-out nervous system, rather than any physical damage, I believed him.

We talked about my leg surgery several years before, and how I was afraid my compartment syndrome was going to come back if I pushed my legs too much.  We sat down and had a rational discussion about this; how unlikely it was, but what the worst case scenario really would be if it came back.  This helped to reduce some of my fear, and give back a sense of control.

We also talked about my ankle, which I had sprained a few months earlier.  It still hurt a lot of the time, and I had a lot of trouble walking and driving.  Tim explained that I wasn’t going to re-sprain my ankle just by performing normal activities.  Since it had been a few months, he said, the majority of the healing had already occurred.  As long as I kept my ankle within the normal range of motion, I wouldn’t be doing anything to make the sprain worse.

This actually made a striking difference in the amount of pain I felt in my ankle.   My nervous system had been interpreting the sensations in my ankle as very dangerous, and as a result it was very painful.  But once my brain understood that my ankle wasn’t in any real danger anymore, my nervous system no longer saw the need to tell me about it all the time. Over the course of the next few weeks, the pain in my ankle gradually melted away.

It’s almost embarrassing to admit something like this– that my ankle, which had been bothering me for months, stopped hurting as soon as someone explained to me that it wasn’t really dangerous.  But it shouldn’t be embarrassing.  This is how our nervous systems work: they take into account both physical signals as well as our mental interpretation of events.

If you’ve undergone the process of central sensitization, your nerves, spinal cord, and brain have changed in ways that cause you to be more sensitive to pain.  Scientists don’t yet know whether or not these physical changes are actually reversible.  But the good news is that whether or not you can undo the effects of central sensitization, you can still break the cycle of pain by changing how you react to pain on a conscious level.

Continued in Part 5.

**The top picture was taken in the Australian Outback, which is where many of Lorimer Moseley’s stories take place.  Published by Mark Veerhart under a Creative Commons license.**

**Mulberry sticks picture courtesy of JodiGreen**

Featured input to nervous system

How a physical therapist helped me through my lowest point: Part Three

This is the third part in a series about an amazing new approach to physical therapy for chronic pain patients, and how the role it played in my life.  To start from the beginning, check out Part One and Part Two.

The biggest difference between the type of physical therapy Tim was introducing me to, compared to traditional physical therapy, is that it focused on the nervous system.

In the traditional model of physical therapy, the physical therapist prescribes stretches and exercises for the patient in order to improve function in one part of his or her body. For example, if it’s your back that hurts, your PT will give you strengthening exercises to build up the muscles in your back and abs. If it’s your knee that hurts, he or she will give you exercises to strengthen the muscles around the knee. This is why, when most of us picture physical therapy, we imagine a patient grunting and sweating in a gym while the therapist looks on.

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Tim, however, was drawing from a different treatment model. In this model, the patient’s pain is coming not from an injury in one specific part of the body, but from an overactive nervous system. Rather than focus on the function of a particular muscle group or joint, treatment actually focuses in on the nervous system, and helping to calm down the patient’s overactive pain response.

The best way I can try to describe this is with graphs.  The first graph below shows the way most people imagine pain to work.  It also shows what most physical therapists are imagining when they prescribe stretches and exercises to improve a patient’s function:

acute pain graph

You can see how, as the intensity of the injury diminishes (represented by the black line) the intensity of the pain diminishes as well (represented by the red line).  This matches our experience of pain in most minor situations: getting a tooth drilled, pulling out a splinter.  When the stimulus goes away, the pain goes away.

However, in situations involving chronic pain (generally defined as a painful experience that lasts for at least two to three months) the pain response works differently.  Prolonged exposure to a painful stimulus actually produces changes in how a person’s nervous system works.  It’s as if it sets off a feedback loop in which pain signals continue to be produced independently of the level of injury.  For this reason, pain persists even after the initial injury has healed:

chronic pain graph 2

This graph is also a good representation of the state I was in when I first came into Tim’s office.  I had a very high level of pain, but it was not correlated with a high level of injury in my body.  This is why I hadn’t seen much improvement with any of my past physical therapists– my pain was coming from my nervous system, not from a specific injury in my body.

“If pain is the patient’s primary symptom, then pain relief should be the primary goal of treatment.”

I once read something along those lines in a blog comment section, and it really stuck with me.

Most physical therapy programs are designed to improve function of a certain part of the body.  But when your pain isn’t coming from a problem with a certain part of your body, you can stretch and strengthen until the cows come home.  It still won’t change your level of pain.

This is why none of the physical therapists I had seen before had been able to help me.  They were all stuck on the idea that I needed to strengthen my back; strengthen my abs; strengthen everything.  Of course, in some ways they were right.  I wasn’t in the greatest shape.

But what Tim was able to identify is that there was a common denominator behind all of the pain I was experiencing in different parts of my body.  Rather than looking at each one as unrelated, he recognized them as the symptoms of an overactive nervous system, or, as he taught me, body alarm system.

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The goal of Tim’s approach was basically to help the patient’s body “remember” what an accurate pain response is supposed to be.  There are a few ways to accomplish this, and I will be discussing them in upcoming posts.  But the general goal of these various techniques is to help the patient’s nervous system get back in touch with with the reality of what’s happening in his or her body.

This graph shows the general goal of treatment:

input to nervous systemThe blue arrows represent the input you want to give to your nervous system.  You’re basically saying to it, “Hey.  Hey you.  You are freaking out for no reason.  This is reality, and it’s over there.”

The role of the physical therapist is basically to help the patient’s nervous system realize it doesn’t need to be on high alert all the time, and to slowly help it calm down.  The idea is that as time goes on, the discrepancy between what the person’s nervous system feels and the actual level of dysfunction in his or her body will slowly shrink.

Now, to be honest, I’m not sure you will ever be able to fully reverse the process of central sensitization.  It’s probably possible, but it hasn’t happened yet for me.  That’s why I didn’t draw the red line going all the way back down to the bottom.  An overactive pain response will always probably be somewhat of a factor for me, but it is a million times better for me now than it used to be.  I’d much rather have the red line close to zero than soaring way up high, totally out of touch with my physical reality.

I’ll be continuing my discussion of this approach to physical therapy, including the specific techniques that Tim taught me, in Part Four.  Stay tuned!

  • Strength training equipment pic: colonnade
  • Balance training equipment pic: kbrookes
Featured A picture I took in my yard today.  Just to liven things up.

How a physical therapist helped me through my lowest point, Part Two

This is the second part in a series about a life-changing experience I had in physical therapy. To start from the beginning, check out Part One.

I couldn’t believe what I was hearing.  I think Tim expected me to be disappointed, or maybe even to contradict him.  After all, he basically just told this patient who had been in pain for months, thinking that she was injured, that there wasn’t as much “wrong” with her body has she thought.

But I was excited.  My curiousity was piqued.

After all, I knew there was something wrong with me that no one had figured out yet.  I could tell that my body wasn’t functioning normally.  I mean, I was twenty-five, and in more pain than my eighty-six year old grandmother.  I was so happy to have someone propose a theory to me that sounded as though it made scientific sense, and didn’t ultimately hinge upon my “being depressed” or “focusing on the pain too much” (both of which were things I had been hearing from healthcare professionals for years).

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Tim explained that he and all of his coworkers had attended an advanced training together on recent developments in pain science.  The way he said “pain science” was very specific; it sounded different than what doctors usually meant when they referred to “pain management.”

Tim explained that the training had taught him to view pain totally differently; that he and his colleagues had learned all sorts of things they hadn’t learned in physical therapy school.  After the training, he’d realized that much of what he’d learned about pain was wrong, that most physical therapists and doctors had it wrong.

What he learned is that sometimes, in people whose bodies have been through some kind of painful or traumatic physical ordeal, the nervous system can starts working differently.  It start overreacting to different stimuli, and cause the person to feel pain when he or she ordinarily wouldn’t.

“It’s as though your body has decided that everything is dangerous,” he said.  “And that makes sense, after everything you’ve been through.  Your body has been through so much that it’s like it thinks it’s made of glass, that even the slightest touch could break it.  But you’re actually much tougher than that, and what we’re going to do is help your nervous system remember that you aren’t made of glass.”

I was excited and confused at the same time.  Tim told me not to worry if it didn’t make sense right away, that it might take a few appointments for me to really understand.

The first thing I had to do, he said, was to go home and watch three online lectures, given by the same instructor who’d led his training.  He urged me, in fact, to watch them more than once, to really pour over them and get everything out of them that I could.  But I had to promise to watch each one at least once before our next appointment.

*****

If you’re a longtime reader of my blog, you’ve probably guessed that the person who gave these online lectures is Neil Pearson.

I really can’t say enough good things about Mr. Pearson.

Once I went home and started playing these lectures on the computer, things really began to click.  I have to admit, it was hard to stay focused, but not because it was boring.  Instead, it was because every new thing Pearson said made me think of my past.  All of these experiences where I’d felt like a big weirdo, where I’d been too embarrassed to let anyone know how overwhelmed I was by certain stimuli because I knew it wasn’t normal, suddenly made sense.

The lectures talked about how pain isn’t always a sign that something’s wrong in the body.  Instead, it is your body’s way of warning you about things.  And it turns out that the body isn’t always right about what it can and can’t handle.

I realized it was as though someone had come along when I wasn’t looking and lowered my pain and physical irritation threshold.  It was as if I was playing Limbo, and the people holding the stick decided to lower it from the height of my neck to the height of my shins.  You can’t play Limbo when the stick is that low.  And you can’t go through life normally when your “pain threshold” is only a fifth of what everyone else’s is.

As I listened to the stories in Mr. Pearson’s lectures, I began to recognize myself in them.  I realized that my nervous system had been on edge, for years.  It wasn’t because I was crazy.  It wasn’t because I was depressed.  In fact, it was something that was happening totally out of my conscious control.

At one point in the lecture, Pearson began to describe the chemical and physical changes which occur in the nervous system as a response to pain, both within the brain and in the spinal cord.  These changes are what cause the change in how a person experiences pain.  This was so much bigger than “you’re depressed.”  And it was actual science; like, the kind with evidence.

Of course I had a lot of questions after watching these videos, but from that moment on, I knew things were going to change for me.  Finally, an answer that made scientific sense, and which seemed to have a solution.

To be continued in Part 3!

And because I know you’ll want to check out the videos now, they are:

Neil Pearson: Overcome Pain, Live Well Again

Featured beautiful sky

How a physical therapist helped me through my lowest point, Part One

beautiful sky

Hitting Rock Bottom.

A few years ago, I was at one of my lowest points. A few things happened in my life, all within a short time period, that caused my pain levels to flare up. I had been attacked by a client at the group home where I worked. In the attack, I was thrown against a wall, which, of course, was not great for my pre-existing back and neck pain. The week before, I had sprained my ankle and was having trouble walking. I was also beginning to experience the beginnings of chondromalacia patella in my right knee.

It was a horrible time in my life. I was going from doctor to doctor, begging for someone to help me, to give me a diagnosis. I couldn’t understand why I was in so much pain; it was like it had taken over my whole body. I was afraid there was something wrong with me, deep down, at a cellular level. I started reading about something called fibromyalgia online, and was frightened by what I read. I realize now that I what I was reading was out-of-date information, but at the time I became very frightened that something in my body’s chemistry was off, causing problems with inflammation.

The absolute worst moment was when I went to see a pain specialist at a highly-regarded hospital near me.

This guy looked great online. He actually listed fibromyalgia amongst his clinical interests. He wasn’t just a random doctor; he was the head of the anesthesiology department. He also had a law degree, which I figured meant he was really smart.

But he was no help at all. Most of the appointment was conducted by a resident (medical student in training). Because he could see many of my records from other physicians electronically, he didn’t seem to think he needed to do an examination of his own. Not once did he walk across the room and look at my back.

I tried my best to express how bad things were. I explained the fears that had plagued me for months, that I was afraid I had fibromyalgia, or a problem with inflammation.  Despite the fact that he’d listed “fibromyalgia” within his clinical interests, he seemed to have no idea what I was talking about.  I also asked him if he could give me some medication for the pain. His eyes got wide, as he suddenly “remembered” that every new patient was supposed to receive a drug test.

I left that day with a lump in my throat and my pride wounded. Somehow, this whole appointment that I had been looking forward to for so long had boiled down to the doctor thinking I just wanted to get high.

*****

The only good thing to come out of that appointment was that the doctor referred me to physical therapy at another hospital in the area. Without going into any detail, he said that a lot of his patients had had “luck” there.

I had actually been to physical therapy at the same hospital a few years earlier, when I had first hurt my back.  I had really liked my physical therapist at the time, so I decided to go back.  As luck would have it, they scheduled me with the same guy.

I filled out my intake paperwork, following the instructions and putting an “X” on the little diagram where they ask you to mark the areas where you have pain. I must have put about twenty X’s on the paper.

When Tim saw this diagram, he paused for a moment. “Hold on a second,” he said. “I’ll be right back.”

When he came back into the room, he explained that he’d asked the secretaries to make a few changes to my referral. He explained that the number of X’s I’d placed on my paper was alarming, that it was a sign there was something more going on with me than just “back pain” or “knee pain.” Instead, there was an underlying factor, causing me to experience pain in so many parts of my body. It was, he said, my nervous system.

“You’re really going to have to trust me on this,” he said. “I know it’s confusing to hear at first, but when people get like this, it’s because their nervous systems are processing pain differently. There’s no way you have injuries in this many different parts of your body, when you haven’t been in a car accident and you’re so young. I am going to teach you about what’s going on. Once you begin to understand that all of this pain is coming from your nervous system, we can start to work with that. You’re going to have to give me the benefit of the doubt in the beginning, but we really can help people get better.”

Click to continue to Part Two.

Featured grand canyon

Understanding pain as an overprotective friend

grand canyon

Let’s say you’re sightseeing at the Grand Canyon.  You are with a trusted friend enjoying a scenic overlook when notice your friend is walking a little bit too close to the edge of the cliff.

“Hey, watch out!” you say.  You can see that no one else is standing that close to the edge.  Your friend keeps going.

“Hey!” you shout.  “I think you’re too close!”  Your friend still keeps going.

You start to panic.  Your pulse races.  You’re starting to get a picture, in your mind, of what it would look if your friend actually fell over the edge.  “OH MY GOD WHAT ARE YOU DOING?” you scream at the top of your lungs.

This is a metaphor that my favorite pain researcher Neil Pearson uses to explain how pain works.  Pain is like a friend that’s trying to protect you, and if you ignore it, it will get louder.

grand canyon 2

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As I touched upon in a previous post, pain isn’t always an indicator that something is wrong in your body.   Sometimes, your nervous system causes you to feel pain as a warning.  For example, maybe you are performing some kind of motion or exercise that is going to hurt you—pain will prevent you from stretching a muscle or a joint past its normal range.  You feel pain before you have pushed the stretch too far and actually strained anything.

To come to terms with chronic pain, you must first understand that pain doesn’t necessarily mean that a part of your body is injured.  Instead, it means that your body is warning you about something, or that it wants you to change your course of action.

A lot of the pain scientists I cite on this blog offer anecdotes about how pain is not always correlated with a person’s level of injury.  This is important to understand, because it can help people with chronic pain and fibromyalgia not to fear the pain so much.  I find these stories fascinating, so I will be passing them on as much as I can without feeling like maybe I’m relying too much on someone else’s work (it’s hard, because I honestly just want everyone to know what these guys say!)

But it’s also important to understand that all these stories about how pain doesn’t mean you are necessarily injured do not mean you should ignore pain.  That is what I absolutely love about Neil Pearson’s approach.  Even though he is all about teaching people not to fear pain so much, he still says that you have to respect it.

grand canyon 3

Pain is like that overprotective friend.  Pain occurs when your nervous system has decided that something you are doing is dangerous.  This is true whether an injury has already occurred (for example, you sprained your ankle and now your body is telling you to get the heck off of it!) or whether your body thinks an injury might occur (for example, you’re pushing a stretch too far).

Regardless of whether or not a physical injury has already occurred, if you try to ignore pain and keep doing what you are doing, it will get louder.   When you’re doing something that your body thinks is dangerous, your nervous system becomes that friend screaming at you to stop getting so close to the edge of the Grand Canyon.  The more you keep going, the louder your nervous system gets because it’s panicking—the same way you would if you saw a beloved friend too close to the edge.

Of course, this doesn’t mean you have to be crippled by your pain, either.  There are basically two ends of the extreme in dealing with pain: one end is to try to be tough and completely ignore it, and the other end is to be terrified of it and let it dictate what you do and don’t do.

When I was a runner in high school, I was far too influenced by the people around me who placed an emphasis on “no pain, no gain.”  (There were a lot of things wrong with the running culture at my high school—a subject for another day).  The mindset that it was good to block out pain and keep going eventually led me to develop compartment syndrome, the injury that ended my running career, and left me unable to walk or stand up for very long until I had surgery a few years later.

After developing this injury, I of course went all the way to the opposite end of the spectrum.  I blamed myself for not listening to my body, and felt as though my injury could have been preventable.  I freaked out every time something hurt, an approach that also ended up being counterproductive.  I mean, it’s good to be careful, but now that I understand that I have issues with central sensitization, I realize that not every pain is worth freaking out over.

There is instead a middle way, where you learn to respect your body’s pain without automatically assuming you are injured.  This means you respect the pain and don’t try to push through it, but you also know not to freak out because you recognize that your nervous system sometimes gives you false alarms.  It’s about being okay with the possibility that maybe you strained something and need to take it easy, while knowing that you probably didn’t.

I will be talking more about other techniques to work with your nervous system in the future, but this metaphor is really the cornerstone to understanding pain. For more information, check out Neil Pearson and his amazing online lectures that I am always trying to get people to watch!

Photo Credits (all from Flickr):

Featured pretty fire

Understanding pain as your body’s alarm system

pretty fire

In my experience, the key to learning to work with your pain instead of against it is to learn to view pain as your body’s alarm system.

In the developed world, most of us are privileged enough to have very little experience with pain.  As children, we only feel pain when we’re at the doctor’s office getting a shot, or when we fall down and skin our knees.  We come to the conclusion that our bodies are designed for us to come to: that pain means something is wrong. 

The truth is that pain a bit more complicated than that.  What I learned in physical therapy is that pain is the body’s alarm system.  It not only warns us when something is wrong, but when the body thinks something might go wrong.  To help you better understand this, I’ve collected the following anecdotes:

  • Pain can stop you from injuring yourself

In his amazing online lectures that I think everyone should watch, Neil Pearson instructs his audience to extend one index finger straight up in the air, and then use the index finger of the other hand to slowly bend the first finger backwards.  It doesn’t take long for this to hurt; however, your finger hasn’t actually been damaged.  The pain is your body’s way of telling you to stop, because if you keep going, it will be damaged.

  • The body’s protective mechanisms don’t always work perfectly– thirst provides an example.

There are many ways that our body can warn us to do something, or not to do something.  Thirst is another example.

Thirst is largely controlled by a part of the brain called the hypothalamus.  This part of the brain has a “thirst center” which measures the ratio of blood cells to water in your blood.  When the percentage of water dips below a certain point, your brain tells you are thirsty.

In his book Painful Yarns, Lorimer Moseley explains how thirst is not as accurate a measure of hydration as we generally believe.  He tells the story of two individuals whose car broke down in the middle of the Australian Outback.  They nearly died of dehydration.  When they were finally rescued, they drank until their stomachs were full of water and then told their rescuers they weren’t thirsty.  In fact, they were still severely dehydrated: most of the water they had consumed was still in their stomachs, not circulating in their bloodstream where it could do them any good.

What had happened is that the act of drinking up all that water had temporarily overridden the thirst signals their brains were sending.  The thirst mechanism is designed to get us to drink, and they had drunk all the water their bodies could handle at that moment.  They were still severely dehydrated, yet they weren’t thirsty.

The essence of what I’m trying to say here is that pain and thirst are mechanisms the body uses to get us to take action in some way.  Neither one is always an accurate indicator of exactly what is happening in the body.  They are a sign that the body wants us to do something.

  • Your body can block out pain signals when something else is more important

One last thing to know about the pain alarm system is that your body can override it if your survival is in jeopardy.  If you are caught in a situation where your life is in danger, your nervous system might decide it is more important for you to focus on what’s going on around you than what’s going on inside your body.

Neil Pearson gives a great example of this.  He tells the story of a patient he once treated who had been hit by a drunk driver on the way to work.  He woke up upside down in his burning car, and realized he had lost an arm in the accident.

The man managed to extricate himself from the car, collect his missing arm, and walk back up to the side of the highway all without feeling any pain. 

As Pearson explains, it’s not as if the nerves in his arm weren’t sending his brain any signals; they were sending signals like crazy.  But his brain knew there were more important things to focus on: retrieving the arm, getting away from the fire, and getting help as soon as possible.  Once he was safely in the ambulance, his brain knew his immediate survival was no longer in question and pain signals set in with a vengeance.

In Conclusion

Pain is your body’s alarm system.  It is not there to give you accurate readings, at all times, of what is going in your body. Rather, it has been designed by millions of years of evolution to get you to change your course of action if your body thinks you need to do something differently.

In the case of people with fibromyalgia and chronic pain, this alarm system has begun to malfunction.  When the body goes through a painful, traumatic experience, it can change the way the nervous system works.  The pain alarm system can become overactive, and your nerves start sending you pain signals at odd times, or all the time, even when nothing is physically wrong.

This isn’t an intuitive process.  As I discusses earlier, pain signals are designed to make us think something is wrong.  Our biology leads us to believe that the amount of pain we feel is equal to the amount of physical damage we have incurred.  But when you begin to understand, on a conscious level, that pain doesn’t necessarily mean there is anything wrong, you can begin to break the cycle of chronic pain.  (I’ll be talking about how in subsequent posts).

Sources:

Beautiful fire picture courtesy of Loving Earth on Flickr.

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Telling the whole story

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“Nobody tells this to people who are beginners, I wish someone told me. All of us who do creative work, we get into it because we have good taste. But there is this gap. For the first couple years you make stuff, it’s just not that good. It’s trying to be good, it has potential, but it’s not. But your taste, the thing that got you into the game, is still killer. And your taste is why your work disappoints you. A lot of people never get past this phase, they quit. Most people I know who do interesting, creative work went through years of this. We know our work doesn’t have this special thing that we want it to have. We all go through this. And if you are just starting out or you are still in this phase, you gotta know its normal and the most important thing you can do is do a lot of work. Put yourself on a deadline so that every week you will finish one story. It is only by going through a volume of work that you will close that gap, and your work will be as good as your ambitions. And I took longer to figure out how to do this than anyone I’ve ever met. It’s gonna take awhile. It’s normal to take awhile. You’ve just gotta fight your way through.” Ira Glass (thanks to Jo Malby for introducing me to this quote!).

My blog, as you can probably guess, means a lot to me.

I’ve had some really meaningful moments on here.  Times when someone has thanked me, so profoundly, for something I’ve written that’s helped them, and I feel like they really get what I’m trying to do here.  Or, in different way, the times when a person or an organization with a lot of followers has shared a link to my blog, and I end up getting hundreds of views and multiple re-shares in one day.  This, of course, doesn’t happen very often. But when it does, it’s an absolutely breathtaking feeling to know my words resonated with so many people.

But in a weird way, all these experiences have sort of made it harder to come on here and write from a place of vulnerability.  To admit that I don’t have it all figured out.  After all, I want to inspire people, not bum them out.  It’s supposed to be “Sunlight in Winter,” not “The Clouds of Winter.”  And the posts that people have really tended to gravitate to, for the most part, tend to be the posts where I talk about everything that I’ve learned.

But my roommate said something really helpful the other day.  In her careful, melodic Peruvian accent, she said, “You know what? I think you should just not give a fuck.  When I read a piece of good writing, I don’t care whether someone thinks they have all the answers, or whether or not they are writing as a professional.  What I am impressed by is their truth– that they had the courage to put something so real, so raw down paper.  When someone tells you about the truth of their experience, it makes you feel that you are not alone.”

And she’s right.  When I think about the different pieces of writing that have resonated with me over the years, it’s not necessarily the straightfoward, informative, “This is what I know now” pieces that have stuck with me.  It’s the writer’s voice that makes the difference.

After all, telling your story is not about skipping ahead to the end, to the answers you found.  It is about how you got through.

So I want to tell you about all of it.  About how, in high school, I starved myself, convinced that if I didn’t I would become fat.  And then I ran myself into the ground– all to later realize it was based on an illusion, and that I wasn’t being healthy at all.

And then, at 17, the leg injury I got from running too much.  For years, I blamed myself, and even after the surgery was afraid to move at all, feeling like I couldn’t trust myself not to break my own body all over again.

And then, at 20, how my nervous system changed.  It was a physiological process, not a psychological one, but I didn’t know that at the time.

And then, a few lost years of thinking I was crazy– of everyone else thinking I was crazy too.  Of my nervous system spinning out of control, and telling me that everything was hurt; everything was damaged…

Until finally, I discovered the work of Neil Pearson (and, by extension, Lorimer Moseley and David Butler)…

And how it changed everything about how I think about myself.  Not just my pain, and my physical body, but myself as a person.  How I realized I didn’t have a psychological problem, and that everyone who told me I did wasn’t seeing clearly.

And now, five years later, I’ve developed a perspective that I am honestly quite proud of.  I’m not afraid of my body anymore.  Not afraid of myself anymore.

I can now hear in my own voice, at times, the same rationality that I used to cling to in the voices of my doctors and physical therapists.  Thanks to all the classes I’ve taken, and the reading I’ve done, and all the questions I’ve sometimes had to push various medical professionals to answer, I’ve actually managed to piece together a larger picture.  One in which I’m not constantly afraid, or thinking something’s wrong with me.

Now I can think objectively.  I can think scientifically.

But I’m not out of the woods yet.

It’s the story of my life that just I find the answers to one problem, another problem develops.   I’ve written before about my issues with the sacroiliac joint, and they have turned to be almost as mysterious and vexing as my chronic pain problem.

But I’m going to write about them.  I’m going to write about all of it.

It’s not just about finding the answers.  It’s about how you get there.

To Be Professional, or Authentic?

So, you may have noticed that I haven’t written very much recently.

Since I started my blog, my policy was generally only to write if things were going well– or at least, to only highlight the positive.

The Internet is tricky. We’re all still figuring out– and as we figure it out, it’s constantly changing.

I’m honestly torn about what exactly I want this blog to be. Do I want it to be professional– kind of like my calling card, to start building connections in the field I hope to go into?

Or do I simply want to be what I’ve always “wanted to be” ever since I read the Little House on the Prairie series as a child– a writer?

I’m torn.

Do I want to create a “reputation” as someone knowledgeable about the body– a future healthcare professional? Or do I want to tell my story, in the hopes it will help someone else out there know she isn’t alone?

It’s awkward. Actually, it’s beyond awkward.

I’ve worked in the helping professions– mental health, specifically. And there, rule #1 is never to talk about yourself– at least, never to offer up anything you wouldn’t mind having attacked later on.

And I’ve seen it– how a person can turn on you, take something you only said in an attempt to be helpful, and try to turn it into something else, twisting your words into something ugly and unrecognizable. Even sinister.

Working in mental health changed me, that’s for sure.

But even without that experience, I think we are all coming to the realization that the Internet is a place that never forgets, where mistakes are never forgiven. In this day and age of screen-shots and screen-caps and whatever else, saying something on the Internet basically means you are saying it forever.

I mean, really. Can I pour my heart out here, admitting my mistakes and defeats… and also expect people to take me seriously as their physical therapist someday?

Honestly, I don’t know.

But I have always wanted to be a writer. To put my stories into the perfect words, to hold them up to the light and examine them, to extract all the meaning from them that I can, and then to share them– that’s always been something I’ve longed to do.

So I guess I’m going to keep trying. To step out on a limb, a little bit. To test the waters.

To see what will happen if I worry less about being “professional” on here (which, frankly, has resulted in me not writing very much at all) and see what happens if I instead focus on being authentic.

Wish me luck!

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Nervous System Basics, Part 2: Excitatory vs Inhibitory

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One of the things that’s helped me as a chronic pain sufferer is to learn all I can about the nervous system, as well as the research that is being done to someday develop more chronic pain treatments.

It’s not so much that I needed to understand every word, so much as the fact that the very act of reading these articles for myself provided me with a sense of vindication at a time when it seemed like everybody else was telling me the it was all in my head.

When I first started reading these articles, I would find that it was some of the same few key words every time which would prevent me from being able to understand an entire article.

Now, a few years and several science classes later. I know enough to at least begin to understand some of these concepts I wondered about for so long.  And it’s a great feeling.

So this series of posts is intended as a means of clearing up some of those very basic key words and concepts for other people, in case there’s anyone else out there in the same boat as me.

My hope is that this series inspires you to read more, research more, and begin to take matters into your own hands.

(To start at Part One of this series, click here).

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Part Two

Nervous system cells, whether they are in the brain, the spinal cord, or the peripheral nerves, communicate with each other via a group of chemical messengers called neurotransmitters.  One nerve cell releases a neurotransmitter in order to create some kind of effect on the next nerve cell in line.

There are two major types of effects a neurotransmitter can have on a nerve cell: excitatory and inhibitory.

Excitatory refers to any stimulus that either causes a nerve cell to fire, or simply makes it more likely to fire (aka more likely to send a signal).

Inhibitory refers to any stimulus that makes a nerve cell less likely to fire (aka less likely to send a signal).

You will often find the words excitatory and inhibitory in scientific articles, whether those articles are discussing how pain works or how pain medication works.

For example, excitatory can refer to something that would encourage the nervous system to send more pain signals, more frequently. One nerve cell can have an excitatory effect on another, making that second cell want to fire.

On the other hand, some nerve cells communicate with other nerve cells and tell them not to fire. This is what is referred to as an inhibitory effect.

Many pain medications work in this way, by inhibiting the activity of nerve cells that transmit messages about pain.

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But the body also has its own built-in inhibitory system when it comes to the nervous system sending pain signals.

Scientists are still discovering how many of these pathways work, and they are incredibly complex. I read about some of them for my neuroscience class last summer, and was blown away by how intricate they are; how many different neurotransmitters and hormones are involved; how many different types of nerve cells and receptors on those cells.

But the gist of the matter is that some nerves can have an inhibitory effect on the activity of other nerves, slowing the overall transmission of pain signals.

This is one way in which the body regulates your experience of pain. Sometimes your body decides it’s important for you to feel pain– like when you are home alone and get a papercut. You look down, see you’re bleeding, and realize you need to be more careful with the papers you’re handling.

Yet sometimes, the body decides it’s more important for your survival to block out those pain signals– for example, if you’re a soldier in battle who has been badly wounded, but still needs to get out of the zone of fire. In those crisis situations, people can feel no pain at all, because of the nervous system’s own inhibitory mechanisms.

Of course, these systems do not always work perfectly. Research suggests that in people with fibromyalgia/chronic pain, the inhibitory pathways might not be working properly, which is why they seem to experience more pain in response to non-harmful stimuli than do other people.

It’s not only that the nerves sending messages about pain are working overtime (which they definitely can!). But the other piece of the puzzle is that the nerve cells responsible for reducing some of those pain signals are underactive.

I’ll be discussing this more in Part 3. Stay tuned!

The beautiful photo at the top was available through a Creative Commons license thanks to Charis Tsevis/Harrison & Star

Medication picture courtesy of Steve Smith

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Nervous System Basics

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As I’ve said time and time again, I really feel that people living with chronic pain/fibromyalgia can benefit immensely from learning about how the body works. Even the feeling that you are just beginning to understand the complex processes making up your experience of pain can help give you a sense of control over things.

And reading about the new research that is being done on pain, even if you don’t completely understand every word, can sometimes give you a reason to remain hopeful at times when you’re feeling stuck.

With that in mind, I’m going to back way up and publish a post I’ve been meaning to write for a very long time.  Here I’ll outline a few key terms and concepts about how the nervous system works. Hopefully it will be helpful to anyone who is interested in learning more about pain.

So let’s get started.

The nervous system can be divided into two main branches.

Photo courtesy of the Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013.
Photo courtesy of the Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013.

The central nervous system consists of the brain and spinal cord, and is shown in pink in the diagram above.

The peripheral nervous system consists of all the nerves in the body, and is shown in yellow.

The brain is the command center for your body, and it is where your experience of pain is processed. It is where you think consciously, but it also controls many unconscious functions, such as breathing, your sense of balance, and the ability to orient your body in space.

The spinal cord is the relay system for messages between the brain and the peripheral nerves. (It can also play a role in affecting how strong your ultimate experience of pain is, but we’ll talk more about that later).

The peripheral nerves have two main jobs:

Sensory: Sensory nerves send signals to the central nervous system about what you are feeling physically. When you stub your toe or get a papercut, it’s sensory nerves that send that signal up your spinal cord to your brain.

Motor: This is (to me) a kind of funny scientific word. It really just means “movement.” The motor nerves of the peripheral nervous system are what tell your muscles to move, as well as tell your organs to perform specific functions.

Pain

When people talk about how pain works, they are generally talking about the relationship between the sensory nerves, the spinal cord, and the brain. The sensory nerves send signals up to the brain about any damage that may have occurred, and the brain decides how to interpret those signals.

But Pain is a Two-Way Street

Historically, people considered this pain pathway to be a very consistent, cut-and-dry system that always worked the same way every time. If a person was in a lot of pain, they had to have a lot of physical damage/injury. If they weren’t in very much pain, they must not have a very serious physical problem.

However, scientific advances in the past few decades have shown that pain is actually much more complicated than that. It turns out that the severity of a person’s pain does not always reflect accurately the amount of physical injury they have experienced.

You can have soldiers in battle who do not even realize they’ve been shot– their peripheral nerves are sending very strong messages of “damage” up to their brains, but their brains tune those signals out because they need to focus on survival.

Conversely, you can have people with chronic pain, who– due to a number of potential factors—can experience excruciating pain in response to a very minor injury, or in fact no injury at all.

Central Sensitization

At the risk of boring my long-time readers, let me define one of my most favorite terms again.  Central sensitization is the process responsible for this last phenomenon, where people can develop an increased sensitivity to pain.

The term refers to a series of changes that can take place in the central nervous system (the brain and the spinal cord) which can ultimately make a person much more sensitive to pain.  In some cases, central sensitization can become a self-perpetuating phenomenon, in which a person continues to feel pain long after their initial injury has healed.

Central sensitization is such a fascinating topic.  There is still much research to be done on it, but so far it is believed to play a role in such seemingly-diverse conditions as fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, temporomandibular disorder, and many others.

One Last Thing

When I first started trying to understand the amazing, interesting new research that’s being done in pain, I kept hitting this one term that mystified me.  The dorsal horn.  What the heck is a dorsal horn?  I was so confused by this for a long time, and it really held me back from understanding a lot of articles.

Turns out, the term dorsal horn refers to an area in the back of the spinal cord.  The back of the spinal cord is where the sensory nerves meet with the spinal cord, so their messages can continue on up to the brain.  It’s pretty simple actually– the sensory nerves connect with the back of the spinal cord, and motor nerves connect in the front.  So when people talk about the dorsal horn, they are  talking about where sensory information is entering the spinal cord and then being relayed on up to the brain.

For more info

If you want a really great overview of the divisions of the nervous system, I highly recommend this video.

Conclusion

I really hope you’ve enjoyed this post!  As you can see, it’s written in a very different tone, and for a very different target audience, than my previous post.  I’m still in the process of figuring out what type of post works best on this blog.  I really want to be able to write about advanced scientific concepts for every day people, and I’ll probably be trying to figure out the best way to do that for a while. Your thoughts/comments/suggestions are always welcome, so please let me know if you have any! Thanks!

Top photo courtesy of Geralt at http://pixabay.com/en/nerves-cells-dendrites-sepia-346928/

Treating Chronic Pain as a Two-Way Street, Part 2

Continued from Part 1

The nervous system has a system of checks and balances that ultimately determine how strong a pain signal is experienced by the individual. Different parts of the spinal cord and brain can play a role in either magnifying or weakening the pain signals traveling through them.

How a pain signal is amplified or dampened depends on a lot of factors (the person’s chemical makeup; genetics; personal history with accident and injury; emotions; context; whether or something else is happening at the moment that’s more important– aka why soldiers in battle can be shot and feel no pain).

One theory posits that chronic pain patients no longer have the same signal-weakening mechanisms that healthy individuals have. This is why they feel things, much more strongly, that might not really register to another person.

This is why, in many cases, I feel as though it’s misleading to talk about chronic pain as though it’s “in” the nervous system; that it’s something the nervous system is just coming up with on its own.

Instead, I think a lot of what chronic pain sufferers feel is pain signals which would be present in anyone– it’s just that in chronic pain sufferers, the pain signals are magnified, while other people might never register them consciously.

Now, this is not definitely not true all of the time.  Research has proven that physical injury/pathology is not necessary for pain.  After all, someone suffering from phantom limb pain where his leg used to be does not still have a leg to have a physical problem in!  But I do think it is possible that it’s the case, in chronic pain patients, more often than some authors realize.

So why don’t we try to stop those pain signals, which helping to perpetuate the chronic pain cycle, from starting in the first place?

Think about what it took to trigger the process of central sensitization in the first place. It’s usually caused by some kind of traumatic physical event. I think it’s a little idealistic to assume that people are always going to bounce back into mint condition three to six months after an injury/illness/surgery and not have any structural reasons at all for pain.

Yes, a tight muscle here or there might not be “painful” enough to consciously register to patients in the general population. But when we’re talking about central sensitization, the criteria for what is “significant” enough to become painful is pretty low.

And if the point is to get the person’s nervous system to calm down, wouldn’t it make sense to try to calm down the thing that’s happening at the very start of the whole signaling cascade? Why not approach the problem by dealing with both the end and the beginning of the cycle?

Now, I get why some treating professionals have downplayed the idea of approaching treatment from this angle. When you’re trying to convince a person that a muscle spasm or a trigger point isn’t “dangerous,” you don’t want to turn around and make it sound like you’re worried about it. If you alarm the person, you’re going to cause his or her nervous system to leap back into action, cranking his or her level of pain back up.

But what if it was possible to educate the patient on pain, and what is and isn’t dangerous, and explain that a muscle spasm isn’t really dangerous at all… while still acknowledging that he or she might be in less pain without the muscle spasm starting the cycle off in the first place?

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I’ve got a lot more thoughts on this subject, but I want to hear your thoughts.  Did you ever feel like you had a doctor, physical therapist or other medical professional who had great advice to give you about living with chronic pain, but didn’t seem to have much interest in looking for any potential physical reasons for your pain? I’m curious… let me know!

Treating Chronic Pain as a Two-Way Street

Many of the books/articles/talks on chronic pain that I’ve seen tend to make big promises about how much better your life will be once you learn to “manage” your chronic pain.

This is true both of sources I really respect (which acknowledge how nervous system function can change over time) and those I don’t (those that take a purely “psychological” approach to dealing with pain).

The general idea is the patient starts out totally screwed up, in a ton of pain, and afraid to do even the simplest things with his or her body.

Then treating professional swoops in with all of his medical knowledge and educates the patient on how he or she doesn’t really have all that serious an injury. The patient then works through his or her “anxieties” and “fears” about pain, and realizes there’s nothing physically wrong in his or her body, and then is able to resume the normal activities of daily life.

But honestly, I don’t think it’s always this simple, for a couple of reasons.

Central sensitization is an automatic physiological process that is out of our control. I was going to refer to it as unconscious, but even that term makes it sound like it’s somewhat psychological, and it’s not. It ‘s only as psychological as our body developing a tolerance to a certain drug, or our heart beating faster when we’re stressed out. It’s not a “mental” thing. If you want to understand it, you’d be better off taking a chemistry or a neuroscience class than you would a psychology class.

When nerves get a lot of practice sending pain signals, they become better at it. And they require less stimulation in order to start sending those pain signals.  (And if you’re new to my blog, you might want to back way up and start here!).

Some of the researchers I discuss on this blog, who have done really pioneering work on pain, have found great ways to help chronic pain patients using metaphors to describe pain as a protective mechanism. Somehow, they’ve found a way to tap into the part of the pain circuits that actually do involve conscious thought , and help the patient experience a reduction in pain by educating them on what is and what isn’t dangerous. I’ve experienced this reduction in pain myself, and I am so, so grateful for it.

But the nervous system, and the way we experience pain, is incredibly complex. No one– not even the people who spend their lives researching pain– truly understands the whole picture, because the whole picture has not yet been mapped out. There are so many different aspects of the brain and the spinal cord and the nerves that people are still researching– different cells and their different roles; the different receptors on these cells; the different chemicals they use to send signals. It’s misleading when some authors imply they can completely “fix” a problem that no one completely understands yet.

Yes, you can tap into one part of the pain cycle with patient education. And sometimes that is going to have a dramatic and life-changing effect. But at the same time, that isn’t going to change the fact that a nerve which finds itself constantly sending pain signals is going to become more efficient at sending those signals. You might never be able to completely eradicate the root of the “problem,” because the problem itself is a basic physiological function.

If that person’s nervous system still has a reason to be sending pain signals, the cycle might never completely end.

This brings me to my next point. Many of the sources I’m referring to tend to discuss pain as though it is either caused by a physical injury (“tissue damage” is the phrase that seems to be most commonly used) or else is an unwanted function of the nervous system.

Some authors imply that if the patient is still in pain 3 to 6 months after the “tissue damage” occurred, then his or her window of healing must have concluded, and any remaining pain must be “in” the person’s nervous system.

But I don’t think it’s such a black-and-white, either/or phenomenon. Instead, I think that a lot of the time, people experiencing chronic pain are experiencing a magnification of pain signals which would be occurring in anyone…

Continued in Part 2!

Everything in moderation, even the best things

This is a really well-written post on an important subject from The Sports Physio.

It is by a physiotherapist, intended for other physiotherapists, but it was also really meaningful to me as a patient. (For my readers in the US, physiotherapist means the same thing as physical therapist).

The author, Adam Meakins, talks about how many physiotherapists are now jumping on the “bandwagon” of viewing chronic pain as a function of a sensitized nervous system.

This is obviously a really important concept to be aware of.

My entire life changed for the better when I finally met a physical therapist who could explain to me that the pain I’d been feeling for so long, which all the other medical professionals were telling me was psychological, was actually due to changes in nervous system function.

But it is possible to take this idea too far—to be so excited about the fact that now you have a straightforward explanation for some patients’ complicated, ongoing pain that is also new and exciting—perhaps, in some cases, even “trendy”—that you overlook other things that could be going on.

Basically, before physical therapists knew anything about the phenomenon of central sensitization, they figured that all pain must be caused by a biomechanical or structural problem in the body. For example: the patient has flat feet and needs orthotics. The patient has a slight difference in leg length. The patient sprained his or her ankle and has scar tissue left over that must be massaged away.

However, as anyone who is educated on the complexities of chronic pain can tell you, there hasn’t always been sufficient evidence to back up these ideas. As Meakins explains,

“… thousands of therapists (are) realising that the traditional postural, structural biomechanical model just doesn’t seem hold up to scrutiny or to the evidence base anymore, and that pain isn’t just due to these factors.”

In the case of chronic pain patients, pain is often being perpetuated by a process within the nervous system, rather than a physical, structural problem. And you, as the treating professional, can achieve miraculous results by educating this person on how their nervous system is playing a role in maintaining their level of pain.

This is why many PT’s now speak somewhat disparagingly about the older, traditional “structural, biomechanical” model.

But when you are too quick to write off the idea that a patient might also have structural issues contributing to their level of pain, you might miss other factors that could be contributing to their pain.

This also happened to me. The PT that first taught me about pain and the nervous system—who, again, changed my entire life for the better—did take these ideas a little too far.

As much as he helped me figure out the mysterious pain that had been plaguing me, in one part of my body or another, for years, he also second-guessed my orthopedist and told me I didn’t have chondromalacia patella in my right knee. And this had overarching, years-long consequences for me, as I ended up injuring that knee to the point where the chondromalacia patella was excruciating and I could barely walk.

Along similar lines, Meakins tells the story of a patient who was diagnosed with Complex Regional Pain Syndrome, after breaking a leg. Her pain stretched on for months and months, and she was told “she would need extensive cognitive rehabilitation and medication for her pain.”

She later sought a second opinion, and it turned out she had physical damage (an osteochondral defect, specifically) that hadn’t healed.

I’ve also noticed a tendency for non-medical professionals to also jump on this bandwagon, without appreciating the other factors that can cause pain.

For example, I have certain members of my family who tend to assume whatever happens with my physical issues is somehow my fault. If I can’t do something, I haven’t tried hard enough. If I do something that makes the pain worse, I’m trying too hard.

Once these family members learned a little bit about how pain can be caused by changes in the nervous system, they started getting angry at me for “giving in.” For not “fighting” the pain hard enough (even though that is exactly what you’re NOT supposed to do when dealing with a problem of this sort. You’re actually supposed to be gentle with your nervous system to allow it to calm down).

And the articles they’ve read by medical professionals dismissing the biomechanical model have only given them ammunition to tell me I don’t have a real problem.

I think this is why I’ve been so reluctant to really talk about the specifics of my sacroiliac joint issue on this blog. I know that some of the pain, of course, is likely being magnified by my nervous system. And I’ve done so much reading on the workings of chronic pain, and the failures of the traditional structural mechanical model, that it’s made me a little bit hesitant to say hey, I think I really have a structural problem here.

But the truth is: I really do think it’s a structural problem. The irony is that it doesn’t actually hurt that much, not in the joint itself. What hurts is all the other areas that have to compensate when I’m limping. When I really stop and think about it, my problem doesn’t even feel like pain, in the truest sense of the word. It actually does feel like a structural problem.

So I’m going to stop apologizing for this problem, and stop doubting its veracity. None of the medical professionals I’ve seen at this point (which includes three physiatrists, seven physical therapists, and four chiropractors) have actually told me I don’t have a problem.

I think we all need to take a step back and realize that while the recent advances in pain science truly have the potential to change patients’ lives for the better, everything– and I do mean everything– is best in moderation.

“Build Me Up from the Bones”

Ever since I heard this song title a few months ago, I haven’t been able to get it out of my head.

Build me up from the bones.

That’s basically exactly what I’ve been doing.

Obviously, it’s intended as a metaphor, and I’m sure the song as a whole deserves its own analysis.  But for me, the title itself is  perfect.

The more knowledge I’ve acquired about the human body, the more I realize that most of the problems I have now are due to lack of muscle strength.

The compartment syndrome when I was 17—that was something else. That was overtraining (too much running, followed by standing up for too many eight-hour shifts at Starbucks) combined with flat feet and no orthotics, combined with eating disorder and lack of nutrition.

But everything since then—that’s all been the indirect result of muscular atrophy.

I first learned about atrophy when my friend fell in second grade gym class and broke her arm. I remember the gym teacher telling us then (after the ambulance had taken my friend away) that when she got her cast off in a few months, her arm would look small and shrunken compared to the other arm.

The teacher explained that when you don’t use a muscle at all for a very long time, your body lets it get weak because it doesn’t think you really need it. And that it can happen quickly– really quickly. That it would take my friend a lot longer to do these exercises to build her arm back up than it had taken for her muscles to get weak with the cast on.

That concept—atrophy—scared me so much when I first learned about it then.

But when it actually happened to me, it was gradual. I didn’t really notice the rest of my body getting weak, because it was overshadowed by so many other problems (namely the compartment syndrome itself, and the problem of needing to locate a chair everywhere I went).

If I could go back in time, I would have joined a pool. Actually, I would have belonged to a pool for the entire time I was running cross-country and track, and done a few workouts a week in there. That’s something a lot of professional athletes do—you can get just as good a cardiovascular workout, and a good strength training workout, depending on what you do, and the risk of injury is just so much smaller.

(In retrospect, I’m not sure how much my coaches would have gone along with that. They were kind of old school—the team was supposed to work out as a unit, every day, and exceptions were for people with injuries, not people trying to prevent them.   But again, if I was to go back in time, knowing what I know now—well, things are just so different now. Let’s just say I wouldn’t have taken no for an answer, but I’m also so much better at advocating for myself now that it probably wouldn’t have come to that).

Regardless, maybe if I’d been working out in a pool all along, I might have managed to keep all the muscles in my body I wasn’t really thinking about– back, shoulders, trunk/core– strong, despite the fact that I couldn’t really use my legs.

I didn’t actually feel the atrophy as it happened. I felt like I was choosing not to use my body to do certain things because of pain, not because of weakness.

But when I threw my back out, a month after my leg surgery—that probably wouldn’t have happened if I hadn’t come so weak.

And that, in turn, is when my nervous system really went crazy—which of course, started off its whole chain of problems, which of course my regular readers already know about.

But I’m coming full circle now.

I’ve addressed the pain—or, more specifically, learned how to address it. (This process of learning to manage chronic pain—it’s not something you do once and are done with. It’s about learning how to think. The knowledge that the more you feel you have control over what’s happening in your body, and that you truly understand what could be causing the pain—that’s an equilibrium that you must continually strive towards and re-create).

And now I see the underlying problem– that I am weak. Less now, of course, now that I’ve been working out in the pool for so long. But nowhere near as strong as your ordinary, average person who might not work out regularly, but has never had an extended period of time where they had to stop using their body.

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When I first started to voice my idea of becoming a physical therapist, there were actually quite a number of people who discouraged me.

“But it’s such a physically demanding career,” they would say. “Can you do that?”

And yes, I’ll be honest—sometimes that question makes me a bit nervous too.

But there’s no reason I can’t get strong again. I am lucky not to have anything wrong with me that is permanent. I just need knowledge.

When I took Kinesiology last summer, that was the point at which everything started to click for me. I learned about the motions each joint of the body can perform, and how the different muscles work together to produce that movement.

I started to understand why some of the exercises I’d been doing hadn’t helped that much, and I actually began to see holes in some of the exercise programs past physical therapists had given me.

I realized how specific muscles can be.  Especially relevant to my case were the muscles of the back and shoulders. You can be doing two almost identical motions with your arm, but a ten degree difference in the angle your arm is at can completely change which muscles are working.

I’d never known things were that specific. I’d always progressed through my back exercises based on my level of pain, doing the easiest, least painful exercises first, figuring I’d work up to doing the tougher ones after a few weeks.   What I know now is that those easy exercises were never going to prepare me for the harder ones, because they simply weren’t working the same muscle groups (despite how similar they all seemed).

It’s frustrating– I’d always told my physical therapists what I was doing, and none of them ever warned me the plan might not work.

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Part of the problem, I believe, is the physical therapy model (at least, in the United States) where the therapist can only focus on one specific diagnosis or part of the body at a time. This means that your physical therapist has to send you back to your primary care doctor, to get a new prescription and a new insurance authorization, just to be able to answer a question about a different part of the body than what they were treating.

Now, all the PT’s I’ve seen haven’t been like that. But there were enough, over the years, that I’m sure it cost me a lot of potential progress.

All of my various diagnoses had the same underlying problem—I was weak and extremely out of shape. Treating each problem one by one wasn’t going to stop the next problem from developing.

I have a great physical therapist now, who is able to think abstractly, and answer all of my questions about strengthening various parts of my body. And that is the kind of physical therapist I would like to be for other people.

The type who understands that strength is important—overall strength. And that you aren’t really helping the patient if you help them strengthen one part of your body, but leave the rest totally weak.

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So now I’m strengthening everything.

The problem is not, primarily, my sacroiliac joint (although that’s obviously what causes me the most grief right now).

The problem is that my muscles are not strong enough to hold my sacroiliac joint securely into its proper alignment.

I’ve had to completely change how I think about my physical problems. When I work out in the pool, I’m not just focusing on fixing my SI joint, or my knees.

I’m troubleshooting.

I’m strengthening everything. Every major muscle group, and every major joint motion. (At least, as best as I can).

I’ve finally broken through the mysterious veil of pain that clouded everything I did, and made me afraid, and made all my physical therapists think I needed psychotherapy.

And now I’m back. I’m building myself up from the bones.  I will get there, to the level of strength I should have had all along.

 

Examined Life: Judith Butler & Sunaura Taylor

This is an amazing excerpt from the film “Examined Life” in which Sunaura Taylor, artist and disability rights activist, and Judith Butler, critical theorist, go for a walk and talk about disability, gender, and the politics of inclusion vs. exclusion.

Their conversation is so interesting that I really don’t need to write anything else, but I can’t watch this and not jot down some of my favorite quotes and ideas…

On Visibility:

In the beginning of the segment, Taylor explains:

“I moved to San Francisco largely because it’s… the most accessible place in the world. …The physical access—the public transportation is accessible; there are curb cuts most places… buildings are accessible… this leads to a social acceptability. That because there’s physical access, there are simply more disabled people out and about in the world and so people have learned how to interact with them and are used to them…. Physical access leads to social access; an acceptance.”

Taylor described how, when she had previously lived in New York City, she would sometimes go into a coffee shop and carry cup to her table in her mouth, but it wasn’t always worth it because of the unwanted attention it attracted.

On the Expectations of Others

This brought Taylor and Butler to the question: Why do people get so upset with someone who doesn’t use a body part in the way that we assume it’s attended?

Butler notes the parallel here to gender studies, which asks: why do people get so upset when someone’s body doesn’t fit our ideas of what a man is, or what a woman is?

What Kind of World Do We Live in?

Taylor explains that she considers it a form of political protest for her to go into a coffee shop and ask for the help she needs. Ultimately, this form of protest poses the question: Do we or do we not live in a world where we help each other?

Butler explains:

“My sense is that what’s at stake here is rethinking the human as a site of interdependency.

I think that when you walk into that coffee shop, you’re basically posing the question ‘Do we or do we not live in a world in which we assist each other? Do we or do we not help each other with basic needs?

And are basic needs there to be decided on as a social issue and not just as my personal individual issue, or your personal individual issue…?”.

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I related to this clip on so many levels. Although much of my blog is about my experience with pain, there have been many periods of my life when I also had to deal with a level of disability, albeit in a much more temporary and transient sense. This only gives me a temporary glimpse into what someone with a life-long disability goes through, but I could definitely identify with some of the perceptions and emotions Taylor and Butler shared.

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My saga with the sacroiliac joint

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So, let me start out by saying that I feel totally crazy writing some of this.

Most of what I write about has a good deal of scientific research to back it up. I take this very seriously, because the internet can be a such cesspool of conspiracy theory and misinformation.  The last thing I would ever want to do is be the kind of blogger who adds to that.

But I don’t really have many scientific facts to back up this post with. And it’s not for lack of trying.

Since this ordeal has started, I’ve seen one orthopedist, five physical therapists, and two physiatrists (the word is confusing, but their specialty is Physical Medicine & Rehabilitation, not Psychiatry).

I’ve also spent a long time trying to find information about the sacroiliac joint online. Google searches turn up next to nothing. And searching the publicly accessible scientific databases such as the National Institutes of Health only turns up articles about people who seem to have different problems than me.

So I’m just going to write this based on my own experience.

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This post picks up after where I left off in “How a physical therapist helped me through my lowest point, Part 8.”  In that post, I talked about how I was developing chondromalacia patella in my right knee, and that it was made worse by the fact that my physical therapist told me the pain wasn’t significant and that I could try to ignore it.

After a few months, things had gone from bad to worse and I was limping almost all of the time.

And, after weeks of limping, came the first time one of my sacroiliac joints locked up.

I was walking along, just minding my own business, when I felt this strange sinking feeling in the back of my left hip. The sinking didn’t hurt, but it was followed immediately by a “catching.” And the catching did hurt.

And once whatever it was that was caught had caught, I could barely lift my leg. Like, I could barely get it off the ground high enough to put it down in front of me. Going up stairs normally, even small ones, was out of the question, because I literally could not get my left leg high enough to place it on the next step, let alone put any weight on it once it was up there.

I had been seeing a chiropractor for a while at that point, because all the exercises I’d been doing in PT had made my lower back to start to hurt.

I went in that day, and he told me right away that it was my sacroiliac joint. I’d only heard of this joint in passing before—just one more word on the diagram in my anatomy and physiology class. It hadn’t even seemed like an important enough joint for us to talk about it at all in class.

It didn’t take him much time at all to click away with his activator and get the joint to fall back into place. I was able to walk out of the office normally, although it was a day or two before I was brave enough to try using that leg normally on stairs.

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A few weeks later, the same thing happened on the right side. I was getting ready for a quick chiropractor visit before I had to drive to class that night when I experienced the same sinking and catching feeling. I felt as though I had a stilt under one leg, although which leg felt like it had the stilt under it kept changing.

I rushed off to the chiropractor, only to have the secretary tell me he was running late. I realized I didn’t have time to wait for him and still make it to class in time, so I burst into tears in the waiting room. It was pretty embarrassing.

Luckily, he came out from the treatment room he’d been in and saw me in tears, so he fit me in.

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This was the beginning of the absolutely crazy pattern I’ve been caught in for the past few years.

I feel crazy, because I’ve fallen into the exact kind of trap that so many people with chronic health problems fall into, and it usually isn’t productive.

I’ve come to count on one type of health professional to help me—and it’s not one that is generally well-respected by mainstream medicine. And I’m not getting the same explanation from him that I’ve gotten from all the others.

But in this case, the thing is… I didn’t really get an explanation at all from any of the others.

And I don’t feel like I was asking them anything super outlandish. Again, this is a joint you’ll find on a basic diagram of the skeletal system. Like, anatomy 101.

I wasn’t asking them to give me their opinion on specific acupuncture points, or the merits of reflexology. This joint is something they’re supposed to be able to help people with.

But it seems like most of the literature and treatments that I found in my attempts to find scientific information with have to do with a sacroiliac joint that is painful. Or inflamed. Or “unstable,” which is the term that means the ligaments that are supposed to hold it in place are too stretched out to do their job.

I couldn’t find anything about what to when the sacroiliac joint becomes stuck.

The ilium, which is the very back of the hip bone, is supposed to line up perfectly evenly with the sacrum, which is the base of your spine. In my case, assuming my chiropractor is correct, my ilium is getting stuck too far back, behind the sacrum.

All of the papers I read, after describing problems that I didn’t sound like mine, concluded with the phrase “further research is needed.”  It was clear that the authors didn’t feel like their results were definitive enough to make a clear pronouncement about the sacroiliac joint, one way or another.

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I’ve spent so much time living with this problem, I can feel it the second my SI joint starts to lock up.

Once in a while it will turn out to be a false alarm– I’ll move in a way that sets off the old familiar pain, and I’ll freak out, but an hour, I’m still able to walk normally.

But all too often, it’s not a false alarm– I feel the catching sensation, and then no matter what I do, I’ll be limping for days, until I finally give up and go back to the chiropractor.

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So this is the trap I’m in. I still go to a chiropractor several times a month.  Once my hip has become caught in that peculiar way, a chiropractic adjustment is the only thing I’ve found that can make it become unstuck.

Meanwhile, I’m reading all these other blogs by people I really respect, who’ve turned out to be right about a lot of other things, who all say that chiropractors are at best misguided, and at worst, con artists.

I’m still waiting to find out that I’ve been completely wrong about the whole thing. That maybe my chiropractor was wrong, and that I didn’t feel exactly what I’ve been feeling.

That maybe the “sticking” feeling isn’t always coming from the joint itself.  That maybe my muscles are just tight, and something about the chiropractic adjustment is loosening them.

That’s why, from time to time, I check in with other medical professionals. But surprisingly, none of the people I saw told me to stay away from chiropractors. Both of the physiatrists I saw actually expressed admiration for someone who had enough expertise to be able to manipulate a joint that was, to them, still quite mysterious.

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The only helpful article I’ve found about the sacroiliac joint, EVER, is this one by Roger Cole.

He explains that in many people, the sacroiliac joint becomes fused as they age. This is particularly true for men, starting around age 30. By 50, almost all men’s sacroiliac joints have become fused.

This means that the two bones, the sacrum and the ilium, fuse and become one bone.  The joint no longer moves at all.

But in women, particularly younger women, as well as people who’ve retained a lot of flexibility through yoga (which, he points out, might not actually be a good thing) this joint tends to remain unfused.

This is one reason why the medical profession might not have a good handle on this joint. Up until recently, it was pretty much only men studying anatomy, contributing to medical textbooks, and practicing medicine. And by the time they’ve actually become successful doctors and surgeons, these men’s own sacroiliac joints have completely fused.

And even for women like me, it seems like most of us need to have some kind of precipitating event to have issues with this joint.   My web research tells me, at least anecdotally, that it seems to most commonly affect women during and after pregnancy.

I don’t think any of my readers will be too surprised that a problem that disproportionately affects women might not have received enough attention from the medical establishment.

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So basically, my plan now is just get stronger.

It’s actually my main chiropractor, Dr. K., who first convinced me to join a pool and stop working out land.

For months, after I had first come to him with a locked up sacroiliac joint, he started telling me that getting stronger would be the only way I’d get better, and stop this problem from happening.

I had all kinds of reasons why I didn’t want to join a pool, but in retrospect, this problem would not have gone on for nearly as long if I’d just stopped the land exercise and joined a pool the minute my knees started hurting.

So for those who are inclined to think of chiropractors as con artists, Dr. K. really got on my case about joining a pool.  He made it clear to me that his adjustments would only help in the short-term, but in the long run I was going to have to get stronger.  And that the only way he saw me doing that was in water.

Over time, he got progressively more emphatic:

“Just go online and see what gyms around here have pools.”

“Just make one phone call about joining.”

“Just go in person and check out one pool.”

Finally I did, and I’m still kicking myself (or I would be, if my joints could move) for not doing it sooner.

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Since I’ve been working out in water for about a year and a half now, I am a million times better.  I haven’t completely stopped my SI joints from “sticking,” but now that I am stronger, they don’t “stick” quite as badly.  It also just doesn’t bother me quite as much when they do, because I have more strength in other areas of my body to compensate with.

So I am not out of the woods yet, but at least I feel like I am learning.

As I’ve promised in previous posts, I plan to be writing more about the specifics of my exercise program, as well as the exercise science concepts that I think are really useful for anyone with chronic pain and biomechanical dysfunction.

Stay tuned!

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Sunlight in the Kitchen

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Here’s something you probably didn’t know about me:

As much trouble as I’ve had with chronic pain over the past ten years, I’ve had almost just as much trouble with digestive issues.

I haven’t written about those issues yet for a few reasons.  For one thing, they’re embarrassing.  Really embarrassing.  I’d much rather talk about running injuries and muscle pain.

For another, I wasn’t sure how many different topics it would make sense to talk about on one blog.

But digestive issues, such as irritable bowel syndrome, are actually pretty closely related to fibromyalgia.   From the time I’ve spend interacting with other bloggers, it seems like most people with fibro have some digestive issues.

I happen to know a little something about all of that.

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In the past ten years, I have been through six gastroenterologists, four nutritionists, and four pelvic-floor physical therapists.

I didn’t find any answers at all until I met my fifth gastroenterologist in 2011.  Even then, what really made the difference is that I had started doing a lot of my own research about what I thought might be causing my issues, and this doctor was open-minded enough to humor me.

At that point, I finally started to figure things out.  None of my issues turned out to be terribly rare, or even hard to diagnose.

It was simply that I had fallen through the cracks– that I was a young, relatively healthy-looking woman, and that the first four doctors I saw found it easier to write my problems off as being caused by stress, rather than ordering some pretty basic testing.

The fact that I had fibromyalgia made it even more likely that these doctors would write me off, because pretty much every medical person knows that these issues are so closely connected.

But just because there are connections between fibromyalgia and irritable bowel syndrome does not mean that treating one will automatically treat the other.  And just because a patient has fibromyalgia does not mean there cannot be other causes and contributing factors to her IBS.

So I have decided to start sharing my experience with digestive issues with others.  To raise awareness about the basic things that most gastroenterologists and other health professionals already know, yet don’t always bother to investigate with their patients.  Once you know about these potential issues, and the tests that can be done to diagnose them, you can begin to take charge of your own health.

I have decided to write about these issues on a second blog, simply because I don’t want to completely overwhelm the people who are already following this one.  I plan to post a lot of recipes/cooking inspirations on the new blog, which I know might not interest every single follower here (and that’s totally ok!).

I hope you will check out my new blog, Sunlight in the Kitchen.

**Strawberries photo courtesy of Sharon Mollerus**

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The benefits of swimming in cold water

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Today, Ruby shocked me by taking her first swim of 2014.  It was awesome.

As you may remember from my previous post about her, Ruby is my family’s 14-year-old Lab mix (she’ll be fifteen in July!).  She is a spunky, spirited dog, but due to some benign tumors in her left hip, as well as arthritis, she is in pain almost constantly.

We’ve done the best we can to keep her pain in check with medication and reassurance, but you can still very easily see how much pain she in.  She limps, often keeping her back legs together and doing a “bunny-hop” to get up the front steps.  She is usually in too much pain to come upstairs at night, so every night I sit and talk to her until she falls asleep at the bottom of the stairs.

But today– well, Ruby simply had an amazing day fetching sticks and walking around the fields at our favorite spot.

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Fetching sticks out of the water… Ruby’s all-time favorite pastime.

Of course, it helps that the weather is finally warmer (trust me, we New Englanders were starting to collectively lose our minds after this completely absurd winter!).  But what I really think made the difference for her today is the benefits that come from swimming in cold water.

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Swimming in the cold isn’t really fun, at least for humans.  Part of the reason I took so long to start working out in a pool after first hurting my knee a few years ago is that when I first tried it, I couldn’t get over how cold it was.  Here I was, trying to warm my muscles up enough for them to loosen up, and I couldn’t stop shivering.  My teeth were chattering audibly.  What the heck.

But when I finally started doing it regularly, I was amazed to find it made an incredible difference in my pain.  Here are the reasons why:

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#1: Reducing blood flow

When you immerse yourself in cold water, it causes the blood vessels in your extremities, particularly those which are the closest to the surface, to constrict.  This is because your body is trying to send as little blood as possible to the periphery of your body, and keep more blood in the center of your body, to help keep your core temperature warm.

From an evolutionary perspective, this is because if we’re trapped out in the freezing cold, or we fall into a freezing lake, it’s essential that we keep our internal organs working.  If it comes down to it, we can survive without a few fingers or toes.  We absolutely cannot survive without a liver.

Of course, when you’re simply swimming in a chilly swimming pool, you’re not anywhere near the point of developing frostbite.  But the minute your body senses that cold stimulus, it starts that process of constricting your blood vessels, which in turn limits the flow of blood to the periphery of your body.

This means that if you have a particular part of your body that’s inflamed– for example, let’s say it’s your ankle–  you can temporarily stop the cycle of inflammation by reducing the flow of blood to that area.   Your blood is what brings the ingredients for more inflammation to your ankle.  If you reduce the flow of blood, you aren’t allowing those ingredients to come and produce more swelling.  The cycle is temporarily stopped.

#2: Cold slows the rate at which your nerves send pain signals

Anyone who’s ever been outside in the winter without gloves knows this: when part of your body gets cold enough, it will start to go numb.

The pool can be a much more subtle version of this.  I know that after I’ve been in the water for about ten minutes, I’ve totally forgotten about the aches and pains that were a “6” out of “10” all day.

This is because, when your nerves are cold, they simply can’t fire as fast.  This gives your brain a little break from receiving all of the constant input it was receiving, which in turn can have a calming effect. By the time you’ve gotten out of the water, your brain is perceiving your pain differently, and it’s sending fewer messages to the nerves in the rest of your body asking for more “information” about the pain.  Needless to say, this is good.

#3: Cold causes your body to release endorphins

Over the past few years, I have heard of many studies that show our bodies release endorphins in response to cold.  (Endorphins are chemicals produced by our bodies that help relieve pain and improve mood).

I actually have a few friends who swear by taking ice cold showers to improve their mood and help them “wake up.”  Of course, I’m not asking you to go swim in ice water– I think you can get the same effects with mildly chilly water.

This phenomenon is something that is not yet completely understood, so I wanted to be sure to provide links to a few credible studies, rather than simply asking you to take my word for it.  Here is one study that looks at cold as a possible treatment for depression; here is another that examines it as a possible treatment for chronic-fatigue syndrome.  (Don’t worry, I definitely didn’t understand all of the mumbo-jumbo either!).

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I have personally found that chilly water makes a much bigger difference in my level of pain than the heated therapy pool I used to work out in.  The therapy pool was relaxing, but I still felt all of the exact same pain that I had been feeling on land.  When I switched to swimming in a regular pool (which is still heated, just not hot) I was shocked to notice that, after about ten minutes, those pains were almost completely gone.

There are many other benefits that come from working out in water.  They are equally fascinating to me, so of course I will be covering them in future posts.  But for now, I will leave you with this:

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A few minutes after she got out of the water today, Ruby sped up and started to prance.  Completely out of the blue, she was trotting, quicker than I’d seen her move in months.  I could just tell what she was thinking:

“I can move!  Wow!  I can move as fast as I want!  I can’t believe I’m not tired!”

It was true– we hadn’t gone for a walk that long in months, let alone a walk and a swim.  It was clear as day, the expression on her face.

For a moment there, we both got to see just what her body was capable of, if only we provided it with the right conditions.

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What’s going on with me right now

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It’s been a few years now since I first began to understand my pain problem– three, to be specific.

Since then, I feel like I’ve made a lot of progress in terms of how I view pain and my nervous system, and how much trust I have in my body.  Finally, I was able to break the cycle I’d been caught in for years, where where I’d go from doctor to doctor, begging them to explain why I was in so much pain.

Unfortunately, at the same time that I’ve gone through these mental and emotional transformations, I’ve also had some very real physical issues to deal with.

I mentioned at the end of “How a physical therapist helped me through my lowest point, Part 8” that I was developing chondromalacia patella in my right knee, and that it was made worse by the fact that my physical therapist told me the pain wasn’t significant and that I could try to ignore it.

I was 26 when this happened… I’m 29 now.

What happened in the intervening years is so incredibly frustrating to look back upon. I thought my problems were ending when I finally solved my pain problem, but thanks to the chondromalacia patella, things were actually going to get a lot worse before they got better.

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The only way to look back on the past three years without feeling completely powerless is to focus on what I could have done differently, knowing what I know now. Now I know:

If only I’d started physical therapy for the chondromalcia patella sooner, it never would have gotten as bad…

If only I’d known that the cortisone injection wouldn’t be worth it; that all the extra fluid in my leg would put me on crutches for a week…

If only I’d known how quickly I would become weak from inactivity, I would have refused to hold still…

If only I’d known that working out in a pool would be the only option for me, I would have joined a pool right away and not wasted any time trying to work out on land…

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Basically, I started physical therapy for my knees too late. I went to physical therapy and did everything my new PT told me, but all of her exercises weren’t enough to counteract the downward spiral I’d ended up on.

As I would learn, there are two ways to weaken a muscle. One is to not use it at all. The other is to completely overuse it so that it doesn’t have a chance to rest.

I was, unfortunately, doing both of those things. It was excruciatingly painful to put any weight onto my right knee, so I moved very, very little—causing all those muscles I wasn’t using to weaken.

Then, when I did move, I was completely overusing the muscles I could use—aka putting all of my weight onto my left leg and completely overworking the muscles of my left hip.

I was doing everything my physical therapist told me, but I just ended up with even more pain in the front of my left hip, and then my right hip, and then the chondromalacia patella started up in my left knee. Then I ended up with pain in my low back.

And then, about six months after I’d really started limping because of my knee, I developed some issues with the sacroiliac joint (where the pelvis meets the spine, in the low back).

wikipedia SI joint

The sacroiliac joint turned into its own saga, which I will have write about in future posts, because there are basically no helpful articles about it online.

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Things only started to get better for me when I started to work out in a pool, and even then, getting stronger was no easy feat.

I finally feel like I’ve started to figure everything out now; three years later.

It meant I had to let go of a lot of things I’d learned about exercise in the past, and really study some basic concepts in order to help myself.

I had to really learn a lot in order to help myself. It was hard to get help from anyone else, because, as anyone who’s been a patient knows, physical therapists (at least in this country) can only focus on one diagnosis and part of the body at a time.

I didn’t need physical therapy for my knees anymore. Or my hips. I needed to strengthen everything.

I didn’t have just one or two weak links anymore… I literally did not have the baseline amount of muscle that would allow me to walk from one end of the house to another and hold all of my joints in place without pain.  (Both the chondromalacia patella and sacroiliac joint issues were ultimately caused by lack of muscle strength).

So I had to start from scratch. From less than nothing, because I had to find a way to move despite the fact that many of the movements we take for granted were impossible for me.

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Ever since the first time I wrote a description for the “About” section of my blog, I’ve said I planned to write about exercise and fitness. I haven’t quite gotten around to that yet, but now you, my readers, know why I will.

I don’t really plan to write about fitness from a bodybuilding or super-overachiever standpoint. That stuff is interesting, but it’s just so far removed from my daily reality right now that I don’t really have much use for it.

What’s important is the basics. Knowing that if you strengthen a muscle without ever stretching it, you will shorten its resting length. That there is a difference between strength and endurance, and if you only train for one, you will never develop the other. Knowing about this little thing called the Golgi tendon reflex, which will allow you to relax just about any muscle you want just by putting pressure on it (the concept behind foam rolling).

These are things that people with chronic pain can benefit from knowing. When I look back, I can actually see how a lot of my issues with pain—confused nervous system or not—were also related to the fact that I was simply so out of shape from the injuries and periods of inactivity I’d had when I was younger. I mean, yes, I had a heightened pain sensitivity, but at the same time, anyone who was as weak as I was was bound to be in pain. There’s just no way that wouldn’t happen.

I hope the things I’m going to write about will be helpful for you all. I’m going to talk about how my perspective on changed, and how I was able to use what I’d learned from Neil Pearson’s techniques to cope with what I was feeling, while at the same time knowing I had some physical issues that I couldn’t immediately change.

So much has changed in my life, even though all the while to the outside observer, it looks like I’ve been holding still. But that is just so, so far from the truth (sometimes I need to remind myself of that!).

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Maybe everything is amazing

I first saw this Louis C.K. clip a couple of weeks ago, and I’ve been thinking about it ever since. (Be sure you watch until the 3:05 mark, which is where he really starts to make his point).

Studying anatomy and physiology and learning about the body has helped me to get to the point where I can start to appreciate just how crazy/complicated/complex our experience as human beings is.

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A lot of people seem to become intimidated when I talk about taking these classes, and say things like, “Yeah, but I’m not any good at science.”

It makes me really sad to hear people say that, because honestly—there was a time when I didn’t think I would be any good at science, either.

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I did pretty badly in science classes in high school because, well, my life was falling apart. I just couldn’t get it together enough to study enough, and when I did, nothing could really become cemented because I hadn’t really slept.

I did much better in the humanities classes, because it was easier to just wing it. I might have been to out of it to memorize chemical structures, but it wasn’t too hard to just read a novel and give my opinion.

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Then after high school: for years, in the back of my mind, I sometimes thought about becoming a physical therapist.

Originally, the idea was born more out of desperation than inspiration. I was so frustrated by the fact that there was always something hurting, all the time, and that I seemed to have a new physical therapy referral every few months. I was always really interested in the explanations the physical therapists gave me, and always did all my exercises, but it didn’t seem to be quite enough. I sometimes wondered if the only way out of this would be to take matters into my own hands, rather than relying on other people for the rest of my life.

Then I met Tim and watched Neil Pearson’s lectures, and all of a sudden my desperation turned to inspiration. There actually was a reason why I was hurting all the time—an overarching reason that I could work on, rather than targeting different parts my body, piecemeal, for the next several decades. And maybe I could help other people like me, like Tim had helped me.

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This is the point at which I actually started to look into what it would take to get into physical therapy school, and saw that I’d have to take all of the science classes I’d so carefully avoided in college.

Now I am grateful that I had to go back and take all of these classes. And I mean, we’re not really talking high level stuff here—we’re talking general chemistry, introduction to physics. The things you would take in your freshman or sophomore year of college.

Basic as they are, these classes have totally changed the way I look at things.

It’s like recognizing there are two sides to every coin. On one side, I can focus on my experience—the way a certain part of my body feels (or, in most cases, hurts).

If I want to flip to the other side of the coin, I can stop and think about the complex forces that are literally holding this part of my body together. The intricate chemical and electrical signals that sensations to travel from my the rest of my body to my brain, and then back again. And the different areas of my brain that are involved in letting me feel the pain, and determining how much of my attention is devoted to the pain, versus paying attention to other things.

And the thing is—you really don’t need to be an expert, at all, to develop this sense of appreciation. I mean honestly, I know nothing. If I wanted to go into more detail than what I just wrote above, well, I’d have to go open a textbook to make sure I didn’t tell you the wrong thing.

It’s not about mastering this information; it’s just about having been exposed to it, and having a sense of just how complex these things are. Complex, yet also orderly. Yes, we live in a chaotic universe, but our bodies have a blueprint that can be broken down into categories and understood.

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Sometimes I daydream about running a class for chronic pain patients. Not an academic class—more like a continuing ed class.

And we would just go over the very basics from anatomy and physiology. And my students could see that, when you just begin to learn about the body, it’s actually more like a language class than a science class.

Just as you would make a chart of the different parts of speech (past, present, future, etc.) you can make a chart of the major systems of the body. And then you can look at each system and break it down further; for example, you can break the skeletal system down into different types of bones, and then look at individual bones.

And then, as teacher, I would focus on the bones of the spine, since the spine is such a grave, sometimes threatening concept for anyone with back pain. I would explain that even though it looks like some kind of alien invention when you look at a diagram, the spine can actually be simple:

There are four parts of the spine. From top to bottom:

Cervical spine= 7 vertebrae that make up your neck

cervical vertebrae

Thoracic spine= 12 vertebrae in upper- and mid-back

thoracic vertebrae

Lumbar spine= 5 vertebrae in lower back

lumbar vertebrae

Sacrum= fused vertebrae at the bottom of the spine, which make up the center of the pelvis

sacral vertebrae

These terms are things that back pain patients hear all the time, and may even have explained to them. But, in my experience, there’s a big difference between having a doctor mention these things to you in passing—in an appointment where you’re scared of what he or she might diagnose you with—and learning something in a calm academic setting.

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The spine is just one example– there are so many different aspects of our physical being that sound complicated, even scary, when explained by a doctor, but look simple– and interesting– when broken down into smaller categories.

It’s helped me immeasurably to begin to understand this. Having a “second side of the coin” to flip to means it’s easier for me to change my perspective on the physical realities I sometimes can’t change.

Now I can’t think about how much something hurts without thinking about the fantastic nature of how it hurts. The fact that I have a bone, with muscles attached to it, with nerves that let those muscles communicate with this fantastic brain I have—it’s all pretty incredible.

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Favorite Posts from My First Year of Blogging: Part One

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When I first started blogging, I had no idea if anyone would actually read what I had written.  I tried out all different types of posts, including more journal-like entries, pictures, and recipes, as I tried to figure out what type of blog mine would be.

Hitting “Publish” on each one of those early posts was such an adventure for me.  I got so excited about each new “Like” and each new follower (actually, I still do).  And each new comment totally made my day.

It’s fun to look back now and see how the blog has evolved.  Each one of my posts was a learning experiment, and each supportive comment I got was an inspiration, helping me to figure out the direction I wanted my blog to go in.

With that in mind, I wanted to include this little timeline of my favorite posts of the past year.  If you’re a newer reader, you probably haven’t seen most of these posts.  And if you’re an older reader, I’m hoping you might remember some of these posts as fondly as I do.

As always, I am curious what you think.  Was there a particular post that resonated with you, or a certain topic you’d like to know more about?  Let me know!

December 2012

A little bit more about my story—A slightly longer version of my story than what you’ll find on my About Me page.

The Pain Clinic—The story of my very disappointing experience at a highly-regarded pain clinic with a months-long waitlist.

Coffee: A Great Tool for Dealing with Chronic Pain—I am obsessed with coffee, and I swear it helps with my level of pain.  I got so sick of seeing so many “alternative health” sites post warnings about the dangers of coffee, without acknowledging some of its potential benefits.  So I wrote this.Photo12280915

Have you Ever Tried Yoga?  This is meant to be a bit tongue-in-cheek.  Please take it with a grain of salt. :)

Names for chronic pain—This is one of the first posts I wrote, to lay a foundation for the topics I would be writing about later.  It outlines some of the various terms that medical professionals use to describe chronic pain states.

Some of the terms are really helpful and interesting; others are unhelpful, or possibly even damaging to the patient’s chances of getting real help.  It’s good to be aware of both.

Christmas 2012— Just photos

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January 2013

Why You Should Learn a Little Anatomy— Please read this one.  I really think it’s great :)

February 2013

Violins and enhanced sensory maps – about how the same parts of our nervous systems that are responsible for talent and learning are also the parts that can cause us to develop chronic pain conditions.  Pain and talent might be two sides of the same coin.

violin on side

How to Talk about Pain: Central Hypersensitivity– I am always so happy when I read articles by a researcher who really gets it.

Know Your Enemy—I stumbled across an opinion piece on Medscape.com written by a rheumatologist who says he intentionally “weeds” fibromyalgia patients out of his practice because they do not “interest” him.

A Post for Aaron Swartz — In honor of a generous spirit and Internet pioneer.

aaron swartz flickr

So… I Lost an Ovary—The title of this one is pretty self-explanatory.  Ugh, what an awful month last February was.

Beware the Red Herring—Looking at how some medical issues—and the pseudoscientific fads that accompany them—can obscure other more important issues.

That’s it for Part One of this look back.  Stay tuned for Part Two!

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