Month: September 2022

Pain Education Series #5

Admin Good Health

Hello, Zeborah Dazzle, PT, WWF here — spokes-zebra and patient educator for Good Health Physical Therapy. We have been talking about pain over the last four posts, and specifically how, in some situations, the nervous system can become sensitized to keep pain levels stirred up. In these instances, the nervous system itself can be as much or more of a cause of the chronic pain than any tissue damage. When the spinal cord and brain become sensitized, this is called central sensitization.  So, our question is how to calm the sensitized nervous system? The model we use is the Calm Nerve House and the basic pillars supporting the house are Pain Education, Sleep, Exercise and Pacing. However, inside the Calm Nerve House there are a number of other self-care techniques which can be calming. Here are a few: 

MASSAGE

There are many kinds of massage therapy. It is wisest to seek out a licensed (which means trained) massage therapist. As a general rule, massage that hurts is NOT helpful for a sensitized nervous system. Firm but gentle massage though, a session aimed at relaxing you can be very soothing. 

SMOKING CESSATION

 

There are several ways in which smoking can increase pain levels. First, smoking floods the lungs and the blood stream with nicotine which is a stimulant. This leads to a nervous system even more on edge. Additionally, besides the damage done directly to lungs which most people are aware of, smoking floods the lungs and blood with carbon monoxide. This compound attaches to the red blood cells whose job is to carry oxygen to every part of your body. So, besides the risk of cancer and lung disease, smoking has the negative effect of depriving vital oxygen to bone, muscle, connective tissue and nerves. 

DIET

While we will not attempt to give specific rules about diet here, it is very wise to remember that the health of the nervous system depends on good nutrition. There have been some powerful studies done over the last few years looking at what the best diet is for humans, and a good general rule is the adage coined by popular author John Robbins: Eat food, not too much, mostly plants.

Another tip is to decrease caffeine consumption. Caffeine is a nervous system stimulant and will tend to turn up the volume on a sensitized nervous system. 

MEDITATION

In 1975, Herbert Benson MD published “The Relaxation Response.” Dr. Benson showed that relaxation techniques such as meditation have immense physical benefits, from lowered blood pressure to a reduction in heart disease. In his book “Full Catastrophe Living” Dr. Jon Kabat-Zin describes positive results achieved with chronic pain sufferers employing mediation and mindful techniques. Virtually every religious tradition teaches a meditation technique as a form of prayer, but meditation does not need to be a religious practice. (And you don’t have to sit cross legged.)

SELF TALK (THOUGHTS AND BELIEFS) 

Our thoughts, and what we choose to believe, have a strong effect on our nervous system and can either increase or decrease stress leading to increased or decreased sensitization. One of the most single toxic beliefs you can take on is: “This pain will never get better.” A trick is to say “cancel” whenever you think this or any other negative declaration. Then work to replace this thought with a positive one such as: “This will pass.”, “I can handle this.”, or “I am getting a little bit better each day.”.   A counselor or trusted spiritual advisor is often an extremely important part of your care team and can help with beliefs and self-talk. 

HUMOR

Have you ever noticed that you cannot simultaneously feel depressed or anxious or overwhelmed by pain and having a good belly laugh? This is because laughter floods the brain with natural pain killing chemicals (neurotransmitters). So, we recommend that you make funny movies, people who make you laugh, funny stories, jokes and stand-up comics a regular habit. Humor helps, and that’s no joke. 

In coming posts, we will look at other topics including exercise and hypermobility spectrum disorder/ hypermobile Ehlers-Danlos Syndrome. 

I would like to thank Dr. Mark Melecki PT for his assistance with this series which relied heavily on materials he compiled for his physical therapy doctoral project.

Until next post, Cheers! 

Zebbie 

Pain Education Series #4

Admin Good Health


Hello, Zeborah Dazzle, PT, WWF here —

Spokes-zebra and patient educator for Good Health Physical Therapy. We have been talking about pain over the last three posts, and specifically how, in some situations, the nervous system can become sensitized to keep pain levels stirred up. In these instances, the nervous system itself can be as much or more of a cause of the chronic pain than any tissue damage. When the spinal cord and brain become sensitized, this is called central sensitization. So, our question is how to calm those sensitized nervous system?
The best results in therapy often happen when multiple approaches are used in a coordinated plan. The model we use is the Calm Nerve House and the basic pillars of the house are Pain Education, Sleep, Exercise and Pacing. Today, let’s talk more about pacing and exercise – which go hand in hand for us zebras.


PACING
Before we even begin to talk about exercise, let’s stop to consider a question: if the nervous system is sensitized and now a significant part of the pain problem, how did it get that way. The answer to this could be made technical and confusing, but it is basically simple. The brain is a learning organ and it learned to sound the pain alarm from repeated injuries, stress, old traumas, and other factors. So, as we try to calm the nervous system, what we are really saying is that we are trying to help the brain learn something new once again.
In helping the brain to learn something new, the key is pacing. By this is meant, enough movement to push the nervous system and muscular system up to the edge and then back away. We do not want to drive the nervous system up to the point where it sounds the pain alarm. To help to do this, there are three pain rules that are very useful.

  1. No sharp pain. Do not intentionally do anything which causes sharp pain, do not try to push through a sharp pain.
  2. Rule of 2-20. Before you start an activity, ask yourself what your pain level is from 0 to 10 (0 is no pain and 10 means call 911). As you perform the activity, if the pain level goes up 2 points or more above the starting level, stop and take a break for 20 minutes. If after 20 minutes, your pain goes back down, you can do a little more of the activity, not a lot more. If it does not go back down, you are done with that activity for that day.
  3. Above 5. If you are getting ready to start an activity, and your pain level is above a 5, it would be
    wise to seek coaching from your physical therapist about how to proceed. If your pain is right at 5,
    proceed slowly and cautiously and see how your body responds. Apply the rule of 2-20 as needed.

EXERCISE

For physical therapists, exercise means movement. That movement could be lifting weights or jogging or playing basketball for some, but that is certainly not where most people with chronic pain start. Overall, physical therapists working with patients having chronic pain apply gentle stretching and strengthening exercises, building gradually, to help the patient re-establish the foundations of movement. In other words, we want to get you feeling well enough to do the stuff you want to and need to be able to do, like: walk through the grocery, stand at work, dust the book shelves, fold the laundry or whatever basic things your life requires of you.

This means that we look for joints that are moving too much or too little, muscles that are weak or too strong relative to a tight muscle, connective tissue that is too tight. The goal is always to establish strong plus flexible plus minimal or no pain. With a sensitized nervous system, this means finding movements that do not overstress the system (see pain rules above) and then consistently and persistently working toward comfortable movement.

A special word here for zebras like me, meaning those with hypermobility spectrum disorder or Ehlers- Danlos Syndrome. Special attention for us must be paid to building the muscle around joints that are too loose, especially those that pop out. This is the way we will work our way back to comfort. Now that we have described the pillars of the Calm Nerve House, in the next post, we will discuss some additional approaches inside the House that help to calm the nerves.

Until next post, Cheers!

Zebbie

Pain Education Series #3

Admin Good Health

9/6/22 Pain 3


Hello, Zeborah Dazzle, PT, WWF here — spokes-zebra and patient educator for Good Health Physical
Therapy. We have been talking about pain over the last two posts, and specifically how, in some
situations, the nervous system can become sensitized to keep pain levels stirred up. In these instances,
the nervous system itself can be as much or more of a cause of the chronic pain than any tissue damage.
When the spinal cord and brain become sensitized, this is called central sensitization. So our question is
how to calm those sensitized nervous system?


The best results in therapy often happen when multiple approaches are used in a coordinated plan. The
model we use is the Calm Nerve House and the basic pillars of the house are Pain Education, Sleep,
Exercise and Pacing. Today, let’s talk more about pain education and sleep.


PAIN EDUCATION
Recent studies have shown that pain education (just the type of thing you are getting in these posts) can
have a positive effect on pain. When patients understand what is happening in their bodies, this helps to
lower fear levels which in turn helps to calm the brain. Additionally, understanding the different factors
which can add together in the brain (See diagram) to sensitize the brain, can be a big help for patients
on their healing journey. For example, knowing that old emotional traumas can teach the brain to be
extra alert for potential injuries, can help guide a patient toward getting help with that trauma. And
knowledge of the other kinds of stresses which sensitize the nervous system can lead the patient to
problem solves ways to lower those stresses. Knowledge is power, especially when we use that
knowledge to guide our decisions.
SLEEP
A fatigued nervous system is a sensitive nervous system, so sleep is crucial to pain control. There is no
one perfect piece of advice to help with sleep, but below is a general list of tips.
Lifestyle
 Get regular exercise each day, preferably in the morning. There is good evidence that regular
exercise improves restful sleep and overall health. This includes stretching and aerobic exercise. Try
to limit exercise 3 hours before bedtime.
· Get plenty of sunlight outdoors, particularly later in the afternoon.
· Use the evening hours for settling down. Avoid challenging or stimulating activities and avoid bright
lights in the evening 2-3 hrs. before bedtime.
· Try to avoid naps during the day.
· Pick a regular bedtime and wakeup time and stick to them throughout the week.
· Avoid all bright screens including phones, tablets, TVs, or other tech devices 1 hour before going to
sleep.
· Once you are in bed, relax from head to toe and guide your mind to pleasant thoughts.
· Don’t command yourself to go to sleep or “clock watch”. This only makes the mind and body more
alert.
· If you lie in bed awake for more than 20-30 minutes, get up and go to a different room to do a quiet
activity. Return to bed when you feel sleepy. Do this as many times during the night as needed.
Food and Drink

 Although small snacks can help you get to sleep, don’t eat a large meal about 2 hours prior to
sleeping.
 Limit how much you drink at night to reduce your need to get up to urinate, but don’t go to bed
thirsty.
 Stop all caffeine consumption no later than 6 hours before you are planning on going to bed.
 Avoid all forms of nicotine prior to sleeping including cigarettes, chewing tobacco, and vaping.   
 Avoid drinking alcohol before bed.
Environment
 Keep your bedroom quiet, dark, and cool. Try using a sleep mask and/or earplugs to help you sleep.
 Run a fan or other steady “white noise” during the night if noises wake you up.
 Reserve the bed for sleeping, sickness or sex only. Do your reading or TV watching in another room.
 Keep your hands and feet warm. If needed, wear warm socks and/or gloves to bed.
 Wear loose-fitting nightclothes. The more comfortable you are, the better you will sleep.
 Try not to sleep with disruptive bed partners such as your children, pets, or spouses.
Until next post – Cheers!
Zebbie

Pain Education Series – #2

Admin Good Health


Hello,

My name is Zeborah Dazzle, PT, WWF, and I am the new spokes zebra and a patient educator for
Good Health Physical Therapy. I am posting some educational pices in between seeing patients, and we
have been discussing pain, especially chronic pain, which is something very familiar to those of us with
EDS and hypermobility.


I finished my last post by describing how the nervous system can become overly sensitized so that the
pain perception being created is no longer in proportion to the injury in the body. As I described, the
nervous system with the brain at the top, is the sensory and control system of the body. Pain is a perception that is the brain’s estimate that the body is being harmed. And it does not always make the
estimate accurately.


When an area of the body has been injured repeatedly, the local nerves can become overly sensitized
and send too many signals to the brain – out of proportion to the injury. This is called peripheral
sensitization. Similarly, there are connector nerve cells in the spinal cord that can get overly sensitized
and allow too many signals to pass to the brain. And finally, the brain is a learning organ and will make
it’s estimate of potential injury based on past experiences and current stresses. Sensitization of the
spinal cord and/ or the brain is called central sensitization. Practically, this means that the nervous
system itself may be as much or more of a problem than any injury to the body such as sprains, strains
or hypermobile joints.


When nerve danger signals hit the brain, they are interpreted by a number of areas of the brain working
together. If the person has a past history of being injured or of physical or emotional stressors, the brain
may over interpret the signals and create too much pain or pain over too large an area. (See the
illustration of different factors that can cause the brain to overestimate.)


How do we get the nervous system to calm down and stop blaring its warning messages (pain)?
One avenue to calm the nervous system can be medication. All medications have their pros and cons, so
we believe that it is very important that you work with your primary care provider to find the right
strategy of medications to use – even if you are just using over-the-counter medications. Now, as you
probably know, we physical therapists do not prescribe drugs though and we have some other
strategies.


It can be useful to look at non-drug approaches to calming the nervous system as being like a house: the
Calm Nerve House. All solid houses have sturdy pillars which hold them up and so does the Calm Nerve
house; while there are many healing approaches in the Calm Nerve House, the pillars are:


 Pain Education – understand your pain and how it works. Knowledge gives power. (This is what
I am working toward with these posts.)
 Sleep – a fatigued nervous system is a nervous system on edge
 Exercise – “motion is lotion”
 Pacing – too much lotion creates commotion


We will talk more in-depth about each of the pillars and some of the content of the Calm Nerve House in
coming posts.


Until next time – Cheers!, Zebbie

Welcoming our Newest Team Member – Pain Education Series – #1

Admin Good Health
Zeborah Dazzle, PT, WWF

Pain Education Series – #1
Hello,

My name is Zeborah Dazzle, PT, WWF and I am the new spokes zebra and a patient educator for
Good Health Physical Therapy. Today, I would like to talk about a topic familiar to all of us with
hypermobility or Ehlers-Danlos syndrome or any one of a number of other kinds of health problems.
Let’s talk about pain.


When I first went through PT school, the model of pain we were taught was something like a doorbell.
Some thing happens to the body, a stimulus, which sets off local nerves, like pressing the doorbell
button, and the wires carry the signal to the brain which registers pain. Ding-dong. ☹
Over the last twenty years though, science has come to recognize that pain is MUCH more complex than
this. Well, actually, not to contradict myself, pain can be as simple as the doorbell model but when it
continues, it becomes much more complex. Let me explain.


Imagine being in the kitchen barefoot (not hard for me since I am always bare hoofed). You drop a heavy
pot and it hits your foot. Ow! Your foot is bruised but not broken and it hurts. This fresh “acute” pain is
like the doorbell model. The pot hit your foot and pushed the button sending signals through the nerves
to the brain. And if your foot heals normally, the pain will fade as the healing happens and then go
away. But sometimes, even as healing happens, pain can continue. Why? Because the nervous system
has become sensitized. And then, the problem becomes more of a nervous system problem than a
bruised foot problem.


As you probably know, the nervous system is the control system for the body. Nerves big and small
reach almost every square centimeter of the body (I’m from South Africa – we think metric there). And
the nervous system is built for learning. So, when pain nerves keep firing over and over, such as if
someone hurts their foot over and over, or if the person has “connective tissue issues” as we like to say,
the nerves learn to be more sensitive. This can include the nerves in the foot, the nerves up the leg, the
spinal cord and especially the brain.


The brain is a learning organ. It is also where signals from the body are interpreted. For example, using a
different sense, your ears receive sound waves, and these are converted to nerve impulses by the
cochlea and then carried to the brain by the hearing (acoustic) nerves. Only in the brain though do the
nerve impulses get interpreted so that you can identify the laughter of a child or anger in someone’s
voice or your favorite song. Many parts of the brain get involved with this including areas that identify
sound, memory centers, areas that recognize speech and language and emotional centers. Pain works in
much this same way.


Pain is the brain’s estimate that the body is being harmed. And the brain does not always get the
estimate right. When the brain is estimating potential harm, it uses what it has already learned about
the world, and it calculates in past learning. So, if you have a history of being abused, or a history of
injuring the body area before, or you are stressed and on edge, the brains estimate is higher than what
is true to the tissues. We call this central sensitization.


I believe that most of us with hypermobility or EDS have brains which are to some degree sensitized. So,
we need to treat the nervous system in our recovery too. What the brain can learn though, it can re-
learn or unlearn. How do we help the brain? More in coming posts. Until next time – Cheers!, Zebbie.