Pain Education Series #4

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.

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.


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!


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

Zeborah Dazzle, PT, WWF

Pain Education Series – #1

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.