The chicken or the egg?

This question about what comes first. The onset of chronic pain (and/or other conditions) from sleep disturbance or the relevance of sleep disturbance due to chronic pain?

Here’s some of what we know about sleep …

Sleep complaints are present in 67-88% of chronic pain disorders and at least 50% of individuals with insomnia – the most commonly diagnosed disorder of sleep impairment – suffer from chronic pain. Further, both chronic pain and sleep disturbances share an array of physical and mental health comorbidities, such as obesity, type 2 diabetes and depression.” 1

One study found that “women who endorse frequent, “sleep problems,” defined as frequently difficult falling asleep or having a sleep disorder, were significantly more likely to develop fibromyalgia 10 years later.” 2

Also, in another how “sleep disturbance temporally preceded increases in pain, … in “temporomandibular disorder (TMD).” 3

Similar research is being conducted in terms of cancer pain, for depression, PTSD and ageing (including Alzheimer’s and dementia).

I knew poor sleep to be a contributing factor for people who live with chronic pain. What I didn’t know was how it affects not only physical health but mental health.

What’s piqued my interest is in new studies where a trend has emerged suggesting that sleep disturbance may be a stronger predictor for pain than pain of sleep disturbance.” 4

…several longitudinal studies convincingly demonstrate that insomnia symptoms significantly increase the risk of developing future chronic pain disorders in previously pain-free individuals, whereas existing pain is not a strong predictor of new incident cases of insomnia.” 5

Not just a stronger predictor for pain, but also in terms of mental health conditions.

This bidirectionality or said another way, “what came first, the chicken or the egg?”

Lots of studies to examine obviously, but here’s one on the positive side “Quality sleep has also been shown to predict chronic widespread pain symptom resolution over 15 months.” 6

Researchers will continue to find out more and doctors will refer out to specialists in many areas. Pretty much the gold standard for treating insomnia now is CBTi or Cognitive Behavioral Therapy for Insomnia.

Yet, there are things you can learn to do for yourself, that will help.

Curious about this? Exploring some practices, tools and gaining resources that can support you in getting a better night’s sleep. What stress and the nervous system have to do with sleep? Or how you might find rest during the day?

I’m offering a 4-week workshop starting Feb. 16th at 7:30pm ET.

You’ll have some time and space to explore, experience what might be helpful for you all in the comfort of your own home. Online. Change into some comfy clothes, grab a warm cup of herbal tea and join in. Anyone can follow along. We’ll be rolling on the floor a little, expending energy maybe by rocking and swaying, taking some breaths together. And learning “all the things your parents/doctors/friends/colleagues never told you… about sleep.” There’s a lot more to it than just laying your head down on a pillow, each night.

References:

  1. Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12):1539-1552. doi:10.1016/j.jpain.2013.08.007
  2. Mork PJ, Nilsen TI. Sleep problems and risk of fibromyalgia: longitudinal data on an adult female population in Norway. Arthritis Rheum. 2012 Jan;64(1):281-4. doi: 10.1002/art.33346. PMID: 22081440.
  3. Quartana PJ, Wickwire EM, Klick B, Grace E, Smith MT. Naturalistic changes in insomnia symptoms and pain in temporomandibular joint disorder: a cross-lagged panel analysis. Pain. 2010 May;149(2):325-331. doi: 10.1016/j.pain.2010.02.029. Epub 2010 Mar 31. PMID: 20359824.
  4. Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12):1539-1552. doi:10.1016/j.jpain.2013.08.007
  5. Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12):1539-1552. doi:10.1016/j.jpain.2013.08.007
  6. K. A. Davies, G. J. Macfarlane, B. I. Nicholl, C. Dickens, R. Morriss, D. Ray, J. McBeth Restorative sleep predicts the resolution of chronic widespread pain: results from the EPIFUND study. Rheumatology (Oxford) 2008 Dec; 47(12): 1809–1813. doi: 10.1093/rheumatology/ken389

It is, a practice

These dinner rolls I made to accompany a warming pot of stew on Friday night, were not too bad. Though it wasn’t my first time making them. I recall the first attempt, some 25 years ago. Not. So. Good.

I had to practice a little. Take some time to get a feel for the dough, figure out how to make rolls, the many pieces of the task at hand.

While working with someone 1:1 in a private session, we usually meet every week or two. The reason being is after an assessment, clarifying of goals or focus, whatever we decide to use in terms of practice… is meant to be, well, practiced. For a while. Noticing any effects.

If you’ve been following along with the morning practices over the last week or so, I’m going to pause and allow space for that. You might go back through the various options. There may be some you are already exploring, using. They are not meant to be ‘the thing’ but rather to be used as an exploration. An inquiry as to what you notice, what feels useful. What does not. If you want to go back and review, the posts are noted below:

  • Nov 3 – Here I am, again
  • Nov 4 – Softening
  • Nov 5 – To breathe
  • Nov 6 – Pause, notice
  • Nov 9 – Ease, into morning
  • Nov 10 – Sense making
  • Nov 11 – Warming up

You might benefit from some included here or what feels right for you might be something altogether different. These are a few suggestions.

We’ll pick this up again on Nov 23rd looking at various practices you might choose to do during the day. Then again, we’ll pause for a week before moving on to evening practices starting on Dec 7th.  I hope you’ll stay tuned. Let me know If you have any noticings, feedback or questions along the way.

If this is something you’d like to explore with me privately, I currently offer 1:1 sessions via Zoom. Information can be found here.

Ease, into morning

Hard to imagine what it felt like so long ago… sitting through a long-haul flight, train ride or long drive to go visit far off friends, in far off places. I’m sure so many, miss it a lot. Yet at the same time the trip itself may have been uncomfortable. Feeling constrained. Unbearable at times. You might get a sense of a similar feeling sitting through endless zoom meetings, or just cooped-up wherever you find yourself most of the day.

You might feel stiff. Sore. Boxed in. If you’re a little older like me, it may take more time or effort to get moving easefully after a long bout of inactivity.  

The same might be said when waking from sleep in the morning. Unless you happen to be a big mover while you sleep, I wonder if you’re rather stationary for the most part? If so, what might be a nourishing way to move your body before getting out of bed?

How might you make the transition from laying in bed to being upright in gravity, a little more easeful?

Come along for this short movement practice. Some of which you may like, some of which you may not. But it might inspire you to move just a little…  making the transition from stillness to mobility, ready to begin the day.

I DON’T DO ALL THESE THINGS.

Yet, as a minimum, I do a few movements with my feet. They are where I tend to hold tension so I like to give them some time, space and gentle movement before I step into the day. It seems to be a good thing.  

What might you notice, what might feel Just Right, For You?

#morningpractice #mornings #move #gentlemovement #wrists #hands #arms #legs #feet, #ankles #time #space #goslow #startsmall #JRFU #JustRightForYou #yogatherapy #yogatoolsforlife

Softening

While still in bed you might consider one place to soften in your body.

Notice where you feel some tension or tightness. Stiffness or rigidity. Perhaps you can begin to soften your jaw a little, your eyes, or maybe soften your breath.

It might be useful to imagine or bring to mind a memory you have of a safe, warm, lovely place. I imagine my toes in soft sand, and that they are as soft and supple as when I was a wee toddler.

I turn over and feel the softness of the duvet cover, my pillow.

Maybe I imagine something soft like the these strange little plants (pictured above) that I seem to be obsessed with. Of them blowing softly in the breeze.

Maybe I imagine the soft snow, landing on my face, as I go out for a walk.

Life is hard enough. Might we move towards, bring in, feel in some way, a touch of softness to it.

Even by just imagining it to be so.

#morningpractice #mornings #softening #notice #nourish #touch #stiffness #rigidity #breath #breeze #imagine #yogatherapy #yogatoolsforlife #JRFU #JustRightForYou #startsmall #goslow

Here I am, again

As you wake in the morning, before anything else, can you notice your first thoughts? Before you look at your phone, even open your eyes. Notice what it is, you’re thinking about.

And consider that. How do these initial thoughts begin or influence your day?

Maybe you can catch a glimpse, almost before you’re even fully conscious. Or maybe you won’t notice anything at all and that’s okay too. But you might want to practice this a little.

For some, with a little practice and curiosity you might find a creative spark or some new insight within these early morning thoughts.

Perhaps, to start, you might just notice that… here you are.

“Here I am, again.”

It is morning. I am awake. This is a new day.

Allow yourself a few moments. Some time and space to just be… with whatever, before the rush of the day draws you forward and up.

That might be enough.

You’ve received another day in the world. And that might be something to notice.

#morningpractice #mornings #notice #awake #alive #noticing #thoughts #gratitude #creativity #creativetime #dreamstate #yogatherapy #yogatoolsforlife

Breath Holding, an Inquiry

Tofino, BC

I was having a discussion with a client this week about the breath and how we breathe. We were talking about the relationship between our body, our breath and how breath moves in relationship to gravity. The forces of gravity, the loads we feel.

Breath awareness is often a focus in yoga. Both in yoga classes and also in a more therapeutic practice of yoga. We spend a lot of time noticing breath, feeling the breath as it moves. Noticing the length of breath, the inhales, the exhales. Where we feel the breath move, in our body.

Taking a different path, perhaps we can explore how breath might not always be moving, or moving so well. As in when you’re holding your breath. Which you might not readily notice throughout the day, unless you pay attention to it.

The basis of this inquiry is from Donna Farhi’s The Breathing Book (highly recommend the book). She states the purpose of the inquiry being:

To identify the situations and activities in which you most commonly engage in breath holding. We don’t usually recognize how much tension we invest in simple activities such as talking or cooking because we don’t recognize the situation as terribly stressful. You may be surprised and disconcerted to discover that you hold your breath in almost every conceivable situation.

Let’s check this out.

Starting today and for the rest of this week, take notice of when you hold your breath. What you’re doing when you hold your breath. Where you are, who you’re with. Make a mental note, or actually write it down so you don’t forget.

You may notice it when you’re speaking on the phone with someone. Perhaps your boss. Or you may notice it when you’re leaning over to make your bed. Or you may notice you hold your breath when your attention is really focused on something, like when driving down busy streets.

Then, you might want to see if you can change it in some way. Just breathe a little more freely if you can. Try not to judge anything, just notice.

I’ve noticed this pattern of breath holding in myself, particularly, in these days. Before I started wearing a mask I would sometimes catch myself holding my breath as I walked by someone. Or when I felt they were standing too near to me. I suspect there was some fear involved in my response. It’s like I didn’t want to take breath in, at that moment.

We’ll do more specific explorations, next week. And maybe get a little curious about how this might affect or influence pain.

Check back with me on Monday (June 29th) for more. In the meantime, keep noticing.

What outcome, or benefit might you expect from attending Pain Care Yoga classes?

don't lose hope picWell, much like anything, it depends. The answer is rarely straightforward and definitive.

As mentioned in the last post everyone comes in with their own experience of pain,  history,  individual, unique life circumstances. What might be helpful for one, will not likely be the same for another.

Below are a few comments made during a recent class, which illustrates this difference, for each person.

“I slept so much better all last week.”

“I’m not really using my cane anymore. My leg feels stronger, and I have no pain.”

“My back went out last week for a couple of days. I was flat on my back, so I used one of the (breath-awareness-distraction) practices and it really helped me get through it.”

And your back now? – Me

“It’s fine, now.”

“I’m so surprised. Normally I cannot walk around without my shoes on.”

Did you feel pain, while we were doing this (walking exploration, practice)? – Me

“No, I had no pain at all.”

I can’t say what will happen for you, or for another. Most often though, people will begin to experience feelings of calm, safety, less or no pain during class. And, some will begin to transition those responses and feelings into their daily lives.

Like most things in life, what we do, what we practice, we get better at. I would say the same, in this case. If you only practice during our class, for an hour a week, you may not see as much progress, notice as much difference. However, if you do a little, each day, I bet your experience will be similar to these others.

What I highlight to people, from both their comments and experiences is that something changed. To get curious about that, and realize they created the change.

It wasn’t something done to them.

From there, they begin to feel some hope. Perhaps a little empowered and more able to start exploring and learn to self-manage or resolve their persistent pain.

If you’re interested in how this might work for you, the next 6-week series of Pain Care Yoga classes begin at the end of February. I’m also available for one-to-one in-person or ‘zoom’ online sessions and would love to hear from you.

 

What do you do, in yoga classes for people living with chronic pain?

one thingThe second question people often ask me about Pain Care Yoga classes, after “who is it that comes to these classes” described here, is “what do you do in them”?

Pain is never just about one thing. You want to know what’s wrong. How you’re going to fix it. And how long it’s going to take. And rightly so, as having long-term pain often changes everything for you and how you live your life.

When it comes to pain, however, it is usually not that simple which is why searching for ‘the thing‘ usually doesn’t work in the long-term. Particularly if you’ve had pain for a long time. Which doesn’t mean to say that it can’t change. It can. We know what can help to bring about change, the best practices research points to.

Two key aspects, education … and movement, are important. So that’s what we do in these classes.

EDUCATION

Some kind of education piece, usually at the start of the class, is provided. I only spend a few minutes on this, but it’s important to do so. One of the most common things I see with people in pain is the fear of moving. If I can help you to understand why it might be safe to move and why it’s important to do so, that’s a good place to begin.

“Current evidence supports the use of pain neuroscience education (PNE) for chronic musculoskeletal (MSK) disorders in reducing pain and improving patient knowledge of pain, improving function and lowering disability, reducing psychosocial factors, enhancing movement, and minimizing healthcare utilization.” [1]

PRACTICE

Then, you practice. You get to experience how you might move, with guidance and guidelines, to learn what’s right for you. Which often won’t be the same as others in the room.

Movement

This is not a typical yoga class with sun salutations, downward dogs, lunges, forward folds, backbends. It is not even what I would call a ‘gentle yoga class’. Yes, we use slow, gentle movements. Yet, sometimes you might begin by just imagining the movement if you don’t yet feel safe to do it. Or you might practice it in your mind, plan out how you might go about it and if it feels right for you. It is always your choice to do or not do anything presented in class. You always get to decide how to move, how far to move, by using a slow, mindful exploration along with guidelines and principles utilized.

Most movements are fairly simple and modifications are always available. You’ll experience a lot of repetition, and rhythmic movements. Movements that cross the midline of the body. Movements that challenge your brain as well as challenging your body.  You, anyone, can really begin wherever you’re at. With what’s right for you.

Breath

There will always be some kind of breathwork or a breath awareness piece in the practice. Again, it’s not so much about controlling the breath, rather what you might notice about your breath. How breath can be an indicator of your physical and emotional state at any given time. Also, learning how breath can help to bring about change to your nervous system, physiology, which can then change your experience of pain.

Awareness

Like breath, awareness is key. So often when you are in pain the last thing you want to do is pay more attention to your body. But in fact, this paying attention is your guide to changing pain. It is in this noticing that you can begin to explore what the signals (or sensations) you feel might be indicating, what might be your unique contributors to pain, what might be the reasons for flare-ups. This practice is not only about noticing your body in class but then also paying attention to your whole self in your environment, in the larger world you live in.

Relaxation

There are many reasons, purposes and benefits to practice relaxation techniques. In most yoga classes this is done at the end of class. Though we’ll also do some kind of formal relaxation practice at the end, relaxation or creating a state of calm is facilitated right from the start.

It is when you are in a place of safety, when you are calm and relaxed, that change is likely to occur. It is this place of calm (a parasympathetic state) when you might first experience a change in your pain. Without this, it’s no different than trying to stretch, exercise, push through and strengthen your pain away, which seems not to work out so well.

If you’re interested in learning more, have any questions or would like to sign up for the next series of classes starting at the end of February, please get in touch here. I’d love for you to experience, how you might learn to change your pain.  Or, if you prefer a one-to-one session, information can be found here.

[1] Adriaan Louw, Kory Zimney, Emilio J. Puentedura & Ina Diener (2016) The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature, Physiotherapy Theory and Practice, 32:5, 332-355, DOI: 10.1080/09593985.2016.1194646

 

Who Attends Yoga Classes for Chronic Pain? All kinds.

hearts croppedMost people I talk to wonder how yoga might help with their long-term, persistent or chronic pain. So, I thought I might tell you this week a little about who comes to these classes, what we do and why, or the outcomes experienced.

Let’s begin with who attends.

Most people in these classes (or private 1-to-1 sessions) have never done yoga before.

Classes tend to consist of people who don’t turn up in yoga studios, who probably never thought of doing yoga to help with their pain. After all, most of the marketing and imaging around yoga is out of reach for many people, let alone people who have difficulty or experience pain when they move.

Most, are around mid-life; perhaps 45 or older.

The oldest student who’s attended is 78. Most are about 50 – 65 years old. Once in a while someone younger will attend, perhaps in their 30’s. Currently, my youngest client is 13.

What are some of the conditions, or diagnoses they have?

The most common condition is people with persistent back pain and/or those with fibromyalgia. Most often, those with fibromyalgia have had it 20 to 30 years or more. Others have osteoarthritis, rheumatoid arthritis, sciatica, other musculoskeletal pain (hips, shoulders, feet, and neck seem to be the most common). Chronic pelvic pain, is another. Or those who are currently going through cancer treatment, or recovering from it.

What are some of the conditions or diagnoses that often accompany persistent pain?

Most often it’s either (or both) anxiety and depression.  Many suffer from irritable bowel syndrome (IBS), chronic fatigue, sleep issues (insomnia, sleep apnea, etc.), incontinence.

You can see there is such a wide variety and it’s not really ‘yoga’ people coming to these particular classes. Again, from what I know about most, they are people who have tried many other things that haven’t worked for them over the long term or are using yoga as complementary to or integrated with other aspects of their personal comprehensive pain management or treatment plan.

Up next on the blog, we’ll dig into what we do in these classes. I hope you’ll join me.

 

 

Let’s Get You Moving Again

Back facts

The Editorial in the British Journal of Medicine (BJM), begins

“Low back pain (LBP) is the leading cause of disability worldwide, and is often associated with costly, ineffective and sometimes harmful care.[1]

I’ve written about this before, here.

What drives disability and poor care?[2]

Unhelpful beliefs about LBP are associated with greater levels of pain, disability, work absenteeism, medication use and healthcare seeking. Unhelpful beliefs are common in people with and without LBP, and can be reinforced by the media, industry groups and well-meaning clinicians.”

The purpose of the editorial (made free due to popular demand, read it here) and the infographic is to “identify 10 common unhelpful beliefs about LBP and outline how they may influence behavioral and psychological responses with pain”.

The authors are also “calling on clinicians to incorporate these into their interactions with patients.”

This is so important. It’s why I always include a touch of education and information as part of my Pain Care Yoga classes. When people are in pain, it’s difficult to understand why it might be safe to move, how important it is to move and how movement “doesn’t mean you are doing harm – FACT #5”.

I hope these FACTS will bring some curiosity to your beliefs. I hope you might consider what you believe and how they might influence your experience of pain, either positively or negatively.

Sometimes, however, information is not enough. I, we, can give you all the ‘FACTS’ but often until you experience that you CAN move without pain it’s difficult to change beliefs.

As called for in the editorial, I am personally committed to bringing evidence-informed information and education to the people I work with and hope to provide a new experience to get you moving again, with confidence.

  1. Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet 2018;391:2368-83.
  2. Buchbinder R, van Tulder M, Oberg B, et al. Low back pain: a call for action. The Lancet 2018;391:2384-8.