As a hypermobile person you may be used to feeling different. Your balance may be less than impressive; your joints and muscles ache for what seems to be no good reason; and, yes, it’s your hips making that clunking sound when you’re trying out the latest exercise your more normal-jointed friend is excited about. You also experience a vast array of non-musculoskeletal weirdness that never ceases to mystify you and those around you. You may by now be well aware that you need a different approach to exercise than others, focusing much more on stability than marathon running, and your collection of splints and special pillows has been growing at an impressive rate. With all of the special attention that your body seems to be demanding, it is easy to forget that it is, still, a body that requires and benefits from the same loving care and attention that human bodies, in general, do.
As a matter of fact, your body may benefit even more than that of your less bendy friends from supporting its basic functions.
Let’s review the four cornerstones of health: sleep, diet, exercise and mind management and some of the ways you can help your body serve you well. Please note that the following is a general overview and not intended to be a comprehensive list of all the comorbidities associated with HSD/hEDS, but rather as a reminder of the importance of general, supportive health practices.
Your soft ligaments, joint capsules and tendons are less able to protect themselves and more easily sustain small injuries, so called micro-injuries. While your spouse or friends seem to get away with a lot of slouching, following their lead reflexively triggers your muscles to work overtime. Your nervous system is straining to maintain homeostasis and your blood circulating in your stretchy veins. Night-time constitutes a well-deserved break for your hard-working body! Deep sleep is when tissues rebuild and repair themselves, and sleep deprivation therefore impairs your body’s ability to sufficiently regenerate tissue overnight. Accumulating, un-repaired, tissue damage leads to pain and soreness, and may even over time contribute to a diagnosis of fibromyalgia. Artificial light at night, the light pollution that seeps through our curtains while we sleep, has been found to contribute to breast and prostate cancer, obesity and depression.
Sleep is also a time for your brain to recover from the events of the day, and for learning (say of those balance and stability exercises you’ve been doing) to be consolidated into long-term memory. And honestly, the very last thing you need when dealing with the demands of a hypermobile body and chronic pain is one of the most reliable outcomes of poor sleep quality, the significant negative effect it has on mood.
So here, shortlisted for your convenience, are the ingredients of a good night’s sleep:
Put simply, your food gives you the building blocks that your body is made of. Genes that code for softer connective tissue seem to be implicated in hypermobility disorders such as HSD (Hypermobility Spectrum Disorder) and hEDS (Hypermobile Ehlers Danlos Syndrome). The softer connective tissue is itself more easily damaged by over-stretching, and also puts the joints and muscles it is meant to protect at risk. This creates an increased demand for effective healing of tissue. It is therefore important to make sure that your body has a steady supply of the necessary building blocks needed for tissue regeneration.
The most important building block of connective tissue structures is collagen, the very fiber that makes your body different. Moderns diets tend to contain less collagen than traditional diets, and collagen supplementation can therefore be a safe way to increase collagen turnover.
Vitamins C and D are also needed for collagen synthesis, and supplementation of these micronutrients may be beneficial.
Hypermobile people often suffer from gastro-intestinal (GI) manifestations of the softer connective tissue and associated disorders, such as delayed stomach emptying and slower motility — the movement of the food through the GI tract — leading to discomfort, bloating and constipation. Eating smaller portions, avoiding snacking, and allowing your system a break from eating through a long overnight fast can be helpful. Ginger is a safe and tasty root that improves gastric emptying and motility and can be used both as a tea and a supplement in capsule form. Overweight is never healthy, and with a hypermobile body it can cause additional problems. Extending the overnight fast to 12-14 hours, and especially for men, who seem to tolerate longer fasts better, up to 16 hours, can be a simple way of improving insulin sensitivity and your body's ability to handle energy.
Many hypermobile individuals notice increased thirst, especially when under stress. Blood pooling in the lower half of the body may trick the kidneys into thinking there is too much, when there is actually too little. Chronic dehydration, fatigue, headaches and dizziness can also be a sign of Dysautonomia. The softer bladder may both signal the need to empty it more frequently, and also empty less completely. This can predispose the individual to UTIs, or urinary tract infections. Drinking a lot of water can be helpful in diluting the urine in the bladder and potentially help prevent UTIs, but can also dilute the electrolytes in the body, leading to a vicious cycle of increased thirst and increased dilution. This can in turn exacerbate symptoms of feeling faint and dizzy when standing up due to orthostatic hypotension or POTS. Adding minerals or electrolytes to your drinking water can be helpful. Some electrolyte brands even come with small travel bottles that are easy to carry in a purse or pocket. Salting your food generously, adding salty foods like olives and pickles, and even taking salt as a supplement can all be of great help. Sodium has been demonized and many initially fear adding more to their diet, but when it ameliorates symptoms without elevating your blood pressure you have little to fear from this important mineral.
Our bodies are designed with the expectation of movement, and simply cannot stay healthy and function well without it. This is just as true for hypermobile individuals as it is for others, but hypermobility presents an added layer of complexity for the would-be exerciser. While it is true that all human bodies require stability, hypermobile bodies rely more heavily on muscles for both proprioception and balance and joint stabilization. If the muscular system faces this challenge untrained, certain muscles are likely to be overburdened and become tight and sore, while leaving joints poorly protected.
Instead of simply looking for a type of exercise that seems like fun, we should create a body that is prepared for exercise. The best place to start is with slow, well-controlled exercises that first stabilize the pelvis/spine/trunk, and then the shoulders and hips. Be aware that while the neck is simply the upper part of your spine, it is also closely connected to your shoulder girdle and therefore affected by any tightness and weakness in this area.
The most effective way to approach this is through an individualized program based on therapeutic exercise and natural, functional movement, prescribed specifically for you with an understanding of your specific needs, and progressed as you improve. This program should also contain a strong focus on balance and proprioception, and not be seen as a static set of exercises, but a gradual, progressive challenge to your body to help it serve you well. Attempting to meet your individual and specific needs through generic movement programs, however popular, may not be quite as effective. Hypermobility is a trait that can have serious consequences and should be treated by degreed healthcare professionals with a thorough understanding of the human body and familiar with the particular set of traits characteristic of hypermobility.
The most fruitful way of seeing any challenge you may have is not “my diagnosis explains my symptom and condemns me to always have it” but rather, “my diagnosis informs and inspires me and means that I have to work even harder on helping my body function optimally”.
Which leads us to the mind.
Just as a hypermobile body means that you may have to pay more attention to exercise than the average person, the added challenges you face also mean that you will benefit more from actively controlling your mind.
The quality and quantity of your sleep is, as mentioned, the sine qua non of a positive mood. Creating an internal locus of control, a sense of empowerment and of not being at the mercy of others, is another important cornerstone for good mental health and thriving. Information is one of your most important tools in this quest. Understanding, not just the basics of your diagnosis, but the repercussions of it for your body in general, is important for your ability to understand and manage symptoms. Hanging your hat on the hope that someone else, some expert, will give you the key to feeling good is looking for fool’s gold. Experts are invaluable as a source of information, but no-one will ever care as much about or know as much about you as you do. Stay on the path of learning and experimentation, gradually adding good habits and beneficial practices to your life as you go. Set goals and be proactive instead of reactive. Simply reacting to pain and dysfunction can feel hopeless and disempowering, while creating a plan for gradual growth and improvement is inspiring and helps you gradually reach functional, meaningful goals.
Joint hypermobility is strongly correlated with anxiety, even in animals. This correlation is probably, at least in part, if not entirely, the result of over-activity of the sympathetic nervous system (the “fight or flight” part of our nervous system). Consciously seeking to counteract the potential negative effects of this on our mood and body is arguably an important part of hypermobility self-care. Calming and centering practices such as meditation, slow breathing, slow walking (a pace of under 3 miles/5 kilometers per hour), and slow, repetitive activities, (e.g., knitting, reading, or t’ai chi, can support the parasympathetic (“rest and regenerate”) part of our nervous system.
The synergy of the four cornerstones
It can be tempting to focus on one of these cornerstones more than others, for example seeking information more than relaxation. Some people rest too much and exercise too little, while others tend to do the opposite. The four cornerstones of good health are, however, synergistic in nature. Sleep is what allows your body to benefit from exercise, retain information and good mood. The dietary building blocks allow you to build and repair connective tissue, and your exercise trains your body to put these tissues to good use. Creating good habits and achieving a good balance allow you to manage problems, improve, and even thrive.
Gather information, become informed, use experts as teachers and guides, but always remember that you are in charge. The path is yours and yours alone and you have a greater influence than anyone else on where it will take you!
You’re faced with a health concern you can’t quite figure out on your own. Maybe you have a bacterial infection, or perhaps a tendon is aching from all the running you’ve been doing. Where do you turn for help? What reasoning do you use to discern what to believe and trust among all the voices vying for your attention?
In the day and age of concepts such as “fake news”, many people are left with the (fortunately erroneous!) impression that there is no consensus in the health sciences either. This article is intended to help you approach taking care of your body, in sickness and health, and finding the help you need to do so, in the most logical and effective way, and in the process help you avoid the many potential pitfalls along the way.
When it comes to the serious infection, most people tend to turn to a medical doctor. They know that by doing this they have chosen a professional that is a graduate of a rigorous program and who will base their recommendation —probably a course of antibiotics — on scientific evidence, not on best guesses or hearsay, or on what some other person told them.
This practice, basing your actions on scientific evidence in addition to the traditionally honored
practices of clinical knowledge and the patient’s desires, is called Evidence Based Practice.
Evidence Based Practice therefore strongly incorporates and emphasizes the scientific method; systematically testing a hypothesis and drawing conclusions based on the findings. Once such as study has been performed, scientists seek to publish their findings in the form of a scientific paper in a peer-reviewed journal. Many different studies then accrue over time, and other scientist authors summarize these many studies into one, and draw conclusions based on these. If 20 studies point to A, and only one, poorly designed, study points to B, we have good reason to conclude that A is correct. We don’t, however, rest on out laurels, and scientific evidence is continuously accumulating, ever refining and enhancing our understanding.
Experts back their claims with scientific references
The above system also leads to a hierarchy of evidence where the opinion of an expert ranks the lowest and systematic reviews the highest. The latter is also what is later used to base practice guidelines on for various types of practitioners, and any “expert” worth listening to also continually refers to the highest levels of evidence to back their claims.
Even lay persons can access many of these scientific papers eg on Pub Med https://www.nlm.nih.gov/bsd/pubmed.html .PubMed is a free resource provided by the NIH for peer-reviewed biomedical and life sciences literature “with the aim of improving health – both globally and personally.”
Unfortunately, the lay press often contributes to the confusion by focusing on individual case control studies and expert opinions, creating among their readers the impression that our scientific consensus is weak and ever changing.
All this means that when you are turning to your medical doctor for help with that serious infection, you can rest assured that her or his recommendation is based on sound scientific evidence, not tradition, guesswork or dogma. You certainly wouldn't have someone with self-proclaimed surgical expertise remove your gallbladder. You'd insist on a professional with a degree proving his or her expertise. This is the rigor with which you arguably should approach all aspects of your healthcare. Scientist have gradually worked to understand physiology, biochemistry etc, other scientists have critiqued and refined their work, and a large body of evidence has accumulated. Your physician has not only received a specific degree based on this, but is also receiving periodic updates to their practice guidelines. All this to make sure that your care is up to date, based on the best of our knowledge today, not on assumptions an not on beliefs that were held 20 years ago.
How about that aching tendon then? When it comes to musculoskeletal issues, there are many, mostly well-intentioned individuals who, thanks to the world-wide web, have found an unprecedented outlet for their creativity. While, in the times before personal computers, only credentialed individuals with formal expertise in any given area were given a platform, usually in the form of publishing a book on any given topic, today anyone with a computer can post videos on Youtube or create entire websites dedicated to their ideas. Any self-proclaimed guru with enough marketing savvy can easily reach an audience large enough to create a course, claiming to certify (usually after a brief course of study), that the certified individual possesses some type of expertise (has become a certified practitioner or expert of this or that).
Convincing as this may sound, a brief course on any given topic doesn’t come anywhere near the knowledge base of a practitioner with a multi-year formal academic degree, based on a rigorous science-based program. Unfortunately this is not always obvious to the unsuspecting audience, which instead may be influenced by a convincing tone or a captivating video. Appearances matter a lot these days, and coming up with a catchy name or slogan goes a long way - just not towards creating good health.
Don’t fall for easy tricks and simple claims - your body is not simple
The greatest enemy of truth, however, tends to be our increasing appetite for simplistic explanations, concepts that can be grasped immediately, without the pre-existing context of a scientific understanding. But the human body is incredibly complex, and any intervention, any concept, any approach that is based on actual scientific evidence is therefore, by definition, going to be complex, not something that is easy to generalize and sell. And at the end of the day, Mother Nature follows her own rules, and only by following those rules can we safely obtain the results we are looking for.
So, with the infection cured by antibiotics, to once again be able to run without pain or injury in that tendon, you need to find out how to proceed. Should you look to various movement practices? Will yoga have the secret sauce? Should you, as your friend recommends, simply rest, because running, she says she's heard, is bad for you anyway? Is there one simple trick you need to find somewhere?
Fortunately, while you may not be sure how to proceed, as your area of expertise may lie elsewhere, science does. While there is a lot left to learn, we do know quite a lot about tendons, and we do not need to waste time, as the saying goes, “throwing some stuff at a wall to see what sticks,” trying various dogmatic approaches that claim that their movement philosophy is the cure-all.
We know that tendons have a certain ability to accept and transmit load (eg the pulling force through it as you’re running). We know that tendons, over time, change according to the load you place on them (inactive people have thinner tendons and ligaments than people who place a great load on their tendons, eg by running or lifting weights). We know that tendons ail (we call this tendinopathy) when the forces we place on them exceed their strength, and their ability to repair overnight. We know that to heal tendinopathy we need to temporarily decrease the load while gently stimulating the tendon to grow stronger.
These basic facts are no less true, but actually more so, in specific cases such as chronic pain, joint hypermobility syndromes, aging etc. Individuals that fit into these categories need to take even greater care to be guided by properly trained healthcare
Consider the source
Can those two funny guys you found on youtube guide you through this? Maybe, although unlikely, but how can you tell whether what they are saying is correct or not? You consider the source, and the sources your source uses. If that sounds complicated, here’s what it means. You consider what, if any, credentials the individual has. Have they gone through a long academic program in order to obtain a, preferably terminal, degree specific to the claims they are making? Are you listening to a DPT (Doctor of Physical Therapy), MD (Medical Doctor, preferentially with a specialization in orthopedics of physiatry), DO (Doctor of Osteopathy), DC (Doctor of Chiropractic) or ND (Naturopathic Doctor), or are you listening to someone who never mentions their credentials because they don’t have any?
If the latter is the case, you are most likely placing your health in hands that lack the requisite competence. I have the utmost respect for autodidacts, and to a certain extent we all have to be responsible for broadening our scope of knowledge and understanding in order not to endanger patients through the almost absurd degree of specialization that exists in health care today. Certainly not all knowledge that is worth sharing has to obtained through formal education. But in order to gain your trust, your source should always at least be able to tell you why they are making the claims that they are. “Everyone knows”, “I’ve noticed” or “I learned this from someone I really trust” are not scientifically valid arguments.
So here are some things to think about and look for when you are about to place what is arguably one of your greatest assets, your health, in the hands of someone, trust their claims and follow their advice:
Once again, the body is complex, and those of us who have devoted years of study and practice to understanding the body are in awe of its complexity and ingenuity. We do not believe that there are easy and quick fixes, nor do we advocate one size fits all approaches. We stay attentive to new research as it emerges and make changes to our clinical practice accordingly. And when our patients ask us for advice, and ask us where our information originated, and why we make the claims we do, we can usually refer to science. We make a clear distinction between our clinical observations and practice guidelines, whether we agree with them or not.
Most of all, we value the knowledgeable patient, and always strive to both educate our patients and help them become a discerning and educated audience for health-related claims, whoever is making them. To this end, our patients have to understand how we arrive at our conclusions, claims and practices. They have to understand the basic structure of the scientific process and it’s clinical application. My hope is that this article has been helpful with that.
To your health, and your knowledge and understanding thereof!
Few topics stir as many emotions and awaken as much fear, hope, confusion and even judgement as our diet. The overabundance of opinions, dogma and conflicting claims repels and confuses us, yet we, justifiably so, feel the need to make sense of it all. We have always known that diet is indeed one of the cornerstones of good health. The founder of western medicine, Hippocrates, well over two thousand years ago strongly emphasized the fundamental role of food and exercise in health. Food is also one of our greatest sensory pleasures, one that brings people together and celebrates our connection to the natural world.
To sort it all out, let’s first consider why we eat, and why we should pay attention to what we eat, in the first place. Food serves several functions: it acts as a source of energy for the body, it serves as a building block for our constantly renewing tissues and it gives us ingredients that facilitate various other processes in the body, among them thinking, hormonal function, reproduction etc. But in a time of relative abundance, we tend to turn our attention from these important roles and focus more on the shadow side of food; the fact that, when eaten in quantities larger than what we need, it can wreak havoc on our bodies and cause negative effects such as obesity, inflammation, and diabetes. This often colors out relationship with food and leads us to think of it not as a life sustaining force but as something of a threat. “Are eggs bad for me?” we ask. “Will carbohydrates harm me?”, “Will eating meat give me a heart attack?”.
As is true for most choices in life, choosing our diet based on fear, without a clear paradigm, can have us running back and forth like a ball boy at a tennis match, vegan this day and keto the next, enthusiastic about the newest food religion one day, fearful that we may still not be getting enough of the latest superfood the next. Choosing a diet based on what it doesn’t contain is arguably not enough. Thinking instead about what our bodies actually need (the “macronutrients” fat, protein and carbohydrate as well as “micronutrients” such as vitamins and minerals), and how to get enough of each type is the only logical and comprehensive approach.
Humans evolved over a very long period of time eating an omnivorous diet, consisting of a wide variety of plant foods and animal foods, sometimes with a bit more to eat, sometimes going for a little while without food. While our genes haven’t had time to change much (read: we still thrive on a very similar diet to the one we evolved with) there have also been some relatively recent changes in our genome, and as opportunistic omnivores we inarguably have much more leeway when choosing what to eat than a single-plant eating panda bear.
While there is no need to buy into the latest egg or lectin scare, there are some things that make their way into our food that we would do better without. These include certain, potentially problematic, (inflammatory, neurotoxic, xenoestrogenic, carcinogenic) non-food aspects of the modern diet. They have less to do with the food items we eat and more to do with how we grow and handle our food. Modern additions to our diet that we did not evolve to tolerate well include things like vegetable seed oils (sunflower-, corn- and safflower oils etc), synthetic trans fats, an abundance of processed acellular carbohydrates, an abundance of refined sugar, pesticides, food coloring, preservatives, pasteurization, and so on. We would do best to view these more recent additions to our lives as science experiments we choose not to participate in. Uniquely nutritious food items no longer ubiquitous in our diet include organ meats and collagen-rich organs like bone, skin and tendons, and making up for this loss may support optimal health.
While science is usually a good starting point for understanding our world, food science is unfortunately not best known for its rigor and quality. Fortunately we do know a great deal about the human body and what it needs, and can most certainly nail down some basic facts. Instead of looking to self-proclaimed gurus espousing complicated diets based on the purported dangers of this or that food item, we might do better to look to our ancestors and our bodies for answers.
Let’s take a big step back and consider a few facts:
There you have it. Like the author Michael Pollan famously said: “Eat food, not too much, mostly plants.” Get enough protein, including collagen, good, natural fats, plenty of plant foods. Consider who you are (your age, activity level, injuries and recovery, body type etc) and choose your macro- and micronutrients accordingly. Eat fresh, organic, grass fed - you know, whatever your great grandparents would have recognized as food. Avoid unnecessary chemicals such as pesticides, preservatives and food coloring whenever you can, and listen to your body.
Love food, don’t fear it, and it will love you back.
In a world where we are swimming in a sea of advice and admonitions, how do you sort through all the information? How do you decide what is relevant to you, and make good use of it?
Seemingly contradictory advice abounds, threatening to confuse the most analytical mind. Should you try the carnivore diet, go vegan, or fast? Should you follow your own daily rhythm and stay productive until the wee hours of the night, or go to sleep when the sun does?
What is often lost in the rush to present a never-ending stream of new, fresh ideas is the fact that there are some unchanging foundational requirements for health. This a basic principle that no new dogma, product, or guru can change.
80 percent of results come from 20 percent of foundational effort
The 80/20 rule, also known as the Pareto Principle, states that 20 percent of the effort you put into any endeavor leads to 80 percent of the results, and conversely, that 80 percent of your effort only leads to an additional 20 percent gain. How does this apply to your search for health and well-being? It means that you get most of the benefits from a few simple things. After these fundamental requirements are met, we benefit relatively little from adding the latest exotic bells and whistles. It therefore stands to reason that we should be paying much more attention to the basics, and much less to the siren song of the new, the expensive, the popular or the latest health fad.
So what are these fundamental principles, our 20 % that will give us 80% of the benefit? The four cornerstones of health are sleep, diet, exercise, and the health of your mind.
Let’s start with sleep, and cover diet, exercise and the mind in subsequent posts.
“There is a time for many words, and there is also a time for sleep.”
― Homer, The Odyssey
Deep sleep is when tissues rebuild and repair themselves. Sleep deprivation therefore impairs your body’s ability to sufficiently regenerate tissue overnight. Accumulating un-repaired tissue damage leads to pain and soreness, and may even over time contribute to a diagnosis of fibromyalgia, or simply looking like, well, you know what. As mentioned in a previous post, sleep is also a time when the brain is cleansed from metabolic waste, making sleep not just one of the best tools for rebuilding the body, but also the brain, protecting us from everything from unhappiness to dementia. Artificial light at night, the light pollution that seeps through our curtains while we sleep, has been found to contribute to breast and prostate cancer, obesity and depression.
Sleep is not only a time for your brain to recover from the events of the day, but also for new information (for example, those new exercises you’ve been doing) to be consolidated into long-term memory. And honestly, the very last thing you need when dealing with the demands of your career, your young children or a surreptitiously aging body, is one of the most reliable outcomes of poor sleep quality, the significant negative effect it has on energy and mood. So here, shortlisted for your convenience are the ingredients of good sleep. These are fundamentals that the night owls among us need to adhere to even more strictly than others, as their circadian rhythm more easily is disrupted by artificial light at night.
The ingredients of a good night’s sleep
If you have been lax with your sleep hygiene, kept late hours or have suffered from insomnia for a while, keep in mind that it does take time for us to change habits and expectations. Make positive choices and give them several weeks to gradually work their magic. Remember, good health is not the result of easy shortcuts but of lifelong, conscious habits.
Now that is something worth sleeping on!
Proprioception - a fancy term for a very useful sense
Do you think of yourself as having good balance and coordination? Most people who rate their coordination as ‘very good' tend to be physically active, doing sports or a demanding form of dance on a regular basis.
Others feel that the movement of their bodies is less than precise, like those of an awkward teenager after a sudden growth spurt. They experience difficulty calculating their height and width and constantly bump into things or often knock things over. Maybe you’ve always though of yourself as clumsy and uncoordinated, or perhaps you’re one of the many who seem to, over time, have misplaced a previously good sense of balance and now limit your activities due to a fear of falling and hurting yourself.
In order for us to move in a coordinated fashion, we have to know where our body is at all times. Our proprioception makes this possible. Proprioception is our ability to feel the position of our body in space, as well as our body’s movement through space. (This ability to sense movement is also called kinesthesia, from the Greek words for movement and sensation.) Proprioception is the reason you know where your body is in space, and what position it is in, even when your eyes are closed.
This system provides the necessary information for the control of posture and movement both consciously and unconsciously, and it is thanks to this amazing ability that we don’t keel over the moment the lights go out and we no longer can see our body.
The stuff that balance is made of
Mechanoreceptors are tiny, specialized sensory receptors that are located within joints, muscles (muscle spindles), ligaments (Golgi tendon organs), joint capsules and tendons. They communicate information about pressure and tissue lengthening to the central nervous system (the brain and the spinal cord), creating proprioception. The deep layers of the skin and the fascia, (the connective tissue layer that covers our muscles and organs and tie the body together as if though through a three-dimensional fishnet), also act as supplemental sources of information for our sense of proprioception. This system helps us both stand, walk and move while our conscious attention is focused on something else, and create precise movement at will. It helps us use just the right amount of muscle tension, and use our joints in a manner that is precise enough to not overload support structures such as ligaments. It helps us balance our tall bodies against the downward pull of gravity, and balance our head on our neck without unnecessary muscle tension and ligament strain.
Balance is an important skill, and most commonly needed in the form of what physical therapists like to call single limb standing, ie standing on one leg. Whether you would like to walk, run, step over or into something, be it a bathtub or a pair of pants, you need to be able to balance your body on one leg. The ability to do so is a skill, and skills are composed of many components. You need the raw muscle strength of muscles such as the gluteus medius, a (as the name implies) medium-sized buttock muscle that helps keep the leg straight underneath you. You need proprioception, the understanding of what is going on based on all that information flowing to your brain and spinal cord from the mechanoreceptors throughout the body, and you need the ability to pull all that together into a movement program, created in the motor cortex in you brain. The motor cortex is where the software for our movements, or motor programs, are stored, and this software is constantly either being improved or deteriorating, depending on how much and how well you use it.
When the system fails
That is all fine and good, the uncoordinated and poorly balanced among us may say. Amazing as this system may be, I am still having trouble with my balance and my coordination, so what gives?
This is a question with many potential answers, so let’s go through them one by one.
In certain individuals one reason proprioception, and therefore balance and coordination, may be decreased, is joint hypermobility. Joint hypermobility is usually caused by a congenitally softer type of connective tissue, making joint capsules, ligaments, and tendons less resistant to stretching. A recent paper estimated the prevalence of generalized joint hypermobility in a university-aged population as 12.5%, while a more severe form of hypermobility called Ehlers-Danlos may affect as many as 1 in 5,000. Stretchier tissues will lengthen father than stiffer ones before they are triggered to signal about lengthening, and this may contribute to the decreased proprioception in hypermobile individuals.
An injury, such as an ankle sprain or ACL tear, may cause hypermobility or laxity in a single joint, causing the proprioceptive input from the injured joint to decrease, leading to instability in this but not other joints.
Aging tends to decrease the input from the periphery, due to deterioration of mechanoreceptors, and perhaps in part due to age-related stiffening of connective tissue, and may also change how the brain processes incoming data. Older people tend to be much less physically active than younger people, and, especially in industrialized societies, loose joint flexibility and range of motion, causing poor communication about joint position for reasons opposite of that of the hypermobile.
Inactivity decreases muscle strength, but in terms of balance and stability the effect of inactivity may be even more deleterious on the levels of the “software” of the brain, resulting in a decrease in the number of brain cells dedicated to propriocetive analysis and the previously mentioned motor programs.
Short- and long term dangers of poor proprioception
With laxity, injuries, inactivity and aging comes a different strategy for using the body. Instead of controlling joint movements in a skilled, precise way, we start to utilize stiffening strategies, which is like moving from the smooth, controlled movements of a jumping cat to the stiffer, wobbling of a duck. This stiffening, which means we are tightening muscles as if though walking on thin, slippery ice, is neither good for muscles, which start to ache and complain under the constant burden, nor is it healthy for our joints, which are not properly protected by these inferior strategies.
With decreased proprioceptive prowess, decreased muscle strength, less effective stabilizing strategies and less impressive brain software comes an increased risk of acute falls and injuries, which can be devastating and present an enormous problem among the elderly. A decreased sense of joint position and movement can also lead to less stability of and a less precise use of joints. This, in turn, can lead to microtraumas, tiny but cumulative injuries, that wear out cartilage and keep muscles and ligaments in a perpetually irritated state, ligaments because of the painful pulling on them and muscles due to the resulting chronic, compensatory stiffness.
Fear not, there is great news!
So are the stretchy, the injured, and the aging among us doomed, (not to speak of those that are stretchy, injured and growing older)? As always, exercise to the rescue!
With continued activity and exercise that challenges and strengthens our body we can all improve, sometimes tremendously so. Due to the incredible plasticity of our body, or the ability to continuously change in order to adapt to the demands placed upon it, we can all compensate for imperfection in one organ by improving another. The initial instability caused by a torn ligament, such as the ACL or MCL ligaments of the knee, can, through therapeutic exercise, be compensated for by increasing reliance on inputs from other tissues.
The incredible muscle control of a classical dancer, who typically is quite hypermobile, is a beautiful demonstration of this ability to adapt and compensate trough continuous training and effort. The negative effects of aging are as much a correlation with increasing levels of inactivity as they are a result of inevitable aging-related changes in tissue. Regular physical exercise maintains the joint position sense, or the proprioceptive ability to feel our joints, of older individuals at near that of non-exercised younger individuals and more than twice as good as that of sedentary older individuals. As a matter of fact, the only strategy that seems to retain or help regain joint proprioception in older individuals is regular physical exercise.
Positive effects of regular physical exercise on knee joint position sense (adapted from Ribeiro & Oliveira, 2010)
Conclusion: start where you are, seek expert advice and keep going!
So whether you have fallen prey to the myth that aging inevitably incapacitates you, or have lost the ability to move without pain in joints --unstable due to inborn laxity, accidents or both-- or whether you’ve been neglecting physical activity lately, or even always, there is a right place to start and much improvement to be had! Perhaps just as importantly, exercise of the right kind can be an invaluable tool for those with enough foresight to want to prevent injuries, whether due to the fact that they are hypermobile, new to exercise or are lucky enough to be getting older.
No matter what the case may be, seeking the advice of a skilled physical therapist may make the difference between success and failure. Our bodies and brains are designed to survive in the moment and will always find a way to perform a movement, no matter how. This means that we almost inevitably end up with potentially harmful compensatory movement patterns. We wobble this way and that, overuse one muscle in order to not use another weak one, and rarely, if ever, find our way back to perfect, natural movement simply by engaging in a sport, a form of exercise, or dance. How we move is just as important as the movement itself, so seek the advice of a physical therapist familiar with your situation for guidance abut how to gradually, safely and effectively find the way back to the best version of you!
Pain exists for a reason. It is a warning sign that helps us protect our tissues. So shouldn’t we always heed the warning, and do everything in out power to avoid pain?
The short answer is no, and this post is the longer, more detailed answer to that question, because pain is too important a phenomenon to misunderstand. Completely disregarding pain signals can lead to inappropriate movement patterns and habits, and subsequently to gradual, or even sudden, tissue breakdown. But being too avoidant of pain can lead to tissue weakness, deconditioning and decreased function. It can even shorten our lives. Sounds like a bit of a dilemma, doesn’t it? But it need not be, so let’s take a closer look.
We have evolved for a lifestyle where pain co-exists with other drivers such as hunger or the need for social belonging and safety. If our prehistoric ancestors hurt their knee or their back a bit, they still had to keep moving in order to forage and hunt. The pain simply meant “move with awareness, maybe a bit slower or differently”. It did not mean “Stop!” Only the excruciating pain of a broken bone would have categorically stopped hunter-gatherers in their tracks. This balancing act helped them recover without weakness.
Today we have high-tech imagery that shows what we are told is damage to our tissues, experts that give us ominous-sounding diagnoses for our ailments, and the ability to put dinner on the table without being physically active. This has gradually lead to a different interpretation of pain. Now virtually all pain seems to mean “stop”. This leads to lifestyle where we carefully avoid feeling more of it by moving less. Unfortunately, relating to pain in this manner can actually lead to the very thing we are trying to protect ourselves from, more pain and decreased function.
Taking steps to avoid pain can sometimes lead to more, and chronic pain.
But just like we use our intellect, instead of our hunger, to tell us when we should get some exercise these days, we can figure out when to move and when to stop even though circumstances don’t dictate the rules anymore. In order to do that we need to take a closer look at the various types of pain and what they mean.
Pain can be divided into four types: nociceptive, peripheral neurogenic, central neurogenic and central sensitization. Peripheral neurogenic is nerve pain like the kind stemming from a pinched nerve. Central neurogenic pain stems from damage to the brain from an insult like a stroke, and central sensitization is an exaggeration of the type and intensity of a painful, and even non-painful, signal that can occur with chronic pain. I’ve written about that here. But most of the time what we’re feeling is musculoskeletal pain, ie the nociceptive type. This is pain stemming from tissue injury such as the pain that may occur after exercise or stubbing a toe, inflammation, pain from cramping, or other phenomena that lead to pain due to hypoxia, or insufficient oxygen in the tissue.
Below is a chart where the various types of pain are organized according to my “traffic light system” that can help you decide how to related to a pain you’re feeling and know whether you should move or avoid movement.
TRAFFIC LIGHT SYSTEM OF PAIN
Red- severe, sharp pain that takes your breath away - Stop doing what you’re doing.
Yellow- Some discomfort that doesn’t seem to get worse with what you’re doing -
Keep moving, with awareness.
Green- movement feels great, or is gradually decreasing the discomfort - Keep right on moving cap’n!
Here are some examples of conditions where you might judge the pain you feel as either a green, yellow or red light:
Green Yellow Red
Muscle soreness from exercise, Soreness and pain in tissues such as A broken or se-
stiff muscles, arthritic joints, ligaments and tendons that have very weakened
been overloaded and hurt (tendonitis, bone or other
plantar fasciosis etc), intense muscle conditions where
cramps and spasm, healing tissues you’ve been told to
Central sensitization avoid loading
Central neurogenic pain the tissue for a
while, recent surgery
As you can see, pain should rarely be interpreted as an absolute ‘stop’.
But, why not err on the side of caution and avoid the discomfort caused by movement when soreness or pain is present? Why, I thought you’d never ask!
The reason we should always move if we can (no red light present) is that our bodies unequivocally need movement. That’s how they are designed. Movement adds forces to our tissues, signaling the need to build them stronger. Movement increases blood circulation, bringing oxygen and building blocks to tissues, helping them grow stronger and repair themselves after use or injury. Movement keeps our nervous system healthy and maintains our ability to feel, coordinate movement and balance. Any time we have to, or choose to, avoid movement, we are choosing not to have these phenomena benefit us, and unfortunately this causes our tissues gradually atrophy, or grow weaker. This makes us not just less able and strong, but also makes us more vulnerable and more at risk for injuries.
Exercise also decreases pain by activating brain
pathways that block pain signals, so suffering from
pain should actually be a motivator for movement,
not movement avoidance.
Speaking of injuries, some of us don’t choose the too careful, pain-pain-avoidant path. They stubbornly keep charging ahead, and see pain as something of a personal offense, and pushing through the pain as a badge of honor. (You know who you are!) Remember the yellow light that means ‘move with awareness’? That also means intelligently changing the load on your tissues as needed, even as you keep moving. A runner whose hamstrings are hurting, and don’t get better with continued running, should of course address the reason for the pain, and during this process s/he will most likely benefit from some modification of their sport; running less or less often. Here the ‘awareness’ leads to change, being aware of what it is that is causing the pain and addressing the issue. (Hint: that most likely means a consultation with a physical therapist. These things can sometimes be hard to figure out on your own.)
And speaking of yellow lights, there are many circumstances that should alert us to the need to ‘move with awareness’ and very gradually give out bodies the chance to grow stronger. If you are increasing your activity level, whether you are a seasoned runner who wants to increase your mileage or are starting an exercise routine for the very first time, give your tissues time to gradually get stronger. Connective tissue, which makes up most of what we are: bones, ligaments, tendons, skin etc, grows stronger much slower than muscles do. Don’t run ahead, literally or figuratively , and only follow the lead of your muscle strength. People with hypermobile joints, approximately 5-15% of the population, should also “start low and go slow” and give their weaker connective tissue a fair chance to grow stronger. If you are recovering from an injury, you are also rebuilding your tissues, so increase activity at an appropriate pace.
So, when in doubt, move. Consult the traffic light system, decide whether yours is a green, yellow or red light, and keep moving. Get some movement every day, and more intense movement at least three times a week, and enjoy growing stronger!
Link to my article about the connection between nutrition and health and recovery of the musculoskeletal system, posted at Physio Network.
Nutrients are substances (fat, protein, carbohydrate, vitamin, minerals) that we absorb from our food. They are the building blocks that our bodies are made of and the helper molecules that make all our bodily processes work. They are what we consist of and what keeps us not only alive, but healthy, happy, and thriving. It is easy to understand that the lack of nutrients can cause poor health and loss of mojo or worse, and that getting the nutrients we need is of utmost importance for anyone wishing to live well and for a long time.
Most people have neither the time nor interest to obtain an in-depth understanding of nutrition, and most of the articles aimed at the general public are written more with what- gets-people-to-click-on-the-link in mind than a comprehensive analysis of facts. This makes it easy for misunderstandings and myths to creep in and distort our sense of what we need from food and how to get it.
Here are 10 common myths related to food and nutrition it is time to let go of:
1) You can get all the nutrients you need from a balanced diet
Our farming practices have actually led to depletion of the soil in which our produce is grown. A Kushi Institute analysis of nutrient data from 1975 to 1997 found that average calcium levels in 12 fresh vegetables dropped 27 percent; iron levels 37 percent; vitamin A levels 21 percent, and vitamin C levels 30 percent. Many common nutritional deficiencies, such as Magnesium deficiency, are not detected in routine lab tests and since the potential symptoms are so many, non-specific and varied (for magnesium deficiency symptoms may include fatigue, high blood pressure, anxiety, trouble sleeping, osteoporosis, muscle cramps, headaches, constipation, etc.) people are rarely aware of them. Since we have changed our dietary practices so much over the past generation or two what might be perceived as a “balanced diet” today is very different from what is was for your grandmother. Highly nutritious foods such as organ meats and collagenous cuts of meat have recently fallen out of favor, while a whole host of non-food food-like substances have crept into our food supply. Cheese-like spread, anyone?
Nutrient deficiencies are actually quite common, and thirty-one percent of the U.S. population is at risk of at least one vitamin deficiency or anemia.
2) Our food is more nutritious than it used to be, so we don’t have to worry about nutrition
While it’s true that we are luckier than some of our forebears in terms our access to fresh and nutritious food, there have also been many detrimental changes to our food supply. We are exposed to large amounts of low-nutrient foods that have been engineered to be enticing, rather than healthy. Our produce is harvested long before it ripens and travels long distances, and our food is prepared and packaged (heated, exposed to light, soaked, mixed with preservatives, etc.) in ways that lead to a loss of nutrients. One change that is likely to have far-reaching consequences is the processing of food, and the change in our eating habits that leaves us with less fiber.
The loss of fiber and other pre-biotics, together with the many additives to our food (preservatives, artificial sweeteners, antibiotics, and more) starves our gut microbiome. This is significant because the health of the gut microbiome has been correlated with virtually every aspect of our health and well-being, affecting mood, skin, digestion and colon health, brain health, cardiovascular function and more. A recent study found that even fibromyalgia, or widespread pain in the body without an apparent physical cause, may be rooted in an altered gut microbiome affecting pain sensitivity and processing.
Understanding that the changes to our food supply have been both good and bad, and that these changes have occurred so gradually that we may not even be aware of them at all, is important for anyone interested in obtaining optimal nutrition from food.
3) You can be equally well-nourished on different diets. It’s literally just a matter of taste
It’s hard to deny that we are living in the age of food fads. We have gone from "All Fat is Bad" to Atkins to Low-Carb/High Fat (LCHF) to Paleo to Vegetarian to Vegan to the Ketogenic diet, and predictably the next fad is just around the corner. Adherents of all popular fads tend to be equally enthusiastic, and reading an account of the wonders of any particular diet can make the most equanimous among us feel worried that we might be missing out on something important.
These food fads create confusion among the general public and a reluctance to listen to any dietary advice. They obscure the fact that there is real and ongoing research in the field of nutrition that is quite different from the breathless headlines about the latest “news” about the supposed danger of eggs (spoiler alert: eggs are really good for you). The truth is that following any diet that is defined by an exclusion of certain food groups leads to a real risk of dietary deficiencies. As an example, the vegan diet excludes all animal products, and because of this vegans tend to be deficient in vitamin D, B12, zinc, iron, calcium and the important fatty acids EPA and DHA.
4) Carbs/eggs/red/meat/fat/ (did miss something?) are bad
Most people get their nutrition-related information through articles they happen to come across online or while waiting for their dental or hair appointment. Usually these types of articles are sensationalistic (and highly unscientific) click-bait reporting based on an isolated study, and only serve to confuse and frustrate the reader. Scientific consensus, on the other hand, is built slowly but surely, based on accumulated scientific findings (the results of many studies, replicated over many years).
Food should not be thought of as either “good” or “bad”, but as a
source of nutrition to be used appropriately.
Are you sedentary? Eat fewer carbohydrates, as these are mainly needed as a source of energy. Are you bicycling hundreds of miles per week? Eat many more carbs. In both cases, eat mainly unprocessed carbs that come with the free bonus of fiber and plant nutrients, and are absorbed more gradually in the body.
The same is true for other oft’ maligned foods. Eggs are great , especially if you choose pastured eggs; red meat is great if you choose grass-fed, organic meat, in appropriate amounts for age and activity level. Avoid less healthy fats such as heated vegetable seed oils (yes, as in fast food fries) and fats become your friend, too, helping you absorb fat soluble vitamins, build cell membranes, and more.
5) Nutritious food is less tasty than junk food
Our taste buds have evolved in order for us to be able to tell a nutrient form a toxin, and our preferences for taste and texture have evolved to guide us to the nutrients we need from food. But manufacturers of modern-day food products employ food scientists to manipulate the taste and texture of processed foods to make them more appealing to consumers, in essence to trick our tastebuds into finding very low nutrient density foods appealing (think: Doritos or fast food, for example).
That does not, however, mean that nutritious food is low in flavor. On the contrary, we can still use our tastebuds to guide us. We simply need to use our logical understanding of the nature of processed foods to motivate us to avoid them, and then use our sense of taste and smell to help us find the best and most nutritious real, unprocessed or minimally processed food. Italians, for example, are famously picky about the quality and freshness of their food, simply because high-quality food tastes better. (Perhaps unsurprisingly, they are also long-lived.) But the reason high quality food tastes better to us is that our tastebuds are still able to detect nutrients as an appealing flavor, texture and smell.
Our taste preferences also change with exposure. Eating a lot of sugar gets our tastebuds used to the taste of increasingly sweet foods, and exposing them to bitter tastes more often “programs” them to enjoy bitter foods. In other words, your current preferences say more about what you have been eating than what foods objectively taste like.
6) If you’re recovering from an injury or surgery and being less active, you should eat less
It may perhaps sound a bit counter-intuitive, but during recovery from injuries and surgeries your protein need is actually increased, and intakes of 2–2.5 g/kg/day are recommended during immobilization, up from the RDA of the modest 0.8 grams of protein per kilogram of body weight. You'll find a helpful online RDA calculator here. Physical activity actually stimulates muscle building in such a way that the body uses the protein it's given more effectively.
7) Senior citizens need much less food than younger people
As people get older they often choose to or think they ought to be less physically active. When this is the case, they of course need fever calories. Therefore, as the amount of food decreases it becomes increasingly important to pay attention to food quality, especially since the same population also, for a number of reasons, tends to absorb nutrients less efficiently. As we get older we also become less sensitive to the muscle-building effect of protein in our diet, and actually need to increase our protein intake after the age of 65.
8) If a diet is helpful for sick people, it’s proof that it’s the best diet for all.
The Ketogenic diet is a low carb/high fat diet. It has historically been used as a non-pharmacological treatment of childhood epilepsy and has more recently gone mainstream and is being studied as an intervention for other neurological diseases such as Alzheimer’s and Parkinson’s disease, as well as diabetes and obesity with varied success.
Does the fact that a friend lost 20 pounds on the Ketogenic diet mean that this diet is superior to others and that everyone should be on it? As mentioned above, following any diet that is defined by an exclusion of certain food groups leads to a real risk of dietary deficiencies. The Ketogenic diet can be low in fiber and certain nutrients, and has to be followed with careful attention to food choice and supplementation. The diet can be directly harmful and be contraindicated for many people, including those who are pregnant, stressed, have a genetic predisposition for high cholesterol, or have low thyroid hormone levels.
The most direct route to health, with the fewest potential pitfalls, continues to be a varied diet, ideally including foods and food preparation methods that maximize nutrient density (think organ meats, soaking legumes prior to cooking, sprouting, sourdough, etc.) that is based on high-quality food with as few harmful substances (antibiotics, pesticides, products from inproperly fed animals) as possible. In other words, a truly healthy diet is based on inclusion of nutritious food through an understanding of what humans need for optimal health, and not solely on the exclusion of certain foods.
If you’re recovering from an injury or surgery and being less active, you should eat less
It may perhaps sound a bit counter-intuitive, but during recovery from injuries and surgeries your protein need is actually increased, and intakes of 2–2.5 g/kg/day are recommended during immobilization, up from the RDA of the modest 0.8 grams of protein per kilogram of body weight. You'll find a helpful online RDA calculator here. Physical activity actually stimulates muscle building in such a way that the body uses the protein it's given more effectively.
6) OK, got it. So I’ll take a multivitamin, that will cover all the bases.
Not so fast! While taking a high quality multivitamin can be better than nothing for some people some times, multi-vitamin preparations are often of low quality, (for example containing synthetic versions of nutrients instead of the form found in food) and may even pose an added disease risk for certain people. The greatest risk multivitamins pose may be a false sense of reassurance, a belief that one has covered all the bases. Unfortunately, there are many potential problems with relying on a multivitamin. One of them is that minerals are way too bulky to fit into one. You can never get all the potassium, magnesium, or calcium you need from a multivitamin pill. Another potential problem is that they do not exclusively contain vitamins or minerals that many people are deficient in, but also those that most people are able to get in sufficient amounts from quality food. Genetic variations, health status, activity level and age are all factors that may affect both the need for and absorption of nutrients, and a one-size-fits-all multi can’t stretch to fit these varying needs.
10) Colorful vegetables are good, white food is bad and other oversimplifications
I know, simple rules of thumb feel helpful, but “no white foods” is not a helpful one. While large amounts of rice and pasta may give you more carbohydrate and less in the way of micronutrients, potatoes are very nutritious - yet also very white.
Avoiding any food without a firm scientific reason to do so imposes unnecessary restrictions, increases the risk of nutrient deficiencies, and helps build an image of food as a dangerous enemy instead of as a source of pleasure, health, and life.
To quote Harvard professor David Sinclair, PhD once more: “Truth is, moderation is key. Don’t eat too often and too much of anything.”
Bon appetit :-) !
The good news is, there’s good news, so read on :-)
One in five Americans suffer from chronic pain and most of them believe they do so because of an injury or breakdown of their tissues. This is called the biomedical model. The biomedical model assumes that injury and pain are the same issue; therefore, an increase in pain is seen as sign of increased tissue injury. Similarly, it is believed that increased tissue injury leads to more pain. This model (called the Cartesian model of pain) is over 350 years old, and is no longer believed to be correct. While there is, in acute pain, often a correlation (although varied, and never absolute) between tissue injury and pain, in chronic pain this correlation starts to fall apart, and fails to provide a complete explanation of the issue.
One reason for this is that tissue injuries heal, and pain that persists months after an injury can logically not be due to said, one-tie, tissue injury. Sometimes there is not even a distinct injury precipitating the onset of pain, but the onset is gradual. Pain is also highly dependent on our attention, stress, emotions, learned behaviors, beliefs and expectations, including beliefs about what the pain means, whether we feel safe or not, whether we feel empowered or helpless. Psychological factors have actually been found to be more predictive of the development of chronic pain than physical ones.
Modern pain neuroscience has enhanced our understanding of pain
The fundamental thing that modern pain neuroscience research has shown is that chronic chronic pain may not correctly represent the health of the tissue, but may be due to extra-sensitive nerves and modulated by our beliefs and expectations.
You could describe the peripheral nerves leading out to our tissues as wires picking up various signals (touch, temperature, pressure etc) and our brain as the processor that interprets these signals. In a well-functioning system the signals are interpreted correctly. Touch is interpreted as touch, movement as movement etc. But this system can malfunction, and the nervous system can start to misinterpret or over-interpret these signals, so that eg stimulation of receptors in muscles and tendons that should result in a sensation of movement instead results in a sensation of pain.
Pain is created and experienced in the brain
Nociception is the word we give our ability to detect potentially harmful stimuli. It is a protective process that helps us avoid harm by either creating a reflex to pull away from the stimulus, for example a thumb tack you just stepped on, or a sensation that is so unpleasant (read:painful) that it results in behavioral strategies on our part to avoid the stimulus (to look around and step carefully in order to avoid stepping on more thumb tacks). Our “wires” lead the signal of a certain input to the brain, the “central processor”, which then makes an executive decision about whether the stimulus is worthy of our attention, and if so, how much of it. If the brain interprets the signal as a result of a potentially harmful phenomenon, it creates a sensation of pain. Worry, fear, negative beliefs and expectations, previous experiences and many other psychological factors affect the brain's decision-making process.
In some people the alarm system gets stuck at a higher level of sensitivity. With the alarm system extra sensitive and close to the “firing level,” it does not take a lot of movement, stress or activity to activate the alarm system. When this happens, it is natural to think that something must be wrong, even though there is no injury or damage to your body. This is called central sensitization. Central sensitization produces hypersensitivity to pain and other sensations by changing the sensory response elicited by normal inputs. Now even those inputs that usually evoke innocuous sensations such as touch, movement etc may be perceived as pain or other worrysome sensations.
Pain in a person with central sensitization may arise spontaneously without any sensory input such as touch, movement or pressure and it can be elicited by normally harmless stimuli such as gentle touch (this is called allodynia). It is exaggerated and prolonged in response to normally painful stimuli (hyperalgesia), and spreads beyond the original painful area (secondary hyperalgesia).(By the way, these fancy terms are just names for the phenomena we observe, not an additional diagnostic label to be worried about!)
The pain in central sensitization is in other words not proportionate to what is going on in the body.
Sometimes this heightened level of responsiveness of the nervous system is felt only in particular part of the body. Chronic episodic pain is pain that, as the name implies, occurs in episodes, instead of always feeling the same. Pain can be triggered by eg stress, and fear of pain and disability can be a powerful stressor. Individuals with chronic or recurring pain therefore have to work diligently at controlling their thoughts and emotions through education, awareness -building practices such as meditation and other means of keeping levels of stress and catastrophizing thoughts low.
Why do some people develop chronic pain?
There are genetic differences in our pain threshold (how quickly we would characterize a stimulus as painful). Hormonal levels affect our sensitivity to pain. As an example, low level of the sex hormone estrogen, as experienced during certain parts of the menstrual cycle and even more so in menopause increase pain sensitivity. Cold this be part of the reason why middle-aged women are the group most often diagnosed with fibromyalgia? More than anything, our thoughts, beliefs and expectations affect pain.
Sometimes an acute injury leads to an adaptation to pain (think of someone with acute low back pain and how they tend to move) that includes altered movement strategies and a decreased levels of movement that in turn set the stage for chronic pain and malfunction that seems seamlessly connected to the initial injury, but actually is arising from the changes we, consciously and not, made in response to the acute pain. Now the initial injury or muscle spasm is long gone, but the patient has made permanent changes to how they view and use their bodies which create ongoing pain.
Central sensitization represents a more fundamental shift in how the nervous system perceives pain, and all of the reasons for this aren’t well understood just yet. However, we know that anxiety, stress and depression are also present in 30–45% of patients. Other factors that may contribute to symptoms include endocrine dysfunction, psychosocial distress, trauma, and disrupted sleep.
Adversity in childhood can set the stage for central sensitization, and so can traumatic events leading to PTSD.
It is as if though the brain learns that the world is a dangerous place and remains a bit more on high
alert, and over-interprets potential signals of danger.
Examples of situations where you’ll find central sensitization are whiplash that persists a long time after the original accident. Fibromyalgia is the prototypic example of central sensitization. Less often, but in a percentage of cases of low back pain, tendon problems, shoulder pain, osteoarthritis, rheumatoid arthritis, pain following cancer treatment, tennis elbow, headaches, shoulder pain, tendonitis of the elbow, knee and ankle central sensitization plays a role. Sometimes central sensitization presents as a heightened sensitivity to pain that seems to move from place to place or be felt in many body regions at the same time. Opiod use can actually lead to an increased pain sensitivity, so called Opioid-induce hyperalgesia.
It may be helpful to think about sensitization in chronic pain as existing on a spectrum, so that you don't either have it or don't have it, but may have more or less of it. All of this also means that when you experience acute pain, you can think and behave in ways that may help prevent chronic pain.
Incorrect beliefs about the nature of pain and a belief that the body is inherently fragile, and subsequent
avoidance of movement out of fear of further damaging what the patient believes is an already
damaged body, are called Fear Avoidance Beliefs and have been strongly correlated with chronic pain.
Is chronic pain always a nervous system problem?
The reason developing a better understanding of the nature of pain is helpful is that it empowers us to take the correct action. This action is not to power trough the pain, but at most to gently "nudge:" it, to move despite moderate pain, through through gritted teeth. To know when to heed it's call and when to call it's bluff.
When we approach out bodies with this enhanced understanding, we don't risk overloading tissue in conditions, such as hypermobility disorders , where there may be chronic overload on certain tissues, contributing to pain. These underlying issues have to be addressed, because, at best, they keep the flame burning under the enhanced, chronic pain.
If you have had pain for a long time and haven't been getting better, you know or suspect that central sensitization plays a role in the pain you’re feeling, or have been wondering why seemingly innocuous activities often make you hurt so much, or lead you into a spiral of pain, take heart! The reason central sensitization develops in the first place is the so called plasticity of the nervous system, in other words it’s ability to change and learn. If your nerves have learned to become too trigger-happy and your brain has learned to exaggerate signals they can also gradually learn to calm down. Working with a qualified healthcare provider and trusting that the sometimes initially counter-intuitive things you’re learning are true is key. After all, pain in central sensitization feels just the same as any other pain, and it can at first be hard for some patients to understand that it is not a discrete physical injury that is driving the pain, but rather a hypersensitivity of the nerves.
It can also be hard for patients with chronic pain to take in the fact that pain does not go away by waiting for "healing" (of tissues that aren't injured) to take place before increasing movement. That is actually placing the cart before the horse. Even acute pain heals faster and better when appropriate movement is part of the treatment plan!
Here are some key points to consider:
Learn to understand chronic pain. It is important to understand that you are not hurting simply
because of a broken body or injured body part. Understand that pain may not correctly
represent the health of the tissue, but may be due to extra-sensitive nerves or incorrect usage of
Understand that movement, properly introduced and performed, is your friend and will not
injure you. Your body is not fragile! Feeling sore after movement does not mean that you have
been injured or hurt.
Approach movement through graded exposure. Graded exposure means that you are, through
gradually increasing exposure to movement, decreasing the sensitivity of the nervous system
and correcting movement-related pain associations. Your fear of movement, pain and of
"getting hurt" will decrease slowly but surely through gradual, positive experiences .
Find the right provider. Some healthcare professionals may not be quite familiar with current
pain neuroscience. If you are only being treatment with drugs, passive treatment modalities or,
conversely being encouraged to completely disregard pain and work
harder, find a provider that can more appropriately guide you through the
process. You need to find and accept a "Goldilocks-level" of gradually increasing exposure to
Learn to not interpret initial discomfort as a sign that your body is being hurt or injured. Your
body is not fragile. Learn to not focus on sensations of discomfort, and be disciplined abut
redirecting you attention to other sensations and phenomena. What part of your body feels
good? Were you able to make some progress with your exercise program? Did you tolerate
more movement before reaching a familiar level of discomfort? A
brain that fears the sensations it experiences creates much more pain than the
brain of person that is informed and feels safe, not scared. Fear of the pain
itself also increases the intensity of pain.
Focus on progress and ability, not on pain and disability.
Think long-term. No matter how seductive various treatments that only temporarily relieve pain
may be, understand that they are not a way out of chronic pain, and actually
may distract you from the important work at hand. When you are
tired it may feel like you need coffee, and coffee would of course temporarily
help. But the actual problem is not that you haven’t had enough coffee, it is
that you haven’t had enough sleep, and that is the problem you actually need to
solve. If you continue to drink coffee instead of getting some sleep, you’ll
soon be in deep trouble. Remember, the problem causing the heightened I pain intensity
doesn’t primarily lie within the tissues, but in the sensitized nerves, incorrect beliefs and incorrect
You need active work more than passive, palliative treatments.
Normalize your body's function. When your body works more like a well-oiled machine than a
cart where the wheels are slowly coming off, you will be loading your bod's tissues isn a way that
strengthens them, instead of weakening and irritating them. Note: in chronic pain conditions
you need a physical therapist to guide you through this process. You already now that
simply trying to move more makes you feels worse!
Knowledge is power. When your brain understands that the
sensations you are noticing are not a sign of danger to your body, it will
actually immediately produce less pain! Remember, the type and amount of pain we
experience is very directly and strongly dependent on our beliefs about the
pain and what it means. Be your own coach and remind yourself of this every day!
A healthy body feels pain sometimes, and gets better by adapting to activity,
not by avoiding it. Waiting for pain to completely go away before returning to
activity is putting the cart before the horse, because resting makes
you weaker, not better adapted for activity. But sudden dramatic increases in
activity may be just as ill advised to the sensitized person. Start low and go
slow is a useful mantra. The body in chronic pain is like a scared cat. You can’t
force it, but you can entice it, and gradually convince it that it is safe to come
out to play.
You are not a passive recipient of pain. It may not feel like it, but pain is a process that takes
place within your own brain, and you have a lot of control over it. By educating yourself,
disciplining your thoughts, finding proper guidance for movement and lifestyle (deep sleep, a
good diet, emotional support, mindfulness and other aspects of a health-supporting lifestyle all
have immense effects on the amount of pain we feel) and trusting your body's inherent strength
and capability you can make powerful changes that help you suffer less.
Remember, the way out of chronic pain lies not in avoiding it, but in understanding it and transcending it. You transcend it by understanding its very nature, that it is not warning or guiding you, but deceiving you. It is simply a sign of a nervous system set on high alert, of having ended up in the dead end of avoiding pain instead of confronting it. The opportunity available to us is to slowly but surely reclaim our health and freedom to move and enjoy life.
Do you have questions about how to address or avoid chronic pain? Comment below!
Actionable ideas for the tired, overworked, fearful, pain-ridden, injured and concerned.
We all know there are benefits to be derived from regular exercise, but most aren’t aware of quite how great they are. In order for us to be motivated to do something we need to find our why, our motivation to devote time and energy to said enterprise.
Sooo many benefits you'll love
This study showed that with regular exercise, 70-year olds had muscle mass and strength identical to their 40-year old counterparts. The authors conclude that the loss of bone, muscle, strength and balance over time is due to increasing levels of inactivity, not age. This is great news, and completely contradicts the commonly held false belief that aging inevitably has to be a period of gradual decline.
Multiple studies and review papers such as this one show the effects of regular exercise on mood, cognition and its power in warding off dementia. As a matter of fact, the great news is that those genetically most at risk for Alzheimer’s disease (those with one or two copies of the so called ApoE4 gene) seem to reap the greatest protective effects from physical exercise! There seems to be justice in the world after all!
Add to this the fact that regular exercise helps prevent the most common diseases (75% for breast cancer, 49% for cardiovascular and heart diseases, 35% for diabetes, 22% for colorectal cancer). Imagine if there was a pill that could do that! We have such a "pill" at our disposal in the form of exercise and with only positive side-effects at that. When exercise is combined with other simple constructive behaviors such as sleeping in a pitch-black room, eating nutritious food and cultivating a peaceful mindset the effects are even more pronounced.
Given how fantastic the effects of exercise are, why aren’t we all out there, reaping the many benefits? (After all, physical exercise even gets you closer to that coveted “look better naked” status.)
But (almost) no-one spontaneously prefers exercise to a comfy seat on the couch, and in a real-world situation many obstacles seem to keep so many of us from reaping the tremendous benefits of regular exercise. To help you move from passivity to physicality I have listed some of the most common obstacles below, along with some hopefully helpful and actionable work-arounds. If you are experiencing obstacles or concerns that aren’t listed below, reach out to me in the comments section!
Time to troubleshoot!
I don’t have the time. Yes, you do. But your available time may be found in small increments during the day. Work by a desk? Type standing, stand and do toe-raises while on the phone, take 30-second breaks (which enhance creative thinking and make you more productive) to do push-ups against your desk, squats over your chair etc. And take the stairs every time. The elevator is for lazy people, and you’re not lazy, just busy. This advice applies to stay-at-home parents as well. Take advantage of the opportunities you may have been missing to strengthen arm and trunk muscles while holding a baby, or leg muscles by performing little lunges carrying groceries.
I’m too tired. If you are truly exhausted, you should not perform strenuous exercise. Yet. You need to work on your burnout and nurture yourself back to health. When tolerated, start with slow, short walks. During your recovery, perform stretching and meditation to stay in touch with your body and its intrinsic value. You know you suffer from this level of exhaustion when any exercise leaves you drained instead of invigorated.
Those who feel tired and therefore unmotivated, but feel awakened and a bit better after some exercise actually need physical exercise to overcome the fatigue. The mitochondria, the little energy factories in your cells, multiply in number in response to exercise. The body rises to the challenge. They key is to re-enter the world of exercise gradually and keep your focus on your improvement, not your challenges.
I have pain. If you’re in pain from the type of acute injury that truly means you should lay off your usual exercise, such as a broken bone, exercise the part of your body that isn’t injured. Most other types of injuries respond better to activity modification, rather than cessation. In other words, lift a lighter weight fewer times, run or walk a shorter distance with a shorter stride length etc.
If you suffer from chronic pain, know that waiting for the pain to go away before starting an exercise program is putting the cart before the horse, and a mindset that will lead you deeper into pain as your body and its tissues keep getting weaker due to inactivity. Exercise decreases pain, and being decondition increases it, so pain is an added reason to exercise. Seek the advice of a physical therapist who will guide you through, and accept that there is going to be some discomfort before you feel better again. A simple rule for how much discomfort is safe is what I call the traffic light test:
Red- severe, sharp pain that takes your breath away - Stop doing what you’re doing
Yellow- Some discomfort that doesn’t seem to get worse with what you’re doing -
keep moving, with awareness
Green- movement feels great, or discomfort is decreasing - Keep right on moving cap’n!
Every time I exercise I get injured. Your amazing body adapts to what you’re using it for. Is your body adapted to sitting? Then you need to give it time to gradually adapt to movement. Want to run? Lengthen your hip flexors, strengthen your glutes, start walking and give your bones, ligaments and muscles time to gradually adapt. Want to lift weights? Work on a stable trunk
( planks, dead bug ) before you add any weight to your extremities, then strengthen buttock muscles and stretch your body to improve your joint range of motion.
And why not add some collagen to your diet (preferably before exercise and before bed and with some vitamin C) to give your body the building blocks for all the connective tissues it will be building.
Remember, an injury means that you are doing something wrong. If you can’t, despite following the above guidelines, figure out exactly what that is, consult with a physical therapist for some additional troubleshooting. Don’t give up on reaping all the benefits of regular exercise because of a few false starts!
I have special limitations. Not everyone can engage in all kinds of movement. If you have spinal stenosis, for example, you may not enjoy uphill running, but you may very well tolerate working out on an exercise bike. Learn how to get the most out of it (doing sprints on the bike, for example, adds a whole new layer of benefits) and you may over time find that other types of exercise get easier. If you can’t run, then walk, use an elliptical trainer or a bike. If you don’t have access to a gym, exercise class or a work-out buddy, use your body weight, household objects and the great outdoors for an equally beneficial experience.
If you are recovering from an injury, progress at a pace that allows all of your tissues to grow stronger. Muscles grow strong faster than ligaments, tendons and bones, so if you feel discomfort in theses tissues simply slow down the pace a bit. Older individuals and those on the hypermobility spectrum need to give their bodies more time to recover and progress.
I am just not motivated enough. Ask yourself what you are motivated to do or want to experience, and how that will play out in a gradually weakening and deteriorating body. Not so great, huh? Tough love, yes, but it is also part of a rather absolute reality that the physical body needs strain (aka exercise) in order to remain healthy.
Ask yourself what you need your body for. Is it playing with the grandkids? Travel? Long hours of work? Attracting a mate? Aging comfortably, with dignity and joy? Exercise is the key for all this, and more. See: the beginning of this post.
And lastly, the close cousin of lack of motivation:
I have to suffer in order to benefit. While vigorous exercise can certainly be a special kind of uncomfortable, it also offers immediate feelings of wellbeing of an even greater magnitude. And for a beginner, exercise does not need to be vigorous. The habit of seeing the world in black and white / can or can’t / good or bad is a counterproductive one, and prevents you from seeing the opportunities you do have. Don’t ask yourself whether you can or can’t do something, ask yourself instead how you can do it. If you are unsure about performing squats, don’t rule them out, but find a safe way to do them (over a chair? holding on to the kitchen sink?). If you have trouble running or lifting weights, don’t give up because of what you can’t do. Ask yourself, instead what can I do? Perhaps you’ll decide to start walking and doing some simple body weight exercises instead. And if you can’t walk yet, you might decide that what you can do is stand up every 15 minutes.
Remember, age is not an excuse (see above). Not having exercised before is not a reason not to start now (the body responds at any age). Injuries should end in recovery. Not possessing the know-how is no problem (make an appointment with a movement expert and learn).
Your quality of life depends on your physical health, and your body, unequivocally needs some form of movement and strain to stay healthy. Find your why and your how and the what will appear!
What would you like to be able to do?