Learning with Laughter

The following information is taken from The International Rehabilitation Medicine Association on Myofascial Pain Syndromes.
 
Why muscle hurt!  The body has 500 muscles which makes up half of our body weight. Being the motors of the body they work with and against gravity together with the cartilage, ligaments and intervertebral discs they also serve as mechanical shock absorbers. Each one can be subjected to acute or chronic strain and develop myofascial trigger points and have own characteristic patterns of referred pain.
 
Definition of Trigger point (TP)  A myofascial TP is defined as a “hyperirritable spot, usually within a taut band of muscle or in the muscle fascia, that is painful on compression and can give rise to characteristic patterns of referred pain and tenderness.
 
Incidence – A meaningful interpretation of incidence must distinguish between ACTIVE TPS that cause pain, either at rest or in relation to muscular activity and LATENT TPS. A latent TP may show all the diagnostic features of an active TP except that it causes pain only when the TP is palpated. The recognition and management of TPS is part of Physiotherapists training.

Recognition - Pain is dull, intense or aching and variable from hour to hour or day to day. Pain intensity strongly related to posture and muscular activity. Pain relates to the use of one muscle group and as such has specific referral pattern

Differential diagnosis – Referred pain of muscular origin can be confused with neurological pain or of a rheumatic/inflammatory origin which can be felt unrelated to muscular activity.  Neurological pain is often associated with loss of or change in sensation and deficits that match a peripheral nerve or root distribution. Physiotherapist are trained to assess these differences.

Emotions like anxiety, anger, fear and frustration facilitates the development and perpetuation of myofascial TPS and intensifies the suffering caused by pain; psychological stress in turn is augmented by the uncertainties and limitations imposed by persistent pain, the cause of which is obscure and which can responds poorly and not quickly enough for our overwhelmed, stressed lifestyle.

Stretch and Massage the Scalenes!

The number of neck muscles, including the upper trapezius, sternomastoid, splenii and suboccipitals muscles, refer pain strongly to the head.

These muscles are frequently responsible for Tension headaches. Masticatory muscles are likely cause of head aches felt side of the head (often first thing in the morning), facial and jaw area, also earaches and toothaches.

Ever had pain referring to the front, sides and back of the shoulder regions as well as down to the index finger?   The TPS in the 3 scalenes muscles can be responsible which are on either side of your neck. They also allow blood to flow into your arm and can lead to a number of problems. Ex: Thoracic Outlet Syndrome. Ever wonder why you sometimes get pain/ weakness/ numbness or tingling fingers at night in ring and pinkie fingers or wedding ring doesn’t fit in the morning? I had a patient once who thought he was having a heart attack because of Scalene TPS!

Scalene Massage

Upper Neck Exercise

Deep massage and slow mindful stretching with breathing can effectively remove symptoms…
Watch the videos on YouTube.
Upper Neck Exercise and the Scalene Massage. 

TMD is often misunderstood as CHVS
SABERS Approach to Management

Follow the SABERS approach:

• S is sleep
• A is awareness of arousal level (increased cortisol levels), How emotions, exercise, excitement and posture affects breathing
• B is breathing
• E is exercise
• R is rest
• S is self esteem.

By addressing all these aspects of a patient’s life the treatment is more likely to be successful.

Sleep – Do you know that sufferers of CHVS will complain: “I have nightmares and vivid dreams, my sheets are always tangled up in legs and my sleeping patterns are awful”.

• Sleep in fetal position with spine straight, teeth apart, tongue on palate, nasal breathing and employing deep abdominal respiratory patterns. Support jaw with the front of the pillow.

• A warm bath before bed can help to relax the body

• Resist TV flipping channels instead read a complex boring “how to” book to lull you off to sleep!

Arousal level of respiratory system- TALK TEST- if you can talk to someone while exercising, this is correct level of exercise because abdominal or lateral costal breathing can be maintained as well as nasal breathing This prevents the people from working above their anaerobic threshold which stresses the body and increase the arousal level (increased cortisol levels)

Breathing – What is good breathing? The cornerstone of this treatment is to practice deep abdominal breathing frequently. Practice TTTT… tongue on palate, teeth apart, lips together, shoulders ‘high beaming’ everyone and stand on the balls of your feet. I have a naughty jingle to remember this “Tongue, teeth, tits and toes lips together breathing slow!”

NOTE: The tongue tip should always be up on the palate even when standing and sitting. Say the letter “n” to know if your tongue is in the right place

• Practice every hour on the hour to take time to breathe 10 breaths slowly. Initially putting red stickers at your computer, on mirror in the car or sign “Just breathe” These all act as a reminder to breathe properly!

If this is hard hold the breath for 2-3 seconds anywhere in breathing cycle then do alternate nostril breathing (December’s newsletter)

How does doctor know if symptoms are caused by HVS?

50-70% patients visiting specialists are habitual over breathers. It may be difficult to pick up the problem because blood gases fluctuate in CHVS. A simple 12 breath test can be performed. The patient is asked to stand and take 12 RAPID breaths, which many sufferers are amazed to find reproduces exactly their distressing symptoms!

Have you heard people say “I thought I was dying… having a heart attack” but when I went to emergency I felt better and the doctor could find nothing wrong. In all three types of chest pain below, many stresses (physical, social and emotional) may combine with hyperventilation to bring it on. Often these stresses are not found in the security of the doctor’s rooms.

There are 3 types of chest pain associated with HVS:
1) Sharp pains felt while breathing in from pressure on the diaphragm from a bloated stomach, caused by “air gulping”, which results in spasm of the diaphragm and pain.
2) Dull aching pain with chest wall soreness, most often after exercise. This is due to overuse of intercostals, and accessory muscles, which tire easily and hurt.
3) Heavy pain behind the breast bone radiating to the neck and arms. This happens when the blood supply to the heart muscle itself is reduced by HVS stress/anxiety, and spasms of the coronary arteries.

Exercise – Do you find yourself saying “I can’t do yoga. It’s too slow. I feel too agitated. It’s torture to lie there and breathe!”

Hyper ventilators will often feel the urge to sigh, yawn (often seen at the beginning of a yoga /Pilates class) or ‘air gulp’. The body will try to loop back to hyperventilation.

In the book Hyperventilation Syndrome (HVS) by physiotherapist Dinah Bradley she says that, “There are 3 muscle groups used for breathing: Diaphragm, intercostals/ chest and the accessory muscles. In normal breathing 70-80% of the work of respiration is done by; the diaphragm (which is the most energy efficient and relaxing way to breathe); the intercostals which attach between each rib lifting them sideways, do 20-30% of the work and lastly the accessory muscles which include the shoulder and neck area. The body will overwork this area during extreme exercise, and STRESS. Chronic Hyper Ventilators, who tend to reverse this ratio using 80 % of effort in neck/shoulder area will as a result, feel pain in this region and can be one of the causes of headaches.”

Rest – Try to have 8 hours of sleep per night to help combat fatigue, and decrease arousal levels. Research shows this will also help control high blood pressure and improve overall health and feeling of well being.

Self-Esteem - Do something you love everyday!!

Any woman who knows the steep slippery slopes of Vancouver’s North Shore, also knows that high heels and icy sidewalks don’t go together.

We’ve all had those experiences when something very serious happens and you can’t stop laughing. This can be a problem as it eventually enlists the participation of the bladder!

It was December, Mum and I, full of Christmas spirit, our ears ringing with carols headed home laden with shopping. The bus swung into our stop by a puddle, dumped us off, and then pulled away. Whoosh, a tidal wave of icy sludge swamped us. 70 year old devout Christian women have never been given credit for the way they can raise foul mouthed language to an art form!

Surprised, my feet skidded away from me and I landed in an inelegant heap. Stooping over me Mum said “Take my hand”.  Humiliated, feeling like an oversized, over-dressed child, I allowed her to pull me up, when suddenly my spiked heel got caught in a drain and snapped off. I lost my balance, grabbed her leg and we started to slide down the icy sidewalk like those naughty men who lie on top of each other in the Olympics! Except we were head to toe!

Eventually Mum rolled off and assumed a “British Army” posture. Erect, Unflappable. However, I detected a slight twitch at the corner of her mouth which suggested she was amused by our antics. Stiff upper lip in place, she said, “Come on Catherine, let’s crawl”. Reluctantly, I joined her in “toddler mode.” We’ve all been in a bizarre situation, when suddenly everything seems funny.  Suddenly I imagined us like sheep with short legs! Giggling, I said “Mum, we could audition for a nativity play!”  “Baaah!” Mum echoed an even louder “Baaah” and we started to laugh.
 
As in many situations where daughters try to take command, mothers always assume control. In this case, approaching the house, I attempted to stand up, trying to regain my adult status once again. “Take my hand, Mum”. Caught up in the moment, I forgot, I only had one spiked heel to walk on. I stumbled. Mum grabbed me and said “Use your heel like a pick axe, Catherine”. Lurching home, clinging to each other, doubled over with laughter, we were barely able to walk in a straight line.

Hearing the laughter, a smiling husband greeted us at the front door. A bewildered expression spread over his face trying to comprehend what he was witnessing. Here was his mother- in- law wet, dirty but deliriously happy who appeared to need support from his giggling wife.  “Ladies, I thought you were shopping, not mud wrestling!”

Every time I drive up that steep hill in North Vancouver I smile and a tear comes to my eye as I recall Mum’s reflection about that afternoon. “Catherine, I haven’t laughed so hard in a long time.” 

Always remember as you age, life will throw out many challenges to overcome, but laughter and memories shared with family is the glue that brightens your days and keeps us together during the tough times. Don’t ever forget that! She went off to bed humming the song, ”Thanks for the memory.”

There is another syndrome which like TMD is often misunderstood or misdiagnosed by many health professionals. It is called the Chronic Hyperventilation Syndrome (CHVS). The symptoms have to be investigated for more serious conditions first, however in many cases if results are inconclusive, CHVS should merit being considered.

CHVS is a condition of the respiratory system in which the rate of breathing increases, venting off carbon dioxide that exceeds the rate at which cellular metabolism is producing carbon dioxide. This generally occurs if the respiratory rate exceeds 18 breaths a minute when the patient is lying down (Normal rate of breathing is 8-12 breaths a minute). The lowered Carbon dioxide concentration in the blood results in an increase in blood alkalinity otherwise known as respiratory alkalosis.

The symptoms resulting from CHVS and can be widespread. They can be Cardiovascular (sharp or dull atypical chest pain, palpitations): Neurological (headaches, dizziness):  Respiratory (shortness of breath, irritable cough which becomes hyperactive when trying to slow breathing): Gastrointestinal (heart burn, difficulty swallowing); Muscular (pain especially occipital, neck, shoulders, in between shoulder blades, cramps, stiffness):  Psychic (anxiety, panic, out of body experience); General (weakness, exhaustion, disturbed sleep, woolly head, night sweating, emotional sweating in armpits and palms).

It is no wonder health professionals find difficulty in recognizing this syndrome. Sufferers may receive a diagnosis of being anxious, prone to panic attacks, treated for depression or thought to be a hypochondriac and given unnecessary tranquilizers and antidepressants.

Can you see that this can become a vicious cycle, erodes self esteem and then worry escalates the symptoms?

Stay tuned for next month’s issue where I discuss how the ‘SABERS Approach’ helps mange TMD as it relates to CHVS.

Stress Management

Humans can cope with sudden stress but are less well adapted to prolonged stresses? Stress is now considered one of the leading health problems and contributes to 90% of visits to the doctor. Common complaints are:

• Muscle tension in jaw, face, shoulders and hips.

• Headaches in temples and behind the eyes,

• Feelings of anxiety and irritability

• Problems sleeping

• Gastrointestinal upset

Causes of Stress:

• ILLNESS OR INJURY; POSITIVE EVENTS SUCH AS JOB PROMOTION OR GOING ON A TRIP;

• LIFE IS 10% WHAT HAPPENS TO US AND 90% HOW WE REACT TO IT. There is no right or wrong way to react to stress. The trick is finding healthy ways to handle stress

Research continues to indicate a positive correlation between a person’s ability to cope with stress and the incidence of disease.

Have you heard of the triune brain?

There are 3 different areas of the triune brain: EACH AREA HAS ITS OWN “UNDERSTANDING”OF THE ENVIRONMENT AND RESPONDS ACCORDINGLY – THEY ARE MUTUALLY DEPENDENT AND INTER TWINED however FUNCTION AS A WHOLE.

The frontal lobe plays a role in logic and sound judgement: The temporal lobe with hearing and smell, parietal lobe processes touch and spoken language, the occipital lobe seeing and reading.

The limbic system mediates emotion and stores memories. All memory begins with Sensory Stimuli. Senses provide continual feedback to the brain on the status of what is going on inside and outside the body’s environment. For example inside if the body is anxious excited or stressed the heart rate, breathing, internal temperature, muscle tension will increase. We can experience visceral feedback – gut feeling. Hence emotions often referred to as …She had “Butterflies in her stomach” before her job interview or “Always rely on you gut instinct”

Outside stimuli are through senses: What we see, hear, taste, touch and smell.

The brainstem is seat of survival and the Fight OR flight Response

This is how stress works …Mind detects a threat.

The threat triggers a response by sending a signal to limbic system where the Amydala, the smoke detector for danger… alerts us to take action. A signal is then sent to the hippocampus where all memories are stored, and then to the Reptilian Brainstem which signals the body to freeze, fight or flee. The adrenal glands then produce adrenaline to increase your metabolism, dilate blood vessels, increase your heart rate, and send extra glucose into your blood stream to serve as a quick source of energy for this action to happen.

Have you noticed that people can often seem irrational and say silly hurtful things when overstressed? Reason for this irrational behaviour is when we are overstressed, the frontal lobes where your logical thinking is performed goes OFFLINE and the Animal Defences Survival comes on line instead.

In summary to quote Psychologist Van der Kolk “The imprint of trauma or being over whelmed, is in the limbic emotional system and brainstem, not in our thinking brains.”   This makes us human and explains why people who are under stress seem irrational. They are unable to think straight!

Here are the 8 tips to help you manage stress:

1) Attitude- keep a positive attitude –become aware of own inner dialogue daily as well as how you communicate. If always negative convince yourself as well as everyone around you (picture)

Focus on successes not failures- focus on process rather than results

2) Realistic expectations-set priorities- write a ‘to do’ list-tackle easy jobs when low on energy

3) Relaxation techniques; Learn deep breathing techniques like alternate nostril breathing and practice whenever you feel rushed or stressed or any breath based exercise like Yoga, Pilates, Tai Chi and qigong My personal favourite is mindfulness. Pat Ogden (psychologist) says:

• Mindfulness is a contemplative state of perception : its goal is to observe “what is” rather than attempting to manipulate or change experience

• To be mindful is to focus on internal states rather than external events and to attend to present experience rather than past or future – “ right here , right now”

• Mindfulness allows difficult thoughts, feelings, emotions just to be there, just observing without having to solve or change them.

• Mindfulness engages the prefrontal cortex thereby reducing arousal

4) Exercise regularly –stretch daily to decrease muscle tone –exercise for at least 30 minutes 4 times a week- When you exercise you feel in control-a key defence against stress. Also don’t time yourself and compare your time to other people, otherwise this becomes another stressor!

5) Eat Healthy- 8 glasses of water a day- 8 servings of fruit and vegetables a day- maintain a balanced diet… too much sugar lowers immune system amongst other things

6) Sleep – 8 hours of sleep a day is recommended- don’t stay in bed to avoid problems- you’ll only get up with more stress! Under 4 hours sleep contributes to high blood pressure

7) Avoid smoking and alcohol-avoid excess caffeine, sugar, fats-all put strain on your body’s ability to cope with stress.

Stressed people are often seen with a “large” coffee in their hands in the morning just to get jump start!

Be kind to yourself- take short breaks to help re-energize and re-focus (could be just taking 10 breaths every hour. – Learn to say NO – take time each day to do something you love.

If you are burnt out and stressed, you cannot be creative and on top of your game -also if you can’t stand yourself how will anyone else stand being around you either!

Bonus: Four of my favourite ways to reduce ‘Holiday Stress’

1) “Best things in life are free”  On Christmas Eve write love notes on a tiny piece of paper for family members. Hide notes in pockets, drawers, inside kitchen cupboards on bottles, under pillows, or in purses/wallets. Stick notes onto mirrors in house and cars..anywhere least expect to find one! Be creative!

2) Like yourself- stop the inner critic and try to accept yourself just as you are. “Do your best, forget the rest!” overwhelmed with stress this can be hard to do… Start to sway slowly from side to side… stand with feet apart, eyes closed, breathe deeply, tongue tip on roof of mouth, teeth are apart and check muscles to see if they are relaxed. Take a slow, deep breath in and hold it for 3 seconds, pause and let it out for 5 seconds. Feel the shoulders relax and tension leave the body. The body remembers how good it felt when mother rocked you to sleep.

3) Stretch arms overhead and smile and think of: three things you like about yourself or someone you adore, fun activities you enjoyed as a child; people who make you laugh or made positive difference in your life. In no time you will feel fun and free.

4) Alternate Nostril Breathing – In this breathing technique inhale for count of 4; hold breath for 16 and exhale for 8.

Using right hand put index finger between eyebrows and

• Inhale through left nostril closing right with thumb to the count of 4

•  Hold breath and close both nostrils with 3rd finger and thumb  for the count of 16

• Exhale through right nostril closing left nostril with 3rd finger for the count of 8

•  Inhale through right nostril keeping left nostril closed with 3rd finger for the count of 4

•  Hold breath and close both nostrils with 3rd finger and thumb  for the count of 16

• Exhale through left nostril keeping right nostril closed for count of 8

This Story is a good example of the triune brain at work. I am a speaker for the Arthritis society and during a talk I embarrassed myself by saying something that could have been interpreted in two ways. You may remember that the hippocampus stores past events that happen to us. It can be triggered in the present to give the person similar feelings as if the “there and then” is actually “here and now”. The brain does not know the difference.

I was standing in a room full of 50 people giving a speech on osteoarthritis. Everyone in the room that day heard me say clearly that one of the early signs is stiffness in the morning that can last for ½ an hour.

Immediately those words left my mouth I scanned the audience to make sure I was making a good connection. It seems I had done so with some of the men because they were smirking. The parietal and frontal areas of my brain realised quickly what they might be thinking! My face and palms started to feel hot, my heart beat faster and my mind started to blank out. The only voice I could hear suddenly was one chirping inside my head “Why are you still standing here”. I remember wanting a big black hole to open and swallow me instantly!! Then I remembered to take a few deep breathes my mind cleared and I was able to continue my talk. However at the end of the speech one of the ‘smirking’ men came over and said “Cathy, Great speech, however I enjoy being stiff in the morning!”

Ever since then when I talk about early signs of Arthritis, I feel my face redden and my heart rate go up. I am careful to say it is the muscles and joints which can feel stiff for half an hour in the morning!

Please keep your eyes peeled for some great articles from Cathy Russell on how she has taken “Learning with Laughter” to heart